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  • Question 1 - A 56-year-old man comes to the clinic complaining of severe pain and redness...

    Incorrect

    • A 56-year-old man comes to the clinic complaining of severe pain and redness in his big toe. He appears to be in good health and there are no signs of infection or fever. He has a history of gout and suspects that it has returned. He is currently on a regular dose of allopurinol. What would be the most suitable course of action?

      Your Answer: Stop allopurinol and commence oral steroids

      Correct Answer: Continue allopurinol and commence colchicine

      Explanation:

      Patients with an acute flare of gout who are already on allopurinol treatment should not discontinue it during the attack, as per the current NICE CKS guidance. Colchicine is a suitable option for acute gout treatment, and oral steroids can be used if colchicine or NSAIDs are not tolerated. Hospital review on the same day is not necessary in the absence of septic joint or red flag features. Aspirin is not recommended for gout treatment.

      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
      175
      Seconds
  • Question 2 - A patient in their 60s with severe intermittent claudication undergoes an axillo-bifemoral bypass....

    Incorrect

    • A patient in their 60s with severe intermittent claudication undergoes an axillo-bifemoral bypass. Two days after the operation, they develop pain in the leg. Examination reveals a warm, erythaematous swelling in the groin.
      What complication has occurred?

      Your Answer: Anastomotic aneurysm

      Correct Answer: The graft has become infected

      Explanation:

      Possible Complications of a Graft Procedure

      Graft procedures are commonly performed to improve blood flow in patients with peripheral arterial disease. However, like any surgical intervention, there are potential complications that may arise. One possible complication is an infected graft, which can cause swelling and abscess formation. Another possibility is graft occlusion, which may occur if there is a surgical error and can lead to the recurrence of claudication symptoms. An anastomotic aneurysm is another rare but serious complication that may cause pulsatile swelling. Embolism is more likely to occur in patients with aneurysmal disease and can present with acute limb ischaemia or petechiae. Finally, an anastomotic leak is an extremely rare complication that may cause sudden pain and swelling at the site of the graft. It is important for patients to be aware of these potential complications and to seek medical attention if they experience any concerning symptoms after a graft procedure.

    • This question is part of the following fields:

      • Surgery
      58.2
      Seconds
  • Question 3 - A mother attends her general practice surgery with her 14-year-old daughter. She is...

    Incorrect

    • A mother attends her general practice surgery with her 14-year-old daughter. She is concerned, as her daughter is yet to start menstruating and has not shown any signs of starting puberty. The mother says that her first period was around the age of 17. On examination, the general practitioner notes a lack of physical manifestations of puberty. She is not underweight.
      What is the most likely cause of delayed puberty in this case?

      Your Answer: Hypothyroidism

      Correct Answer: Constitutional delay

      Explanation:

      The most common reason for delayed puberty in women is constitutional delay, which is a normal variation where puberty starts later than usual. This may be due to a family history of late menarche. However, it is important to refer the patient to a specialist for further investigation. Hypogonadotrophic hypogonadism is another cause, which is a result of a deficiency in gonadotrophin-releasing hormone secretion. This can be managed by restoring weight in cases such as athletes, dancers, or anorexia sufferers. Primary gonadal failure is rare and may occur in isolation or as part of chromosomal anomalies. Hormone replacement therapy is the treatment for this condition. Hyperprolactinaemia is a rare cause of primary amenorrhoea, which is caused by high levels of prolactin from a tumour. However, it is unlikely to affect normal development. Hypothyroidism can also cause amenorrhoea, but it is usually accompanied by other symptoms such as cold intolerance, mood changes, and weight gain.

    • This question is part of the following fields:

      • Gynaecology
      13.4
      Seconds
  • Question 4 - As part of the investigation of breathlessness, a 68-year-old patient has spirometry performed....

    Correct

    • As part of the investigation of breathlessness, a 68-year-old patient has spirometry performed. You learn that he spent all his working life in a factory. The following results are available:
      Measured Expected
      FEV1 (L) 2.59 3.46
      FVC (L) 3.16 4.21
      Ratio (%) 82 81
      Which of the following is the most likely cause?

      Your Answer: Asbestosis

      Explanation:

      Possible Respiratory Diagnoses Based on Pulmonary Function Testing Results

      Based on the patient’s age and history of factory work, along with a restrictive defect on pulmonary function testing, asbestosis is the most likely diagnosis. Other possible respiratory diagnoses include allergic bronchopulmonary aspergillosis (ABPA), asthma, emphysema, and bronchiectasis. ABPA and asthma are associated with an obstructive picture on pulmonary function tests, while emphysema and bronchiectasis are also possible differentials based on the history but are associated with an obstructive lung defect. However, it would be unusual for an individual to have their first presentation of asthma at 72 years old. Therefore, a thorough evaluation of the patient’s medical history, physical examination, and additional diagnostic tests may be necessary to confirm the diagnosis.

    • This question is part of the following fields:

      • Respiratory
      30.3
      Seconds
  • Question 5 - A 35-year-old man with HIV disease visits the clinic with complaints of fatigue...

    Correct

    • A 35-year-old man with HIV disease visits the clinic with complaints of fatigue and weakness. His lab results, taken eight weeks apart, are shown below.

      Results 1:
      Hb - 145 g/L
      WBC - 4.0 ×109/L
      Platelets - 70 ×109/L
      CD4 - 120 cells/mm3

      Results 2:
      Hb - 76 g/L
      WBC - 4.3 ×109/L
      Platelets - 200 ×109/L
      CD4 - 250 cells/mm3

      The normal ranges for these values are:
      Hb - 130-180 g/L
      WBC - 4-11 ×109/L
      Platelets - 150-400 ×109/L

      What is the most likely explanation for these results?

      Your Answer: Started highly active antiretroviral therapy

      Explanation:

      HAART and its Effects on CD4 and Platelet Counts

      Treatment with highly active antiretroviral therapy (HAART) has been initiated between the first and second test results. This therapy involves a combination of three or more antiretroviral agents from different classes, including two nucleoside analogues and either a protease inhibitor or a non-nucleoside reverse transcriptase inhibitor. The use of HAART has resulted in an increase in both CD4 count and platelet count.

      However, antiretroviral therapies can also cause anaemia in HIV-positive patients, with zidovudine (AZT) being the most common culprit due to its bone marrow suppression effects. In severe cases, patients may require blood transfusions. Macrocytosis, or the presence of abnormally large red blood cells, is a common finding in patients taking AZT and can be used as an indicator of adherence to therapy.

    • This question is part of the following fields:

      • Infectious Diseases
      24.6
      Seconds
  • Question 6 - What is a true statement about obsessive compulsive disorder (obsessional neurosis)? ...

