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  • Question 1 - A 60-year-old man with a previous diagnosis of multiple endocrine neoplasia type 2...

    Correct

    • A 60-year-old man with a previous diagnosis of multiple endocrine neoplasia type 2 (MEN 2) presents to you 2 days after having undergone a total thyroidectomy. He reports experiencing cramps in his calves and thighs and tingling around his lips. Upon examination, you observe positive Chvostek’s sign and Trousseau sign. Further investigations reveal his serum calcium level to be 2 mmol/l and his serum phosphate level to be 1.8 mmol/l. What is the most likely explanation for these findings?

      Your Answer: Acquired hypoparathyroidism

      Explanation:

      Differential diagnosis of hypocalcaemia and hyperphosphataemia

      Acquired hypoparathyroidism is a likely cause of the biochemical abnormalities observed in a patient who recently underwent a total thyroidectomy. This condition results from damage to the parathyroid glands during surgery, leading to insufficient secretion of parathyroid hormone and subsequent hypocalcaemia and hyperphosphataemia. Other potential causes of these abnormalities include chronic renal failure and vitamin D deficiency, but these do not match the patient’s clinical history. Pseudohypoparathyroidism, a rare genetic disorder characterized by target tissue resistance to parathyroid hormone, is not a likely explanation either. Pseudopseudohypoparathyroidism, another rare inherited disorder that mimics the physical features of pseudohypoparathyroidism without the biochemical changes, is not relevant to this case. Therefore, acquired hypoparathyroidism is the most probable diagnosis, and appropriate management should include calcium and vitamin D supplementation, as well as monitoring for potential complications such as seizures and tetany.

    • This question is part of the following fields:

      • Endocrinology
      240
      Seconds
  • Question 2 - A 35-year old woman who is currently 20 weeks pregnant is concerned about...

    Correct

    • A 35-year old woman who is currently 20 weeks pregnant is concerned about the possibility of her child having congenital hip dislocation. She herself had the condition at birth, which went undiagnosed for 15 months and required corrective surgery. Despite the surgery, she has experienced hip pain throughout her adult life and is now scheduled for a hip replacement due to osteoarthritis. What is a known risk factor for congenital hip dislocation?

      Your Answer: Breech presentation

      Explanation:

      Congenital hip dislocation is more likely to occur in females, babies who were in a breech presentation, those with a family history of the condition, firstborns, and those with oligohydramnios. The left hip is more commonly affected and screening for the condition can be done through the Barlow and Ortolani tests during a baby check. Ultrasound examination can also be done for at-risk babies to detect congenital hip dislocation.

      Selected Facts about Lower Limb Anatomy

      The lower limb anatomy is a complex system that is often tested in medical examinations. One of the important aspects of this system is the nerves that control the motor and sensory functions of the lower limb. The femoral nerve, for example, controls knee extension and thigh flexion, and is responsible for the sensation in the anterior and medial aspect of the thigh and lower leg. This nerve is commonly injured in cases of hip and pelvic fractures, as well as stab or gunshot wounds.

      Another important nerve is the obturator nerve, which controls thigh adduction and provides sensation to the medial thigh. Injuries to this nerve can occur in cases of anterior hip dislocation. The lateral cutaneous nerve of the thigh, on the other hand, does not control any motor function but is responsible for the sensation in the lateral and posterior surfaces of the thigh. Compression of this nerve near the ASIS can lead to meralgia paraesthetica, a condition characterized by pain, tingling, and numbness in the distribution of the lateral cutaneous nerve.

      The tibial nerve controls foot plantarflexion and inversion and provides sensation to the sole of the foot. This nerve is not commonly injured as it is deep and well-protected. The common peroneal nerve, which controls foot dorsiflexion and eversion, is often injured at the neck of the fibula, resulting in foot drop. The superior gluteal nerve controls hip abduction and is commonly injured in cases of misplaced intramuscular injection, hip surgery, pelvic fracture, or posterior hip dislocation. Injury to this nerve results in a positive Trendelenburg sign. Finally, the inferior gluteal nerve controls hip extension and lateral rotation and is generally injured in association with the sciatic nerve. Injury to this nerve results in difficulty rising from a seated position, as well as an inability to jump or climb stairs.

    • This question is part of the following fields:

      • Musculoskeletal
      222.4
      Seconds
  • Question 3 - A 25-year-old female graduate student presents to her primary care physician with complaints...

