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  • Question 1 - A General Practitioner (GP) sees a 28-month-old girl who is failing to thrive....

    Correct

    • A General Practitioner (GP) sees a 28-month-old girl who is failing to thrive. The GP carries out some tests and discovers antibody to tissue transglutaminase in the girl’s plasma.
      What is the most likely diagnosis?

      Your Answer: Coeliac disease

      Explanation:

      Comparison of Conditions Causing Malabsorption and Failure to Thrive

      Coeliac Disease, Cystic Fibrosis, Ulcerative Colitis, Crohn’s, and Phenylketonuria are all conditions that can cause malabsorption and failure to thrive. However, they differ in their causes and associated autoantibodies.

      Coeliac Disease is an autoimmune disease of the small intestine that can occur at any age. It is characterized by the presence of antibodies to α-gliadin, tissue transglutaminase, and anti-endomysial. Duodenal biopsy confirms the diagnosis.

      Cystic Fibrosis is a genetic condition that can cause malabsorption and failure to thrive, but it is not associated with autoantibodies.

      Ulcerative Colitis and Crohn’s are inflammatory bowel diseases that can cause malabsorption and weight loss. However, they typically present at 15-30 years and are not associated with the autoantibodies found in Coeliac Disease.

      Phenylketonuria is another genetic condition that can cause failure to thrive but is not associated with autoantibodies. It is caused by absent phenylalanine hydroxylase enzyme activity, leading to the accumulation of phenylalanine and production of neurotoxic byproducts.

      In summary, while these conditions share some similarities in their presentation, they differ in their underlying causes and associated autoantibodies. Proper diagnosis and management are crucial for improving patient outcomes.

    • This question is part of the following fields:

      • Paediatrics
      9.1
      Seconds
  • Question 2 - A 50-year-old truck driver is admitted with a left-sided facial droop, dysphasia and...

    Correct

    • A 50-year-old truck driver is admitted with a left-sided facial droop, dysphasia and dysarthria. His symptoms slowly improve and he is very eager to return to work as he is self-employed. After 3 weeks, he has made a complete clinical recovery and neurological examination is normal. As per the guidelines of the Driver and Vehicle Licensing Agency (DVLA), when can he recommence driving his truck?

      Your Answer: 12 months after onset of symptoms

      Explanation:

      Driving Restrictions Following Stroke or TIA

      After experiencing a stroke or transient ischaemic attack (TIA), there are various restrictions on driving depending on the time elapsed since onset of symptoms and the type of vehicle being driven.

      For car drivers, it is recommended that they do not drive for at least 4 weeks after a TIA or stroke. After 1 month, they may resume driving if there has been satisfactory recovery.

      However, for lorry or bus drivers, licences will be revoked for 1 year following a stroke or TIA. After 12 months, relicensing may be offered subject to satisfactory clinical recovery. Functional cardiac testing and medical reports may be required.

      For car drivers who have had a single TIA or stroke, they may resume driving 1 month after the event following satisfactory clinical recovery.

      Overall, it is important to follow these restrictions to ensure the safety of both the driver and others on the road.

    • This question is part of the following fields:

      • Neurology
      125.2
      Seconds
  • Question 3 - Which gland produces thyroid stimulating hormone (TSH) in the endocrine system? ...

    Correct

    • Which gland produces thyroid stimulating hormone (TSH) in the endocrine system?

      Your Answer: Anterior pituitary

      Explanation:

      The Thyroid Hormone Axis

      The thyroid hormone axis is a complex system that involves the hypothalamus, pituitary gland, and thyroid gland. The hypothalamus produces a hormone called thyrotropin-releasing hormone (TRH), which stimulates the anterior pituitary gland to release thyroid-stimulating hormone (TSH). TSH then stimulates the thyroid gland to produce and release the thyroid hormones thyroxine (T4) and tri-iodothyronine (T3).

      Both T4 and T3 are primarily bound to proteins in the bloodstream, but it is the free, unbound hormones that are biologically active. The secretion of TSH is inhibited by the presence of thyroid hormones in the bloodstream. This negative feedback loop helps to regulate the levels of thyroid hormones in the body.

      In summary, the thyroid hormone axis is a tightly regulated system that involves multiple hormones and glands working together to maintain proper levels of thyroid hormones in the body.

    • This question is part of the following fields:

      • Endocrinology
      48.9
      Seconds
  • Question 4 - A 55-year-old man, who has been a heavy drinker for many years, arrives...

    Incorrect

    • A 55-year-old man, who has been a heavy drinker for many years, arrives at the Emergency Department with intense abdominal pain. During the abdominal examination, caput medusae is observed. Which vessels combine to form the obstructed blood vessel in this patient?

      Your Answer: Superior mesenteric and left gastric veins

      Correct Answer: Superior mesenteric and splenic veins

      Explanation:

      Understanding the Hepatic Portal Vein and Caput Medusae

      The hepatic portal vein is formed by the union of the superior mesenteric and splenic veins. When this vein is obstructed, it can lead to caput medusae, a clinical sign characterized by dilated varicose veins that emanate from the umbilicus, resembling Medusa’s head. This condition is often seen in patients with cirrhotic livers, particularly those who are alcoholics.

      While the inferior mesenteric vein can sometimes contribute to the formation of the hepatic portal vein, this is only true for about one-third of individuals. The left gastric vein, on the other hand, does not play a role in the formation of the hepatic portal vein.

      It’s important to note that the right and left common iliac arteries are not involved in this condition. Additionally, neither the inferior mesenteric artery nor the paraumbilical veins contribute to the formation of the hepatic portal vein.

      Understanding the anatomy and physiology of the hepatic portal vein and caput medusae can aid in the diagnosis and treatment of patients with liver disease.

    • This question is part of the following fields:

      • Gastroenterology
      260.9
      Seconds
  • Question 5 - Lila, a 30-year-old pregnant woman, (gravidity 1, parity 0) currently 27+5, visits her...

    Incorrect

    • Lila, a 30-year-old pregnant woman, (gravidity 1, parity 0) currently 27+5, visits her general practitioner (GP) complaining of reflux. The GP prescribes a new medication for her reflux. Upon reviewing Lila's medical records, the GP notes that she is scheduled for a cervical smear test in two weeks. Lila reports no new discharge, bleeding, or pain. What is the recommended timing for Lila's next cervical smear test?

      Your Answer: In 2 weeks' time

      Correct Answer: 3 months post-partum

      Explanation:

      Cervical screening is typically postponed during pregnancy until…

      Cervical Cancer Screening in the UK

      Cervical cancer screening is a well-established program in the UK that aims to detect pre-malignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that around 15% of cervical adenocarcinomas are frequently undetected by screening.

      The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification, and the NHS has now moved to an HPV first system. This means that a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

      All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. However, cervical screening cannot be offered to women over 64. In Scotland, screening is offered from 25-64 every five years.

      In special situations, cervical screening in pregnancy is usually delayed until three months post-partum, unless there are missed screenings or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.

      It is recommended to take a cervical smear around mid-cycle, although there is limited evidence to support this advice. Overall, the UK’s cervical cancer screening program is an essential tool in preventing cervical cancer and promoting women’s health.

