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Question 1
Correct
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You see a 65-year-old gentleman who was diagnosed with heart failure and an ejection fraction of 35%. He is currently on the maximum tolerated dose of an ACE-I and beta blocker. He reports to still be symptomatic from his heart failure.
What would be the next appropriate step in his management to improve his prognosis?Your Answer: Refer to a heart failure specialist as no other drugs should be prescribed in primary care
Explanation:MRA Treatment for Heart Failure Patients
According to NICE guidelines, patients with heart failure and a reduced ejection fraction who continue to experience symptoms of heart failure should be offered an MRA such as spironolactone or eplerenone. Previously, only a heart failure specialist could initiate these treatments. However, now it is recommended that all healthcare professionals involved in the care of heart failure patients should consider offering these treatments to improve symptoms and reduce the risk of hospitalization. This guideline update aims to ensure that more patients have access to effective treatments for heart failure.
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This question is part of the following fields:
- Cardiovascular Health
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Question 2
Correct
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A 32 year old woman who is 15 days postpartum visits your clinic complaining of feeling feverish and hot for the past 3 days. She reports having a painful, swollen, and red right breast. During examination, her temperature is 37.8 degrees, and there is firmness and erythema in the upper quadrant of the right breast. Based on the diagnosis of puerperal mastitis, what is the most appropriate advice to provide her?
Your Answer: Advise her to continue Breastfeeding
Explanation:Mastitis is a common condition that affects breastfeeding women, typically occurring six weeks after giving birth. It can be difficult to distinguish between an engorged breast, blocked duct, non-infectious mastitis, and infected mastitis. Milk accumulation in breast tissue can cause an inflammatory response, leading to bacterial growth and resulting in a painful breast with fever, malaise, and a tender, red, swollen, and hard area of the breast.
If symptoms do not improve or worsen after 12-24 hours despite effective milk removal, or if a nipple fissure is infected, infectious mastitis should be suspected. Breast milk culture is not routinely required unless mastitis is severe, there has been no response to antibiotics, or this is recurrent mastitis.
Management of mastitis involves relieving pain with simple analgesia and warm compresses, and ensuring complete emptying of the breast after feeding. Breastfeeding should be continued as it improves milk removal and prevents nipple damage. If pain prevents breastfeeding, expressing breast milk by hand or pump is recommended until breastfeeding can be resumed.
Antibiotics are only recommended if necessary, and the first line antibiotic is flucloxacillin for 14 days (erythromycin if penicillin allergic). Intravenous antibiotics are rarely needed, but urgent referral to breast surgeons for drainage may be necessary if a breast abscess is suspected.
Breastfeeding Problems and Management
Breastfeeding can come with its own set of challenges, but most of them can be managed with proper care and attention. Some common issues include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These problems can be addressed by seeking advice on positioning, breast massage, and using appropriate creams and suspensions.
Mastitis is a more serious condition that affects around 1 in 10 breastfeeding women. It is important to seek treatment if symptoms persist or worsen, including systemic illness, nipple fissures, or infection. The first-line antibiotic is flucloxacillin, and breastfeeding or expressing should continue during treatment. If left untreated, mastitis can lead to a breast abscess, which requires incision and drainage.
Breast engorgement is another common issue that can cause pain and discomfort. It usually occurs in the first few days after birth and can affect both breasts. Hand expression of milk can help relieve the discomfort of engorgement, and complications can be avoided by addressing the issue promptly.
Raynaud’s disease of the nipple is a less common but still significant problem that can cause pain and blanching of the nipple. Treatment options include minimizing exposure to cold, using heat packs, avoiding caffeine and smoking, and considering oral nifedipine.
Concerns about poor infant weight gain can also arise, prompting consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight until weight gain is satisfactory is also recommended. With proper management and support, most breastfeeding problems can be overcome, allowing for a successful and rewarding breastfeeding experience.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 3
Incorrect
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What is the correct statement regarding thrombolytic treatment of acute ischaemic stroke?
Your Answer: Thrombolysis is effective when given up to 12 hours after onset of symptoms
Correct Answer: Control of malignant or severe hypertension is required before thrombolysis
Explanation:Thrombolysis in Acute Ischaemic Stroke: Guidelines and Considerations
Thrombolysis is a treatment option for acute ischaemic stroke, but it must be administered within a narrow window of opportunity. Before thrombolysis can be given, haemorrhage must be excluded by CT scan. Unfortunately, only a minority of patients meet the criteria for thrombolysis due to the time-sensitive nature of the treatment.
While thrombolysis can reduce long-term deaths and disability, it does come with a small increase in short-term deaths. Uncontrolled hypertension is a risk factor that should be addressed before thrombolysis is considered. Additionally, there are several contraindications, including recent surgery, current anticoagulation, previous intracranial bleeding, urinary tract bleeding, and known cerebral aneurysm.
It’s important to note that thrombolysis is not beneficial for transient ischaemic attacks (TIAs). Overall, the decision to administer thrombolysis in acute ischaemic stroke requires careful consideration and adherence to guidelines.
