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Question 1
Incorrect
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An 80-year-old man comes to the clinic with a complaint of worsening voiding-predominant lower urinary tract symptoms for the past year, including poor flow, hesitancy, and terminal dribbling. There are no red flag features. The patient's international prostate symptom score is 15, and prostate examination reveals a slightly enlarged, smooth prostate. Urine dipstick results are normal, and blood tests show normal renal function and a normal prostate-specific antigen level.
What is the most appropriate class of medication to consider starting for this patient?Your Answer: 5-alpha reductase inhibitors
Correct Answer: Alpha-1 antagonists
Explanation:For patients with troublesome symptoms of benign prostatic hyperplasia, alpha-1 antagonists are the first-line medication to consider. This is particularly true for patients with predominantly voiding symptoms, such as the patient in this case who has an IPPS of 15. Alpha-1 agonists like tamsulosin and alfuzosin are recommended for patients with moderate-to-severe voiding symptoms (IPSS ≥ 8) and are likely to provide relief for this patient’s symptoms.
On the other hand, 5-alpha reductase inhibitors are only indicated for patients with significantly enlarged prostates, which is not the case for this patient. Therefore, they are not appropriate for him at this time. Similarly, anti-muscarinic medication is only recommended for patients with a combination of storage and voiding symptoms that persist after treatment with an alpha-blocker alone. Since this patient only reports voiding symptoms and is not currently on any treatment, this class of medication is not indicated for him.
Finally, GnRH analogues are commonly used in prostate cancer treatment, but they have been found to have a poor side effect profile when used for benign prostatic hypertrophy. As a result, they are not appropriate for this patient.
Benign prostatic hyperplasia (BPH) is a common condition that affects older men, with around 50% of 50-year-old men showing evidence of BPH and 30% experiencing symptoms. The risk of BPH increases with age, with around 80% of 80-year-old men having evidence of the condition. BPH typically presents with lower urinary tract symptoms (LUTS), which can be categorised into voiding symptoms (obstructive) and storage symptoms (irritative). Complications of BPH can include urinary tract infections, retention, and obstructive uropathy.
Assessment of BPH may involve dipstick urine tests, U&Es, and PSA tests. A urinary frequency-volume chart and the International Prostate Symptom Score (IPSS) can also be used to assess the severity of LUTS and their impact on quality of life. Management options for BPH include watchful waiting, alpha-1 antagonists, 5 alpha-reductase inhibitors, combination therapy, and surgery. Alpha-1 antagonists are considered first-line treatment for moderate-to-severe voiding symptoms, while 5 alpha-reductase inhibitors may be indicated for patients with significantly enlarged prostates and a high risk of progression. Combination therapy and antimuscarinic drugs may also be used in certain cases. Surgery, such as transurethral resection of the prostate (TURP), may be necessary in severe cases.
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This question is part of the following fields:
- Surgery
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Question 2
Incorrect
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An 80-year-old man arrives at the emergency department with lower gastrointestinal bleeding. He has a history of alcohol abuse but no other medical issues. Upon examination, you observe abdominal distension, splenomegaly, visible veins on the abdominal wall, and bright red blood per rectum. His blood pressure is 120/64 mmHg, his pulse is 100 bpm, and his oxygen saturation is 98% on air. Blood tests reveal the following results: ALP 405 u/L (30 - 100), ALT 95 u/L (3 - 40), and Albumin 31 g/L (35 - 50). Based on these findings, what is the most likely diagnosis?
Your Answer: Rectal cancer
Correct Answer: Rectal varices
Explanation:In patients with portal hypertension and lower gastrointestinal bleeding, it is important to consider rectal varices as a possible cause. This was the case for the patient in question, who presented with typical signs of portal hypertension, including ascites, splenomegaly, and caput medusae. The most common cause of portal hypertension is cirrhosis, which was indicated by the patient’s blood test results and history of alcohol abuse. However, it is important to note that liver function tests (LFTs) can be normal in patients with cirrhosis.
Rectal varices are a likely cause of lower gastrointestinal bleeding in patients with portal hypertension, as they can cause swelling of the veins in the anorectal region. While haemorrhoids are a possibility, they are less likely in this case as the patient did not report any associated symptoms. Rectal examination would still be necessary to rule out haemorrhoids, as they can also be asymptomatic.
Rectal cancer is unlikely as the patient did not exhibit any signs or symptoms suggestive of malignancy. However, rectal examination would still be necessary to exclude this possibility, as lower GI bleeding is a red flag symptom.
The patient did not have a history of bleeding problems, and his symptoms were not suggestive of a bleeding disorder. However, it is important to note that prothrombin time (PT) can provide useful information on liver function. A high PT indicates that the liver is not producing enough blood clotting proteins, which can be a sign of liver damage or cirrhosis.