    Correct

    • What is a true statement about obsessive compulsive disorder (obsessional neurosis)?

      Your Answer: Patients have good insight

      Explanation:

      Obsessional Neurosis and Obsessional Compulsive Disorder

      Obsessional neurosis is a mental disorder characterized by repetitive rituals, irrational fears, and disturbing thoughts that are often not acted upon. Patients with this condition maintain their insight and are aware of their illness, which can lead to depression. On the other hand, obsessional compulsive disorder is a similar condition that typically starts in early adulthood and affects both sexes equally. Patients with this disorder often have above-average intelligence.

      It is important to note that Sigmund Freud’s theory that obsessive compulsive symptoms were caused by rigid toilet-training practices is no longer widely accepted. Despite this, the causes of these disorders are still not fully understood. However, treatment options such as cognitive-behavioral therapy and medication can help manage symptoms and improve the quality of life for those affected. these disorders and seeking appropriate treatment can make a significant difference in the lives of those who suffer from them.

    • This question is part of the following fields:

      • Psychiatry
      11.9
      Seconds
  • Question 7 - A 36-year-old man presents to the emergency department following a fall from a...

    Correct

    • A 36-year-old man presents to the emergency department following a fall from a ladder of approximately 2.5 meters. According to his wife, he lost consciousness for around 30 seconds before regaining it. The paramedics who attended the scene noted that he had vomited once and had a GCS of 14 due to confused speech, which remains the same. Upon examination, he has a laceration on his head, multiple lacerations on his body, and a visibly broken arm. However, his cranial nerve, upper limb, and lower limb neurological examinations are normal. What aspect of his current condition warrants a head CT?

      Your Answer: Loss of consciousness and height of fall

      Explanation:

      A head CT scan is necessary within 8 hours for patients who have experienced a dangerous mechanism of injury, such as falling from a height of 5 stairs or more or more than 1 meter. Additionally, individuals who have lost consciousness and have a dangerous mechanism of injury should also undergo a head CT within 8 hours. A GCS score of under 13 on initial assessment or under 15 two hours after the injury would also indicate the need for a head CT within 1 hour. However, a short period of loss of consciousness alone or loss of consciousness with one episode of vomiting is not an indication for a head CT. Additional risk factors, such as age over 65, bleeding disorder/anticoagulant use, or more than 30 minutes of retrograde amnesia, must also be present for a head CT to be necessary within 8 hours.

      NICE Guidelines for Investigating Head Injuries in Adults

      Head injuries can be serious and require prompt medical attention. The National Institute for Health and Care Excellence (NICE) has provided clear guidelines for healthcare professionals to determine which adult patients need further investigation with a CT head scan. Patients who require immediate CT head scans include those with a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment, suspected open or depressed skull fractures, signs of basal skull fractures, post-traumatic seizures, focal neurological deficits, and more than one episode of vomiting.

      For patients with any loss of consciousness or amnesia since the injury, a CT head scan within 8 hours is recommended for those who are 65 years or older, have a history of bleeding or clotting disorders, experienced a dangerous mechanism of injury, or have more than 30 minutes of retrograde amnesia of events immediately before the head injury. Additionally, patients on warfarin who have sustained a head injury without other indications for a CT head scan should also receive a scan within 8 hours of the injury.

      It is important for healthcare professionals to follow these guidelines to ensure that patients receive appropriate and timely care for their head injuries. By identifying those who require further investigation, healthcare professionals can provide the necessary treatment and support to prevent further complications and improve patient outcomes.

    • This question is part of the following fields:

      • Surgery
      515.4
      Seconds
  • Question 8 - Samantha is a 28-year-old woman who has been diagnosed with epilepsy and is...

    Correct

    • Samantha is a 28-year-old woman who has been diagnosed with epilepsy and is currently taking carbamazepine. She has just given birth to a baby boy and is uncertain about breastfeeding. Samantha is worried that her medication may harm her baby if she continues to breastfeed. What guidance would you offer Samantha regarding her antiepileptic medication and breastfeeding?

      Your Answer: Continue carbamazepine, continue breastfeeding

      Explanation:

      Mothers often have concerns about the use of antiepileptic medication during and after pregnancy, particularly when it comes to breastfeeding. However, according to a comprehensive document released by the Royal College of Obstetricians and Gynaecologists, nearly all antiepileptic drugs are safe to use while breastfeeding. This is because only negligible amounts of the medication are passed to the baby through breast milk, and studies have not shown any negative impact on the child’s cognitive development. Therefore, it is recommended that mothers continue their current antiepileptic regime and are encouraged to breastfeed. It is important to note that stopping the medication without consulting a neurologist can lead to further seizures.

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

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

    • This question is part of the following fields:

      • Obstetrics
      15.1
      Seconds
  • Question 9 - What is the most appropriate description of how furosemide works? ...

    Incorrect

    • What is the most appropriate description of how furosemide works?

      Your Answer: Antagonist of angiotensin 1 receptors

      Correct Answer: Inhibition of NKCC2

      Explanation:

      Loop Diuretics and their Mechanisms of Action

      Loop diuretics are commonly used to treat fluid retention in patients with heart failure, liver cirrhosis, and kidney disease. The primary mechanism of action of loop diuretics is the inhibition of NKCC2, the luminal Na-K-2Cl symporter in the thick ascending limb of the loop of Henle. This inhibition results in increased excretion of sodium, calcium, and magnesium, leading to a reduction in fluid volume. Furosemide is the first choice loop diuretic for the treatment of fluid retention.

      Other diuretics, such as spironolactone, work by blocking aldosterone receptors, resulting in potassium retention and sodium excretion. Angiotensin receptor blockers, on the other hand, work by antagonizing angiotensin 1 receptors. Indapamide’s primary mode of action is by blocking net calcium inflow, while thiazides such as hydrochlorothiazide block the thiazide-sensitive Na Cl co-transporter.

      In summary, loop diuretics are effective in treating fluid retention by inhibiting NKCC2, resulting in increased excretion of sodium, calcium, and magnesium. Other diuretics work through different mechanisms, such as blocking aldosterone receptors or angiotensin 1 receptors. the mechanisms of action of these diuretics is crucial in selecting the appropriate treatment for patients with fluid retention.

    • This question is part of the following fields:

      • Pharmacology
      7.4
      Seconds
  • Question 10 - A 30-year-old man presents to his GP with a fungal nail infection. He...

