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Question 1
Correct
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A 28-year-old gravida 4, para 3 undergoes an assisted delivery with mid-cavity forceps following a prolonged second stage. After a couple of weeks, the patient visits her GP complaining of difficulty walking. Upon examination, she displays a limp in her left leg, a numb thigh, weak knee extension, and the absence of patellar reflex. Her right leg appears normal. What nerve has been affected by the forceps delivery?
Your Answer: Femoral nerve
Explanation:The observed symptoms indicate that the femoral nerve has been affected. Although nerve damage during instrumental delivery is uncommon, it can occur during challenging deliveries and mid-cavity forceps use. The table below outlines the nerves that may be impacted by forceps and the corresponding clinical manifestations.
Nerve Clinical features
Femoral nerve Weakness in extending the knee, absence of the patellar reflex, and numbness in the thigh
Lumbosacral trunk Weakness in dorsiflexing the ankle and numbness in the calf and foot.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.
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This question is part of the following fields:
- Musculoskeletal
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Question 2
Incorrect
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A 25-year-old man is diagnosed with schizophrenia and medical management is initiated by the Community Psychiatry team. Two days later, he presents to the Emergency Department with a temperature and severe muscle rigidity. The patient’s mother notes that he has been confused, and at times seems to be drowsy. He has also developed a tremor and seems to be having difficulty walking. Following assessment, a diagnosis of neuroleptic malignant syndrome (NMS) is made.
NMS is a serious side-effect of neuroleptic drugs.
Which of the following is true regarding NMS?Your Answer: It is associated only with the use of high potency neuroleptic drugs
Correct Answer: It occurs with all known neuroleptic drugs
Explanation:Understanding Neuroleptic Malignant Syndrome: Symptoms, Treatment, and Prognosis
Neuroleptic Malignant Syndrome (NMS) is a rare but life-threatening reaction to neuroleptic medication. It can occur either on initiation of therapy or after a dose increase and is associated with all known neuroleptic drugs. Symptoms include muscular rigidity, hyperthermia, change in consciousness, delirium, and autonomic instability. The pathophysiology of NMS is not entirely understood, but it is thought to be secondary to dopamine D2 receptor antagonism.
Prognosis is best when the syndrome is identified and treated early. Treatment involves discontinuing all neuroleptic medications, and symptoms tend to settle within 1-2 weeks. The risk of recurrence may be reduced by switching to an atypical, rather than a high-potency, antipsychotic. Sometimes these patients will be managed in the Intensive Care Unit depending on the severity of their symptoms.
Contrary to popular belief, NMS has been associated with all known neuroleptic drugs, including clozapine. Reintroduction of the drug that caused NMS increases the risk of mortality. The use of high-potency neuroleptics like haloperidol has been associated with a mildly increased risk.
In addition to withdrawal of the afflicting medication, adjunctive medications can be given such as muscle relaxants like lorazepam and bromocriptine, however, evidence for these is limited. Most patients will be significantly dehydrated and will have rhabdomyolysis, therefore fluids should be given to prevent renal failure.
In conclusion, understanding the symptoms, treatment, and prognosis of NMS is crucial for healthcare professionals who prescribe neuroleptic medication. Early identification and prompt treatment can improve outcomes for patients.
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This question is part of the following fields:
- Pharmacology
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Question 3
Incorrect
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What is the most frequent location for a carcinoid tumor?
Your Answer: Oesophagus
Correct Answer: Small bowel
Explanation:Carcinoid Tumours and Neuroendocrine Tumours
Carcinoid tumours are a type of neuroendocrine tumour that originates from endocrine cells. These tumours can be found in various organs, but the most common location is the gastrointestinal tract, particularly the small intestine. The pancreas and lungs are also potential sites for carcinoid tumours. While some carcinoid tumours may not cause any symptoms, larger tumours and those located in the small intestine can lead to carcinoid syndrome. This occurs when the tumour cells release bioactive substances such as serotonin and bradykinin into the bloodstream, causing symptoms such as bronchospasm, diarrhoea, flushing, and heart damage.
Other types of neuroendocrine tumours are derived from different endocrine cell types and may secrete different hormones. Examples include insulinoma, gastrinoma (Zollinger-Ellison syndrome), VIPoma, and somatostatinoma. Not all neuroendocrine tumours are functional, meaning they may not secrete hormones even if they originate from an endocrine cell.
Treatment for carcinoid tumours typically involves surgical resection and/or somatostatin analogues such as octreotide, which can reduce the secretion of serotonin by the tumour. Most carcinoid tumours do not metastasize, but those that do may not be suitable for surgical resection depending on the extent of metastasis. However, some patients may benefit from octreotide and chemotherapy agents to manage symptoms.
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This question is part of the following fields:
- Oncology
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Question 4
Correct
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A 67-year-old man presents with weakness of the thighs and shoulders leading to difficulty climbing stairs and lifting objects. He has also noticed a purple-coloured rash, most pronounced on his face and affecting the eyelids. On examination, he has itchy and painful papules over the metacarpophalangeal (MCP) joints. He is subsequently diagnosed with dermatomyositis.
What investigations will be included in the next steps of his management?Your Answer: CT chest/abdomen/pelvis
Explanation:Dermatomyositis is often associated with an underlying malignancy, making it crucial to thoroughly investigate patients for cancer. A CT scan of the chest, abdomen, and pelvis is the most reliable and efficient method for detecting any potential malignancy. While a chest x-ray may identify lung cancer, it is not as accurate and may miss tumors in other areas. An MRI of the brain is unlikely to be helpful as intracerebral pathology is not typically associated with dermatomyositis. The most common cancers associated with dermatomyositis are lung, breast, and ovarian cancer. A PET scan may be used for staging and detecting metastases after an initial CT scan. An ultrasound of the MCP joints is unnecessary for diagnosis confirmation and would not be a reliable method for evaluating Gottron papules. A biopsy may be necessary if diagnostic uncertainty remains.
Dermatomyositis is a condition that causes inflammation and muscle weakness, as well as distinct skin lesions. It can occur on its own or be associated with other connective tissue disorders or underlying cancers, particularly ovarian, breast, and lung cancer. Screening for cancer is often done after a diagnosis of dermatomyositis. Polymyositis is a variant of the disease that does not have prominent skin manifestations.
The skin features of dermatomyositis include a photosensitive macular rash on the back and shoulders, a heliotrope rash around the eyes, roughened red papules on the fingers’ extensor surfaces (known as Gottron’s papules), extremely dry and scaly hands with linear cracks on the fingers’ palmar and lateral aspects (known as mechanic’s hands), and nail fold capillary dilation. Other symptoms may include proximal muscle weakness with tenderness, Raynaud’s phenomenon, respiratory muscle weakness, interstitial lung disease (such as fibrosing alveolitis or organizing pneumonia), dysphagia, and dysphonia.
Investigations for dermatomyositis typically involve testing for ANA antibodies, which are positive in around 80% of patients. Approximately 30% of patients have antibodies to aminoacyl-tRNA synthetases, including antibodies against histidine-tRNA ligase (also called Jo-1), antibodies to signal recognition particle (SRP), and anti-Mi-2 antibodies.
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This question is part of the following fields:
- Musculoskeletal
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Question 5
Incorrect
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A 35-year-old Afro-Caribbean woman presents with complaints of cold and painful hands during winter. She reports that her hands change color from pale to blue and red in the morning. Despite using gloves and hand warmers, her symptoms have only slightly improved. She is interested in trying medications to alleviate her symptoms. Based on the probable diagnosis, which medication should be prescribed?