    • This question is part of the following fields:

      • Obstetrics
      148.2
      Seconds
  • Question 6 - A 57-year-old man is admitted to the Intensive Care Unit (ICU) with a...

    Correct

    • A 57-year-old man is admitted to the Intensive Care Unit (ICU) with a severe exacerbation of COPD. Despite full intervention, being intubated and ventilated, he fails to respond to treatment and continues to steadily deteriorate. It is believed that the patient is now brain dead.
      The patient is unconscious, fails to respond to outside stimulation and it is believed that his heart rate and breathing are only being maintained by the ventilator. The patient has agreed in the past to be an organ donor, and brainstem death verification is sought. The consultant with six years’ experience is present to certify brainstem death; however, a further person is needed for the process.
      Which of the following people is most appropriate to certify brainstem death along with the consultant?

      Your Answer: An ST4 doctor with five years full GMC registration

      Explanation:

      Certification of Brainstem Death: Who Can Verify and Who Cannot

      Brain death is the irreversible loss of brain function, including the brainstem. To diagnose brainstem death, all three criteria of apnoea, coma, and absence of brainstem reflexes must be present. The verification of brainstem death is typically done in the ICU, where patients are mechanically ventilated.

      According to the guidelines set by the Academy of Medical Royal Colleges, two doctors must verify brainstem death. Both doctors must have at least five years of full medical registration and be trained and competent in performing the assessment. At least one of the two doctors must be a consultant. They must both agree that all three criteria are met and that there is no reversible cause that can be treated.

      It is important to note that any doctor who has received training in death certification can certify a death following cardiorespiratory arrest. However, only doctors who meet the above criteria can verify brainstem death.

      The coroner is not involved in death verification unless the circumstances of the death are suspicious or meet strict referral criteria.

      Nursing staff should not verify death unless they have received specific training. In certifying brainstem death, two qualified doctors, one of whom must be a consultant, and both of whom must have been fully registered with the GMC for at least five years, must perform the tests.

      Relatives and next of kin should not be involved in the verification of death. They can be informed of the death as soon as it is confirmed by medical practitioners.

      Who Can Verify Brainstem Death? A Guide to Certification.

    • This question is part of the following fields:

      • Ethics And Legal
      269
      Seconds
  • Question 7 - What is the neuronal factor that influences the velocity of action potential transmission?...

    Correct

    • What is the neuronal factor that influences the velocity of action potential transmission?

      Your Answer: Axon myelination

      Explanation:

      Factors Affecting Action Potential Speed in Neurons

      Action potential speed in neurons is influenced by various structural factors. The diameter and length of the axon determine the amount of resistance an action potential will encounter during propagation. Axonal myelination is another important factor that increases the speed of action potentials by enabling saltatory conduction between nodes of Ranvier. Myelin sheaths, which are electrically insulating materials that wrap around axons, cause action potentials to propagate via saltatory conduction, thus increasing their speed. Additionally, the kinetics of voltage-gated ion channels, especially sodium and potassium, play a critical role in the generation of action potentials.

      On the other hand, there are factors that do not affect the propagation speed of an action potential. The number of dendrites a neuron has only affects the transmission of action potentials between neurons. The type of neurotransmitter and receptor type only influence the ultimate outcome of the action potential, but not its speed. Similarly, the postsynaptic potential only promotes or inhibits action potentials, but does not affect their speed of conduction.

      In summary, the speed of action potentials in neurons is determined by structural factors such as axon diameter and length, axonal myelination, and the kinetics of voltage-gated ion channels. Other factors such as the number of dendrites, type of neurotransmitter and receptor, and postsynaptic potential do not affect the speed of action potential propagation.

    • This question is part of the following fields:

      • Neurology
      15.5
      Seconds
  • Question 8 - A 78-year-old man presents to the emergency department with a 2-day history of...

    Incorrect

    • A 78-year-old man presents to the emergency department with a 2-day history of vomiting and abdominal pain. He has a medical history of heart failure and COPD. Upon examination, his abdomen is soft and non-tender, and his vital signs are as follows: blood pressure 105/72 mmHg, pulse 94 bpm, respiratory rate 14/min, and temperature 36.9 deg C. His initial blood tests reveal hyponatremia with a sodium level of 123 mmol/L (135 - 145). What is the best approach to manage this patient's hyponatremia?

      Your Answer: IV 3% sodium chloride

      Correct Answer: IV isotonic normal saline

      Explanation:

      Hypertonic saline is not the appropriate treatment for this patient as they do not have acute severe hyponatraemia with symptoms.

      Treating Hyponatremia: Factors to Consider

      Hyponatremia, if left untreated, can lead to cerebral edema and brain herniation. Therefore, it is crucial to identify and treat it promptly. However, the management of hyponatremia is complex and depends on several factors. These include the duration and severity of hyponatremia, the patient’s symptoms, and the suspected cause of hyponatremia. Over-rapid correction can also result in osmotic demyelination syndrome, which can cause irreversible symptoms.

      In all patients, initial steps include ruling out a spurious result and reviewing medications that may cause hyponatremia. For chronic hyponatremia without severe symptoms, the treatment approach depends on the suspected cause. If hypovolemic, normal saline may be given as a trial. If euvolemic, fluid restriction and medications such as demeclocycline or vaptans may be considered. If hypervolemic, fluid restriction and loop diuretics or vaptans may be used.

      For acute hyponatremia with severe symptoms, patients require close monitoring and may need hypertonic saline to correct the sodium level more quickly. However, over-correction can lead to osmotic demyelination syndrome, which can cause irreversible symptoms.

      Vasopressin/ADH receptor antagonists (vaptans) can be used in some cases but should be avoided in patients with hypovolemic hyponatremia and those with underlying liver disease. They can also stimulate thirst receptors, leading to the desire to drink free water.

      Overall, treating hyponatremia requires careful consideration of various factors to avoid complications and ensure the best possible outcome for the patient.

    • This question is part of the following fields:

      • Medicine
      128.3
      Seconds
  • Question 9 - A 35-year-old male was given steroids after a kidney transplant. After two years,...

    Correct

    • 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: 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
      8.1
      Seconds
  • Question 10 - A 25 year old patient presents to the accident and emergency department after...

    Correct

    • A 25 year old patient presents to the accident and emergency department after being involved in a fight an hour ago. Due to being intoxicated, the patient is unable to provide much history. Upon examination, the patient has significant facial swelling on the lower left side and bruising around the left eye. The patient does not experience tenderness when palpated on either side of the nose. However, when asked to bite down, the patient complains of an unusual sensation in their mouth, and the left side teeth come together before the right side. Additionally, two teeth are missing on the left side. What would be the most appropriate next investigation?

      Your Answer: Mandible radiography with (orthopantogram)

      Explanation:

      Imaging for Mandibular Fractures: Options and Considerations

      Mandibular fractures are less common now with the use of seat belts in motor vehicles, but they still occur, especially in young males. A standard mandible series, including a PA view, Towne view, and left and right oblique views, along with an orthopantogram (OPG), can provide a full evaluation of the mandible and teeth. If further imaging is needed, a CT of the facial skeleton and mandible may be necessary.