Understanding Lower Gastrointestinal Bleeding
Lower gastrointestinal bleeding, also known as colonic bleeding, is characterized by the presence of bright red or dark red blood in the rectum. Unlike upper gastrointestinal bleeding, colonic bleeding rarely presents as melaena type stool. This is because blood in the colon has a powerful laxative effect and is rarely retained long enough for transformation to occur. Additionally, the digestive enzymes present in the small bowel are not present in the colon. It is important to note that up to 15% of patients presenting with hematochezia will have an upper gastrointestinal source of haemorrhage.
Right-sided bleeds tend to present with darker coloured blood than left-sided bleeds. Haemorrhoidal bleeding, on the other hand, typically presents as bright red rectal bleeding that occurs post defecation either onto toilet paper or into the toilet pan. However, it is very unusual for haemorrhoids alone to cause any degree of haemodynamic compromise.
There are several causes of lower gastrointestinal bleeding, including colitis, diverticular disease, cancer, and angiodysplasia. The management of lower gastrointestinal bleeding involves prompt correction of any haemodynamic compromise. Unlike upper gastrointestinal bleeding, the first-line management is usually supportive. When haemorrhoidal bleeding is suspected, a proctosigmoidoscopy is reasonable as attempts at full colonoscopy are usually time-consuming and often futile. In the unstable patient, the usual procedure would be an angiogram, while in others who are more stable, a colonoscopy in the elective setting is the standard procedure. Surgery may be necessary in some cases, particularly in patients over 60 years, those with continued bleeding despite endoscopic intervention, and those with recurrent bleeding.
In summary, lower gastrointestinal bleeding is a serious condition that requires prompt attention. It is important to identify the cause of the bleeding and manage it accordingly to prevent further complications.
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This question is part of the following fields:
- Surgery
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Question 3
Incorrect
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A 27-year-old man presents with a 6-month history of depressed mood. He reports feeling fatigued and having suicidal thoughts on a daily basis. His appearance is disheveled and he has made multiple suicide attempts in the past few months. The psychiatrist decides to initiate electroconvulsive therapy (ECT) for his depression, scheduled to begin in a week. The patient is currently taking 100 mg of sertraline daily. What is the appropriate course of action regarding his medication prior to ECT treatment?
Your Answer: Stop the sertraline completely
Correct Answer: Reduce the sertraline daily dose
Explanation:Before commencing ECT treatment, it is important to reduce the dosage of antidepressant medication, but not to stop it completely. The recommended approach is to gradually decrease the dosage to the minimum level. In some cases, an increased dosage of antidepressants may be added towards the end of the ECT course. It is not advisable to increase the dosage or discontinue the medication altogether. Switching to an alternative psychiatric drug, such as another SSRI or lithium, is also not recommended as it can be risky before ECT treatment.
Electroconvulsive therapy (ECT) is a viable treatment option for patients who suffer from severe depression that does not respond to medication, such as catatonia, or those who experience psychotic symptoms. The only absolute contraindication for ECT is when a patient has raised intracranial pressure.
Short-term side effects of ECT include headaches, nausea, short-term memory impairment, memory loss of events prior to the therapy, and cardiac arrhythmia. However, these side effects are typically temporary and resolve quickly.
Long-term side effects of ECT are less common, but some patients have reported impaired memory. It is important to note that the benefits of ECT often outweigh the potential risks, and it can be a life-changing treatment for those who have not found relief from other forms of therapy.
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This question is part of the following fields:
- Psychiatry
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Question 4
Incorrect
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A study comparing contrast CT colonography with colonoscopy as the reference technique for detecting large bowel carcinoma was conducted on 500 patients. The data obtained is as follows:
Investigation CT Positive CT Negative
Colonoscopy positive 40 15
Colonoscopy negative 25 420
What is the most accurate description of the performance of CT versus colonoscopy for diagnosing large bowel cancer?Your Answer: There are 340 false negatives
Correct Answer: There are 20 false positives
Explanation:Evaluating CT Colonography as a Test for Bowel Cancer
Colonoscopy is currently the reference standard for detecting bowel cancer. However, CT colonography is a new test being evaluated for its effectiveness in identifying the disease. In a study of 400 patients, 40 were found to have bowel cancer through colonoscopy. Of these 40, CT scanning correctly identified 30 (true positives) but missed 10 (false negatives). On the other hand, out of the 360 patients without the disease, CT scanning identified 20 as having cancer (false positives), while the remaining 340 were correctly identified as not having the disease (true negatives).
This information can be better visualized through a table, where the new test (CT colonography) is compared to the reference standard (colonoscopy). The table shows that out of the 40 patients with bowel cancer, CT scanning correctly identified 30 (true positives) but missed 10 (false negatives). Meanwhile, out of the 360 patients without the disease, CT scanning incorrectly identified 20 as having cancer (false positives), while the remaining 340 were correctly identified as not having the disease (true negatives). This study aims to evaluate the effectiveness of CT colonography as a test for bowel cancer and determine if it can be a viable alternative to colonoscopy.