    Correct

    • A 25-year-old female graduate student presents to her primary care physician with complaints of weight gain and excessive hair growth on her face and upper chest. She reports having irregular periods, with only one occurring every 2-3 months. Upon examination, the patient is found to have elevated levels of testosterone at 3.5 nmol/l and an elevated LH:FSH ratio. Additionally, she is overweight with a BMI of 28 and has acne. What is the most probable diagnosis?

      Your Answer: Polycystic ovarian syndrome (PCOS)

      Explanation:

      Differential diagnosis for a woman with typical PCOS phenotype and biochemical markers

      Polycystic ovarian syndrome (PCOS) is a common endocrine disorder that affects reproductive-aged women. Its diagnosis is based on the presence of at least two of the following criteria: oligo-ovulation or anovulation, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries on ultrasound. However, other conditions can mimic or coexist with PCOS, making the differential diagnosis challenging. Here are some possible explanations for a woman who presents with the typical PCOS phenotype and biochemical markers:

      – Cushing syndrome: This rare disorder results from chronic exposure to high levels of cortisol, either endogenously (e.g., due to a pituitary or adrenal tumour) or exogenously (e.g., due to long-term glucocorticoid therapy). Cushing syndrome can cause weight gain, central obesity, moon face, buffalo hump, purple striae, hypertension, glucose intolerance, and osteoporosis. However, it is not associated with a high LH: FSH ratio, which is a hallmark of PCOS.
      – Androgen-secreting tumour: This is a rare cause of hyperandrogenism that can arise from the ovary, adrenal gland, or other tissues. The excess production of androgens can lead to virilization, hirsutism, acne, alopecia, menstrual irregularities, and infertility. However, the testosterone level in this case would be expected to be higher than 3.5 nmol/l, which is the upper limit of the normal range for most assays.
      – Simple obesity: This is a common condition that can affect women of any age and ethnicity. Obesity can cause insulin resistance, hyperinsulinemia, dyslipidemia, inflammation, and oxidative stress, which can contribute to the development of PCOS. However, the abnormal testosterone and LH: FSH ratio suggest an underlying pathology that is not solely related to excess adiposity. Moreover, at a BMI of 28, the patient’s weight is not within the range for a clinical diagnosis of obesity (BMI ≥ 30).
      – Complete androgen insensitivity syndrome: This is a rare genetic disorder that affects the androgen receptor, leading to a lack of response to androgens in target tissues. As a result, affected individuals have a female phenotype despite having XY chromosomes. They typically present with primary amenorrhea

    • This question is part of the following fields:

      • Gynaecology
      21.2
      Seconds
  • Question 4 - A 22-year-old woman comes to the surgery, distressed that her midwife has advised...

    Correct

    • A 22-year-old woman comes to the surgery, distressed that her midwife has advised her to stop taking sertraline at 10 weeks of pregnancy. She had taken it during her previous two pregnancies and had two healthy children. She insists on knowing the potential risks associated with sertraline use during the first trimester. What are the increased risks during this period?

      Your Answer: Congenital heart defects

      Explanation:

      When considering the use of SSRIs during pregnancy, it is important to assess both the potential benefits and risks. Research has shown that using SSRIs during the first trimester may slightly increase the risk of congenital heart defects in the baby. Additionally, using SSRIs during the third trimester can lead to persistent pulmonary hypertension in the newborn. It is important to note that paroxetine, in particular, has been associated with a higher risk of congenital malformations, especially when used during the first trimester.

      Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.

      The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.

      When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.

      When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.

    • This question is part of the following fields:

      • Psychiatry
      31.8
      Seconds
  • Question 5 - A 75-year-old man is referred following a collapse at home. He is currently...

    Incorrect

    • A 75-year-old man is referred following a collapse at home. He is currently taking diclofenac for persistent low back pain. Upon examination, he appears pale and has a pulse of 110 beats per minute. His blood pressure is 110/74 mmHg while sitting and drops to 85/40 mmHg when standing. What is the most appropriate next step?

      Your Answer: 24 ambulatory ECG

      Correct Answer: Digital rectal examination

      Explanation:

      Syncopal Collapse and Possible Upper GI Bleed

      This patient experienced a syncopal collapse, which is likely due to hypovolemia, as evidenced by her postural drop in blood pressure. It is possible that she had an upper gastrointestinal (GI) bleed caused by gastric irritation from her non-steroidal anti-inflammatory drug (NSAID) use. A rectal examination that shows melaena would confirm this suspicion.

      To determine the cause of her condition, a full blood count is necessary. Afterward, appropriate fluid resuscitation, correction of anemia, and an upper GI endoscopy should be performed instead of further cardiological or neurological evaluation.