Your Answer: Mycophenolate
Correct Answer: Nifedipine
Explanation:Nifedipine is a recommended medication for treating Raynaud’s phenomenon. Patients with this condition should be advised to keep their hands warm and quit smoking. NICE suggests other treatments such as evening primrose oil, sildenafil, and prostacyclin for severe attacks or digital gangrene. Chemical or surgical sympathectomy may be helpful for those with severe disease. Propranolol, a beta-blocker, may worsen the condition as it commonly causes cold peripheries. Ibuprofen, an analgesic, may alleviate pain but not other symptoms. Amitriptyline, a tricyclic antidepressant, is also used for neuropathic pain but not specifically for Raynaud’s.
Understanding Raynaud’s Phenomenon
Raynaud’s phenomenon is a condition where the digital arteries and cutaneous arteriole overreact to cold or emotional stress, causing an exaggerated vasoconstrictive response. It can be classified as primary or secondary. Primary Raynaud’s disease is more common in young women and presents with bilateral symptoms. On the other hand, secondary Raynaud’s phenomenon is associated with underlying connective tissue disorders such as scleroderma, rheumatoid arthritis, and systemic lupus erythematosus, among others.
Factors that suggest an underlying connective tissue disease include onset after 40 years, unilateral symptoms, rashes, presence of autoantibodies, and digital ulcers. Management of Raynaud’s phenomenon involves referral to secondary care for patients with suspected secondary Raynaud’s phenomenon. First-line treatment includes calcium channel blockers such as nifedipine. In severe cases, IV prostacyclin (epoprostenol) infusions may be used, and their effects may last for several weeks or months.
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This question is part of the following fields:
- Musculoskeletal
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Question 6
Incorrect
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A 68-year-old man presents to the Emergency Department with worsening abdominal pain over the past two days. The pain started in the lower left side of his abdomen and he has been experiencing diarrhoea. He has a medical history of hypertension, chronic kidney disease, and diverticular disease. On examination, his heart rate is 120 bpm, blood pressure is 135/80 mmHg, temperature is 38.5ºC, and oxygen saturation is 96% on air. His abdomen is tender throughout with involuntary guarding and rebound tenderness. Blood tests reveal the following results:
Hb 140 g/l Na+ 140 mmol/l Bilirubin 9 µmol/l
Platelets 730 * 109/l K+ 4.2 mmol/l ALP 70 u/l
WBC 18.9 * 109/l Urea 6.3 mmol/l ALT 36 u/l
Neuts 16.1 * 109/l Creatinine 115 µmol/l γGT 57 u/l
Lymphs 2.0 * 109/l Amylase 8 u/l Albumin 35 g/l
Which diagnostic test would be most appropriate to confirm the diagnosis?Your Answer: Abdominal x-ray
Correct Answer: Erect chest x-ray
Explanation:To detect bowel perforation, an erect chest x-ray is commonly used. This is particularly useful in cases of suspected perforated diverticulitis, as it can reveal the presence of pneumoperitoneum (air under the diaphragm). A supine chest x-ray is not as effective in detecting this. While an abdominal x-ray can also suggest pneumoperitoneum, it is less sensitive than an erect chest x-ray. An intravenous urogram is not necessary in this case, as the patient’s symptoms do not align with those of ureteric colic, which is the most likely diagnosis. Ultrasound may also reveal air in the abdominal cavity, but its accuracy and image quality can vary greatly, making it a less optimal choice.
An erect chest x-ray is a useful tool for diagnosing an acute abdomen, as it can reveal the presence of free air in the abdomen, also known as pneumoperitoneum. This abnormal finding is indicative of a perforated abdominal viscus, such as a perforated duodenal ulcer. On an abdominal film, Rigler’s sign, also known as the double wall sign, may be visible. However, CT scans are now the preferred method for detecting free air in the abdomen.
The image used on license from Radiopaedia shows an erect chest x-ray with air visible under the diaphragm on both sides. Another image from Radiopaedia demonstrates an abdominal x-ray with numerous loops of small bowel outlined by gas, both within the lumen and free within the peritoneal cavity. Ascites, or fluid in the abdomen, is also visible, with mottled gas densities over bilateral paracolic gutters. In a normal x-ray, only the luminal surface should be visible outlined by gas, while the serosal surface should not be visible as it is normally in contact with other intra-abdominal content of similar density. However, in this case, gas abuts the serosal surface, making it visible. As this film was obtained supine, ascites pools in the paracolic gutters, with fluid mixed in with gas bubbles.
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This question is part of the following fields:
- Surgery
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Question 7
Incorrect
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You are seeing a 67-year-old woman who has recently been diagnosed with urge incontinence. She has tried conservative measures, such as optimizing fluid and caffeine intake and completing six weeks of bladder training, which have helped to some extent. However, her main symptom of nocturia continues to affect her sleep and well-being. She has no other medical history and currently takes no regular medication. What is the next most appropriate treatment?
Your Answer: Botulinum toxin
Correct Answer: Oxybutinin
Explanation:Management Options for Urge Incontinence: Medications, Procedures, and Desmopressin
Urge incontinence is a common condition that can significantly impact a patient’s quality of life. While conservative treatments such as pelvic floor exercises and bladder training are often the first line of management, some patients may require additional interventions. Here are some options for managing urge incontinence:
Oxybutinin: This anticholinergic medication is often used as first-line treatment for urge incontinence that has not responded to conservative measures. It works by inhibiting muscarinic action on acetylcholine receptors, preventing muscle contraction. However, it is contraindicated in certain patients and can cause side effects such as dry mouth and constipation.
Percutaneous sacral nerve stimulation: This procedure involves a small stimulator that delivers stimulation to the sacral nerve, leading to contraction of the external sphincter and pelvic floor muscles. It is reserved for patients who have failed other treatments or cannot perform intermittent self-catheterization.
Augmentation cystoplasty: This surgical procedure is reserved for severe cases of urge incontinence that have not responded to other management options. It involves resecting a segment of the small bowel and suturing it to the bladder to increase its size. However, it is associated with numerous complications and requires follow-up.
Botulinum toxin: This is the first-line invasive management for patients who have not improved on anticholinergic medication or do not want drug therapy. It is injected into the bladder to inhibit the release of acetylcholine and provide symptom relief for up to six months.
Desmopressin: This synthetic analogue of antidiuretic hormone is used as second-line management for nocturia in patients with urge incontinence. It works by signaling the transportation of aquaporins in the collecting ducts of the kidney, leading to water reabsorption and less urine production. However, it is contraindicated in certain patients and can cause side effects such as hyponatremia and fluid retention.
In summary, there are several options for managing urge incontinence, ranging from medications to procedures. It is important to consider the patient’s individual needs and contraindications when selecting a treatment plan.
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This question is part of the following fields:
- Gynaecology
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Question 8
Incorrect
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Perinuclear antineutrophil cytoplasmic antibodies (pANCA) are most commonly associated with which medical condition?