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This question is part of the following fields:
- Clinical Sciences
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Question 5
Incorrect
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A 68-year-old man with a history of uncontrolled hypertension experiences painful swelling in his right knee after starting a new medication prescribed by his GP. What is the most conclusive test to confirm his diagnosis?
The definitive investigation to confirm his diagnosis is crucial in determining the appropriate treatment plan for this patient.Your Answer: Serum uric acid levels
Correct Answer: Joint aspirate for microscopy
Explanation:Gout: Symptoms, Causes, and Diagnosis
Gout is a medical condition characterized by severe joint pain, redness, and swelling, particularly in the metatarsophalangeal joint of the big toe. This condition is caused by hyperuricaemia, which leads to the deposition of sodium monourate crystals in the joint. Gout attacks can be triggered by various factors, including trauma, surgery, starvation, infection, and diuretics.
Diagnosing gout can be challenging, as serum uric acid levels are not always elevated. However, the identification of urate crystals in tissues and synovial fluid can accurately confirm the diagnosis. During an acute attack of gout, serum uric acid levels may even fall acutely and be within the normal range. Microscopy of synovial fluid can reveal negatively birefringent crystals and neutrophils with ingested crystals.
In summary, gout is a painful condition that can be caused by various factors and is characterized by joint pain, redness, and swelling. Accurate diagnosis can be made by identifying urate crystals in tissues and synovial fluid, as serum uric acid levels may not always be elevated.
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This question is part of the following fields:
- Pharmacology
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Question 6
Incorrect
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A 55-year-old smoker is referred by his General Practitioner (GP) for diagnostic spirometry after presenting with worsening respiratory symptoms suggestive of chronic obstructive pulmonary disease (COPD).
Regarding spirometry, which of the following statements is accurate?Your Answer:
Correct Answer: FEV1 is a good marker of disease severity in COPD
Explanation:Common Misconceptions about Pulmonary Function Tests
Pulmonary function tests (PFTs) are a group of tests that measure how well the lungs are functioning. However, there are several misconceptions about PFTs that can lead to confusion and misinterpretation of results. Here are some common misconceptions about PFTs:
FEV1 is the only marker of disease severity in COPD: While FEV1 is a good marker of COPD disease severity, it should not be the only factor considered. Other factors such as symptoms, exacerbation history, and quality of life should also be taken into account.
Peak flow is helpful in the diagnosis of COPD: Peak flow is not a reliable tool for diagnosing COPD. It is primarily used in monitoring asthma and can be affected by factors such as age, gender, and height.
Residual volume can be measured by spirometer: Residual volume cannot be measured by spirometer alone. It requires additional tests such as gas dilution or body plethysmography.
Vital capacity increases with age: Vital capacity actually decreases with age due to changes in lung elasticity and muscle strength.
Peak flow measures the calibre of small airways: Peak flow is a measure of the large and medium airways, not the small airways.
By understanding these common misconceptions, healthcare professionals can better interpret PFT results and provide more accurate diagnoses and treatment plans for patients.
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This question is part of the following fields:
- Respiratory
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Question 7
Incorrect
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A 55-year-old woman from India visits the general practice clinic, reporting fatigue and tiredness after completing household tasks. During the examination, the physician observes periodic involuntary contractions of her left arm and multiple lumps beneath the skin. The doctor inquires about the patient's medical history and asks if she had any childhood illnesses. The patient discloses that she had a severe throat infection in India as a child but did not receive any treatment.
What is the most frequent abnormality that can be detected by listening to the heart during auscultation?Your Answer:
Correct Answer: An opening snap after S2, followed by a rumbling mid-diastolic murmur
Explanation:Common Heart Murmurs and their Association with Rheumatic Heart Disease
Rheumatic heart disease (RHD) is a condition resulting from untreated pharyngitis caused by group A beta-haemolytic streptococcal infection. RHD can lead to heart valve dysfunction, most commonly the mitral valve, resulting in mitral stenosis. The characteristic murmur of mitral stenosis is a mid-diastolic rumbling murmur that follows an opening snap after S2. Aortic stenosis can also be present in RHD but is less prevalent. Other heart murmurs associated with RHD include a high-pitched blowing diastolic decrescendo murmur, which is associated with aortic regurgitation, and a continuous machine-like murmur that is loudest at S2, consistent with patent ductus arteriosus. A late systolic crescendo murmur with a mid-systolic click is seen in mitral valve prolapse. A crescendo-decrescendo systolic ejection murmur following an ejection click describes the murmur heard in aortic stenosis. It is important to recognize these murmurs and their association with RHD for proper diagnosis and management.