    • This question is part of the following fields:

      • Emergency Medicine
      72.1
      Seconds
  • Question 6 - A 28-year-old individual visits the neurology clinic with complaints of experiencing multiple instances...

    Correct

    • A 28-year-old individual visits the neurology clinic with complaints of experiencing multiple instances of involuntary shaking in different limbs. They have some control over which limb is affected the most but are unable to stop the shaking. The intensity of the shaking increases gradually and then subsides in a similar manner. The patient reports that the shaking is more severe when they feel anxious. What is the probable diagnosis?

      Your Answer: Pseudoseizures

      Explanation:

      Distinguishing between pseudoseizures and true seizures can be challenging as they share some similarities. However, one key difference is that pseudoseizures tend to have a gradual onset, while true seizures have a sudden onset. Pseudoseizures are often linked to psychiatric conditions and are not voluntary, but rather compulsive and unwanted movements. It is common for individuals experiencing pseudoseizures to have some control over the location of their symptoms. While dystonia may involve shaking, it typically results in rigidity rather than gradual onset and offset.

      Understanding Psychogenic Non-Epileptic Seizures

      Psychogenic non-epileptic seizures, also known as pseudoseizures, are a type of seizure that is not caused by abnormal electrical activity in the brain. Instead, they are believed to be caused by psychological factors such as stress, trauma, or anxiety. These seizures can be difficult to diagnose as they often mimic true epileptic seizures, but there are certain factors that can help differentiate between the two.

      Factors that may indicate pseudoseizures include pelvic thrusting, a family history of epilepsy, a higher incidence in females, crying after the seizure, and the seizures not occurring when the individual is alone. On the other hand, factors that may indicate true epileptic seizures include tongue biting and a raised serum prolactin level.

      Video telemetry is a useful tool for differentiating between the two types of seizures. It involves monitoring the individual’s brain activity and behavior during a seizure, which can help determine whether it is caused by abnormal electrical activity in the brain or psychological factors.

      It is important to accurately diagnose and treat psychogenic non-epileptic seizures as they can have a significant impact on an individual’s quality of life. Treatment may involve therapy to address underlying psychological factors, as well as medication to manage any associated symptoms such as anxiety or depression.

    • This question is part of the following fields:

      • Medicine
      42.7
      Seconds
  • Question 7 - A 10-year-old boy comes to his General Practitioner (GP) complaining of generalised itch...

    Incorrect

    • A 10-year-old boy comes to his General Practitioner (GP) complaining of generalised itch for the past few days. He mentions that it is causing him to lose sleep at night. Upon examination, the GP observes linear burrows on the hands and evidence of excoriation on the abdomen and limbs. The GP suspects scabies as the underlying cause.
      What is the initial treatment recommended for non-crusted scabies?

      Your Answer: Clotrimazole 2% cream

      Correct Answer: Permethrin 5% cream

      Explanation:

      Treatment Options for Scabies: Understanding the Role of Different Medications

      Scabies is a skin condition caused by the Sarcoptes scabiei parasite. The primary treatment for non-crusted scabies is permethrin 5% cream, which is an insecticide. If permethrin is not tolerated or contraindicated, malathion can be used as a second-line agent. It is important to apply permethrin cream over the entire body and wash it off after 8-12 hours. Treatment should be repeated after one week.

      Clotrimazole 2% cream, which is an antifungal medication, is not effective in treating scabies. Similarly, topical antibiotics like fusidic acid cream are not used to treat scabies unless there is a secondary bacterial infection.

      Steroids like hydrocortisone 1% ointment are not used to treat scabies directly, but they can be used to alleviate symptoms like itching. Oral antibiotics like flucloxacillin are only necessary if there is a suspected secondary bacterial infection.

      In summary, understanding the role of different medications in treating scabies is crucial for effective management of the condition.

    • This question is part of the following fields:

      • Dermatology
      92.4
      Seconds
  • Question 8 - A 70-year-old man with a lengthy history of hypertension is undergoing an eye...

    Correct

    • A 70-year-old man with a lengthy history of hypertension is undergoing an eye examination. He has been experiencing deteriorating headaches and reduced visual acuity over the past few weeks. Upon fundoscopy, he displays flame haemorrhages, cotton wool spots, arteriovenous nipping, and papilloedema. What level of hypertensive retinopathy does this correspond to?

      Your Answer: Grade IV

      Explanation:

      Grade IV hypertensive retinopathy is indicated by papilloedema, which is a severe manifestation that requires immediate attention due to its association with high morbidity and mortality. The various grades of hypertensive retinopathy have distinct characteristics, which are outlined below.