Your Answer: Goodpasture's syndrome
Correct Answer: Churg-Strauss syndrome
Explanation:ANCA Associated Vasculitis: Common Findings and Management
Anti-neutrophil cytoplasmic antibodies (ANCA) are associated with small-vessel vasculitides such as granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, and microscopic polyangiitis. ANCA associated vasculitis is more common in older individuals and presents with renal impairment, respiratory symptoms, systemic symptoms, and sometimes a vasculitic rash or ear, nose, and throat symptoms. First-line investigations include urinalysis, blood tests for renal function and inflammation, ANCA testing, and chest x-ray. There are two main types of ANCA – cytoplasmic (cANCA) and perinuclear (pANCA) – with varying levels found in different conditions. ANCA associated vasculitis should be managed by specialist teams and the mainstay of treatment is immunosuppressive therapy.
ANCA associated vasculitis is a group of small-vessel vasculitides that are associated with ANCA. These conditions are more common in older individuals and present with renal impairment, respiratory symptoms, systemic symptoms, and sometimes a vasculitic rash or ear, nose, and throat symptoms. To diagnose ANCA associated vasculitis, first-line investigations include urinalysis, blood tests for renal function and inflammation, ANCA testing, and chest x-ray. There are two main types of ANCA – cytoplasmic (cANCA) and perinuclear (pANCA) – with varying levels found in different conditions. ANCA associated vasculitis should be managed by specialist teams and the mainstay of treatment is immunosuppressive therapy.
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This question is part of the following fields:
- Musculoskeletal
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Question 9
Incorrect
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Mrs. Smith is a 67-year-old woman who presents with worsening abdominal pain and nausea. She has not had a bowel movement in 5 days.
During examination, her vital signs are as follows: O2 saturation of 97%, respiratory rate of 18, heart rate of 110, and blood pressure of 100/70. She does not have a fever.
Upon palpation of her abdomen, there is significant guarding and she experiences pain when pressure is released. It is suspected that she has peritonism due to bowel obstruction and an urgent abdominal x-ray is ordered.
The x-ray reveals that Mrs. Smith is suffering from large bowel obstruction caused by a sigmoid volvulus. What is the most appropriate course of treatment for her?Your Answer: Insertion of an NG tube and administration of IV fluids
Correct Answer: Urgent laparotomy
Explanation:If a patient with sigmoid volvulus experiences bowel obstruction accompanied by symptoms of peritonitis, it is recommended to forego flexible sigmoidoscopy and opt for urgent midline laparotomy. This is especially important if previous attempts at decompression have failed, if necrotic bowel is observed during endoscopy, or if there is suspicion or confirmation of perforation or peritonitis. Urgent laparotomy is crucial in preventing bowel necrosis or perforation.
Understanding Volvulus: A Condition of Twisted Colon
Volvulus is a medical condition that occurs when the colon twists around its mesenteric axis, leading to a blockage in blood flow and closed loop obstruction. Sigmoid volvulus is the most common type, accounting for around 80% of cases, and is caused by the sigmoid colon twisting on the sigmoid mesocolon. Caecal volvulus, on the other hand, occurs in around 20% of cases and is caused by the caecum twisting. This condition is more common in patients with developmental failure of peritoneal fixation of the proximal bowel.
Sigmoid volvulus is often associated with chronic constipation, Chagas disease, neurological conditions like Parkinson’s disease and Duchenne muscular dystrophy, and psychiatric conditions like schizophrenia. Caecal volvulus, on the other hand, is associated with adhesions, pregnancy, and other factors. Symptoms of volvulus include constipation, abdominal bloating, abdominal pain, and nausea/vomiting.
Diagnosis of volvulus is usually done through an abdominal film, which shows signs of large bowel obstruction alongside the coffee bean sign for sigmoid volvulus. Small bowel obstruction may be seen in caecal volvulus. Management of sigmoid volvulus involves rigid sigmoidoscopy with rectal tube insertion, while caecal volvulus usually requires operative management, with right hemicolectomy often being necessary.
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This question is part of the following fields:
- Surgery
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Question 10
Incorrect
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A 48-year-old woman presented to the general medical clinic with a complaint of progressive diffuse myalgia and weakness that had been ongoing for three months. She reported experiencing difficulty walking up and down stairs due to weakness in her shoulder muscles and thighs. Her medical history included hypertension and hyperlipidemia, for which she took atenolol and simvastatin regularly. On examination, there were no abnormalities in the cranial nerves or detectable neck weakness. However, there was general myalgia in the upper limbs and proximal weakness of 3/5 with preserved distal power. A similar pattern of weakness was observed in the lower limbs with preserved tone, reflexes, and sensation.
The following investigations were conducted: haemoglobin, white cell count, platelets, ESR (Westergren), serum sodium, serum potassium, serum urea, serum creatinine, plasma lactate, serum creatine kinase, fasting plasma glucose, serum cholesterol, plasma TSH, plasma T4, and plasma T3. Urinalysis was normal.
Based on these findings, what is the likely diagnosis?Your Answer: Mitochondrial myopathy
Correct Answer: Statin-induced myopathy
Explanation:Statins and Muscle Disorders
Myalgia, myositis, and myopathy are all known side effects of HMG-CoA reductase inhibitors, commonly known as statins. The risk of these muscle disorders increases when statins are taken in combination with a fibrate or with immunosuppressants. If therapy is not discontinued, rhabdomyolysis may occur, which can lead to acute renal failure due to myoglobinuria. Inclusion body myositis is a type of inflammatory myopathy that causes weakness in a distal and asymmetric pattern. On the other hand, McArdle’s disease is an autosomal recessive condition that typically presents in children with painful muscle cramps and myoglobinuria after intense exercise. This condition is caused by a deficiency in myophosphorylase, which impairs the body’s ability to utilize glucose. There are no additional neurological symptoms to suggest a mitochondrial disorder, and the plasma lactate level is normal. Finally, neuroleptic malignant syndrome is a rare but serious side effect of antipsychotic medication.
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This question is part of the following fields:
- Emergency Medicine
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Question 11
Incorrect
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A 55-year-old woman visits her General Practitioner (GP) with complaints of feeling down for some time. She reports experiencing episodes lasting approximately three minutes where she suddenly becomes very anxious and hyperventilates. Upon further inquiry, the GP discovers that this has been progressively worsening over the past two months. The patient is interested in knowing if there are any medications that could assist her.
What is the mode of action of monoamine oxidase inhibitors?Your Answer: Reduced re-uptake of neurotransmitter
Correct Answer: Build up of neurotransmitter in synaptic cleft
Explanation:Neurotransmitter Effects of Different Medications
Different medications have varying effects on neurotransmitters in the brain. Here are some examples:
Monoamine oxidase inhibitors (MAOIs) are primarily used as antidepressants and can also be used to manage panic attacks and anxiety disorders. They work by inhibiting the activity of enzymes monoamine oxidase A and B found within the synaptic cleft. This results in a reduction in the breakdown of monoamine neurotransmitters such as serotonin, melatonin, adrenaline, and noradrenaline, leading to a build-up of these neurotransmitters within the synaptic cleft.
Benzodiazepines are GABA agonists that bind to GABA receptors in the neurone membrane and potentiate the action of the receptor, increasing conduction of chloride ions across the membrane. This results in membrane hyperpolarisation, making the neurone less likely to fire. This can explain both the analgesic and sedative effects of benzodiazepines.
Stimulant medication such as amphetamines inhibit the re-uptake of dopamine and to a lesser extent noradrenaline and serotonin. Selective serotonin re-uptake inhibitors also inhibit the re-uptake of serotonin. This leads to a reduced re-uptake of neurotransmitters.