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This question is part of the following fields:
- Cardiology
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Question 8
Incorrect
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A 7-year-old girl is discovered unresponsive in the bathtub and is rushed to the emergency department in a state of paediatric cardiac arrest. Despite attempts to establish peripheral IV access, the medical team is unable to do so. The decision is made by the registrar to insert an intraosseous line. What is the most frequently used insertion site for this type of line?
Your Answer:
Correct Answer: Proximal tibia
Explanation:When it is difficult to obtain vascular access in an emergency situation, intraosseous access is often used. This method can be used for both adults and children, with the proximal tibia being the most common site for insertion. In paediatric cases, it is recommended to attempt two peripheral intravenous lines before moving on to intraosseous access. Other potential sites for insertion include the distal femur and humeral head.
Different Routes for Venous Access
There are various methods for establishing venous access, each with its own advantages and disadvantages. The peripheral venous cannula is easy to insert and has a wide lumen for rapid fluid infusions. However, it is unsuitable for administering vasoactive or irritant drugs and may cause infections if not properly managed. On the other hand, central lines have multiple lumens for multiple infusions but are more difficult to insert and require ultrasound guidance. Femoral lines are easier to manage but have high infection rates, while internal jugular lines are preferred. Intraosseous access is typically used in pediatric practice but can also be used in adults for a wide range of fluid infusions. Tunnelled lines, such as Groshong and Hickman lines, are popular for long-term therapeutic requirements and can be linked to injection ports. Finally, peripherally inserted central cannulas (PICC lines) are less prone to major complications and are inserted peripherally.
Overall, the choice of venous access route depends on the patient’s condition, the type of infusion required, and the operator’s expertise. It is important to weigh the benefits and risks of each method and to properly manage any complications that may arise.
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This question is part of the following fields:
- Surgery
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Question 9
Incorrect
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A 68-year-old man presents to the General Surgical Outpatient Clinic with a 4-week history of altered bowel habit. There is no history of rectal bleeding, although faecal occult blood testing is positive. He denies any other symptoms from the abdominal point of view, and his general examination is otherwise unremarkable.
You discuss this case with the patient and agree that the next best step would be to undergo a colonoscopy and some blood tests. The results are shown below:
Bloods:
Investigation Result Normal value
Haemoglobin 112g/l 135–175 g/l
White cell count (WCC) 7.2 × 109/l 4–11 × 109/l
Platelets 205 × 109/l 150–400 × 109/l
Urea 4.5 mmol/l 2.5–6.5 mmol/l
Creatinine 71 mmol/l 50–120 μmol/l
Sodium (Na+) 135 mmol/l 135–145 mmol/l
Potassium (K+) 4.1 mmol/l 3.5–5.0 mmol/l
Endoscopy Report:
The endoscope was passed to the caecum without complication. The caecum was identified with confidence as the ileocaecal valve and appendicular orifice were seen and also confirmed with transillumination. There are multiple diverticulae seen in the sigmoid colon. A large ulcerated and haemorrhagic lesion resembling a tumour was found at the splenic flexure. Multiple biopsies were taken and sent for histology. Small polyp found in ascending colon, snared without complication.
Follow-up with histology results in General Surgery Clinic in one week. Histology to be discussed at the next gastrointestinal multidisciplinary meeting.
The histology results come back as adenocarcinoma of the colon involving the splenic flexure. Further staging reveals no initial metastatic disease.
Which of the following is the next best course of action?Your Answer:
Correct Answer: Proceed to left hemicolectomy
Explanation:Surgical Options for Bowel Carcinoma: Choosing the Right Procedure
When it comes to resecting bowel carcinoma, the location of the tumor and the blood supply to the bowel are the primary factors that determine the appropriate operation. It’s crucial to ensure that the remaining bowel has a good blood supply after the resection.
For tumors in the splenic flexure or descending colon, a left hemicolectomy is the most suitable procedure. This operation involves removing part of the transverse colon, descending colon, and sigmoid up to the upper rectum, which are supplied by the left colic artery and its branches.
If the tumor is located in the transverse colon, a transverse colectomy may be performed. An extended right hemicolectomy is necessary for tumors in the hepatic flexure.
For non-metastatic bowel cancer, surgical removal of the tumor and a portion of the bowel is the primary treatment. However, if the patient refuses surgery, chemotherapy alone can be used, but the prognosis may vary.
Preoperative neoadjuvant chemotherapy and surgery are not recommended at this point since there are no identifiable metastases, and the histology results are not yet available to determine the grade of the tumor and the number of mesenteric lymph nodes affected.
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This question is part of the following fields:
- Colorectal
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Question 10
Incorrect
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A 50-year-old man is recuperating from an appendectomy in the surgical ward. He is administered an antiemetic to alleviate post-anaesthesia nausea. After two hours, he is discovered contorting in his bed, incapable of communicating. His limbs are stiff and inflexible.