      Understanding Hypertensive Retinopathy: Keith-Wagener Classification

      Hypertensive retinopathy is a condition that affects the eyes due to high blood pressure. The Keith-Wagener classification is a system used to categorize the different stages of hypertensive retinopathy. Stage I is characterized by narrowing and twisting of the blood vessels in the eyes, as well as an increased reflection of light known as silver wiring. In stage II, the blood vessels become compressed where they cross over veins, leading to arteriovenous nipping. Stage III is marked by the appearance of cotton-wool exudates, which are white patches on the retina caused by blocked blood vessels. Additionally, there may be flame and blot hemorrhages that can collect around the fovea, resulting in a ‘macular star.’ Finally, stage IV is the most severe stage and is characterized by papilloedema, which is swelling of the optic disc at the back of the eye. Understanding the Keith-Wagener classification can help healthcare professionals diagnose and manage hypertensive retinopathy.

    • This question is part of the following fields:

      • Ophthalmology
      64.4
      Seconds
  • Question 9 - A 6-year-old boy is discovered to have an incidental murmur. He is healthy...

    Incorrect

    • A 6-year-old boy is discovered to have an incidental murmur. He is healthy and progressing normally. The first heart sound is regular, but the second heart sound appears to be broadly split, and this splitting is unchanging regardless of inhalation or exhalation. A faint mid-systolic murmur is heard over the pulmonary region. The electrocardiogram (ECG) reveals an rSr' pattern in V1 and prominent P waves. What is the probable diagnosis?

      Your Answer: Patent ductus arteriosus

      Correct Answer: Atrial septal defect

      Explanation:

      Atrial septal defects (ASDs) are often asymptomatic and produce fixed splitting of the second heart sound. They are of three types and are often picked up during auscultation. The rSr change on the ECG can be caused by ASDs, right ventricular hypertrophy, or pulmonary embolus. The mechanism resulting in splitting of the heart sounds in ASDs is due to the difference in compliance between the left and right ventricles. The extra flow through the right side due to an ASD causes the splitting to be widened, and the lack of variation with ventilation suggests an intra-atrial connection is the cause. ASDs can lead to right ventricular failure and paradoxical embolisation of venous clots into the systemic circulation.

    • This question is part of the following fields:

      • Paediatrics
      128.8
      Seconds
  • Question 10 - A 28-year-old primigravida woman is rushed for an emergency caesarean section due to...

    Incorrect

    • A 28-year-old primigravida woman is rushed for an emergency caesarean section due to fetal distress and hypoxia detected on cardiotocography. She is currently at 31 weeks gestation.
      After delivery, the baby is admitted to the neonatal intensive care unit (NICU) and given oxygen to aid breathing difficulties.
      Several weeks later, during an ophthalmological examination, the baby is found to have bilateral absent red reflex and retinal neovascularisation.
      What is the probable diagnosis?

      Your Answer: Congenital cataracts

      Correct Answer: Retinopathy of prematurity

      Explanation:

      Risks Associated with Prematurity

      Prematurity is a condition that poses several risks to the health of newborns. The risk of mortality increases with decreasing gestational age. Premature babies are at risk of developing respiratory distress syndrome, intraventricular haemorrhage, necrotizing enterocolitis, chronic lung disease, hypothermia, feeding problems, infection, jaundice, and retinopathy of prematurity. Retinopathy of prematurity is a significant cause of visual impairment in babies born before 32 weeks of gestation. The cause of this condition is not fully understood, but it is believed that over oxygenation during ventilation can lead to the proliferation of retinal blood vessels, resulting in neovascularization. Screening for retinopathy of prematurity is done in at-risk groups. Premature babies are also at risk of hearing problems.

    • This question is part of the following fields:

      • Obstetrics
      55
      Seconds
  • Question 11 - During your ward round on the paediatric unit you review a 7-year-old African...

    Incorrect

    • During your ward round on the paediatric unit you review a 7-year-old African American male who has been admitted for chemotherapy as he has recently been diagnosed with acute lymphoblastic leukaemia (ALL). His father anxiously asks you what his chance of survival is and how you determine this.

      Upon reviewing the patient's medical records, you notice that he is on the 10th percentile for weight and the 25th percentile for height. His white cell count at diagnosis was 15 * 10^9/l and there were no noted T or B cell markers on his blood film.

      What is the poor prognostic factor in this case?