    Incorrect

    • A 30-year-old man presents to his GP with a fungal nail infection. He has a history of asthma since childhood, which is well-controlled with inhalers. He recently sustained a meniscal injury while playing soccer and has been taking 1 g paracetamol every six hours for the past week. The GP plans to start him on fluconazole 50 mg daily for the fungal nail infection. Before initiating treatment, the GP orders a routine blood panel:

      Haemoglobin: 141 g/L (130-180)
      Mean cell volume: 80.1 fL (80-96)
      White cell count: 5.3 ×109/L (4-11)
      Platelets: 350 ×109/L (150-400)
      Prothrombin time: 11.3 sec (11.5-15.5)
      APTT: 29.9 sec -
      Urea: 4.4 mmol/L (3-7)
      Creatinine: 89 μmol/ (50-100)
      Sodium: 141 mmol/L (137-144)
      Potassium: 4.8 mmol/L (3.5-4.9)
      Total bilirubin: 56 μmol/L (1-22)
      Conjugated bilirubin: 7 μmol/L (0-3.4)
      Unconjugated bilirubin: 48 μmol/L -
      ALP: 90 U/L (40-125)
      ALT: 34 U/L (0-35)
      Gamma GT: 16 U/L (10-85)
      Albumin: 44 g/L (37-49)

      Which medication, if any, will require a dose adjustment based on the results of these blood tests?

      Your Answer: beclomethasone inhaler

      Correct Answer: No dose adjustments are required

      Explanation:

      Gilbert’s Syndrome and the Safety of Common Medications

      Gilbert’s syndrome is a hereditary condition that affects up to 10% of the population. It is characterized by a high level of unconjugated bilirubin in the blood due to reduced activity of the enzyme glucuronyltransferase. While clinical features may be absent, some patients may experience faint jaundice during times of stress or illness. However, Gilbert’s syndrome does not affect life expectancy or increase the risk of liver failure or dysfunction.

      When it comes to medication, fluconazole should be used with caution in patients with existing liver disease as it may cause liver damage. Regular monitoring of liver function tests is recommended, and the drug should be discontinued if evidence of hepatotoxicity develops. Paracetamol is safe in therapeutic doses and does not cause liver damage unless taken in overdose. beclomethasone and salbutamol are also safe to use in patients with hepatic dysfunction.

      In summary, Gilbert’s syndrome and its effects on liver function is important when considering medication safety. While some drugs may require caution or monitoring, many common medications can be safely used in patients with this condition.

    • This question is part of the following fields:

      • Pharmacology
      12.4
      Seconds
  • Question 11 - A 67-year-old woman presents with right-sided pleural effusion. Thoracentesis is performed and the...

    Incorrect

    • A 67-year-old woman presents with right-sided pleural effusion. Thoracentesis is performed and the pleural fluid analysis reveals the following results:
      Pleural fluid Pleural fluid analysis Serum Normal value
      Protein 2.5 g/dl 7.3 g/dl 6-7.8 g/dl
      Lactate dehydrogenase (LDH) 145 IU/l 350 IU/l 100-250 IU/l
      What is the probable diagnosis for this patient?

      Your Answer: Viral pleuritic

      Correct Answer: Heart failure

      Explanation:

      Causes of Transudative and Exudative Pleural Effusions

      Pleural effusion is the accumulation of fluid in the pleural space, which can be classified as transudative or exudative based on Light’s criteria. The most common cause of transudative pleural effusion is congestive heart failure, which can also cause bilateral or unilateral effusions. Other causes of transudative effusions include cirrhosis and nephrotic syndrome. Exudative pleural effusions are typically caused by pneumonia, malignancy, or pleural infections. Nephrotic syndrome can also cause transudative effusions, while breast cancer and viral pleuritis are associated with exudative effusions. Proper identification of the underlying cause is crucial for appropriate management of pleural effusions.

    • This question is part of the following fields:

      • Respiratory
      27.3
      Seconds
  • Question 12 - A 6-month-old girl is brought to the emergency department by her worried father....

    Correct

    • A 6-month-old girl is brought to the emergency department by her worried father. He reports that she has had a low-grade fever and a runny nose for the past week, and in the last few days, she has been struggling to breathe and making grunting noises. He is concerned because she is not eating well and her diapers are not as wet as usual. Upon examination, you observe chest retractions, wheezing, and bilateral inspiratory crackles.
      What is the most suitable treatment for the probable diagnosis?

      Your Answer: Admit for supportive treatment

      Explanation:

      The appropriate action for a child with bronchiolitis is to admit them for supportive treatment, as antibiotics are not necessary. This condition is typically caused by RSV and can be managed with supportive care. However, if the child is experiencing severe respiratory distress and a significant reduction in feeding, they should be admitted to the hospital for treatment. Admitting for IV antibiotics would not be appropriate unless pneumonia or another bacterial infection was suspected. Salbutamol nebulisers are not typically effective for bronchiolitis. Discharging the child home with advice or oral antibiotics would not be appropriate if they are showing signs of potentially serious illness.

      Bronchiolitis is a condition where the bronchioles become inflamed, and it is most commonly caused by respiratory syncytial virus (RSV). This virus is responsible for 75-80% of cases, with other causes including mycoplasma and adenoviruses. Bronchiolitis is most prevalent in infants under one year old, with 90% of cases occurring in those aged 1-9 months. The condition is more serious in premature babies, those with congenital heart disease or cystic fibrosis. Symptoms include coryzal symptoms, dry cough, increasing breathlessness, and wheezing. Hospital admission is often necessary due to feeding difficulties associated with increasing dyspnoea.

      Immediate referral is recommended if the child has apnoea, looks seriously unwell, has severe respiratory distress, central cyanosis, or persistent oxygen saturation of less than 92% when breathing air. Clinicians should consider referral if the child has a respiratory rate of over 60 breaths/minute, difficulty with breastfeeding or inadequate oral fluid intake, or clinical dehydration. Immunofluorescence of nasopharyngeal secretions may show RSV, and management is largely supportive. Humidified oxygen is given via a head box if oxygen saturations are persistently low, and nasogastric feeding may be necessary if children cannot take enough fluid/feed by mouth. Suction may also be used for excessive upper airway secretions. NICE released guidelines on bronchiolitis in 2015 for more information.

    • This question is part of the following fields:

      • Paediatrics
      15.8
      Seconds
  • Question 13 - Liam is a 22-year-old man who has had unprotected sexual intercourse and has...

    Incorrect

    • Liam is a 22-year-old man who has had unprotected sexual intercourse and has taken levonorgestrel 2 hours ago. He has vomited once since and is uncertain about what to do next. What is the most crucial advice to give Liam regarding his risk of pregnancy?