What drug would you prescribe to remedy his condition?Your Answer:
Correct Answer: Procyclidine
Explanation:Extrapyramidal Side-Effects and Antiemetics
Extrapyramidal side-effects (EPS) can occur with certain medications, including antiemetics. EPS can cause acute dystonia, which presents as involuntary muscle contractions and spasms. The first-line treatment for acute dystonia is procyclidine, given by slow intravenous injection. The dose usually takes 5-10 minutes to be effective, but relief may take up to 30 minutes.
Trazodone is not an antiemetic but an antipsychotic that can cause EPS. Metoclopramide is an antiemetic that can induce EPS, making it important to monitor patients for acute dystonia. Ondansetron can also cause EPS, but it is less common than with metoclopramide and haloperidol. Domperidone is another antiemetic that can cause EPS and should be used with caution in patients at risk for acute dystonia.
In summary, EPS is a potential side-effect of some antiemetics, and procyclidine is the first-line treatment for acute dystonia. Healthcare providers should monitor patients for EPS and adjust treatment as necessary to prevent or manage this condition.
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This question is part of the following fields:
- Pharmacology
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Question 11
Incorrect
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A father on the pediatric ward tells the doctor that his 2-year-old child has been having trouble with their feeds and has been vomiting a green substance. The child was born at term via vaginal delivery. On examination, the abdomen is soft but appears to be distended. An abdominal x-ray is ordered, which shows a 'double bubble' sign. What is the most probable diagnosis?
Your Answer:
Correct Answer: Intestinal atresia
Explanation:The most likely cause of bilious vomiting on the first day of life is intestinal atresia. This is because the presence of bilious vomiting in early life suggests a bowel obstruction, and the fact that it has occurred on the first day of life indicates an underlying structural issue. Children with Down’s syndrome are at a higher risk of developing this condition, especially at the duodenum. The diagnosis of intestinal/duodenal atresia is further supported by the presence of the ‘double bubble’ on the x-ray.
Biliary atresia is an incorrect answer as it would not cause the clinical picture described above. This condition results in neonatal jaundice beyond 14 days of life, with dark urine and pale stools.
Malrotation with volvulus is also an incorrect answer. While it can cause bilious vomiting, it tends to present around 3 to 7 days following birth.
Necrotising enterocolitis is another incorrect answer. Although it can cause bilious vomiting, it typically does not occur so early following birth. Additionally, it is usually a condition of prematurity and is rarely seen in infants born at term.
Causes and Treatments for Bilious Vomiting in Neonates
Bilious vomiting in neonates can be caused by various disorders, including duodenal atresia, malrotation with volvulus, jejunal/ileal atresia, meconium ileus, and necrotising enterocolitis. Duodenal atresia occurs in 1 in 5000 births and is more common in babies with Down syndrome. It typically presents a few hours after birth and can be diagnosed through an abdominal X-ray that shows a double bubble sign. Treatment involves duodenoduodenostomy. Malrotation with volvulus is usually caused by incomplete rotation during embryogenesis and presents between 3-7 days after birth. An upper GI contrast study or ultrasound can confirm the diagnosis, and treatment involves Ladd’s procedure. Jejunal/ileal atresia is caused by vascular insufficiency in utero and occurs in 1 in 3000 births. It presents within 24 hours of birth and can be diagnosed through an abdominal X-ray that shows air-fluid levels. Treatment involves laparotomy with primary resection and anastomosis. Meconium ileus occurs in 15-20% of babies with cystic fibrosis and presents in the first 24-48 hours of life with abdominal distension and bilious vomiting. Diagnosis involves an abdominal X-ray that shows air-fluid levels, and a sweat test can confirm cystic fibrosis. Treatment involves surgical decompression, and segmental resection may be necessary for serosal damage. Necrotising enterocolitis occurs in up to 2.4 per 1000 births, with increased risks in prematurity and inter-current illness. It typically presents in the second week of life and can be diagnosed through an abdominal X-ray that shows dilated bowel loops, pneumatosis, and portal venous air. Treatment involves conservative and supportive measures for non-perforated cases, while laparotomy and resection are necessary for perforated cases or ongoing clinical deterioration.
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This question is part of the following fields:
- Surgery
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Question 12
Incorrect
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A 20-year old man presents to the Surgical Assessment Unit complaining of sudden onset abdominal pain. What physical examination finding is most indicative of a possible diagnosis of appendicitis?
Your Answer:
Correct Answer: Tenderness over McBurney’s point
Explanation:Common Abdominal Exam Findings and Their Significance
Abdominal exams are an important part of diagnosing various medical conditions. Here are some common findings and their significance:
Tenderness over McBurney’s point: This is a sign of possible appendicitis. McBurney’s point is located a third of the way from the right anterior superior iliac spine to the umbilicus.
Grey–Turner’s sign: Flank bruising is a sign of retroperitoneal hemorrhage, which is commonly associated with acute pancreatitis.