      Your Answer: White cell count over 11 * 10^9/l at diagnosis

      Correct Answer: Male sex

      Explanation:

      Male gender is identified as a negative prognostic factor, while being Caucasian does not have a significant impact on prognosis. Other factors that may indicate a poor prognosis include presenting with the disease either less than two years or more than ten years after onset, having B or T cell surface markers, and having a white blood cell count greater than 20 billion per liter at the time of diagnosis.

      Acute lymphoblastic leukaemia (ALL) is a type of cancer that commonly affects children and accounts for 80% of childhood leukaemias. It is most prevalent in children between the ages of 2-5 years, with boys being slightly more affected than girls. Symptoms of ALL can be divided into those caused by bone marrow failure, such as anaemia, neutropaenia, and thrombocytopenia, and other features like bone pain, splenomegaly, and hepatomegaly. Fever is also present in up to 50% of new cases, which may indicate an infection or a constitutional symptom. Testicular swelling may also occur.

      There are three types of ALL: common ALL, T-cell ALL, and B-cell ALL. Common ALL is the most common type, accounting for 75% of cases, and is characterized by the presence of CD10 and a pre-B phenotype. Poor prognostic factors for ALL include age less than 2 years or greater than 10 years, a white blood cell count greater than 20 * 109/l at diagnosis, T or B cell surface markers, non-Caucasian ethnicity, and male sex.

    • This question is part of the following fields:

      • Paediatrics
      35.4
      Seconds
  • Question 12 - A 50-year-old, overweight accountant presents to the hospital with sudden onset of breathlessness...

    Incorrect

    • A 50-year-old, overweight accountant presents to the hospital with sudden onset of breathlessness and right posterior lower chest pain. This occurs three weeks after undergoing right total hip replacement surgery. The patient has a medical history of bronchiectasis and asthma, but denies any recent change in sputum colour or quantity. On air, oxygen saturation is 89%, but rises to 95% on (35%) oxygen. The patient is apyrexial. Chest examination reveals coarse leathery crackles at both lung bases. Peak flow rate is 350 L/min and chest radiograph shows bronchiectatic changes, also at both lung bases. Full blood count is normal.

      What is the most appropriate investigation to conduct next?

      Your Answer: Ventilation/perfusion scan

      Correct Answer: CT-pulmonary angiography

      Explanation:

      CT Pulmonary Angiography as the Preferred Diagnostic Tool for Pulmonary Embolism

      Computerised tomography (CT) pulmonary angiography is the most suitable diagnostic tool for patients suspected of having a pulmonary embolism. This is particularly true for patients with chronic lung disease, as a ventilation perfusion scan may be difficult to interpret. In this case, the patient almost certainly has a pulmonary embolism, making CT pulmonary angiography the investigation of choice.

      It is important to note that while ventilation perfusion scans are useful in diagnosing pulmonary embolisms, they may not be the best option for patients with underlying lung disease. This is because the scan can be challenging to interpret, leading to inaccurate results. CT pulmonary angiography, on the other hand, provides a more accurate and reliable diagnosis, making it the preferred diagnostic tool for patients suspected of having a pulmonary embolism.

    • This question is part of the following fields:

      • Respiratory
      38.3
      Seconds
  • Question 13 - A 6-year-old girl comes to the emergency department with a 4-day history of...

    Correct

    • A 6-year-old girl comes to the emergency department with a 4-day history of fever. She has no medical history, allergies, is developing normally and is up-to-date on her immunizations.

      Vital signs:
      - Respiratory rate: 18
      - SpO2: 97%
      - Heart rate: 95
      - Cap. refill time: 2 sec
      - BP: 112/80 mmHg
      - AVPU: Alert
      - Temperature: 39.2ºC

      During the examination, a rough-textured maculopapular rash is found to be widespread. Her tongue is swollen, red, and covered with white papillae, and her tonsils are erythematosus. All other system examinations are normal.

      What is the most likely diagnosis based on these findings?

      Your Answer: Scarlet fever

      Explanation:

      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
      44
      Seconds
  • Question 14 - A 68-year-old male comes to the Emergency Department with lower back pain and...

    Incorrect

    • A 68-year-old male comes to the Emergency Department with lower back pain and difficulty standing without assistance. He has a history of metastatic lung cancer and is currently receiving palliative care. During examination, severe neurological deficits are observed in both legs. What would be a late sign in this patient, considering the probable diagnosis?

      Your Answer: Saddle anaesthesia

      Correct Answer: Urinary incontinence

      Explanation:

      Cauda equina syndrome typically manifests as lower back pain, sciatica, and decreased perianal sensation. As the condition progresses, urinary incontinence may develop.