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This question is part of the following fields:
- Neurology
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Question 4
Incorrect
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A 67-year-old man presents for follow-up of his spirometry-confirmed chronic obstructive pulmonary disease. His spirometry shows an FEV1 of 40%. He has not sought medical attention for his chest in several years and only uses salbutamol as inhaled therapy. He reports using at least two puffs of salbutamol four times a day, but his breathlessness is limiting his ability to engage in enjoyable activities. Despite his current treatment, he continues to experience persistent breathlessness. He has no history of asthma and is a former smoker. What is the appropriate next step in his management?
Your Answer: Add in a regular inhaled corticosteroid
Correct Answer: Continue the same inhaled treatment but use short courses of oral steroid when he exacerbates
Explanation:Treatment options for suboptimal control in COPD patients
To determine the appropriate treatment for suboptimal control in COPD patients, it is recommended to consult the NICE guidance on Chronic obstructive pulmonary disease (CG115). If a patient has suboptimal control despite using a regular short-acting beta 2-agonist (SABA), oral theophylline may be considered at a later stage in the treatment ladder. However, LAMA+LABA should be offered to patients who have spirometrically confirmed COPD, do not have asthmatic features or steroid responsiveness, and remain breathless or have exacerbations despite using a short-acting bronchodilator. It is important to note that adding a regular inhaled steroid is not recommended in the treatment ladder as it is inferior to LABA/ICS combination or LAMA. By following these guidelines, healthcare professionals can provide optimal treatment for COPD patients with suboptimal control.
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This question is part of the following fields:
- Respiratory Health
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Question 5
Incorrect
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A 16-year-old male is brought to clinic as his parents are concerned about changes in his behaviour.
Which of the following suggest a diagnosis of schizophrenia?Your Answer: Memory impairment
Correct Answer: Feelings of panic in buses and shops
Explanation:Symptoms of Schizophrenia, Anxiety Disorder, and Mania
Incongruity of affect is a symptom of schizophrenia where the emotion expressed is inappropriate to the circumstances. Although it is not considered a primary symptom, it is consistent with the diagnosis. Auditory hallucinations, particularly third person, are typical of schizophrenia, but clouding of consciousness is not. On the other hand, panic in crowds is indicative of an anxiety disorder, while grandiose ideations suggest mania. It is important to note that these symptoms may overlap and coexist in some cases, making it crucial to seek professional help for proper diagnosis and treatment.
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This question is part of the following fields:
- Mental Health
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Question 6
Incorrect
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A 32-year-old woman is experiencing perennial rhinitis and has found relief from antihistamines and an intranasal corticosteroid. She is seeking a refill and has questions about her condition, including why she doesn't only experience symptoms in the summer like some of her acquaintances. She is also curious about the possibility of testing. What is the most suitable explanation?
Your Answer: Patch tests are indicated
Correct Answer: Mainly adults have this condition
Explanation:Understanding Perennial Rhinitis: Causes and Diagnosis
Perennial rhinitis is a condition that occurs throughout the year, and it is more common in adults than in children. While seasonal rhinitis is more likely to affect older children and adolescents, perennial rhinitis is persistent and can be caused by various allergens, including house-dust mites, feathers, animal dander, or allergens at work.
Skin-prick testing is the most sensitive way to investigate the condition, as it measures specific IgE antibodies in the blood. However, it may not always be sensitive enough, and other tests, such as patch testing, may be indicated.
It is important to note that not all cases of perennial rhinitis have an allergic cause, but the response to medication can often provide clues. If an allergic cause is suspected, avoidance measures may be considered to manage symptoms.
Overall, understanding the causes and diagnosis of perennial rhinitis can help individuals manage their symptoms and improve their quality of life.
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This question is part of the following fields:
- Allergy And Immunology
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Question 7
Incorrect
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A 6-year-old boy comes to you complaining of sudden and severe pain in his right ear after recently having an ear infection. During examination, you notice a perforated eardrum. He has a soccer game next week and is eager to play. What advice would you give him regarding this situation?
Your Answer: Avoid swimming for the first week after perforation, and then resume swimming as normal
Correct Answer: Avoid swimming until the perforation is completely healed
Explanation:It is recommended to refrain from swimming until a perforated tympanic membrane has fully healed, which typically takes longer than a week. Using a swimming cap may not offer adequate protection. Antibiotics should only be prescribed if there is an infection present, and oral antibiotics are preferred over drops.
Perforated Tympanic Membrane: Causes and Management
A perforated tympanic membrane, also known as a ruptured eardrum, is often caused by an infection but can also result from barotrauma or direct trauma. This condition can lead to hearing loss and increase the risk of otitis media.
In most cases, no treatment is necessary as the tympanic membrane will typically heal on its own within 6-8 weeks. However, it is important to avoid getting water in the ear during this time. Antibiotics may be prescribed if the perforation occurs after an episode of acute otitis media. This approach is supported by the 2008 Respiratory Tract Infection Guidelines from NICE.