      In cases of suspected mandibular fractures, it is important to document the function of the marginal mandibular nerve and sensation over the chin. If teeth are missing, a chest X-ray may be necessary to check for inhaled foreign bodies. Lateral facial radiographs are not typically used for the facial skeleton, and MRI is not the first choice for bony injuries but can be useful for evaluating TMJ pathology.

      It is important to consider the potential risks and benefits of each imaging option, especially in terms of ionizing radiation exposure. Chest radiographs and CT scans involve higher doses of radiation and should not be the first choice unless necessary. Overall, a thorough evaluation of mandibular fractures requires careful consideration of the patient’s individual needs and circumstances.

    • This question is part of the following fields:

      • Plastics
      103.6
      Seconds
  • Question 11 - A 55-year-old obese woman, who recently returned from a trip to Japan, presents...

    Incorrect

    • A 55-year-old obese woman, who recently returned from a trip to Japan, presents with chronic diarrhoea, fatigue, and greasy, bulky stools. She is a non-smoker and non-drinker who consumes meat. Stool examination confirms steatorrhoea, and blood tests reveal elevated folic acid levels and reduced vitamin B12 levels. The only abnormal finding on a CT scan of the abdomen is multiple diverticula in the jejunum. What is the most likely cause of this patient's macrocytic anaemia?

      Your Answer: Acquired deficiency of intrinsic factor

      Correct Answer: Increased utilisation of vitamin B12 by bacteria

      Explanation:

      Causes of Vitamin B12 Deficiency: An Overview

      Vitamin B12 deficiency can be caused by various factors, including bacterial overgrowth syndrome, acquired deficiency of intrinsic factor, chronic pancreatic insufficiency, dietary deficiency, and fish tapeworm infestation.

      Bacterial Overgrowth Syndrome: This disorder is characterized by the proliferation of colonic bacteria in the small bowel, resulting in diarrhea, steatorrhea, and macrocytic anemia. The bacteria involved are usually Escherichia coli or Bacteroides, which can convert conjugated bile acids to unconjugated bile acids, leading to impaired micelle formation and steatorrhea. The bacteria also utilize vitamin B12, causing macrocytic anemia.

      Acquired Deficiency of Intrinsic Factor: This condition is seen in pernicious anemia, which does not have diarrhea or steatorrhea.

      Chronic Pancreatic Insufficiency: This is most commonly associated with chronic pancreatitis caused by high alcohol intake or cystic fibrosis. However, in this case, the patient has no history of alcohol intake or CF, and blood tests do not reveal hyperglycemia. CT abdomen can detect calcification of the pancreas, characteristic of chronic pancreatitis.

      Dietary Deficiency of Vitamin B12: This is unlikely in non-vegetarians like the patient in this case.

      Fish Tapeworm Infestation: This infestation can cause vitamin B12 deficiency, but it is more common in countries where people commonly eat raw freshwater fish. In this case, the presence of diarrhea, steatorrhea, and CT abdomen findings suggestive of jejunal diverticula make bacterial overgrowth syndrome more likely.

      In conclusion, vitamin B12 deficiency can have various causes, and a thorough evaluation is necessary to determine the underlying condition.

    • This question is part of the following fields:

      • Gastroenterology
      22.8
      Seconds
  • Question 12 - A 78-year-old man with a history of dementia was admitted to your medical...

    Correct

    • A 78-year-old man with a history of dementia was admitted to your medical ward from a nursing home in Scotland a week ago. A swallow assessment was performed after the patient was noticed to have difficulty eating and drinking; which concluded that the patient was at high risk of aspiration. The care team therefore wish to make him nil by mouth and start intravenous (IV) fluids. You have explained the situation to him and asked for his consent, which he refused. You are not content that he has fully understood the gravity of the situation, as a result of his dementia. You note that the patient does not have a welfare attorney or guardian with power to consent.
      Which of the following would be the most appropriate way to proceed in this scenario?

      Your Answer: Issue a certificate under section 47 of the Adults with Incapacity (Scotland) Act 2000 and begin the treatment

      Explanation:

      How to Proceed with Medical Treatment for an Incapacitated Adult in Scotland

      When an adult lacks capacity and there is no welfare attorney or guardian with power to consent, medical treatment decisions can be difficult. However, in Scotland, the Adults with Incapacity (Scotland) Act 2000 provides a solution. Under section 47 of the Act, a medical practitioner can issue a certificate of incapacity in relation to the treatment in question. This authorizes the practitioner or others under their direction to provide reasonable interventions related to the treatment authorized.

      It is important to note that medical treatment is defined as any healthcare procedure designed to promote or safeguard the physical or mental health of the adult. Therefore, if the treatment is necessary to safeguard or promote the patient’s health, a section 47 certificate should be issued and the treatment commenced.

      It is not necessary to contact the nursing home or seek consent from relatives. Instead, the medical practitioner can proceed with treatment under the principle of necessity, as authorized by the Act. There is no need to apply to a court to make a decision.

      In summary, when faced with a medical treatment decision for an incapacitated adult in Scotland, the Adults with Incapacity (Scotland) Act 2000 provides a clear path forward. By issuing a section 47 certificate and proceeding with necessary treatment, medical practitioners can safeguard and promote the health of their patients.

    • This question is part of the following fields:

      • Ethics And Legal
      82.9
      Seconds
  • Question 13 - A 25-year-old woman presents with an ectopic pregnancy that has been confirmed by...

    Incorrect

    • A 25-year-old woman presents with an ectopic pregnancy that has been confirmed by ultrasound. However, the ultrasound report only mentions that the ectopic pregnancy is located in the 'left fallopian tube' without providing further details. To ensure appropriate management, you contact the ultrasound department to obtain more specific information. Which location of ectopic pregnancy is most commonly associated with a higher risk of rupture?

      Your Answer: Fimbriae

      Correct Answer: Isthmus

      Explanation:

      The risk of rupture is higher in ectopic pregnancies that are located in the isthmus of the fallopian tube. This is because the isthmus is not as flexible as other locations and cannot expand to accommodate the growing embryo/fetus. It should be noted that ectopic pregnancies can occur in various locations, including the ovary, cervix, and even outside the reproductive organs in the peritoneum.

      Understanding Ectopic Pregnancy: The Pathophysiology

      Ectopic pregnancy is a medical condition where the fertilized egg implants outside the uterus, usually in the fallopian tube. According to statistics, 97% of ectopic pregnancies occur in the fallopian tube, with most of them happening in the ampulla. However, if the implantation occurs in the isthmus, it can be more dangerous. The remaining 3% of ectopic pregnancies can occur in the ovary, cervix, or peritoneum.

      During ectopic pregnancy, the trophoblast, which is the outer layer of the fertilized egg, invades the tubal wall, leading to bleeding that may dislodge the embryo. The natural history of ectopic pregnancy involves three possible outcomes: absorption, tubal abortion, or tubal rupture.

      Tubal abortion occurs when the embryo dies, and the body expels it along with the blood. On the other hand, tubal absorption occurs when the tube does not rupture, and the blood and embryo are either shed or converted into a tubal mole and absorbed. However, if the tube ruptures, it can lead to severe bleeding, shock, and even death.

      In conclusion, understanding the pathophysiology of ectopic pregnancy is crucial in diagnosing and managing this potentially life-threatening condition. Early detection and prompt treatment can help prevent complications and improve outcomes.