      Your Answer: Reassure Zoe that levonorgestrel will prevent pregnancy and no further action is required

      Correct Answer: Take a second dose of levonorgestrel as soon as possible

      Explanation:

      If a patient vomits within 3 hours of taking levonorgestrel, it is recommended to prescribe a second dose of emergency hormonal contraception to be taken as soon as possible, according to NICE guidelines. Therefore, reassuring Zoe that she is protected from pregnancy is incorrect as she needs to take another dose. Additionally, while it may be advisable for Zoe to start a regular form of contraception, this is not the most important advice to give initially. Instead, she should be offered choices of contraception, including long-acting reversible contraceptives. It is also incorrect to recommend other forms of emergency contraception, such as ulipristal acetate and the IUD, as Zoe has already taken levonorgestrel and the guidelines are clear that a second dose of this should be taken in this circumstance. However, if Zoe experiences persistent vomiting or diarrhea for more than 24 hours after taking emergency hormonal contraception, then the IUD may be offered.

      Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.

    • This question is part of the following fields:

      • Gynaecology
      9.9
      Seconds
  • Question 14 - You are the on-call general practitioner and are called urgently to the nurses’...

    Incorrect

    • You are the on-call general practitioner and are called urgently to the nurses’ room where a 6-year-old boy receiving his school vaccinations has developed breathing difficulties. The child has swollen lips and is covered in a blotchy rash; respiratory rate is 40, heart rate is 140 and there is a wheeze audible without using a stethoscope.
      After lying the patient flat and raising his legs, what immediate action is required?

      Your Answer: Administer 1 mg of adrenaline im

      Correct Answer: Administer 150 micrograms of adrenaline intramuscularly (im)

      Explanation:

      Anaphylaxis Management: Administering Adrenaline

      Anaphylaxis is a severe and life-threatening hypersensitivity reaction that requires immediate management. The Resuscitation Council guidelines outline three essential criteria for recognizing anaphylaxis: sudden-onset, rapidly progressive symptoms, life-threatening Airway/Breathing/Circulation problems, and skin and mucosal changes.

      The first step in anaphylaxis management is to administer adrenaline intramuscularly (im) at a dilution of 1:1000. The appropriate dosage for adrenaline administration varies based on the patient’s age. For a 4-year-old patient, the recommended dose is 150 micrograms im. However, adrenaline iv should only be administered by experienced specialists and is given at a dose of 50 micrograms in adults and 1 microgram/kg in children and titrated accordingly.

      Adrenaline administration is only the first step in the treatment of anaphylaxis. It is crucial to follow the anaphylaxis algorithm, which includes establishing the airway and giving high-flow oxygen, iv fluid challenge, and chlorphenamine.

      It is essential to note that administering an incorrect dose of adrenaline can be dangerous. For instance, administering 1 mg of adrenaline im is inappropriate for the management of anaphylaxis. Therefore, it is crucial to follow the Resuscitation Council guidelines and administer the appropriate dose of adrenaline based on the patient’s age.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
      17.3
      Seconds
  • Question 15 - A 32-year-old female complains of fatigue and frequent headaches. During the swinging light...

    Incorrect

    • A 32-year-old female complains of fatigue and frequent headaches. During the swinging light test, an abnormality is noticed in her eyes. Both pupils appear to dilate as the light is moved from the left to the right eye. However, the pupillary response to accommodation is normal bilaterally. Fundoscopy also reveals normal findings bilaterally. The patient has a medical history of type one diabetes and hypertension. What is the probable cause of this patient's symptoms?

      Your Answer: Argyll Robertson pupil on the right

      Correct Answer: Marcus-Gunn Pupil (relative afferent pupillary defect) on the right

      Explanation:

      The swinging light test can diagnose Marcus Gunn pupil (also known as relative afferent pupillary defect). If there is damage to the afferent pathway (retina or optic nerve) of one eye, the affected eye’s pupil will abnormally dilate when a light is shone into it because the healthy eye’s consensual pupillary relaxation response will dominate. This condition can be found in patients with multiple sclerosis, so it should be ruled out in this patient based on the history. However, the history and examination findings do not suggest raised intracranial pressure, which typically presents with symptoms such as a headache, vomiting, bilateral blurred vision, and seizures, and often shows bilateral papilloedema on fundoscopy. Although the patient is diabetic, diabetic eye disease typically does not affect pupillary light responses, and some abnormality on fundoscopy would be expected. The information provided does not match Holmes-Aide’s pupil, which is a dilated pupil that poorly reacts to direct light but slowly reacts to accommodation. The history also does not suggest Argyll Robertson pupil, which is characterised by a constricted pupil that does not respond to light but responds to accommodation and is often associated with neurosyphilis.

      Understanding Relative Afferent Pupillary Defect

      A relative afferent pupillary defect, also known as the Marcus-Gunn pupil, is a condition that can be identified through the swinging light test. This condition is caused by a lesion that is located anterior to the optic chiasm, which can be found in the optic nerve or retina.

      When conducting the swinging light test, the affected eye will appear to dilate when light is shone on it, while the normal eye will not. This is due to the fact that the afferent pathway of the pupillary light reflex is disrupted. The pathway starts from the retina, then goes through the optic nerve, lateral geniculate body, and midbrain. The efferent pathway, on the other hand, starts from the Edinger-Westphal nucleus in the midbrain and goes through the oculomotor nerve.

      There are various causes of relative afferent pupillary defect, such as retina detachment and optic neuritis, which is commonly associated with multiple sclerosis. Understanding this condition is important in diagnosing and treating patients who may be experiencing vision problems.

    • This question is part of the following fields:

      • Ophthalmology
      17.9
      Seconds
  • Question 16 - On a set of MRI scans being examined for a 21-year-old woman suspected...

    Correct

    • On a set of MRI scans being examined for a 21-year-old woman suspected of having Cushing syndrome due to weight gain and excess facial hair, which structure would be found posterior to the left suprarenal (adrenal) gland?

      Your Answer: Crus of diaphragm

      Explanation:

      Anatomy of the Posterior Abdominal Wall

      The posterior abdominal wall is a complex structure consisting of various muscles, fascia, and organs. Here are some key components:

      Crus of Diaphragm: The left suprarenal (adrenal) gland is located in the posterior abdomen and is enclosed by the perirenal fascia, which attaches it to the left crus of the diaphragm. The left crus is a tendinous structure arising from the anterior bodies of the L1 and L2 vertebrae.

      Psoas Major Muscle: This muscle is responsible for the lateral flexion of the lumbar spine and assists in the stabilization and flexion of the hip. It is found in the posterior abdomen, bound by fascia.

      Quadratus Lumborum Muscle: This quadrilateral muscle is associated with the lateral flexion and extension of the vertebral column. It is located posteriorly to the colon, kidney, psoas muscle, and diaphragm.

      Transversus Abdominis Muscle: This is the innermost muscle forming the anterior abdominal muscles, lying posterior to the internal oblique and anterior to the transversalis fascia.

      Thoracolumbar Fascia: This diamond-shaped fascia encloses the intrinsic muscles of the back and is affected in piriformis syndrome and sacro-iliac joint pains. It is not anatomically associated with the adrenal glands.