Tricyclic antidepressants, some SSRIs, clozapine, and olanzapine are anticholinergic medication that competitively bind to the acetylcholine receptor on the postsynaptic neurone, reducing the amount of acetylcholine binding. This results in an antibody to acetylcholine receptor.
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This question is part of the following fields:
- Pharmacology
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Question 12
Incorrect
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A 5-year-old girl comes to her general practice clinic with her mother. She has been experiencing nasal congestion, sneezing, and a sore throat for the past few days. During the examination, her pulse rate is 80 bpm, respiratory rate is 20 breaths per minute, and temperature is 36.9 °C. She has no significant medical history. What is the probable diagnosis?
Your Answer: Hay fever
Correct Answer: Common cold
Explanation:Possible Diagnosis for a Young Girl with Respiratory Symptoms
A young girl is experiencing respiratory symptoms, including sore throat, sneezing, and nasal congestion. Here are some possible diagnoses to consider:
1. Common cold: This is a common viral infection that can cause mild fever, especially in children.
2. Hay fever: This is an allergic reaction to specific allergens, such as pollen, that can cause similar symptoms to the common cold, but with a chronic and fluctuating course.
3. Infectious mononucleosis: This is a viral infection that can cause fatigue, fever, laryngitis, and a rash, but is less likely in this case.
4. influenzae: This is a seasonal viral infection that can cause more severe symptoms, such as high fever, headache, and muscle aches.
5. Meningitis: This is a serious bacterial infection that can cause non-specific respiratory symptoms, but also tachycardia, hypotension, high fever, photophobia, neck stiffness, and petechial rash, which are not mentioned here.
Possible Diagnoses for a Young Girl with Respiratory Symptoms
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This question is part of the following fields:
- Respiratory
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Question 13
Incorrect
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A 7-year-old girl is brought to the pediatrician's office by her father. She has been experiencing nighttime itching around her bottom and has mentioned to her father that she has seen small white strands moving in her stool. She is not constipated and is generally healthy. No one else in the household has reported similar symptoms. The girl lives with her father and her two-year-old brother.
What should be the next course of action?Your Answer: Mebendazole and hygiene measures for his parents and three-month-old sister
Correct Answer: Mebendazole and hygiene measures for the patient and his parents, as his sister is too young
Explanation:It is recommended to treat asymptomatic household contacts of patients with threadworms, even if they show no symptoms. In the case of this boy with threadworms, the appropriate course of action would be to administer Mebendazole and advise on hygiene measures for both the patient and his parents. It is not necessary to send a sample to the laboratory for confirmation as empirical treatment is recommended. Advising on hygiene and fluid intake alone would not be sufficient to treat the infection. It is important to note that Mebendazole should not be given to children under six months old, so treating the patient’s three-month-old sister is not appropriate. Permethrin is not a suitable treatment for threadworms as it is used to treat scabies.
Threadworm Infestation in Children
Threadworm infestation, caused by Enterobius vermicularis or pinworms, is a common occurrence among children in the UK. The infestation happens when eggs present in the environment are ingested. In most cases, threadworm infestation is asymptomatic, but some possible symptoms include perianal itching, especially at night, and vulval symptoms in girls. Diagnosis can be made by applying Sellotape to the perianal area and sending it to the laboratory for microscopy to see the eggs. However, most patients are treated empirically, and this approach is supported in the CKS guidelines.
The CKS recommends a combination of anthelmintic with hygiene measures for all members of the household. Mebendazole is the first-line treatment for children over six months old, and a single dose is given unless the infestation persists. It is essential to treat all members of the household to prevent re-infection. Proper hygiene measures, such as washing hands regularly, keeping fingernails short, and washing clothes and bedding at high temperatures, can also help prevent the spread of threadworm infestation.
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This question is part of the following fields:
- Paediatrics
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Question 14
Correct
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A 55-year-old man with Tourette's and poorly controlled type 2 diabetes presents to you with concerns about intermittent chest pain on exertion. He drinks 21 units of alcohol per week and smokes 20 cigarettes a day. His father died of a myocardial infarction at the age of 56 years. You refer him for suspected angina, provide advice on worsening chest pain, and prescribe a GTN spray for use as needed. While prescribing the GTN spray, you notice a medication on his prescription list that he should avoid taking while being investigated for chest pain or using the GTN spray. What medication is this referring to?
Your Answer: Sildenafil
Explanation:Sildenafil, a type of PDE 5 inhibitor, should not be used together with nitrates and nicorandil due to potential risks of significant hypotension and myocardial infarction. On the other hand, there are no known interactions between nitrates and metformin, gliclazide, sitagliptin, or atorvastatin according to the BNF.
Understanding Phosphodiesterase Type V Inhibitors
Phosphodiesterase type V (PDE5) inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. These drugs work by increasing the levels of cGMP, which leads to the relaxation of smooth muscles in the blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which was the first drug of its kind. It is a short-acting medication that is usually taken one hour before sexual activity.
Other PDE5 inhibitors include tadalafil (Cialis) and vardenafil (Levitra). Tadalafil is longer-acting than sildenafil and can be taken on a regular basis, while vardenafil has a similar duration of action to sildenafil. However, these drugs are not suitable for everyone. Patients taking nitrates or related drugs, those with hypotension, and those who have had a recent stroke or myocardial infarction should not take PDE5 inhibitors.
Like all medications, PDE5 inhibitors can cause side effects. These may include visual disturbances, blue discolouration, non-arteritic anterior ischaemic neuropathy, nasal congestion, flushing, gastrointestinal side-effects, headache, and priapism. It is important to speak to a healthcare professional before taking any medication to ensure that it is safe and appropriate for you.
Overall, PDE5 inhibitors are an effective treatment for erectile dysfunction and pulmonary hypertension. However, they should only be used under the guidance of a healthcare professional and with careful consideration of the potential risks and benefits.
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This question is part of the following fields:
- Pharmacology
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Question 15
Incorrect
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A 65-year-old woman with known CKD stage 4 due to type 2 diabetes and obesity is admitted with cellulitis that has not responded to oral antibiotics. MRSA is detected in swabs, and she is started on IV vancomycin. She is also taking carbamazepine, omeprazole, warfarin, and chloramphenicol eye drops. Three days later, the laboratory urgently calls to report her vancomycin level is 54 (therapeutic range 10-20), and regular dosing is immediately stopped. What is the most likely cause of her elevated levels?
Your Answer: Interaction with warfarin
Correct Answer: Inadequate renal clearance
Explanation:Vancomycin and its Clearance in CKD Patients
Vancomycin is a drug that is primarily cleared through the kidneys. In patients with stage 4 chronic kidney disease (CKD), the drug may accumulate in the body due to regular dosing in excess of what the kidneys can handle. This can lead to high levels of vancomycin in the bloodstream. However, liver enzyme inhibitors such as omeprazole and carbamazepine do not affect vancomycin clearance. Therefore, they are unlikely to increase the drug levels in the body.
Warfarin, on the other hand, does not affect liver enzymes but may be altered by enzyme inducers or inhibitors. It is important to monitor warfarin levels in patients taking vancomycin to avoid any potential drug interactions. Although obesity may affect the volume of distribution of vancomycin, dosing for normal renal function is unlikely to lead to high levels in obese patients. Overall, it is crucial to consider the patient’s renal function and adjust the vancomycin dose accordingly to prevent toxicity.