Murphy’s sign: This suggests cholecystitis. The examiner places their hand below the right costal margin and the tender gallbladder moves inferiorly on inhalation, causing the patient to catch their breath.
Tinkling bowel sounds: High-pitched, ‘tinkling’ bowel sounds are typically associated with mechanical bowel obstruction.
Absent bowel sounds: This is suggestive of paralytic ileus, which most commonly occurs after abdominal surgery.
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This question is part of the following fields:
- Gastroenterology
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Question 13
Incorrect
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A 21-year-old motorcyclist is in a road traffic collision. His breathing is irregular. Upon examination, he has multiple rib fractures, including 2 fractures in the 3rd rib and 3 fractures in the 4th rib. What is the underlying condition?
Your Answer:
Correct Answer: Flail chest injury
Explanation:A flail chest is identified when an individual has multiple rib fractures, with at least two fractures in more than two ribs. This condition is often accompanied by pulmonary contusion.
Thoracic Trauma: Common Conditions and Treatment
Thoracic trauma can result in various conditions that require prompt medical attention. Tension pneumothorax, for instance, occurs when pressure builds up in the thorax due to a laceration to the lung parenchyma with a flap. This condition is often caused by mechanical ventilation in patients with pleural injury. Symptoms of tension pneumothorax overlap with cardiac tamponade, but hyper-resonant percussion note is more likely. Flail chest, on the other hand, occurs when the chest wall disconnects from the thoracic cage due to multiple rib fractures. This condition is associated with pulmonary contusion and abnormal chest motion.
Pneumothorax is another common condition resulting from lung laceration with air leakage. Traumatic pneumothoraces should have a chest drain, and patients should never be mechanically ventilated until a chest drain is inserted. Haemothorax, which is most commonly due to laceration of the lung, intercostal vessel, or internal mammary artery, is treated with a large bore chest drain if it is large enough to appear on CXR. Surgical exploration is warranted if more than 1500 ml blood is drained immediately.
Cardiac tamponade is characterized by elevated venous pressure, reduced arterial pressure, and reduced heart sounds. Pulsus paradoxus may also occur with as little as 100 ml blood. Pulmonary contusion is the most common potentially lethal chest injury, and arterial blood gases and pulse oximetry are important. Early intubation within an hour is necessary if significant hypoxia is present. Blunt cardiac injury usually occurs secondary to chest wall injury, and ECG may show features of myocardial infarction. Aorta disruption, diaphragm disruption, and mediastinal traversing wounds are other conditions that require prompt medical attention.
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This question is part of the following fields:
- Surgery
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Question 14
Incorrect
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A 65-year-old man comes in with symptoms of lower urinary tract and is given the option of a PSA test. As per NHS recommendations, which of the following factors may affect the PSA level?
Your Answer:
Correct Answer: Vigorous exercise in the past 48 hours
Explanation:Prostate specific antigen (PSA) is an enzyme produced by both normal and cancerous prostate cells. It is commonly used as a marker for prostate cancer, but its effectiveness as a screening tool is still debated. The NHS Prostate Cancer Risk Management Programme (PCRMP) has released guidelines for handling requests for PSA testing in asymptomatic men. While a recent European trial showed a reduction in prostate cancer deaths, it also revealed a high risk of over-diagnosis and over-treatment. As a result, the National Screening Committee has decided not to introduce a screening programme, but rather allow men to make an informed decision. The PCRMP recommends age-adjusted upper limits for PSA levels, while NICE Clinical Knowledge Summaries suggest a lower threshold for referral. PSA levels can also be raised by factors such as benign prostatic hyperplasia, prostatitis, and urinary tract infections.
The specificity and sensitivity of PSA testing are poor, with a significant number of men with elevated PSA levels not having prostate cancer, and some with normal PSA levels having the disease. Various methods are used to add meaning to PSA levels, including age-adjusted upper limits and monitoring changes in PSA levels over time. It is also debated whether digital rectal examination causes a rise in PSA levels. It is important to note that PSA testing should be postponed after certain events, such as ejaculation or instrumentation of the urinary tract.
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This question is part of the following fields:
- Surgery
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Question 15
Incorrect
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A 72-year-old woman takes medication for hypertension and raised cholesterol. At her annual check-up, she reports that she is feeling well. Among the results of her blood tests are the following: serum calcium 2.90 mmol/l (2.1–2.8 mmol/l), serum phosphate 0.80 mmol/l (1.0–1.5 mmol/l) and alkaline phosphatase 215 iu/l (53–128 iu/l).
Which of the following is the most likely explanation of these results in this woman?Your Answer:
Correct Answer: Primary hyperparathyroidism
Explanation:Differential diagnosis for hypercalcaemia with hypophosphataemia and normal alkaline phosphatase
Primary hyperparathyroidism is a common cause of hypercalcaemia, often detected incidentally on routine blood tests. In this condition, the parathyroid glands produce excessive amounts of parathyroid hormone, which increases calcium reabsorption from bones and kidneys and decreases phosphate reabsorption from kidneys. As a result, patients may have elevated serum calcium and low serum phosphate levels, but normal or slightly elevated alkaline phosphatase levels.