      Understanding the Posterior Abdominal Wall Anatomy

    • This question is part of the following fields:

      • Endocrinology
      12
      Seconds
  • Question 17 - A 35-year-old man with acquired immune deficiency syndrome (AIDS) presents to the Emergency...

    Incorrect

    • A 35-year-old man with acquired immune deficiency syndrome (AIDS) presents to the Emergency Department with fever, dyspnea, and overall feeling unwell. The attending physician suspects Pneumocystis jirovecii pneumonia. What is the most characteristic clinical feature of this condition?

      Your Answer: An obstructive pattern of pulmonary function tests (PFTs)

      Correct Answer: Desaturation on exercise

      Explanation:

      Understanding Pneumocystis jirovecii Pneumonia: Symptoms and Diagnosis

      Pneumocystis jirovecii pneumonia is a fungal infection that affects the lungs. While it is rare in healthy individuals, it is a significant concern for those with weakened immune systems, such as AIDS patients, organ transplant recipients, and individuals undergoing certain types of therapy. Here are some key symptoms and diagnostic features of this condition:

      Desaturation on exercise: One of the hallmark symptoms of P. jirovecii pneumonia is a drop in oxygen levels during physical activity. This can be measured using pulse oximetry before and after walking up and down a hallway.

      Cavitating lesions on chest X-ray: While a plain chest X-ray may show diffuse interstitial opacification, P. jirovecii pneumonia can also present as pulmonary nodules that cavitate. High-resolution computerised tomography (HRCT) is the preferred imaging modality.

      Absence of cervical lymphadenopathy: Unlike some other respiratory infections, P. jirovecii pneumonia typically does not cause swelling of the lymph nodes in the neck.

      Non-productive cough: Patients with P. jirovecii pneumonia may experience a dry, non-productive cough due to the thick, viscous nature of the secretions in the lungs.

      Normal pulmonary function tests: P. jirovecii pneumonia does not typically cause an obstructive pattern on pulmonary function tests.

      By understanding these symptoms and diagnostic features, healthcare providers can more effectively diagnose and treat P. jirovecii pneumonia in at-risk patients.

    • This question is part of the following fields:

      • Respiratory
      13.4
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  • Question 18 - A 65-year-old man, who is taking long-term warfarin for atrial fibrillation, comes to...

    Correct

    • A 65-year-old man, who is taking long-term warfarin for atrial fibrillation, comes to the surgery for review. He has had a recent review at the Cardiology Clinic and you understand that he has had some of his long-term medication changed. He also has type II diabetes and has recently been started on medication for neuropathy. In addition, he is following a ‘juicing diet’ to lose weight.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 131 g/l 135–175 g/l
      White cell count (WCC) 5.7 × 109/l 4–11 × 109/l
      Platelets 201 × 109/l 150–400 × 109/l
      Sodium (Na+) 139 mmol/l 135–145 mmol/l
      Potassium (K+) 4.9 mmol/l 3.5–5.0 mmol/l
      Creatinine 115 µmol/l 50–120 µmol/l
      International normalised ratio (INR) 4.9 (previously 2.1)
      Which one of the following medications/dietary changes is most likely to be responsible?

      Your Answer: Grapefruit juice

      Explanation:

      Drug Interactions with Warfarin: Effects of Grapefruit Juice, Amlodipine, Bisoprolol, Orange Juice, and Carbamazepine on INR

      Warfarin is a commonly prescribed anticoagulant medication that requires careful monitoring of the international normalized ratio (INR) to ensure therapeutic efficacy and prevent adverse events. However, certain drugs, herbal products, and foods can interact with warfarin and affect its metabolism, leading to changes in INR levels.

      Grapefruit juice and cranberry juice are known inhibitors of the cytochrome p450 enzyme system, which is responsible for metabolizing warfarin. As a result, these juices can downregulate warfarin metabolism and increase INR levels in some patients. On the other hand, orange juice has no effect on warfarin metabolism.

      Amlodipine and bisoprolol are two commonly prescribed medications that do not affect INR levels. However, they may cause side effects such as dizziness, fatigue, and gastrointestinal disturbances.

      Carbamazepine, a medication used to treat seizures and neuropathic pain, is a cytochrome p450 enzyme inducer. This means that it can increase the metabolism of warfarin and lead to a fall in INR levels. Therefore, clinicians must monitor INR levels closely when prescribing carbamazepine to patients taking warfarin.

      In summary, understanding the potential drug interactions with warfarin is crucial for clinicians to ensure safe and effective treatment. Regular monitoring of INR levels is essential when prescribing medications that may interact with warfarin.

    • This question is part of the following fields:

      • Pharmacology
      13.3
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  • Question 19 - A 51-year-old man with schizoaffective disorder has been stabilized on haloperidol for the...

    Correct

    • A 51-year-old man with schizoaffective disorder has been stabilized on haloperidol for the past 13 years. He expresses concern about a medication side-effect that began approximately two years ago but has worsened over time, despite taking breaks from the medication for up to three months. He describes involuntary facial movements such as lip smacking and excessive blinking. Assuming the patient is not on any other medications, what is the most probable issue he is experiencing?

      Your Answer: Tardive dyskinesia

      Explanation:

      Common Movement Disorders Caused by Medications

      Medications used to treat various conditions can sometimes cause movement disorders as side effects. Here are some common movement disorders caused by medications:

      1. Tardive dyskinesia: This is a largely irreversible side effect of long-term anti-psychotic therapy, resulting in stereotyped oral-facial movements such as lip smacking, grimacing, tongue movements, or excessive blinking.

      2. Akinesia: This is the inability to initiate movement, feeling locked in and frozen.

      3. Acute dystonia: This is a sudden-onset muscle contraction that causes abnormal posturing or twisting. It can be very painful and occurs very quickly after ingestion.

      4. Akathisia: This is restlessness secondary to an inner feeling of angst or stress if sitting still. In Greek, it literally means can’t sit still.

      5. Chorea: This may be caused by adverse effects of drug treatments, especially medications for Parkinson’s disease, epilepsy, and schizophrenia. There can be involuntary writhing, jerking, or dancing movements often of the hands or feet.

      Common Movement Disorders Caused by Medications

    • This question is part of the following fields:

      • Pharmacology
      14.1
      Seconds
  • Question 20 - Which blood test is the most sensitive for diagnosing acute pancreatitis? ...

    Correct

    • Which blood test is the most sensitive for diagnosing acute pancreatitis?

      Your Answer: Lipase

      Explanation:

      If the clinical presentation does not match the amylase level, it is important to consider that the serum amylase can fluctuate rapidly and produce an inaccurate negative result. In such cases, it is recommended to conduct a serum lipase test or a CT scan.