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This question is part of the following fields:
- Nephrology
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Question 16
Incorrect
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An older man in his 70s arrives with a caregiver who reports that he has been exhibiting aggressive and withdrawn behavior, and failing to recognize staff members, which is unusual for his typically mild-mannered personality. He has a medical history of hypertension, chronic obstructive pulmonary disease, ischaemic heart disease, benign prostatic hyperplasia, and bilateral knee replacements, but has not previously shown signs of cognitive impairment. Upon examination, he has mild crepitations in his chest and tenderness and distension in the suprapubic region of his abdomen. A digital rectal exam reveals a large, smooth prostate and soft stool in the rectum.
What initial test is most likely to uncover the cause of his delirium?Your Answer: Blood glucose
Correct Answer: Bladder scan
Explanation:In older patients, acute urinary retention can manifest as delirium. This is evident in a man with prostatic hyperplasia who presents with abdominal distension and suprapubic tenderness. An ultrasound scan of his bladder is necessary to confirm the diagnosis and catheterisation can relieve the large volume of urine. While a blood glucose sample is part of a confusion screen, it would not aid in diagnosing acute urinary retention. Similarly, blood cultures and a CT head may not be helpful in this scenario. A chest X-ray may be done due to the patient’s COPD, but it is unlikely to assist in diagnosing acute urinary retention.
Acute urinary retention is a condition where a person suddenly becomes unable to pass urine voluntarily, typically over a period of hours or less. It is a common urological emergency that requires investigation to determine the underlying cause. While it is more common in men, it rarely occurs in women, with an incidence ratio of 13:1. Acute urinary retention is most frequently seen in men over 60 years of age, and the incidence increases with age. It has been estimated that around a third of men in their 80s will develop acute urinary retention over a five-year period.
The most common cause of acute urinary retention in men is benign prostatic hyperplasia, a non-cancerous enlargement of the prostate gland that presses on the urethra, making it difficult for the bladder to empty. Other causes include urethral obstructions, such as strictures, calculi, cystocele, constipation, or masses, as well as certain medications that affect nerve signals to the bladder. In some cases, there may be a neurological cause for the condition. Acute urinary retention can also occur postoperatively and in women postpartum, typically due to a combination of risk factors.
Patients with acute urinary retention typically experience an inability to pass urine, lower abdominal discomfort, and considerable pain or distress. Elderly patients may also present with an acute confusional state. Unlike chronic urinary retention, which is typically painless, acute urinary retention is associated with pain and discomfort. A palpable distended urinary bladder may be detected on abdominal or rectal examination, and lower abdominal tenderness may also be present. All patients should undergo a rectal and neurological examination, and women should also have a pelvic examination.
To confirm the diagnosis of acute urinary retention, a bladder ultrasound should be performed. The bladder volume should be greater than 300 cc to confirm the diagnosis, but if the history and examination are consistent with acute urinary retention, an inconsistent bladder scan does not rule out the condition. Acute urinary retention is managed by decompressing the bladder via catheterisation. Further investigation should be targeted by the likely cause, and patients may require IV fluids to correct any temporary over-diuresis that may occur as a complication.
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This question is part of the following fields:
- Surgery
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Question 17
Correct
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A 19-year-old woman is admitted to the hospital three days after becoming confused, disoriented, and having an unsteady gait. During the past four months she has been depressed and has declined food. She has lost approximately 12 kg in weight.
She appears thin and is disoriented in time and place. She reports having double vision. Neither eye abducts normally. Her gait is unsteady although the limbs are strong. The liver and spleen are not enlarged.
What would be the most appropriate initial step in her treatment?Your Answer: Intravenous thiamine
Explanation:Wernicke’s Encephalopathy
Wernicke’s encephalopathy is a sudden neurological disorder caused by a deficiency of thiamine, a vital nutrient. It is characterized by a triad of symptoms, including acute mental confusion, ataxia, and ophthalmoplegia. The oculomotor findings associated with this condition include bilateral weakness of abduction, gaze evoked nystagmus, internuclear ophthalmoplegia, and vertical nystagmus in the primary position.
Wernicke’s encephalopathy is commonly linked to chronic alcohol abuse, but it can also occur in individuals with poor nutritional states, such as those with dialysis, advanced malignancy, AIDS, and malnutrition. Urgent treatment is necessary and involves administering 100 mg of fresh thiamine intravenously, followed by 50-100 mg daily. It is crucial to give IV/IM thiamine before treating with IV glucose solutions, as glucose infusions may trigger Wernicke’s disease or acute cardiovascular beriberi in previously unaffected patients or worsen an early form of the disease.
In summary, Wernicke’s encephalopathy is a serious neurological disorder that requires prompt treatment. It is essential to recognize the symptoms and underlying causes of this condition to prevent further complications. Early intervention with thiamine supplementation can help improve outcomes and prevent the progression of the disease.
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This question is part of the following fields:
- Neurology
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Question 18
Correct
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A 16-year-old patient is brought into the emergency department by her friends at 2 am, following a night out. Her friends are worried as she is sweating excessively and is extremely disoriented. They also mention she has become jerky and rigid over the last 30 minutes. Upon further questioning, they reveal that the patient has used recreational drugs.
During the examination, the patient's temperature is found to be 38.4ºC and she remains disorientated. Her medical history includes depression and hypothyroidism, for which she takes fluoxetine and levothyroxine. Based on the symptoms, what is the likely cause of this presentation?Your Answer: MDMA
Explanation:The combination of SSRIs and MDMA can lead to a higher risk of serotonin syndrome. In this case, the patient is likely experiencing serotonin syndrome due to their prescription of fluoxetine and symptoms of hyperthermia, confusion, muscle rigidity, and myoclonus. MDMA is an illegal substance that is known to increase the risk of serotonin syndrome, making it the correct answer. Cannabis, cocaine, heroin, and paracetamol are all incorrect as they do not increase the risk of serotonin syndrome. Other drugs that do increase the risk include St. Johns Wort, monoamine oxidase inhibitors, tramadol, SSRIs, and amphetamines.
Understanding Serotonin Syndrome
Serotonin syndrome is a potentially life-threatening condition caused by an excess of serotonin in the body. It can be triggered by a variety of medications and substances, including monoamine oxidase inhibitors, SSRIs, St John’s Wort, tramadol, ecstasy, and amphetamines. The condition is characterized by neuromuscular excitation, hyperreflexia, myoclonus, rigidity, autonomic nervous system excitation, hyperthermia, sweating, and altered mental state, including confusion.
Management of serotonin syndrome is primarily supportive, with IV fluids and benzodiazepines used to manage symptoms. In more severe cases, serotonin antagonists such as cyproheptadine and chlorpromazine may be used. It is important to note that serotonin syndrome can be easily confused with neuroleptic malignant syndrome, which has similar symptoms but is caused by a different mechanism. Both conditions can cause a raised creatine kinase (CK), but it tends to be more associated with NMS. Understanding the causes, features, and management of serotonin syndrome is crucial for healthcare professionals to ensure prompt and effective treatment.
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This question is part of the following fields:
- Pharmacology
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Question 19
Incorrect
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A 25-year-old woman, a known type 1 diabetic, was asked to attend the General Practice (GP) Surgery for her results in the diabetic retinopathy screening.
You asked your GP supervisor if you can examine her eyes so that you can get signed off for using a direct ophthalmoscope. You found out that she had some dot-and-blot haemorrhages in her right eye with some venous looping and beading in the peripheral retina.