      The most likely diagnosis for this patient is cauda equina syndrome, which is characterized by compression of the lumbosacral nerve roots. This can be caused by metastatic spinal cord compression or spinal fractures that compromise spinal stability. It is important to note that CES can present in various ways, and there is no single symptom or sign that can definitively diagnose or rule out the condition. Symptoms may include lower back pain, bilateral sciatica, decreased perianal sensation, reduced anal tone, fecal incontinence, and urinary dysfunction such as incontinence, decreased awareness of bladder filling, and loss of urge to void.

      Cauda equina syndrome (CES) is a rare but serious condition that occurs when the nerve roots in the lower back are compressed. It is crucial to consider CES in patients who present with new or worsening lower back pain, as a late diagnosis can result in permanent nerve damage and long-term leg weakness and urinary/bowel incontinence. The most common cause of CES is a central disc prolapse, typically at L4/5 or L5/S1, but it can also be caused by tumors, infections, trauma, or hematomas. CES can present in various ways, and there is no single symptom or sign that can diagnose or exclude it. Possible features include low back pain, bilateral sciatica, reduced sensation in the perianal area, decreased anal tone, and urinary dysfunction. Urgent MRI is necessary for diagnosis, and surgical decompression is the recommended management.

    • This question is part of the following fields:

      • Musculoskeletal
      55.5
      Seconds
  • Question 15 - A 38-year-old woman comes in for her routine anatomy ultrasound scan at 20...

    Incorrect

    • A 38-year-old woman comes in for her routine anatomy ultrasound scan at 20 weeks’ gestation. The ultrasound reveals significant fetal structural abnormalities, such as holoprosencephaly, cleft palate, short limbs, polydactyly, bilateral club feet, enlarged kidneys, and polyhydramnios.
      What is the probable underlying diagnosis of the unborn child?

      Your Answer: Potter syndrome

      Correct Answer: Patau syndrome

      Explanation:

      Common Genetic Disorders and Their Prenatal Ultrasound Findings

      Prenatal ultrasound is a valuable tool for detecting genetic disorders in fetuses. Here are some common genetic disorders and their corresponding ultrasound findings:

      1. Patau Syndrome (Trisomy 13)
      Trisomy 13 has a prevalence of 1 per 6500 births. Fetuses with trisomy 13 may have brain anomalies such as holoprosencephaly, midfacial hypoplasia, ventriculomegaly, and microcephaly. Other possible findings include cleft lip and palate, microphthalmia, hypotelorism, and cardiac defects.

      2. Cystic Fibrosis (CF)
      Hyperechogenic fetal bowel is a possible ultrasound finding in fetuses with CF. This may be a normal variant, but it can also be associated with severe disease.

      3. Down Syndrome
      20% of second-trimester fetuses with Down syndrome have major structural anomalies such as polyhydramnios, double bubble, and large cardiac septal defects. Other possible markers include nuchal fold thickness, pyelectasis, and short long bones.

      4. Klinefelter Syndrome
      Klinefelter syndrome is characterized by two or more X chromosomes in boys, resulting in infertility and small testicles. Ultrasound findings may be subtle, and many people may not realize they are affected.

      5. Potter Syndrome
      Potter syndrome is suspected when severe oligohydramnios and intrauterine growth retardation are present. Ultrasound findings may include pulmonary hypoplasia, abnormal facies, and limb abnormalities such as club feet and contractures.

      In conclusion, prenatal ultrasound can provide valuable information for detecting genetic disorders in fetuses. It is important for healthcare providers to be aware of the possible ultrasound findings associated with these disorders.

    • This question is part of the following fields:

      • Genetics
      175.6
      Seconds
  • Question 16 - A 65-year-old patient in the Intensive Care Unit has been on ventilatory support...

    Incorrect

    • A 65-year-old patient in the Intensive Care Unit has been on ventilatory support for the last two weeks after a significant traumatic brain injury. A decision has to be made about whether they are taken off life support and whether or not the patient has irreversible brain damage.
      In which of the following circumstances can brain death be diagnosed?

      Your Answer: Hypophosphataemia

      Correct Answer: A ventilator-supported patient

      Explanation:

      Understanding the Factors that Affect Brain Death Diagnosis

      Brain death diagnosis is a critical process that determines the cessation of brain function, which is irreversible and leads to the death of an individual. However, several factors can affect the accuracy of this diagnosis, and they must be excluded before confirming brain death.