    • This question is part of the following fields:

      • Gynaecology
      19.3
      Seconds
  • Question 14 - A Cardiotocogram (CTG) is performed on a 29-year-old female at 37 weeks gestation...

    Incorrect

    • A Cardiotocogram (CTG) is performed on a 29-year-old female at 37 weeks gestation who has arrived at labour ward in spontaneous labour. The CTG shows a foetal heart rate of 120 bpm and variable decelerations and accelerations are present. There are no late decelerations. However, the midwife notices a 15 minute period where the foetal heart rate only varies by 2-3bpm. The mum is worried as she has not felt her baby move much for about 15 mins and would like to know what the likely cause is. She starts crying when she tells you that she took some paracetamol earlier as she was in so much pain from the contractions and is concerned this has harmed her baby. What is the most probable reason for this reduced variability?

      Your Answer: Foetal acidosis

      Correct Answer: Foetus is sleeping

      Explanation:

      Episodes of decreased variability on CTG that last less than 40 minutes are often attributed to the foetus being asleep. However, if the decreased variability persists for more than 40 minutes, it can be a cause for concern. Other factors that can lead to decreased variability in foetal heart rate on CTG include maternal drug use (such as benzodiazepines, opioids or methyldopa – but not paracetamol), foetal acidosis (usually due to hypoxia), prematurity (which is not applicable in this case), foetal tachycardia (heart rate above 140 bpm, which is also not the case here), and congenital heart abnormalities.

      Cardiotocography (CTG) is a medical procedure that measures pressure changes in the uterus using either internal or external pressure transducers. It is used to monitor the fetal heart rate, which normally ranges between 100-160 beats per minute. There are several features that can be observed during a CTG, including baseline bradycardia (heart rate below 100 beats per minute), which can be caused by increased fetal vagal tone or maternal beta-blocker use. Baseline tachycardia (heart rate above 160 beats per minute) can be caused by maternal pyrexia, chorioamnionitis, hypoxia, or prematurity. Loss of baseline variability (less than 5 beats per minute) can be caused by prematurity or hypoxia. Early deceleration, which is a decrease in heart rate that starts with the onset of a contraction and returns to normal after the contraction, is usually harmless and indicates head compression. Late deceleration, on the other hand, is a decrease in heart rate that lags behind the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction. This can indicate fetal distress, such as asphyxia or placental insufficiency. Variable decelerations, which are independent of contractions, may indicate cord compression.

    • This question is part of the following fields:

      • Obstetrics
      63.9
      Seconds
  • Question 15 - A 50-year-old man presents to his GP with concerns about erectile dysfunction. He...

    Correct

    • A 50-year-old man presents to his GP with concerns about erectile dysfunction. He has been experiencing this for the past year and is feeling embarrassed and anxious about it, as it is causing issues in his marriage. On examination, the GP notes that the patient is overweight with a BMI of 27 kg/m2, but does not find any other abnormalities. The GP orders HbA1c and lipid tests. What other steps should the GP take at this point?

      Your Answer: Morning testosterone

      Explanation:

      The appropriate test to be conducted on all men with erectile dysfunction is the morning testosterone level check. Checking for Chlamydia and gonorrhoeae NAAT is not necessary. Prolactin and FSH/LH should only be checked if the testosterone level is low. Referring for counseling may be considered if psychological factors are suspected, but other tests should be conducted first. Endocrinology referral is not necessary at this stage, but may be considered if the testosterone level is found to be reduced.

      Erectile dysfunction (ED) is a condition where a man is unable to achieve or maintain an erection that is sufficient for sexual activity. It is not a disease but a symptom that can be caused by organic, psychogenic, or mixed factors. It is important to differentiate between the causes of ED, with gradual onset of symptoms, lack of tumescence, and normal libido favoring an organic cause, while sudden onset of symptoms, decreased libido, and major life events favoring a psychogenic cause. Risk factors for ED include cardiovascular disease, alcohol use, and certain medications.

      To assess for ED, it is recommended to measure lipid and fasting glucose serum levels to calculate cardiovascular risk, as well as free testosterone levels in the morning. If free testosterone is low or borderline, further assessment may be needed. PDE-5 inhibitors, such as sildenafil, are the first-line treatment for ED and should be prescribed to all patients regardless of the cause. Vacuum erection devices can be used as an alternative for those who cannot or will not take PDE-5 inhibitors.

      For young men who have always had difficulty achieving an erection, referral to urology is appropriate. Additionally, people with ED who cycle for more than three hours per week should be advised to stop. Overall, ED is a common condition that can be effectively managed with appropriate treatment.

    • This question is part of the following fields:

      • Surgery
      22.9
      Seconds
  • Question 16 - A 32-year-old woman gives birth to a 37-week gestational age male neonate. Within...

    Incorrect

    • A 32-year-old woman gives birth to a 37-week gestational age male neonate. Within 6 hours after delivery, the neonate shows signs of excessive respiratory efforts and tachypnoea. There is grunting and intercostal retraction. A chest X-ray reveals bilateral pulmonary oedema with a ground-glass appearance. What antenatal examination findings are most likely to have been observed in the mother?

      Your Answer: Positive indirect Coombs’ test

      Correct Answer: Fasting blood sugar of 14.0 mmol/l

      Explanation:

      The neonate in question has a fasting blood sugar level of 14.0 mmol/l and is suffering from neonatal respiratory distress syndrome (NRDS). This is a common condition in premature infants, and those born to diabetic mothers are at an increased risk due to delayed lung maturation. An elevated total thyroxine concentration is a normal response to pregnancy and is not related to NRDS. Maternal hypocalcaemia also has no relation to NRDS. A positive indirect Coombs’ test indicates a risk of Rh isoimmunisation in the fetus, which can lead to complications such as erythroblastosis fetalis and jaundice, but is not directly related to NRDS. Elevated titres of anti-nuclear and anti-SSA antibodies are associated with maternal systemic lupus erythematosus and fetal conduction heart block, but again, this is not directly related to NRDS unless it leads to preterm birth. Overall, prematurity and maternal diabetes are the major risk factors for NRDS.

    • This question is part of the following fields:

      • Paediatrics
      15.3
      Seconds
  • Question 17 - A 14-year-old boy presents to the clinic for a routine check-up due to...

    Correct

    • A 14-year-old boy presents to the clinic for a routine check-up due to his recent development of poor near vision, without any history of eye trauma. He is tall, measuring at the 99th percentile for his age, and is performing well in school. During the medical history, he reports experiencing fatigue easily during physical activity. Upon examination, you observe that he has a high arched palate, pectus excavatum, and long arms. Additionally, you notice a bounding pulse and an early diastolic murmur at the left sternal edge during the cardiovascular exam. What is the most likely diagnosis?

      Your Answer: Marfan syndrome

      Explanation:

      Marfan syndrome is a connective tissue disease with cardiovascular complications such as aortic root dilation and aneurysm. Diagnosis is based on clinical features, family history, and genetic testing. The Ghent criteria are commonly used, with emphasis on cardiac manifestations. Echocardiographic surveillance is required, and prophylactic medications are used to reduce the chance of aortic root dilation. Aortic regurgitation may require surgery. Marfan syndrome is associated with non-cardiac features, and the clinical criteria can be found on the American National Marfan Foundation website.