What is the next step in management for this patient's eye condition?Your Answer: Fast-track referral to ophthalmology
Correct Answer: Routine referral to ophthalmology
Explanation:Appropriate Management Plan for Pre-Proliferative Diabetic Retinopathy
Pre-proliferative diabetic retinopathy requires routine referral to ophthalmology as the appropriate management plan. The waiting time for this referral is usually less than 13 weeks. Observation every 4-6 months is the usual management plan, and pan-retinal photocoagulation is only necessary in selected cases, such as in the only eye where the first eye was lost to proliferative diabetic retinopathy or prior to cataract surgery. Referring to an optometrist for a regular eye test is not appropriate for any type of diabetic retinopathy. Annual screening is only appropriate if there is none or background retinopathy. Fast-track referral to ophthalmology is only necessary if there are signs of proliferative retinopathy. Pan-retinal laser photocoagulation is not necessary in pre-proliferative retinopathy and is not the immediate next step in management.
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This question is part of the following fields:
- Ophthalmology
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Question 20
Correct
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A 25-year-old woman visits her GP with complaints of mild abdominal pain and vaginal bleeding. She is currently 6 weeks pregnant and is otherwise feeling well. On examination, she is tender in the right iliac fossa and has a small amount of blood in the vaginal vault with a closed cervical os. There is no cervical excitation. Her vital signs are stable, with a blood pressure of 120/80 mmHg, heart rate of 80 bpm, temperature of 36.5ºC, saturations of 99% on air, and respiratory rate of 14 breaths/minute. A urine dip reveals blood only, and a urinary pregnancy test is positive. What is the most appropriate course of action?
Your Answer: Refer for immediate assessment at the Early Pregnancy Unit
Explanation:A woman with a positive pregnancy test and abdominal, pelvic or cervical motion tenderness should be immediately referred for assessment due to the risk of an ectopic pregnancy. Arranging an outpatient ultrasound or reassuring the patient is not appropriate. Urgent investigation is necessary to prevent the risk of rupture. Expectant management may be appropriate for a woman with vaginal bleeding and no pain or tenderness, but not for this patient who has both.
Bleeding in the First Trimester: Understanding the Causes and Management
Bleeding in the first trimester of pregnancy is a common concern for many women. It can be caused by various factors, including miscarriage, ectopic pregnancy, implantation bleeding, cervical ectropion, vaginitis, trauma, and polyps. However, the most important cause to rule out is ectopic pregnancy, as it can be life-threatening if left untreated.
To manage early bleeding, the National Institute for Health and Care Excellence (NICE) released guidelines in 2019. If a woman has a positive pregnancy test and experiences pain, abdominal tenderness, pelvic tenderness, or cervical motion tenderness, she should be referred immediately to an early pregnancy assessment service. If the pregnancy is over six weeks gestation or of uncertain gestation and the woman has bleeding, she should also be referred to an early pregnancy assessment service.
A transvaginal ultrasound scan is the most important investigation to identify the location of the pregnancy and whether there is a fetal pole and heartbeat. If the pregnancy is less than six weeks gestation and the woman has bleeding but no pain or risk factors for ectopic pregnancy, she can be managed expectantly. However, she should be advised to return if bleeding continues or pain develops and to repeat a urine pregnancy test after 7-10 days and to return if it is positive. A negative pregnancy test means that the pregnancy has miscarried.
In summary, bleeding in the first trimester of pregnancy can be caused by various factors, but ectopic pregnancy is the most important cause to rule out. Early referral to an early pregnancy assessment service and a transvaginal ultrasound scan are crucial in identifying the location of the pregnancy and ensuring appropriate management. Women should also be advised to seek medical attention if they experience any worrying symptoms or if bleeding or pain persists.
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This question is part of the following fields:
- Obstetrics
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Question 21
Correct
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A 32-year-old, G2P1, presents to the obstetrics assessment unit with vaginal bleeding and mild abdominal pain at 15 weeks gestation. What aspect of her medical history would raise concern for a possible miscarriage?
Your Answer: Large cervical cone biopsy
Explanation:There are several factors that can increase the risk of miscarriage, including age, previous miscarriages, chronic conditions, uterine or cervical problems (such as large cervical cone biopsies or Mullerian duct anomalies), smoking, alcohol and illicit drug use, and weight. Invasive prenatal tests like chorionic villus sampling and amniocentesis also carry a slight risk of miscarriage. It’s important to note that other options are not considered risk factors for 2nd-trimester miscarriage.
Miscarriage: Understanding the Epidemiology
Miscarriage, also known as abortion, refers to the expulsion of the products of conception before 24 weeks. To avoid any confusion, the term miscarriage is often used. According to epidemiological studies, approximately 15-20% of diagnosed pregnancies will end in miscarriage during early pregnancy. In fact, up to 50% of conceptions may not develop into a blastocyst within 14 days.
Recurrent spontaneous miscarriage, which is defined as the loss of three or more consecutive pregnancies, affects approximately 1% of women. Understanding the epidemiology of miscarriage is important for healthcare providers and patients alike. It can help to identify risk factors and provide appropriate counseling and support for those who have experienced a miscarriage. By raising awareness and promoting education, we can work towards reducing the incidence of miscarriage and improving the overall health and well-being of women and their families.
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This question is part of the following fields:
- Obstetrics
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Question 22
Correct
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remove
Your Answer: 8.90%
Explanation:Calculating Positive Predictive Value Using a Contingency Table
When analyzing screening test results, a contingency table can be useful. Sensitivity and specificity can be calculated from this table, but this question specifically asks for the positive predictive value. This value represents the proportion of individuals with a positive test result who actually have the disease. To calculate this value, the formula a/(a + b) is used, where a is the number of true positives and b is the number of false positives. By knowing the prevalence, sensitivity, specificity, and population size, the contingency table can be completed and the positive predictive value can be calculated. An overestimation of this value can lead to incorrect diagnoses and treatment.
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This question is part of the following fields:
- Statistics
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Question 23
Incorrect
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A 50-year-old man comes to the emergency department complaining of high fever and severe pain in the upper abdomen. He appears disheveled and admits to consuming 50 units of alcohol per week. Despite experiencing symptoms for two days, he delayed seeking medical attention due to a fear of hospitals. What is the most appropriate test to order for the most probable diagnosis?
Your Answer: Amylase
Correct Answer: Lipase
Explanation:Serum lipase is more useful than amylase for diagnosing acute pancreatitis in late presentations (>24 hours). This patient’s lipase level is >3 times normal, confirming the diagnosis. Ultrasound can investigate for bile duct stones, but CT scans are not used for diagnosis.
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.
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This question is part of the following fields:
- Surgery
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Question 24
Correct
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A 25-year-old veterinary student is being evaluated for possible Addison's disease due to symptoms of weight loss, hypotension, and fatigue. As part of the diagnostic process, the patient undergoes testing to measure cortisol levels before and after receiving synthetic adrenocorticotropic hormone (ACTH) injection (short-synacthen test). What is a true statement regarding cortisol in this scenario?
Your Answer: It has a peak hormonal concentration in the morning
Explanation:Misconceptions about Cortisol: Clarifying the Facts
Cortisol is a hormone that has been the subject of many misconceptions. Here are some clarifications to set the record straight:
1. Peak Hormonal Concentration: Cortisol has a diurnal variation and peaks in the morning upon waking up. Its lowest level is around midnight.