If the tympanic membrane doesn’t heal by itself, myringoplasty may be performed. This surgical procedure involves repairing the perforation with a graft of tissue taken from another part of the body. With proper management, a perforated tympanic membrane can be successfully treated and hearing can be restored.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 8
Correct
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A mother brings her 18-month-old daughter in for review. She started walking three months ago. The mother has noticed that her daughter seems to be 'bow-legged' when she walks.
Examination of the knees and hips is unremarkable with a full range of movement. Leg length is equal. On standing the intercondylar distance is around 7cm.
What is the most appropriate action?Your Answer: Reassure that it is a normal variant and likely to resolve by the age of 4 years
Explanation:It is common for children under the age of 3 to have bow legs, which is considered a normal variation. Typically, this condition resolves on its own by the time the child reaches 4 years old.
Common Variations in Lower Limb Development in Children
Parents may become concerned when they notice what appears to be abnormalities in their child’s lower limbs. This often leads to a visit to the primary care physician and a referral to a specialist. However, many of these variations are actually normal and will resolve on their own as the child grows.
One common variation is flat feet, where the medial arch is absent when the child is standing. This is typically seen in children of all ages and usually resolves between the ages of 4-8 years. Orthotics are not recommended, and parental reassurance is appropriate.
Another variation is in-toeing, which can be caused by metatarsus adductus, internal tibial torsion, or femoral anteversion. In most cases, these will resolve on their own, but severe or persistent cases may require intervention such as serial casting or surgical intervention. Out-toeing is also common in early infancy and usually resolves by the age of 2 years.
Bow legs, or genu varum, are typically seen in the first or second year of life and are characterized by an increased intercondylar distance. This variation usually resolves by the age of 4-5 years. Knock knees, or genu valgum, are seen in the third or fourth year of life and are characterized by an increased intermalleolar distance. This variation also typically resolves on its own.
In summary, many variations in lower limb development in children are normal and will resolve on their own. However, if there is concern or persistent symptoms, intervention may be appropriate.
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This question is part of the following fields:
- Children And Young People
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Question 9
Incorrect
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A 50-year-old man complains of frequent palpitations. These usually occur when he eats and subside abruptly after he finishes eating. They are not accompanied by chest pain, but, on occasion, he also feels lightheaded. He has no reflux symptoms or dyspepsia. He is otherwise well and on presentation his blood pressure is 136/84 mmHg, his pulse is in sinus rhythm, and examination of his heart and abdomen are normal. His electrocardiogram (ECG) is normal.
What is the most appropriate investigation?Your Answer: Helicobacter pylori (H. pylori) serology
Correct Answer: 24 hour portable electrocardiogram (ECG)
Explanation:The Most Appropriate Investigation for Palpitations and Dizziness: A Cardiac Investigation
When a patient presents with palpitations and dizziness, a cardiac cause is often suspected. While the association with food may be a red herring, the combination of symptoms suggests a need for further investigation. An ECG or examination of the pulse may not reveal an underlying cause unless the patient is experiencing symptoms at that exact moment. Therefore, a 24 hour portable ECG is often recommended to assess the cardiac rhythm over a longer period of time.
A chest X-ray is unlikely to be helpful in the absence of chest pain or respiratory symptoms. Similarly, an endoscopy may be indicated for dyspeptic symptoms, but the history of palpitations and dizziness suggests a cardiac cause. H. pylori testing is only relevant for dyspeptic symptoms, and thyroid function tests are important for anyone experiencing palpitations, as hyperthyroidism can be a cause.
In summary, when a patient presents with palpitations and dizziness, a cardiac investigation is the most appropriate first step. A 24 hour portable ECG can provide valuable information about the cardiac rhythm over a longer period of time.
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This question is part of the following fields:
- Gastroenterology
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Question 10
Incorrect
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An evidence hierarchy reflects the relative authority of various types of biomedical research.
Five types of study are listed below:
Case-control study
Case report
Cohort study
Randomised controlled trial
Systematic review and meta-analysis.
Placing the strongest evidence first and the weakest evidence last, which of the following is the correct order for the weighting carried by these different types of primary study when making decisions about interventions for elderly patients?
Your Answer: 23451
Correct Answer: 54312
Explanation:The Hierarchy of Research Studies in Evidence-Based Medicine
In evidence-based medicine, there is a general consensus on the hierarchy of research studies. Randomized controlled trials (RCTs) are considered the strongest type of study, followed by observational studies such as cross-sectional surveys, cohort studies, and case-control studies. Case reports are ranked lower on the hierarchy, while expert opinion and anecdotal experience are at the bottom.
Systematic reviews and meta-analyses are often placed above RCTs in the hierarchy because they combine data from multiple RCTs and other study types. Evidence hierarchies are essential in evidence-based medicine as they help clinicians and researchers determine the strength and quality of evidence to inform clinical decision-making.
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This question is part of the following fields:
- Population Health
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