Other possible causes of hypercalcaemia with hypophosphataemia and normal alkaline phosphatase include occult malignancy, especially if it involves bone, but this would usually result in a higher alkaline phosphatase level. Paget’s disease of bone, a chronic disorder of bone remodeling, may also cause hypercalcaemia, but it typically presents with a much higher alkaline phosphatase level as a marker of bone destruction.
Thyrotoxicosis, a condition of excess thyroid hormone, can also lead to hypercalcaemia, but this patient has no symptoms suggestive of hyperthyroidism. Phaeochromocytoma, a rare tumor of the adrenal gland that secretes catecholamines, may cause hypertension, but it is not typically associated with hypercalcaemia or hypophosphataemia.
Therefore, the most likely diagnosis in this case is primary hyperparathyroidism, which may be part of a multiple endocrine neoplasia (MEN) type 2 syndrome that also involves the thyroid gland and adrenal medulla. Further evaluation, including imaging studies and genetic testing, may be necessary to confirm the diagnosis and guide management.
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This question is part of the following fields:
- Endocrinology
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Question 16
Incorrect
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In pharmacokinetics, how is the rate of elimination or metabolism of an active drug from the body calculated?
Your Answer:
Correct Answer: Clearance
Explanation:Pharmacokinetics: How the Body Processes Drugs
Pharmacokinetics refers to the processes involved in how the body processes drugs. It involves four main processes: absorption, distribution, metabolism, and excretion. Metabolism and excretion are responsible for removing active drugs from the body. Metabolism converts drugs into inactive metabolites, while excretion removes the drug or its metabolite from the body. Renal excretion is the most common method of drug excretion, but some drugs may also be excreted in the bile or faeces.
Clearance is the rate at which active drugs are removed from the circulation. It involves both renal excretion and hepatic metabolism, but in practice, clearance usually measures only the renal excretion of a drug. The glomerular filtration rate affects drug clearance, but even individuals with normal kidney function can have widely varying rates of drug clearance. The structure and distribution of a drug can also affect its clearance.
In summary, pharmacokinetics is the study of how the body processes drugs, involving absorption, distribution, metabolism, and excretion. Clearance is the rate at which active drugs are removed from the circulation, and it involves both renal excretion and hepatic metabolism. The glomerular filtration rate and drug structure and distribution can affect drug clearance.
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This question is part of the following fields:
- Pharmacology
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Question 17
Incorrect
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A 65-year-old female presents with tiredness and vague aches for many years. The following results were obtained:
- Serum sodium: 135 mmol/L (133-144)
- Serum potassium: 3.4 mmol/L (3.5-4.9)
- Serum urea: 5.8 mmol/L (2.5-7.5)
- Serum creatinine: 100 μmol/L (50-100)
- Serum calcium: 2.78 mmol/L (2.20 - 2.60)
- Serum albumin: 38 g/L (35-50)
- Corrected calcium: 3.02 mmol/L (2.20-2.60)
- Serum phosphate: 0.87 mmol/L (0.80 - 1.45)
- Serum alk phosphatase: 117 IU/L (30-115)
- Serum asp transaminase: 20 I U/L (5-45)
- Serum bilirubin: 8 umol/L (1-17)
The patient appears generally well, with a blood pressure of 160/80 mmHg, a pulse of 80 beats per minute, normal heart, chest and abdominal examination. What is the most likely diagnosis?Your Answer:
Correct Answer: Hyperparathyroidism
Explanation:Hypercalcaemia and Primary Hyperparathyroidism
Hypercalcaemia is a condition characterized by high levels of calcium in the blood. While there are several possible causes of hypercalcaemia, primary hyperparathyroidism is the most likely diagnosis for a patient with a long history of the condition, no weight loss, and no respiratory symptoms. Although other conditions can also cause hypercalcaemia, the absence of these symptoms makes them less likely. In cases of primary hyperparathyroidism, phosphate levels will typically be at the lower end of the normal range.
Primary hyperparathyroidism is relatively common in elderly populations, with up to 1% of individuals affected. Symptoms can include renal calculi, depression, bone pain, and abdominal pain from peptic ulceration. Hypertension is also a common feature. Additionally, the polyuria associated with hypercalcaemia may lead to mild hypokalaemia.
In summary, hypercalcaemia is a condition that can have several possible causes, but primary hyperparathyroidism is the most likely diagnosis for a patient with a long history of the condition, no weight loss, and no respiratory symptoms. This condition can cause a range of symptoms, including renal calculi, depression, bone pain, and abdominal pain, as well as hypertension and mild hypokalaemia.