      Understanding Acute Pancreatitis

      Acute pancreatitis is a condition that is commonly caused by alcohol or gallstones. It occurs when the pancreatic enzymes start to digest the pancreatic tissue, leading to necrosis. The main symptom of acute pancreatitis is severe epigastric pain that may radiate through to the back. Vomiting is also common, and examination may reveal epigastric tenderness, ileus, and low-grade fever. In rare cases, periumbilical discolouration (Cullen’s sign) and flank discolouration (Grey-Turner’s sign) may be present.

      To diagnose acute pancreatitis, doctors typically measure the levels of serum amylase and lipase in the blood. While amylase is raised in 75% of patients, it does not correlate with disease severity. Lipase, on the other hand, is more sensitive and specific than amylase and has a longer half-life. Imaging tests, such as ultrasound and contrast-enhanced CT, may also be used to assess the aetiology of the condition.

      Scoring systems, such as the Ranson score, Glasgow score, and APACHE II, are used to identify cases of severe pancreatitis that may require intensive care management. Factors that indicate severe pancreatitis include age over 55 years, hypocalcaemia, hyperglycaemia, hypoxia, neutrophilia, and elevated LDH and AST. It is important to note that the actual amylase level is not of prognostic value.

      In summary, acute pancreatitis is a condition that can cause severe pain and discomfort. It is typically caused by alcohol or gallstones and can be diagnosed through blood tests and imaging. Scoring systems are used to identify cases of severe pancreatitis that require intensive care management.

    • This question is part of the following fields:

      • Surgery
      3.4
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  • Question 21 - A 29-year-old woman presents to her GP seeking guidance on conception, specifically regarding...

    Incorrect

    • A 29-year-old woman presents to her GP seeking guidance on conception, specifically regarding the use of supplements or medication. She has no significant medical or family history and has previously given birth to two healthy children in the past three years without complications. Upon examination, she appears to be in good health, with a BMI of 31 kg/m2. What is the most suitable course of action for this patient?

      Your Answer: 400mcg of folic acid

      Correct Answer: 5mg of folic acid

      Explanation:

      Pregnant women with a BMI greater than 30 kg/m2 should be prescribed a high dose of 5mg folic acid instead of the standard 400 micrograms. Therefore, the lifestyle and dietary advice given to this patient is incorrect. Additionally, prescribing 75 mg of aspirin is not appropriate for this patient as it is typically given to women with one high-risk factor or two moderate-risk factors for pre-eclampsia, and a BMI over 35 would only qualify as a single moderate-risk factor. While 150 mg of aspirin is an alternative dose for pre-eclampsia prophylaxis, 75 mg is more commonly used in practice.

      Folic Acid: Importance, Deficiency, and Prevention

      Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

      To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.

      In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.

    • This question is part of the following fields:

      • Gynaecology
      12.9
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  • Question 22 - An older gentleman with prostate cancer is beginning treatment with morphine elixir for...

    Correct

    • An older gentleman with prostate cancer is beginning treatment with morphine elixir for painful bone metastases. What would be the most suitable advice to give to his caregiver?

      Your Answer: A laxative will need to be used

      Explanation:

      Managing Pain in Terminally Ill Patients

      Managing pain in terminally ill patients can be challenging, but there are several strategies that can be employed to provide relief. When prescribing narcotics, it is important to start a laxative regimen to prevent constipation. Sedation may occur in the first few days, but this typically wears off. If pain relief is inadequate, the dose should be increased, although it is important to note that cocaine may produce hallucinations. It is also important to note that addiction is not a concern in terminally ill patients. Injections are typically three times more effective than oral medication. By employing these strategies, healthcare providers can help alleviate pain and improve the quality of life for terminally ill patients.

    • This question is part of the following fields:

      • Oncology
      14
      Seconds
  • Question 23 - Liam is an 8-year-old boy brought in by his father with a 2...

    Incorrect

    • Liam is an 8-year-old boy brought in by his father with a 2 day history of fever and sore throat. Today he has developed a rash on his torso. He is eating and drinking well, but has not been to school for the last 2 days and has been feeling tired.

      On examination, Liam is alert, smiling and playful. He has a temperature of 37.8°C. His throat appears red with petechiae on the hard and soft palate and his tongue is covered with a white coat through which red papillae are visible. There is a blanching rash present on his trunk which is red and punctate with a rough, sandpaper-like texture.

      What is the appropriate time for Liam to return to school, given the most likely diagnosis?

      Your Answer: 48 hours after commencing antibiotics

      Correct Answer: 24 hours after commencing antibiotics

      Explanation:

      If a child has scarlet fever, they can go back to school after 24 hours of starting antibiotics. The symptoms described are typical of scarlet fever, including a strawberry tongue and a rough-textured rash with small red spots on the palate called Forchheimer spots. Charlotte doesn’t need to be hospitalized but should take a 10-day course of phenoxymethylpenicillin (penicillin V). According to NICE, the child should stay away from school, nursery, or work for at least 24 hours after starting antibiotics. It’s also important to advise parents to take measures to prevent cross-infection, such as frequent handwashing, avoiding sharing utensils and towels, and disposing of tissues promptly.

      Scarlet fever is a condition caused by erythrogenic toxins produced by Group A haemolytic streptococci, usually Streptococcus pyogenes. It is more prevalent in children aged 2-6 years, with the highest incidence at 4 years. The disease spreads through respiratory droplets or direct contact with nose and throat discharges, especially during sneezing and coughing. The incubation period is 2-4 days, and symptoms include fever, malaise, headache, nausea/vomiting, sore throat, ‘strawberry’ tongue, and a rash that appears first on the torso and spares the palms and soles. The rash has a rough ‘sandpaper’ texture and desquamation occurs later in the course of the illness, particularly around the fingers and toes.

      To diagnose scarlet fever, a throat swab is usually taken, but antibiotic treatment should be initiated immediately, rather than waiting for the results. Management involves administering oral penicillin V for ten days, while patients with a penicillin allergy should be given azithromycin. Children can return to school 24 hours after commencing antibiotics, and scarlet fever is a notifiable disease. Although usually a mild illness, scarlet fever may be complicated by otitis media, rheumatic fever, acute glomerulonephritis, or rare invasive complications such as bacteraemia, meningitis, or necrotizing fasciitis, which may present acutely with life-threatening illness.

    • This question is part of the following fields:

      • Paediatrics
      18.1
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  • Question 24 - A 28-year-old woman presents with a 48-hour history of headache and malaise that...