    • This question is part of the following fields:

      • Paediatrics
      14.3
      Seconds
  • Question 18 - A 50-year-old man presents to the rheumatology clinic after experiencing an acute monoarthropathy...

    Incorrect

    • A 50-year-old man presents to the rheumatology clinic after experiencing an acute monoarthropathy in his left big toe's metatarsophalangeal joint. The synovial fluid analysis revealed the presence of negatively birefringent crystals under polarised light. After resolving the inflammation with acute treatment, the rheumatologist decides to start prophylactic treatment with allopurinol to prevent future occurrences. What is the most suitable medication to begin with allopurinol?

      Your Answer: Febuxostat

      Correct Answer: Diclofenac

      Explanation:

      When starting allopurinol for prophylactic treatment of gout, it is important to use NSAID or colchicine ‘cover’ to prevent an acute flare up of gout. This is because starting allopurinol can trigger an acute flare up of gout. In this case, diclofenac, an NSAID, should be given alongside allopurinol initially. Azathioprine use is contraindicated alongside allopurinol due to the risk of toxicity. Febuxostat is an alternative to allopurinol but should not be used alongside it. Hydroxychloroquine and methotrexate are not used in the treatment of gout but have a role in maintenance treatment for other rheumatological diseases.

      Gout is caused by chronic hyperuricaemia and is managed acutely with NSAIDs or colchicine. Urate-lowering therapy (ULT) is recommended for patients with >= 2 attacks in 12 months, tophi, renal disease, uric acid renal stones, or prophylaxis if on cytotoxics or diuretics. Allopurinol is first-line ULT, with an initial dose of 100 mg od and titrated to aim for a serum uric acid of < 300 µmol/l. Lifestyle modifications include reducing alcohol intake, losing weight if obese, and avoiding high-purine foods. Consideration should be given to stopping precipitating drugs and losartan may be suitable for patients with coexistent hypertension.

    • This question is part of the following fields:

      • Musculoskeletal
      88.2
      Seconds
  • Question 19 - An 80-year-old man presents to the emergency department with urinary retention. Upon examination,...

    Incorrect

    • An 80-year-old man presents to the emergency department with urinary retention. Upon examination, a catheter is inserted and 900 ml of residual urine is drained. The patient also complains of upper back pain over the spinal vertebrae. The patient has a history of metastatic prostate cancer and has recently started treatment. What type of prostate cancer treatment is the patient likely receiving?

      Your Answer: Prostate radiotherapy

      Correct Answer: Goserelin (GnRH agonist)

      Explanation:

      Starting management for metastatic prostate cancer with GnRH agonists may lead to a phenomenon called tumour flare, which can cause bone pain, bladder obstruction, and other symptoms. This was observed in a 78-year-old man who presented with urinary retention and bone pain after recently starting treatment. GnRH agonists work by overstimulating the hormone cascade to suppress testosterone production, which initially causes an increase in testosterone levels before subsequent suppression. Bicalutamide is not the best answer as it does not cause the testosterone surge seen with GnRH agonist use. Bilateral orchidectomy is not typically associated with tumour flare as it aims to rapidly decrease testosterone levels. GnRH antagonists, such as degarelix, may be a better option as they avoid the risk of tumour flare by avoiding the testosterone surge.

      Management of Prostate Cancer

      Localised prostate cancer (T1/T2) can be managed through various treatment options depending on the patient’s life expectancy and preference. Conservative approaches such as active monitoring and watchful waiting can be considered, as well as radical prostatectomy and radiotherapy (external beam and brachytherapy). On the other hand, localised advanced prostate cancer (T3/T4) may require hormonal therapy, radical prostatectomy, or radiotherapy. However, patients who undergo radiotherapy may develop proctitis and are at a higher risk of bladder, colon, and rectal cancer.

      For metastatic prostate cancer, the primary goal is to reduce androgen levels. A combination of approaches is often used, including anti-androgen therapy, synthetic GnRH agonist or antagonists, bicalutamide, cyproterone acetate, abiraterone, and bilateral orchidectomy. GnRH agonists such as Goserelin (Zoladex) may result in lower LH levels longer term by causing overstimulation, which disrupts endogenous hormonal feedback systems. This may cause a rise in testosterone initially for around 2-3 weeks before falling to castration levels. To prevent a rise in testosterone, anti-androgen therapy is often used initially. However, this may result in a tumour flare, which stimulates prostate cancer growth and may cause bone pain, bladder obstruction, and other symptoms. GnRH antagonists such as degarelix are being evaluated to suppress testosterone while avoiding the flare phenomenon. Chemotherapy with docetaxel may also be an option for the treatment of hormone-relapsed metastatic prostate cancer in patients who have no or mild symptoms after androgen deprivation therapy has failed, and before chemotherapy is indicated.

    • This question is part of the following fields:

      • Surgery
      134
      Seconds
  • Question 20 - A 68-year-old woman presents to the Emergency Department with acute agitation, fever, nausea...

    Incorrect

    • A 68-year-old woman presents to the Emergency Department with acute agitation, fever, nausea and vomiting. On examination, she is disorientated and agitated, with a temperature of 40 °C and heart rate of 130 bpm, irregular pulse, and congestive cardiac failure. She has a history of hyperthyroidism due to Graves’ disease, neutropenia and agranulocytosis, and cognitive impairment. She lives alone. Laboratory investigations reveal the following results:
      Test Result Normal reference range
      Free T4 > 100 pmol/l 11–22 pmol/l
      Free T3 > 30 pmol/l 3.5–5 pmol/l
      Thyroid stimulating hormone (TSH) < 0.01 µU/l 0.17–3.2 µU/l
      TSH receptor antibody > 30 U/l < 0.9 U/l

      What should be included in the management plan for this 68-year-old patient?

      Your Answer: Prednisolone, paracetamol, tri-iodothyronine

      Correct Answer: Propylthiouracil, iodine, propranolol, hydrocortisone

      Explanation:

      Treatment Options for Thyroid Storm in Graves’ Disease Patients

      Thyroid storm is a life-threatening condition that requires immediate medical attention in patients with Graves’ disease. The following are some treatment options for thyroid storm and their potential effects on the patient’s condition.

      Propylthiouracil, iodine, propranolol, hydrocortisone:
      This combination of medications can help inhibit the synthesis of new thyroid hormone, tone down the severe adrenergic response, and prevent T4 from being converted to the more potent T3. Propylthiouracil and iodine block the synthesis of new thyroid hormone, while propranolol and hydrocortisone help decrease the heart rate and blood pressure.

      Carbimazole, iodine, tri-iodothyronine:
      Carbimazole and iodine can inhibit the synthesis of thyroid hormone, but tri-iodothyronine is very potent and would do the opposite of the therapeutic aim.

      Esmolol, thyroxine, dexamethasone:
      Esmolol and dexamethasone can tone down the severe adrenergic response and prevent T4 from being turned into T3. However, thyroxine would do the opposite of the therapeutic aim and make the situation worse.

      Lugol’s iodine, furosemide, thyroxine:
      Lugol’s iodine can be used to treat hyperthyroidism, but furosemide is not appropriate for addressing thyroid storm. Thyroxine would make the situation worse.