2. Protein or Steroid: Cortisol is a steroid hormone, not a protein.
3. Blood Glucose: Cortisol increases blood glucose levels via various pathways, contrary to the belief that it lowers blood glucose.
4. Anabolic or Catabolic: Cortisol is a catabolic hormone that causes a breakdown of larger molecules to smaller molecules.
5. Stimulated by Renin or ACTH: Cortisol is stimulated by adrenocorticotropic hormone (ACTH) released from the anterior pituitary, not renin.
By understanding the true nature of cortisol, we can better appreciate its role in our bodies and how it affects our health.
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This question is part of the following fields:
- Endocrinology
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Question 25
Correct
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A 35-year-old male with a history of daily alcohol consumption for the last five years is admitted to the hospital emergency room. He is experiencing acute visual hallucinations, seeing spiders all around him, and is unable to recognize his family members. He is also exhibiting aggressive behavior and tremors. The patient had stopped drinking alcohol for two days prior to admission. On examination, he has a blood pressure of 170/100 mmHg, tremors, increased psychomotor activity, fearful affect, hallucinatory behavior, disorientation, impaired judgment, and insight. What is the most likely diagnosis?
Your Answer: Delirium tremens
Explanation:Delirium Tremens
Delirium tremens (DT) is a severe and potentially life-threatening condition that can occur when someone abruptly stops drinking alcohol. Symptoms can begin within a few hours of cessation, but they may not peak until 48-72 hours later. The symptoms of DT can include tremors, irritability, insomnia, nausea and vomiting, hallucinations (auditory, visual, or olfactory), confusion, delusions, severe agitation, and seizures. Physical findings may be non-specific and include tachycardia, hyperthermia, hypertension, tachypnea, diaphoresis, tremor, mydriasis, ataxia, altered mental status, hallucinations, and cardiovascular collapse.
It is important to note that not everyone who stops drinking alcohol will experience DT. However, those who have a history of heavy alcohol use or have experienced withdrawal symptoms in the past are at a higher risk. DT can be a medical emergency and requires immediate treatment.
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This question is part of the following fields:
- Psychiatry
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Question 26
Incorrect
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A 60-year-old woman with localised breast cancer is considering starting tamoxifen therapy. She has a history of well-controlled hypertension (on amlodipine) and underwent a total hysterectomy with bilateral salpingo-oophorectomy 3 years ago. What is the most crucial aspect for the woman to be informed about regarding the proposed treatment?
Your Answer: Increased risk of osteoporosis
Correct Answer: Increased risk of venous thromboembolism
Explanation:Tamoxifen therapy is known to increase the risk of venous thromboembolism, a condition where blood clots form in the veins and can potentially travel to the lungs, causing serious complications. Tamoxifen is commonly used in the treatment of oestrogen receptor-positive breast cancer, as it selectively blocks oestrogen from binding to receptors in breast tissue, reducing the risk of cancer recurrence. However, tamoxifen is believed to have oestrogen-like effects in other parts of the body, which can increase the risk of venous thromboembolism.
It is important to note that tamoxifen therapy does not increase cholesterol levels, but may actually decrease total serum cholesterol, particularly low-density lipoproteins (LDLs). Tamoxifen is also not associated with an increased risk of osteoporosis, as it is believed to have a protective effect on bone tissue.
While tamoxifen is known to increase the risk of endometrial cancer, this risk is not relevant in patients who have had a total hysterectomy, as in the case of this patient. Similarly, the risk of ovarian cancer is not a major concern in this patient, as she has had her ovaries removed during her previous surgery. However, it is important to counsel the patient on the increased risk of venous thromboembolism associated with tamoxifen therapy.
Tamoxifen: A SERM for Breast Cancer Management
Tamoxifen is a medication that belongs to the class of Selective oEstrogen Receptor Modulators (SERMs). It works by acting as an antagonist to the oestrogen receptor while also partially agonizing it. This medication is commonly used in the management of breast cancer that is positive for oestrogen receptors. However, tamoxifen can cause some adverse effects such as menstrual disturbances like vaginal bleeding and amenorrhoea, hot flashes, venous thromboembolism, and endometrial cancer. Climacteric side-effects are also common, with 3% of patients stopping tamoxifen due to this reason. Typically, tamoxifen is used for five years after the removal of the tumour. For those who are at risk of endometrial cancer, raloxifene is a better option as it is a pure oestrogen receptor antagonist and carries a lower risk of endometrial cancer.
Overall, tamoxifen is a useful medication for the management of breast cancer that is positive for oestrogen receptors. However, it is important to be aware of the potential adverse effects that it can cause. Patients who experience any of these side-effects should consult their healthcare provider. Additionally, for those who are at risk of endometrial cancer, raloxifene may be a better option to consider.
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This question is part of the following fields:
- Pharmacology
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Question 27
Incorrect
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A 29-year-old woman presents to the clinic with concerns about her pregnancy. She is currently at 30 weeks gestation and reports that her pregnancy has been going smoothly thus far. However, over the past few days, she has noticed a decrease in fetal movement. She denies any recent illnesses or feeling unwell and has no significant medical history. On obstetric abdominal examination, there are no notable findings and the patient appears to be in good health. What is the recommended initial management in this case?
Your Answer: Cardiotocography for 20 minutes
Correct Answer: Handheld Doppler
Explanation:When a pregnant woman reports reduced fetal movements after 28 weeks of gestation, the first step recommended by the RCOG guidelines is to use a handheld Doppler to confirm the fetal heartbeat. If the heartbeat cannot be detected, an ultrasound should be offered immediately. However, if a heartbeat is detected, cardiotocography should be used to monitor the heart rate for 20 minutes. Fetal blood sampling is not necessary in this situation. Referral to a fetal medicine unit would only be necessary if no movements had been felt by 24 weeks.
Understanding Reduced Fetal Movements
Introduction:
Reduced fetal movements can indicate fetal distress and are a response to chronic hypoxia in utero. This can lead to stillbirth and fetal growth restriction. It is believed that placental insufficiency may also be linked to reduced fetal movements.Physiology:
Quickening is the first onset of fetal movements, which usually occurs between 18-20 weeks gestation and increases until 32 weeks gestation. Multiparous women may experience fetal movements sooner. Fetal movements should not reduce towards the end of pregnancy. There is no established definition for what constitutes reduced fetal movements, but less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) is an indication for further assessment.Epidemiology:
Reduced fetal movements affect up to 15% of pregnancies, with 3-5% of pregnant women having recurrent presentations with RFM. Fetal movements should be established by 24 weeks gestation.Risk factors for reduced fetal movements:
Posture, distraction, placental position, medication, fetal position, body habitus, amniotic fluid volume, and fetal size can all affect fetal movement awareness.Investigations:
Fetal movements are usually based on maternal perception, but can also be objectively assessed using handheld Doppler or ultrasonography. Investigations are dependent on gestation at onset of RFM. If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used.Prognosis:
Reduced fetal movements can represent fetal distress, but in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication. However, between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis. Recurrent RFM requires further investigations to consider structural or genetic fetal abnormalities. -
This question is part of the following fields:
- Obstetrics
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Question 28
Incorrect
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A 2-year-old girl is brought to the emergency department by her father due to pain in her left hip and a new limp. She has no past medical history except for a recent cold she had 2 weeks ago, from which she has recovered. There is no history of trauma to the hip. Her developmental milestones have been normal so far.