    Correct

    • A 28-year-old woman presents with a 48-hour history of headache and malaise that has worsened in the last 6 hours. She has vomited twice and recently had a sore throat. Her general practitioner has been treating her with a topical anti-fungal cream for vaginal thrush. On examination, she is photophobic and has moderate neck stiffness. The Glasgow Coma Score is 15/15, and she has no focal neurological signs. Her temperature is 38.5 °C. A computed tomography (CT) brain scan is reported as ‘Normal intracranial appearances’. A lumbar puncture is performed and CSF results are as follows: CSF protein 0.6 g/l (<0.45), cell count 98 white cells/mm3, mainly lymphocytes (<5), CSF glucose 2.8 mmol/l (2.5 – 4.4 mmol/l), and blood glucose 4.3 mmol/l (3-6 mmol/l). What is the most likely diagnosis?

      Your Answer: Acute viral meningitis

      Explanation:

      Distinguishing Acute Viral Meningitis from Other Neurological Disorders

      Acute viral meningitis is characterized by mild elevation of protein, a mainly lymphocytic cellular reaction, and a CSF: blood glucose ratio of >50%. In contrast, bacterial meningitis presents with a polymorph leukocytosis, lower relative glucose level, and more severe signs of meningism. Tuberculous meningitis typically presents subacutely with very high CSF protein and very low CSF glucose. Fungal meningitis is rare and mainly occurs in immunocompromised individuals. Guillain–Barré syndrome, an autoimmune peripheral nerve disorder causing ascending paralysis, is often triggered by a recent viral illness but presents with focal neurological signs, which are absent in viral meningitis. Accurate diagnosis is crucial for appropriate treatment and management.

    • This question is part of the following fields:

      • Neurology
      26.9
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  • Question 25 - A 50-year-old woman visits her doctor with new symptoms of flushing, severe insomnia,...

    Incorrect

    • A 50-year-old woman visits her doctor with new symptoms of flushing, severe insomnia, and headaches. She has a medical history of asthma and a spontaneous deep vein thrombosis. These symptoms are affecting her daily routine, and she has not had her period for 12 months. After discussing the benefits and risks of hormonal replacement therapy, they decide to start treatment. What is the most suitable hormonal replacement therapy regimen for this patient?

      Your Answer: Oral estradiol and levonorgestrel-releasing intrauterine system

      Correct Answer: Transdermal estradiol and levonorgestrel

      Explanation:

      For women at risk of venous thromboembolism, transdermal HRT is the recommended option. In the case of a patient presenting with severe menopausal symptoms such as flushing, insomnia, and headaches, hormonal replacement therapy (HRT) may be prescribed after weighing the benefits and risks.

      If the patient has a uterus, oral estradiol only should not be prescribed as it can cause endometrial hyperplasia and increase the risk of malignancy. Oral estradiol and levonorgestrel are a common combination for HRT, but in the case of a patient with a history of deep vein thrombosis, transdermal delivery is a more appropriate option as it does not increase the risk of developing a new clot compared to oral options.

      The levonorgestrel-releasing intrauterine system can also be prescribed as HRT, but in this case, transdermal delivery is still the preferred option due to the patient’s medical history. Oral levonorgestrel alone is not used as HRT as it does not address the lack of estrogen that causes menopausal symptoms.

      Hormone replacement therapy (HRT) involves a small dose of oestrogen and progesterone to alleviate menopausal symptoms. The indications for HRT have changed due to the long-term risks, and it is primarily used for vasomotor symptoms and preventing osteoporosis in younger women. HRT consists of natural oestrogens and synthetic progestogens, and can be taken orally or transdermally. Transdermal is preferred for women at risk of venous thromboembolism.

    • This question is part of the following fields:

      • Pharmacology
      9.2
      Seconds
  • Question 26 - A 65-year-old man visited the dermatology clinic in the summer with a rash...

    Incorrect

    • A 65-year-old man visited the dermatology clinic in the summer with a rash on his forearms, shins, and face. Which medication is most likely to be linked with this photosensitive rash?

      Your Answer: Clopidogrel

      Correct Answer: Bendroflumethiazide

      Explanation:

      Adverse Effects of Cardiology Drugs

      Photosensitivity is a frequently observed negative reaction to certain cardiology drugs, such as amiodarone and thiazide diuretics. This means that patients taking these medications may experience an increased sensitivity to sunlight, resulting in skin rashes or other skin-related issues. Additionally, ACE inhibitors and A2RBs, which are commonly prescribed for cardiovascular conditions, have been known to cause rashes that may also be photosensitive. It is important for patients to be aware of these potential side effects and to take necessary precautions, such as wearing protective clothing and using sunscreen, when exposed to sunlight.

    • This question is part of the following fields:

      • Cardiology
      5.6
      Seconds
  • Question 27 - A 70-year-old man presents with fatigue, pallor and shortness of breath. He has...

    Incorrect

    • A 70-year-old man presents with fatigue, pallor and shortness of breath. He has been battling with an indolent colon carcinoma for the past 5 years. He also suffers from insulin-dependent diabetes, hypertension, coronary artery disease and rheumatoid arthritis. He has been feeling unwell for the past few weeks. He denies any history of melaena or haematochezia and has been amenorrhoeic for decades. A bedside stool guaiac test is negative for any blood in the stool. He is well nourished, reports taking daily supplements and is not a vegetarian. He reports that his haematocrit is 0.28 (0.35–0.55) and haemoglobin level 100 g/l (115–155 g/l).
      What additional findings would you expect to observe in his full blood count?

      Your Answer: Reticulocytosis

      Correct Answer: Increased ferritin

      Explanation:

      Understanding Anaemia of Chronic Disease: Increased Ferritin and Decreased TIBC

      Anaemia of chronic disease is a type of anaemia that is commonly seen in patients with chronic inflammatory conditions. It is characterised by a low haemoglobin level and low haematocrit, but unlike iron deficiency anaemia, it is associated with increased ferritin levels and decreased total iron-binding capacity (TIBC). This is because ferritin is a serum reactive protein that is elevated in response to the underlying inflammatory process.

      Diagnosis of anaemia of chronic disease requires the presence of a chronic inflammatory condition and anaemia, which can be either normocytic or microcytic. It is important to note that a haemoglobin level of <80 g/l is very rarely associated with this type of anaemia. Treatment involves addressing the underlying disorder causing the anaemia and monitoring the haemoglobin level. Blood transfusion is only used in severe cases. It is important to differentiate anaemia of chronic disease from other types of anaemia. For example, it is characterised by a low reticulocyte count, and not reticulocytosis. Serum transferrin receptor is not affected in anaemia of chronic disease and would therefore be normal. Additionally, TIBC is reduced in anaemia of chronic disease, whereas it is increased in iron deficiency anaemia. Finally, anaemia of chronic disease is associated with either microcytosis or normocytosis, whereas macrocytosis is associated with other types of anaemia such as folate deficiency, vitamin B12 deficiency, alcohol excess, and myelodysplastic disease. In summary, understanding the unique features of anaemia of chronic disease, such as increased ferritin and decreased TIBC, can aid in its diagnosis and management.