      Prednisolone, paracetamol, tri-iodothyronine:
      Prednisolone can prevent T4 from being converted to T3, but it is usually available in oral form and may not be efficient in addressing thyroid storm. Tri-iodothyronine would exacerbate the patient’s condition, and paracetamol is not indicated for this condition.

      In conclusion, the treatment options for thyroid storm in Graves’ disease patients depend on the patient’s condition and medical history. It is important to consult with a healthcare professional to determine the best course of action.

    • This question is part of the following fields:

      • Endocrinology
      103.4
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  • Question 21 - You are a male FY1 working in obstetrics. A 35-year-old female is on...

    Incorrect

    • You are a male FY1 working in obstetrics. A 35-year-old female is on the ward in labour, 10 minutes ago she suffered a placental abruption and is in need of emergency care. Her midwife comes to see you, informing you that she is requesting to only be seen and cared for by female doctors. How do you respond?

      Your Answer: Accept her wishes and ask around for a female doctor to come to the ward

      Correct Answer: Ask the midwife to immediately summon senior medical support, regardless of gender

      Explanation:

      Placental abruption is a critical obstetric emergency that requires immediate attention to prevent severe blood loss and potential harm to both the mother and baby. While patients have the right to choose their doctor, this right does not apply in emergency situations where prompt treatment is necessary to save the patient’s life. Therefore, suggesting that the patient wait for a female doctor or return in an hour is inappropriate and could result in a dangerous delay in medical care. It is also unnecessary to label the comment as sexist and document it in the patient’s notes. While it is important to respect the patient’s preferences, the priority in this situation is to provide urgent medical attention. Similarly, asking a midwife to take on the role of a doctor is not a safe or appropriate solution, as their training and responsibilities differ. Ultimately, if a female doctor is not available, the patient must be treated by a male doctor to address the emergency as quickly and effectively as possible.

      Placental Abruption: Causes, Symptoms, and Risk Factors

      Placental abruption is a condition that occurs when the placenta separates from the uterine wall, leading to maternal bleeding into the space between them. Although the exact cause of this condition is unknown, certain factors have been associated with it, including proteinuric hypertension, cocaine use, multiparity, maternal trauma, and increasing maternal age. Placental abruption is not a common occurrence, affecting approximately 1 in 200 pregnancies.

      The clinical features of placental abruption include shock that is disproportionate to the visible blood loss, constant pain, a tender and tense uterus, and a normal lie and presentation of the fetus. The fetal heart may be absent or distressed, and there may be coagulation problems. It is important to be aware of other conditions that may present with similar symptoms, such as pre-eclampsia, disseminated intravascular coagulation (DIC), and anuria.

      In summary, placental abruption is a serious condition that can have significant consequences for both the mother and the fetus. Understanding the risk factors and symptoms of this condition is important for early detection and appropriate management.

    • This question is part of the following fields:

      • Obstetrics
      26.9
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  • Question 22 - A 50-year-old woman comes to see her GP complaining of persistent abdominal cramping,...

    Correct

    • A 50-year-old woman comes to see her GP complaining of persistent abdominal cramping, bloating, and diarrhoea that has been going on for 5 months. She reports no blood in her stools, no unexplained weight loss, and no fatigue. Her medical history includes obesity, but there is no family history of any relevant conditions.

      Upon examination, her heart rate is 80 bpm, her blood pressure is 130/75 mmHg, and she has no fever. Both her abdominal and pelvic exams are unremarkable, and there is no pallor or jaundice.

      What is the most appropriate next step in managing this patient's symptoms?

      Your Answer: Measure serum CA-125

      Explanation:

      If a woman aged 50 or older presents with persistent symptoms of irritable bowel syndrome (IBS), such as cramping, bloating, and diarrhoea, ovarian cancer should be suspected even without other symptoms like unexplained weight loss or fatigue. This is because ovarian cancer often presents with non-specific symptoms similar to IBS and rarely occurs for the first time in patients aged 50 or older. It is important to measure serum CA-125 to help diagnose ovarian cancer. An abdominal and pelvic examination should also be carried out, but if this is normal, measuring CA-125 is the next step. Ultrasound scans of the abdomen and pelvis are recommended once CA-125 has been measured, and if these suggest malignancy, other ultrasounds may be considered under specialist guidance. Measuring anti-TTG antibodies is not necessary in this case, as IBS rarely presents for the first time in patients aged 50 or older. Urgent referral to gastroenterology is not appropriate unless the patient has features of inflammatory bowel disease.

      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
      46.1
      Seconds
  • Question 23 - A typically healthy and fit 35-year-old man presents to the Emergency Department (ED)...

    Correct

    • A typically healthy and fit 35-year-old man presents to the Emergency Department (ED) with palpitations that have been ongoing for 4 hours. He reports no chest pain, has a National Early Warning Score (NEWS) of 0, and the only physical finding is an irregularly irregular pulse. An electrocardiogram (ECG) confirms that the patient is experiencing atrial fibrillation. The patient has no notable medical history.
      What is the most suitable course of action?

      Your Answer: Medical cardioversion (amiodarone or flecainide)

      Explanation:

      Management of Atrial Fibrillation: Treatment Options and Considerations

      Atrial fibrillation (AF) is a common cardiac arrhythmia that requires prompt management to prevent complications. The following are the treatment options and considerations for managing AF:

      Investigations for Reversible Causes
      Before initiating any treatment, the patient should be investigated for reversible causes of AF, such as hyperthyroidism and alcohol. Blood tests (TFTs, FBC, U and Es, LFTs, and coagulation screen) and a chest X-ray should be performed.

      Medical Cardioversion
      If no reversible causes are found, medical cardioversion is the most appropriate treatment for haemodynamically stable patients who present within 48 hours of the onset of AF. Amiodarone or flecainide can be used for this purpose.

      DC Cardioversion
      DC cardioversion is indicated for haemodynamically unstable patients, including those with shock, syncope, myocardial ischaemia, and heart failure. It is also appropriate if medical cardioversion fails.

      Anticoagulation Therapy with Warfarin
      Patients who remain in persistent AF for over 48 hours should have their CHA2DS2 VASc score calculated. If the score is equal to or greater than 1 for men or equal to or greater than 2 for women, anticoagulation therapy with warfarin should be initiated.

      Radiofrequency Ablation
      Radiofrequency ablation is not a suitable treatment for acute AF.

      24-Hour Three Lead ECG Tape
      Sending the patient home with a 24-hour three lead ECG tape and reviewing them in one week is not necessary as the diagnosis of AF has already been established.

      In summary, the management of AF involves investigating for reversible causes, considering medical or DC cardioversion, initiating anticoagulation therapy with warfarin if necessary, and avoiding radiofrequency ablation for acute AF.

    • This question is part of the following fields:

      • Cardiology
      19.5
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  • Question 24 - A 55-year-old woman visits her doctor complaining of fatigue and weakness. She has...