      One of the primary conditions for brain death diagnosis is the patient’s inability to maintain their own heartbeat and ventilation, requiring the support of a ventilator. However, this condition alone is not sufficient, and two other factors must be present, including unconsciousness and clear evidence of irreversible brain damage.

      Hypothermia is one of the factors that can confound the examination of cortical and brainstem function, making it difficult to diagnose brain death accurately. Similarly, encephalopathy secondary to hepatic failure and severe hypophosphataemia can also impact cortical and brainstem function, leading to inaccurate brain death diagnosis.

      Finally, sedation by anaesthetic or neuroparalytic agents can depress the neurological system, making it appear as if the patient is brain dead when they are not. Therefore, it is crucial to consider all these factors and exclude them before confirming brain death diagnosis.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
      114.5
      Seconds
  • Question 17 - A 52-year-old male taxi driver presented with altered consciousness. He was discovered on...

    Incorrect

    • A 52-year-old male taxi driver presented with altered consciousness. He was discovered on the roadside in this state and brought to the Emergency Department. He had a strong smell of alcohol and was also found to be icteric. Ascites and gynaecomastia were clinically present. The following morning during examination, he was lying still in bed without interest in his surroundings. He was able to report his name and occupation promptly but continued to insist that it was midnight. He was cooperative during physical examination, but once the attending doctor pressed his abdomen, he swore loudly, despite being known as a generally gentle person. What is the grading of hepatic encephalopathy for this patient?

      Your Answer: 3

      Correct Answer: 2

      Explanation:

      Understanding the West Haven Criteria for Hepatic Encephalopathy

      The West Haven Criteria is a scoring system used to assess the severity of hepatic encephalopathy, a condition where the liver is unable to remove toxins from the blood, leading to brain dysfunction. The criteria range from 0 to 4, with higher scores indicating more severe symptoms.

      A score of 0 indicates normal mental status with minimal changes in memory, concentration, intellectual function, and coordination. This is also known as minimal hepatic encephalopathy.

      A score of 1 indicates mild confusion, euphoria or depression, decreased attention, slowing of mental tasks, irritability, and sleep pattern disorders such as an inverted sleep cycle.

      A score of 2 indicates drowsiness, lethargy, gross deficits in mental tasks, personality changes, inappropriate behavior, and intermittent disorientation.

      A score of 3 presents with somnolence but rousability, inability to perform mental tasks, disorientation to time and place, marked confusion, amnesia, occasional fits of rage, and speech that is present but incomprehensible.

      A score of 4 indicates coma with or without response to painful stimuli.

      Understanding the West Haven Criteria is important in diagnosing and managing hepatic encephalopathy, as it helps healthcare professionals determine the severity of the condition and develop appropriate treatment plans.

    • This question is part of the following fields:

      • Gastroenterology
      93.1
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  • Question 18 - A 17-year-old girl is brought to the Emergency Department via ambulance with reduced...

    Incorrect

    • A 17-year-old girl is brought to the Emergency Department via ambulance with reduced level of consciousness, non-blanching rash, headache, neck stiffness and fever. Her mother accompanies her and states that this confusion started several hours previously. She also states that her daughter has not passed urine since the previous day, at least 16 hours ago. On clinical examination, she appears unwell and confused, and she has a purpuric rash over her lower limbs. Her observation results are as follows:
      Temperature 39.5 °C
      Blood pressure 82/50 mmHg
      Heart rate 120 bpm
      Respiratory rate 20 breaths per minute
      Which of the following are high-risk criteria when diagnosing and risk-stratifying suspected sepsis?

      Your Answer: Not passing urine for the previous 16 hours

      Correct Answer: Systolic blood pressure of 82 mmHg

      Explanation:

      Understanding the High-Risk Criteria for Suspected Sepsis

      Sepsis is a life-threatening condition that requires prompt medical attention. To help healthcare professionals identify and grade the severity of suspected sepsis, certain high-risk criteria are used. Here are some important points to keep in mind:

      – A systolic blood pressure of 90 mmHg or less, or a systolic blood pressure of > 40 mmHg below normal, is a high-risk criterion for grading the severity of suspected sepsis. A moderate- to high-risk criterion is a systolic blood pressure of 91–100 mmHg.
      – Not passing urine for the previous 18 hours is a high-risk criterion for grading the severity of suspected sepsis. For catheterised patients, passing < 0.5 ml/kg of urine per hour is also a high-risk criterion, as is a heart rate of > 130 bpm. Not passing urine for 12-18 hours is considered a ‘amber flag’ for sepsis.
      – Objective evidence of new altered mental state is a high-risk criteria for grading the severity of suspected sepsis. Moderate- to high-risk criteria would include: history from patient, friend or relative of new onset of altered behaviour or mental state and history of acute deterioration of functional ability.
      – Non-blanching rash of the skin, as well as a mottled or ashen appearance and cyanosis of the skin, lips or tongue, are high-risk criteria for severe sepsis.
      – A raised respiratory rate of 25 breaths per minute or more is a high-risk criterion for sepsis, as is a new need for oxygen with 40% FiO2 (fraction of inspired oxygen) or more to maintain saturation of > 92% (or > 88% in known chronic obstructive pulmonary disease). A raised respiratory rate is 21–24 breaths per minute.