    • This question is part of the following fields:

      • Haematology
      18.7
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  • Question 28 - A 32-year-old primiparous woman with type 1 diabetes mellitus is at 12 weeks’...

    Correct

    • A 32-year-old primiparous woman with type 1 diabetes mellitus is at 12 weeks’ gestation and attended for her nuchal scan. She is currently on insulin treatment. Her HbA1c at booking was 34 mmol/mol (recommended at pregnancy < 48 mmol/mol).
      What is the most appropriate antenatal care for pregnant women with pre-existing diabetes?

      Your Answer: Women with diabetes should be seen in the Joint Diabetes and Antenatal Clinic every one to two weeks throughout their pregnancy

      Explanation:

      Guidelines for Managing Diabetes in Pregnancy

      Managing diabetes in pregnancy requires close monitoring to reduce the risk of maternal and fetal complications. The National Institute for Health and Care Excellence (NICE) has provided guidelines for healthcare professionals to follow when caring for women with diabetes during pregnancy.

      Joint Diabetes and Antenatal Clinic Visits

      Women with diabetes should be seen in a Joint Diabetes and Antenatal Clinic every one to two weeks throughout their pregnancy. This ensures that any problems are addressed promptly and appropriately.

      Serial Fetal Scanning

      Women with diabetes should be offered serial fetal scanning from 26 weeks’ gestation every four weeks. This helps to monitor and prevent complications such as macrosomia, polyhydramnios, stillbirth, and congenital anomalies.

      Delivery by Induction of Labour or Caesarean Section

      Women with diabetes should be advised to deliver by induction of labour or Caesarean section between 38 and 39+6 weeks’ gestation. This is because diabetes is associated with an increased risk of stillbirth, and the risk is managed by inducing labour when the pregnancy reaches term.

      Induction at 41+6 Weeks’ Gestation

      Women with diabetes who do not opt for an elective induction or a Caesarean section between 37+0 to 38+6 weeks’ gestation and wish to await spontaneous labour should be warned of the risks of stillbirth and neonatal complications. In cases of prolonged pregnancy, the patient should be offered induction by, at most, 40+6 weeks’ gestation.

      Retinal Assessment

      All women with pre-existing diabetes should be offered retinal assessment at 16–20 weeks’ gestation. If initial screening is normal, then they are offered a second retinal screening test at 28 weeks’ gestation. If the booking retinal screening is abnormal, then a repeat retinal screening test is offered to these women earlier than 28 weeks, usually between 16 and 20 weeks’ gestation.

    • This question is part of the following fields:

      • Obstetrics
      34.3
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  • Question 29 - A 29-year-old man is admitted to a psychiatry ward from the emergency department....

    Correct

    • A 29-year-old man is admitted to a psychiatry ward from the emergency department. He was brought by a concerned family member who was worried by his recent behaviour. He had been engaging in large amounts of shopping, spending nearly every night at the mall and hardly sleeping. When asked if he understands the risks of overspending, he is convinced that nothing can go wrong. He struggles to focus on the topic and begins rambling about buying various different items that are sure to make him happy. A diagnosis of a manic episode is made and he is stabilised on treatment with quetiapine. Subsequently it is decided to initiate lithium to maintain his mood.
      When should his serum lithium levels next be monitored?

      Your Answer: 1 week - 12 hours after last dose

      Explanation:

      To prevent future manic episodes, this patient with an acute manic episode can be prescribed lithium as a prophylactic mood stabilizer. When starting or changing the dose of lithium, weekly monitoring of lithium levels is necessary, with samples taken 12 hours after the last dose. After treatment is established, monitoring frequency can be reduced to every 3 months, with samples still taken 12 hours after the last dose. Additionally, U&E and TFTs should be monitored every 6 months after starting treatment.

      Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in treatment-resistant depression. It has a narrow therapeutic range of 0.4-1.0 mmol/L and is primarily excreted by the kidneys. The mechanism of action is not fully understood, but it is believed to interfere with inositol triphosphate and cAMP formation. Adverse effects may include nausea, vomiting, diarrhea, fine tremors, nephrotoxicity, thyroid enlargement, ECG changes, weight gain, idiopathic intracranial hypertension, leucocytosis, hyperparathyroidism, and hypercalcemia.

      Monitoring of patients taking lithium is crucial to prevent adverse effects and ensure therapeutic levels. It is recommended to check lithium levels 12 hours after the last dose and weekly after starting or changing the dose until levels are stable. Once established, lithium levels should be checked every three months. Thyroid and renal function should be monitored every six months. Patients should be provided with an information booklet, alert card, and record book to ensure proper management of their medication. Inadequate monitoring of patients taking lithium is common, and guidelines have been issued to address this issue.

    • This question is part of the following fields:

      • Psychiatry
      22.1
      Seconds
  • Question 30 - Which statement about nail changes is accurate? ...

    Correct

    • Which statement about nail changes is accurate?

      Your Answer: Ridges in the nails may be seen in psoriasis

      Explanation:

      Common Nail Changes and Their Causes

      Nail changes can be a sign of underlying health conditions. Here are some common nail changes and their causes:

      Psoriasis: Ridges, pits, and onycholysis (separation of the nail from the nail bed) are features of psoriasis.

      Splinter haemorrhages: Although splinter haemorrhages occur in bacterial endocarditis, trauma is the most common cause. They can also be associated with rheumatoid arthritis, scleroderma, systemic lupus erythematosus, and psoriasis.

      White nails: White nails are a feature of hypoalbuminaemia.

      Koilonychia: Iron deficiency causes koilonychia and may cause onycholysis. Vitamin B12 deficiency does not cause nail changes.

      Clubbing: Ischaemic heart disease does not cause clubbing.

    • This question is part of the following fields:

      • Dermatology
      13.7
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SESSION STATS - PERFORMANCE PER SPECIALTY

Musculoskeletal (0/1) 0%
Surgery (2/3) 67%
Gynaecology (0/3) 0%
Respiratory (1/3) 33%
Infectious Diseases (1/1) 100%
Psychiatry (2/2) 100%
Obstetrics (2/2) 100%
Pharmacology (2/5) 40%
Paediatrics (1/2) 50%
Acute Medicine And Intensive Care (0/1) 0%
Ophthalmology (0/1) 0%
Endocrinology (1/1) 100%
Oncology (1/1) 100%
Neurology (1/1) 100%
Cardiology (0/1) 0%
Haematology (0/1) 0%
Dermatology (1/1) 100%
Passmed