    Correct

    • A 55-year-old woman visits her doctor complaining of fatigue and weakness. She has been experiencing difficulty getting up from chairs, lifting objects, and climbing stairs for the past 2 months. However, she has no issues with other movements like knitting or writing. Upon examination, she has bilateral hip and shoulder weakness. Blood tests reveal the following results: calcium 2.4 mmol/L (2.1-2.6), thyroid stimulating hormone (TSH) 4.5 mU/L (0.5-5.5), free thyroxine (T4) 12.4 pmol/L (9.0 - 18), creatine kinase (CK) 1752 U/L (35 - 250), and ESR 62 mm/hr (< 40). What is the most probable diagnosis?

      Your Answer: Polymyositis

      Explanation:

      Polymyositis: An Inflammatory Disorder Causing Muscle Weakness

      Polymyositis is an inflammatory disorder that causes symmetrical, proximal muscle weakness. It is believed to be a T-cell mediated cytotoxic process directed against muscle fibers and can be idiopathic or associated with connective tissue disorders. This condition is often associated with malignancy and typically affects middle-aged women more than men.

      One variant of the disease is dermatomyositis, which is characterized by prominent skin manifestations such as a purple (heliotrope) rash on the cheeks and eyelids. Other features of polymyositis include Raynaud’s, respiratory muscle weakness, dysphagia, and dysphonia. Interstitial lung disease, such as fibrosing alveolitis or organizing pneumonia, is seen in around 20% of patients and indicates a poor prognosis.

      To diagnose polymyositis, doctors may perform various tests, including an elevated creatine kinase, EMG, muscle biopsy, and anti-synthetase antibodies. Anti-Jo-1 antibodies are seen in a pattern of disease associated with lung involvement, Raynaud’s, and fever.

      The management of polymyositis involves high-dose corticosteroids tapered as symptoms improve. Azathioprine may also be used as a steroid-sparing agent. Overall, polymyositis is a challenging condition that requires careful management and monitoring.

    • This question is part of the following fields:

      • Musculoskeletal
      26.4
      Seconds
  • Question 25 - A 47-year-old woman arrives at the Emergency department with weakness in her arms...

    Incorrect

    • A 47-year-old woman arrives at the Emergency department with weakness in her arms and legs. She had recently attended a BBQ where she consumed canned food. During the examination, you observe weakness in all four limbs, bilateral ptosis, and slurred speech. Her husband reports that she experienced diarrhea the day before and has been constipated today. What is the probable diagnosis?

      Your Answer: Guillain-Barré syndrome

      Correct Answer: Botulism

      Explanation:

      Botulism: Causes, Types, Symptoms, and Treatment

      Botulism is a severe illness caused by the botulinum toxin, which is produced by the bacteria Clostridium botulinum. There are three main types of botulism: food-borne, wound, and infant botulism. Food-borne botulism occurs when food is not properly canned, preserved, or cooked, and becomes contaminated with infected soil. Wound botulism occurs when a wound becomes infected with the bacteria, usually in intravenous drug abusers. Infant botulism occurs when a baby ingests spores of the C. botulinum bacteria.

      Symptoms of botulism can occur between two hours and eight days after exposure to the toxin. These symptoms include blurred vision, difficulty swallowing (dysphagia), difficulty speaking (dysphonia), diarrhea and vomiting, and descending weakness/paralysis that may progress to flaccid paralysis. In certain serotypes, patients may rapidly progress to respiratory failure. It is important to note that patients remain alert throughout the illness.

      Botulism is a serious condition that requires prompt treatment. The antitoxin is effective, but recovery may take several months. Guillain-Barré syndrome, which is an ascending paralysis that often occurs after a viral infection, would not fit the case vignette described. Myasthenia gravis is an autoimmune chronic condition that typically worsens with exercise and improves with rest. A cerebrovascular accident usually causes weakness in muscles supplied by one specific brain area, whereas the weakness in botulism is generalized. Viral gastroenteritis is not usually associated with weakness, unless it is Guillain-Barré syndrome a few weeks after the infection.

    • This question is part of the following fields:

      • Infectious Diseases
      19.4
      Seconds
  • Question 26 - In the context of biostatistics, which statement accurately describes type I error in...

    Incorrect

    • In the context of biostatistics, which statement accurately describes type I error in relation to the clinical trial evaluating the efficacy of a new HPV vaccine compared to the current vaccine?

      Your Answer: Decreasing the significance level increases the chance of a type I error being made

      Correct Answer: Occurs when the null hypothesis is rejected erroneously

      Explanation:

      Understanding Type I and Type II Errors in Statistical Analysis

      In statistical analysis, errors can occur when interpreting data. Type I errors occur when the null hypothesis is rejected erroneously, leading to the incorrect conclusion that something is true when it is not. This is also known as a false-positive error or alpha error. On the other hand, type II errors occur when an investigator mistakenly concludes that there is no difference between two study populations when a difference actually exists. This is also referred to as a false-negative error or beta error, represented by the Greek letter beta.

      The probability of a type I error decreases as the significance level decreases, while the probability of a type II error increases. The cut-off points set for a particular test determine the magnitudes of both type I and type II errors. Therefore, decreasing the significance level increases the chance of a type I error being made, but decreases the chance of a type II error occurring, and vice versa.

      Understanding these types of errors is crucial in statistical analysis to ensure accurate conclusions are drawn from the data.

    • This question is part of the following fields:

      • Statistics
      6.1
      Seconds
  • Question 27 - A 78-year-old man is referred to rheumatology outpatients with increasing pain in the...

    Correct

    • A 78-year-old man is referred to rheumatology outpatients with increasing pain in the left leg. On examination, the left leg is slightly larger than the right and appears slightly deformed. An X-ray demonstrates cortical expansion and coarsening of trabeculae in keeping with Paget’s disease of bone.
      What is likely to be found on serum biochemistry?

      Your Answer: Raised ALP, normal calcium, normal phosphate

      Explanation:

      Interpreting Blood Test Results for Paget’s Disease and Other Conditions

      Paget’s disease of bone is a chronic disorder that affects bone turnover and can lead to bone pain and deformity. When interpreting blood test results, a raised alkaline phosphatase (ALP) level is a key indicator of Paget’s disease, while normal levels of calcium and phosphate are typical. However, if calcium is raised along with ALP, other conditions such as parathyroid disease or cancer may be the cause. If ALP and calcium are both raised, osteitis fibrosa cystica may be the culprit, while raised levels of all three (ALP, calcium, and phosphate) may indicate vitamin D intoxication or Milk alkali syndrome. Treatment for Paget’s disease typically involves analgesia, with bisphosphonates as a secondary option if needed. It’s important to seek specialist input for proper diagnosis and management.

    • This question is part of the following fields:

      • Clinical Biochemistry
      10.6
      Seconds
  • Question 28 - A 25-year-old man with type I diabetes mellitus visits his General Practitioner (GP)...

    Correct

    • A 25-year-old man with type I diabetes mellitus visits his General Practitioner (GP) with concerns about his deteriorating glycaemic control. The GP suspects poor compliance with diet and medication. What is the most effective approach to enhance his compliance during a brief consultation?

      Your Answer: Motivational interview

      Explanation:

      Effective Psychological Interventions in Primary Care

      Primary care settings are often the first point of contact for patients seeking help for mental health or physical conditions. To provide effective care, healthcare professionals can employ various psychological interventions. Here are some of the most effective ones:

      Motivational Interviewing: This patient-centred approach involves resisting a didactic course of action, understanding the reasons for the change in behaviour, listening to the patient’s ideas, concerns or expectations, and empowering the patient to understand they are able to change their behaviour. It has been proven to increase compliance with medication.