Upon examination, she is not running a fever. She tolerates slight movement of her left hip, but excessive motion causes her to cry.
The following investigations were conducted:
- Hemoglobin (Hb) level: 125 g/L (normal range for females: 110-140)
- Platelet count: 220 * 109/L (normal range: 150 - 400)
- White blood cell (WBC) count: 9.5 * 109/L (normal range: 4.0 - 11.0)
What is the most appropriate next step in managing this patient?Your Answer: Refer for urgent ultrasound of the hip
Correct Answer: Refer for urgent paediatric assessment
Explanation:It is important to arrange urgent assessment for a child under 3 years old who presents with an acute limp. Referral for urgent paediatric assessment is the correct course of action, as transient synovitis is rare in this age group and septic arthritis is more common. Rest and analgesia should not be recommended, as further investigations are needed to rule out septic arthritis, which may involve an ultrasound or synovial fluid aspirate. Referral for an urgent MRI or X-ray of the hip is also not appropriate at this stage, as these investigations would be considered by a paediatrician after an initial urgent assessment.
Causes of Limping in Children
Limping in children can be caused by various factors, which may differ depending on the child’s age. One possible cause is transient synovitis, which has an acute onset and is often accompanied by viral infections. This condition is more common in boys aged 2-12 years. On the other hand, septic arthritis/osteomyelitis may cause a child to feel unwell and have a high fever. Juvenile idiopathic arthritis may cause a painless limp, while trauma can usually be diagnosed through the child’s history. Development dysplasia of the hip is usually detected in neonates and is six times more common in girls. Perthes disease, which is due to avascular necrosis of the femoral head, is more common in children aged 4-8 years. Finally, slipped upper femoral epiphysis may occur in children aged 10-15 years and is characterized by the displacement of the femoral head epiphysis postero-inferiorly. It is important to identify the cause of a child’s limp in order to provide appropriate treatment and prevent further complications.
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This question is part of the following fields:
- Paediatrics
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Question 29
Incorrect
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A 45-year-old man comes to the eye clinic complaining of bilateral redness around the corneal limbus. He has been experiencing this for one day and is in a lot of pain, particularly when reading the newspaper. He also reports sensitivity to light and blurry vision. Additionally, he has a headache that is affecting his entire head and back pain that is more severe in the morning but improves throughout the day.
During the examination, the patient's pupils are fixed and small, with an oval shape. There is no hypopyon, but his eyes are very watery.
What is the most appropriate course of action for managing this patient's symptoms?Your Answer: Steroid eye drops
Correct Answer: Steroid and cycloplegic eye drops
Explanation:The recommended treatment for anterior uveitis is a combination of steroid and cycloplegic (mydriatic) eye drops. This patient exhibits typical symptoms of anterior uveitis, which may be caused by a systemic condition like ankylosing spondylitis. The patient experiences pain, redness, watering, blurry vision, and small, fixed, oval-shaped pupils in both eyes around the corneal limbus. Although hypopyon may not always be present, the patient’s back pain that improves throughout the day may suggest ankylosing spondylitis. Steroid and cycloplegic eye drops are the appropriate treatment options. Cyclopentolate helps relieve pain caused by muscle spasms controlling the pupil and prevents the formation of synechiae that may affect the pupils function. Steroids help treat the underlying inflammation. Bilateral laser iridotomy is not suitable for this patient, as it is most appropriate for acute closed-angle glaucoma. High flow oxygen and sumatriptan may seem like a possible treatment for cluster headaches due to the patient’s lacrimation, red eyes, and headache, but this presentation is more consistent with anterior uveitis. Topical sodium cromoglicate is not appropriate for this patient, as it is used to treat allergic conjunctivitis, which typically presents with watery, red, itchy eyes in patients with a history of atopy.
Anterior uveitis, also known as iritis, is a type of inflammation that affects the iris and ciliary body in the front part of the uvea. It is a common cause of red eye and is associated with HLA-B27, which may also be linked to other conditions. Symptoms of anterior uveitis include sudden onset of eye discomfort and pain, small or irregular pupils, intense sensitivity to light, blurred vision, redness, tearing, and the presence of pus and inflammatory cells in the front part of the eye. This condition may be associated with ankylosing spondylitis, reactive arthritis, ulcerative colitis, Crohn’s disease, Behcet’s disease, and sarcoidosis. Urgent review by an ophthalmologist is necessary, and treatment may involve the use of cycloplegics and steroid eye drops.
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This question is part of the following fields:
- Ophthalmology
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Question 30
Correct
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A 28-year-old G3P2 woman at 32 weeks gestation presents to the emergency department with sudden and severe lower abdominal pain that started 45 minutes ago. She reports a small amount of vaginal bleeding but her baby is still active, although movements are slightly reduced. She has had regular antenatal care and her medical history is unremarkable, except for a 10 pack-year smoking history. Her two previous children were born vaginally and are healthy at ages 4 and 6.
The patient is alert and oriented but in significant pain. Her vital signs are within normal limits except for a blood pressure of 150/95 mmHg and a heart rate of 120 beats per minute. A cardiotocograph shows a normal baseline fetal heart rate with appropriate accelerations and no decelerations.
What is the most likely diagnosis and what is the next appropriate step in management?Your Answer: Admit the mother and administer steroids
Explanation:It is likely that the patient is experiencing placental abruption, which is a medical emergency. The severity of the abruption and the risks to both the mother and the baby determine the management approach. This patient has risk factors such as chronic hypertension and smoking. Steroids should be administered to assist in fetal lung development if the fetus is alive, less than 36 weeks, and not in distress. The patient’s vital signs are stable, but the volume of vaginal bleeding may not accurately reflect the severity of the bleed. The fetal status is assessed using a cardiotocograph, which indicates whether the fetus is receiving adequate blood and nutrients from the placenta. Expectant management is not appropriate, and intervention is necessary to increase the chances of a positive outcome. Immediate caesarean section is only necessary if the fetus is in distress or if the mother is experiencing significant blood loss. Vaginal delivery is only appropriate if the fetus has died in utero, which is not the case here.
Placental Abruption: Causes, Management, and Complications
Placental abruption is a condition where the placenta separates from the uterine wall, leading to maternal haemorrhage. The severity of the condition depends on the extent of the separation and the gestational age of the fetus. Management of placental abruption is crucial to prevent maternal and fetal complications.
If the fetus is alive and less than 36 weeks, immediate caesarean delivery is recommended if there is fetal distress. If there is no fetal distress, close observation, administration of steroids, and no tocolysis are recommended. The decision to deliver depends on the gestational age of the fetus. If the fetus is alive and more than 36 weeks, immediate caesarean delivery is recommended if there is fetal distress. If there is no fetal distress, vaginal delivery is recommended. If the fetus is dead, vaginal delivery should be induced.
Placental abruption can lead to various maternal complications, including shock, disseminated intravascular coagulation (DIC), renal failure, and postpartum haemorrhage (PPH). Fetal complications include intrauterine growth restriction (IUGR), hypoxia, and death. The condition is associated with a high perinatal mortality rate and is responsible for 15% of perinatal deaths.
In conclusion, placental abruption is a serious condition that requires prompt management to prevent maternal and fetal complications. Close monitoring and timely intervention can improve the prognosis for both the mother and the baby.
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This question is part of the following fields:
- Obstetrics
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