      By understanding these high-risk criteria, healthcare professionals can quickly identify and treat suspected sepsis, potentially saving lives.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
      60.9
      Seconds
  • Question 19 - A 6-year-old child complains of difficulty in hearing. He has had several fractures...

    Correct

    • A 6-year-old child complains of difficulty in hearing. He has had several fractures following minor falls. On examination, his legs appear short and deformed, and his sclera appear blue.
      What is the most likely diagnosis?

      Your Answer: Osteogenesis imperfecta

      Explanation:

      Genetic Disorders Affecting Bone and Connective Tissue

      There are several genetic disorders that affect bone and connective tissue, resulting in various physical characteristics and health complications.

      Osteogenesis Imperfecta, also known as brittle bone disease, is a condition where bones are excessively fragile and prone to fractures. Type I, also called osteogenesis imperfecta tarda, is characterized by bony deformities, blue sclera, teeth abnormalities, deafness, and heart valve abnormalities.

      Achondroplasia, previously known as dwarfism, is characterized by short limbs on a normally sized trunk, with a large skull and small face.

      Alport Syndrome is characterized by deafness and renal failure.

      Marfan Syndrome is a connective tissue disorder that results in tall stature, long arms, arachnodactyly, high-arched palate, and pectus excavatum.

      Osteopetrosis, also known as marble bone disease, is a condition where bones are dense and brittle.

    • This question is part of the following fields:

      • Paediatrics
      27.8
      Seconds
  • Question 20 - A 28-year-old man comes to the clinic complaining of gradual weight loss. He...

    Incorrect

    • A 28-year-old man comes to the clinic complaining of gradual weight loss. He has lost 8 kg over the past three months, and his previous weight was 62 kg.

      Two years ago, he volunteered at a child rehabilitation program in India and contracted pulmonary tuberculosis, which was successfully treated. A recent chest x-ray showed no suspicious lesions in the lungs, and there is no lymphadenopathy. He denies having a fever or night sweats.

      During the examination, he reveals that he has been drinking one bottle of wine per day for the past three weeks, following a breakup with his girlfriend.

      Which test is likely to show a positive result for the weight loss?

      Your Answer: Stool test for fat globules

      Correct Answer: Abdominal x ray

      Explanation:

      Overlooked Causes of Weight Loss: Addison’s Disease

      Weight loss can be caused by a variety of factors, and it is important to consider all possibilities when investigating the underlying cause. One often overlooked cause is Addison’s disease, which can occur as a result of past tuberculosis affecting the adrenal glands. This rare condition can be identified through abdominal x-rays, which may show adrenal calcification shadows.

      While alcohol abuse can lead to liver damage and hepatitis, it is not likely to be the cause of weight loss in this case. Similarly, steatorrhoea, a manifestation of malabsorption, can cause weight loss, but there are no other indications of malabsorption in this patient’s history.

      Thyrotoxicosis, or an overactive thyroid, can also cause weight loss, but it is usually accompanied by other symptoms such as anxiety, tremors, and eye signs. Finally, surreptitious laxative abuse can lead to weight loss, but it is not likely to be the cause in this case given the patient’s history of tuberculosis.

      Overall, it is important to consider all possible causes of weight loss, including rare conditions like Addison’s disease, in order to provide the most effective treatment and care for patients.

    • This question is part of the following fields:

      • Endocrinology
      64
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Endocrinology (1/2) 50%
Musculoskeletal (1/2) 50%
Gynaecology (1/1) 100%
Psychiatry (1/1) 100%
Emergency Medicine (0/1) 0%
Medicine (1/1) 100%
Dermatology (0/1) 0%
Ophthalmology (1/1) 100%
Paediatrics (2/4) 50%
Obstetrics (0/1) 0%
Respiratory (0/1) 0%
Genetics (0/1) 0%
Acute Medicine And Intensive Care (0/2) 0%
Gastroenterology (0/1) 0%
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