      Cognitive Behavioural Therapy (CBT): This talking therapy explores the patient’s understanding, concepts and reactions towards a certain problem, gradually building behavioural changes to challenge the concepts and manage the problem. It is used predominantly in the treatment of anxiety and depression, but can also be employed in many other mental health or physical conditions.

      Self-Help Materials: Self-help materials in the form of leaflets and aids are a useful tool in the primary care setting, but the patient needs to be motivated for change in order for these to work.

      Psychotherapy: This form of counselling employs various techniques to induce behavioural changes and habits that will stay with the patient in the long term. This requires a set amount of sessions over a period of time and therefore, cannot be performed in a short consultation.

      Supportive Counselling: This psychological intervention has been shown to be best suited for treating mild to moderate depression and can be used in combination with other methods such as CBT.

      By employing these psychological interventions, healthcare professionals can provide effective care for patients seeking help for mental health or physical conditions in primary care settings.

    • This question is part of the following fields:

      • Psychiatry
      11.5
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  • Question 29 - A 26-year-old electrician is instructed to be nil by mouth upon admission with...

    Correct

    • A 26-year-old electrician is instructed to be nil by mouth upon admission with suspected appendicitis, and is prescribed IV fluids to be given before and after the procedure to ensure proper hydration.
      What is the composition of a bag of normal saline 0.9% (in mmol/l)?

      Your Answer: Sodium 154, chloride 154, potassium 0, bicarbonate 0

      Explanation:

      Different Types of Intravenous Solutions and Their Uses

      Intravenous solutions are used in hospitals for various purposes such as rehydration, fluid resuscitation, and management of electrolyte imbalances. Here are some common types of intravenous solutions and their compositions:

      1. 0.9% Normal Saline (NaCl)
      Composition: Sodium 154, Chloride 154, Potassium 0, Bicarbonate 0
      Use: Rehydration and maintenance
      Note: Excessive use can lead to hyperchloraemic acidosis.

      2. 5% Dextrose
      Composition: Sodium 30, Chloride 30, Potassium 0, Bicarbonate Dextrose 50 g
      Use: Treatment of hypoglycaemia or fluid loss without electrolyte imbalance
      Note: Can also be used in the treatment of hyperkalaemia in combination with intravenous insulin.

      3. Hartmann’s Solution
      Composition: Sodium 131, Chloride 111, Potassium 5, Bicarbonate 29, Calcium 2
      Use: Fluid resuscitation in the operative and post-operative period, as well as initial management in injuries
      Note: Use may lead to hyperkalaemia, so its use needs to be monitored.

      4. 10% Dextrose
      Composition: Sodium 30, Chloride 30, Potassium 0, Bicarbonate Dextrose 100 g
      Use: Treatment of hypoglycaemia
      Note: This is a sterile hypertonic solution.

      5. Gelofusin
      Composition: Sodium 154, Chloride 125, Potassium 0
      Use: Volume expander in shock arising from burns or septicaemia, and in the immediate treatment of haemorrhage while awaiting for blood to become available
      Note: This is a colloid solution or plasma substitute containing modified fluid gelatin.

      Intravenous solutions are an essential part of medical treatment, and their appropriate use can help in the management of various medical conditions.

    • This question is part of the following fields:

      • Pharmacology
      89.3
      Seconds
  • Question 30 - A 32-year-old woman presents to the antenatal clinic at 40-weeks gestation for her...

    Incorrect

    • A 32-year-old woman presents to the antenatal clinic at 40-weeks gestation for her first pregnancy. She reports no contractions yet. Upon examination, her abdomen is soft and a palpable uterus indicates a term pregnancy. The cervix is firm and dilated to 1 cm, with the foetal head stationed 1 cm below the ischial spines. The obstetrician performs a membrane sweep and decides to initiate treatment with vaginal prostaglandins. What is the most probable complication of this procedure?

      Your Answer: Cord prolapse

      Correct Answer: Uterine hyperstimulation

      Explanation:

      When inducing labour in a patient who is past her due date, the main complication to watch out for is uterine hyperstimulation. The recommended method for inducing labour according to NICE guidelines is vaginal prostaglandins, which can be administered as a gel, tablet or slow-release pessary. A membrane sweep may also be performed alongside this. Vaginal prostaglandins work by ripening the cervix and stimulating uterine contractions. If uterine hyperstimulation occurs, tocolytic agents can be given to relax the uterus and slow contractions. It’s important to note that a breech presentation is not a complication of induction of labour, especially in cases where the foetus is stationed in the pelvis below the ischial spines. Chorioamnionitis, which is inflammation of the foetal membranes due to bacterial infection, is a risk during prolonged labour and repeated vaginal examinations, but it is not the main complication of induction of labour. Cord prolapse is also a possible complication, but it is more common when the presenting part of the foetus is high, which is not the case in this pregnancy where the foetal head is stationed 1 cm below the ischial spine.

      Induction of labour is a process where labour is artificially started and is required in about 20% of pregnancies. It is indicated in cases of prolonged pregnancy, prelabour premature rupture of the membranes, maternal medical problems, diabetic mother over 38 weeks, pre-eclampsia, obstetric cholestasis, and intrauterine fetal death. The Bishop score is used to assess whether induction of labour is necessary and includes cervical position, consistency, effacement, dilation, and fetal station. A score of less than 5 indicates that labour is unlikely to start without induction, while a score of 8 or more indicates a high chance of spontaneous labour or response to interventions made to induce labour.

      Possible methods of induction include membrane sweep, vaginal prostaglandin E2, oral prostaglandin E1, maternal oxytocin infusion, amniotomy, and cervical ripening balloon. The NICE guidelines recommend vaginal prostaglandins or oral misoprostol if the Bishop score is less than or equal to 6, while amniotomy and an intravenous oxytocin infusion are recommended if the score is greater than 6.

      The main complication of induction of labour is uterine hyperstimulation, which refers to prolonged and frequent uterine contractions that can interrupt blood flow to the intervillous space and result in fetal hypoxemia and acidemia. Uterine rupture is a rare but serious complication. Management includes removing vaginal prostaglandins and stopping the oxytocin infusion if one has been started, and considering tocolysis.

    • This question is part of the following fields:

      • Obstetrics
      4.4
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SESSION STATS - PERFORMANCE PER SPECIALTY

Paediatrics (2/3) 67%
Neurology (2/2) 100%
Endocrinology (1/2) 50%
Gastroenterology (1/3) 33%
Obstetrics (0/4) 0%
Ethics And Legal (2/2) 100%
Medicine (0/1) 0%
Nephrology (1/1) 100%
Plastics (1/1) 100%
Gynaecology (0/1) 0%
Surgery (1/2) 50%
Musculoskeletal (1/2) 50%
Cardiology (1/1) 100%
Infectious Diseases (0/1) 0%
Statistics (0/1) 0%
Clinical Biochemistry (1/1) 100%
Psychiatry (1/1) 100%
Pharmacology (1/1) 100%
Passmed