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This question is part of the following fields:
- Clinical Sciences
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Question 18
Incorrect
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A 70-year-old man is in hospice care and his family is concerned about his lack of food and water intake. They fear that this may cause him discomfort and pain.
What is the most crucial side-effect of dehydration due to poor oral intake that needs to be addressed in an actively dying patient?Your Answer:
Correct Answer: Xerostomia
Explanation:Understanding the Effects of Dehydration in End-of-Life Care
Dehydration is a common occurrence in end-of-life care, but it is important to understand its effects on the patient. Xerostomia, or dry mouth, can be treated to improve the patient’s comfort and reduce family anxiety. However, dehydration does not cause pain or hunger in the dying patient. Low urine output may eventually occur, but it is not important to treat as it does not cause distress. Drowsiness may result from dehydration and uraemia, or the build-up of toxins from impaired kidney function. Understanding these effects can help caregivers provide appropriate care for the dying patient.
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This question is part of the following fields:
- Palliative Care
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Question 19
Incorrect
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You are a healthcare professional working in a general practice. Your next patient is a 70-year-old man who has come for a follow-up appointment to review his recent blood test results. During his last visit, you had expressed concern about his elevated plasma glucose levels and advised him to make some lifestyle changes. He reports that he has made some dietary modifications and has started walking to the local shops instead of driving.
The patient has a medical history of coeliac disease, chronic kidney disease, and osteoarthritis. His fasting blood test results are as follows:
- Hemoglobin (Hb): 146 g/L (normal range for males: 135-180; females: 115-160)
- Platelets: 235 * 109/L (normal range: 150-400)
- White blood cells (WBC): 7.0 * 109/L (normal range: 4.0-11.0)
- Sodium (Na+): 139 mmol/L (normal range: 135-145)
- Potassium (K+): 4.4 mmol/L (normal range: 3.5-5.0)
- Urea: 10.4 mmol/L (normal range: 2.0-7.0)
- Creatinine: 216 µmol/L (normal range: 55-120)
- Estimated glomerular filtration rate (eGFR): 28 ml/minute
- C-reactive protein (CRP): <5 mg/L (normal range: <5)
- Plasma glucose: 7.3 mol/L (normal range: <6 mmol/L)
- Hemoglobin A1c (HbA1c): 54 mmol/mol
What would be the most appropriate course of action for managing this patient's HbA1c levels?Your Answer:
Correct Answer: Sitagliptin
Explanation:This individual has been diagnosed with type 2 diabetes mellitus, as evidenced by elevated blood glucose levels on two separate occasions and an HbA1c measurement of >48 mmol/mol. Despite receiving lifestyle advice, medication is necessary for treatment. However, due to an eGFR <30ml/minute, metformin is not a suitable option. Instead, sitagliptin, a DPP-4 inhibitor, is the most appropriate treatment. While the DESMOND course may be beneficial for ongoing management, it does not replace the need for medication in this case. Metformin is a medication commonly used to treat type 2 diabetes mellitus. It belongs to a class of drugs called biguanides and works by activating the AMP-activated protein kinase (AMPK), which increases insulin sensitivity and reduces hepatic gluconeogenesis. Additionally, it may decrease the absorption of carbohydrates in the gastrointestinal tract. Unlike other diabetes medications, such as sulphonylureas, metformin does not cause hypoglycemia or weight gain, making it a first-line treatment option, especially for overweight patients. It is also used to treat polycystic ovarian syndrome and non-alcoholic fatty liver disease. While metformin is generally well-tolerated, gastrointestinal side effects such as nausea, anorexia, and diarrhea are common and can be intolerable for some patients. Reduced absorption of vitamin B12 is also a potential side effect, although it rarely causes clinical problems. In rare cases, metformin can cause lactic acidosis, particularly in patients with severe liver disease or renal failure. However, it is important to note that lactic acidosis is now recognized as a rare side effect of metformin. There are several contraindications to using metformin, including chronic kidney disease, recent myocardial infarction, sepsis, acute kidney injury, severe dehydration, and alcohol abuse. Additionally, metformin should be discontinued before and after procedures involving iodine-containing x-ray contrast media to reduce the risk of contrast nephropathy. When starting metformin, it is important to titrate the dose slowly to reduce the incidence of gastrointestinal side effects. If patients experience intolerable side effects, modified-release metformin may be considered as an alternative.
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This question is part of the following fields:
- Pharmacology
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Question 20
Incorrect
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A 42-year-old man is brought to the Intensive Care Unit after accidental drowning in a lake. He was a swimmer who got into trouble and was underwater for approximately 10 minutes before being rescued. He was found unresponsive and not breathing, and bystanders immediately started performing CPR while waiting for emergency services. Upon arrival at the ICU, he is intubated and ventilated, and his vital signs are as follows: blood pressure 90/60 mmHg, pulse 130 bpm, oxygen saturations 85%, and temperature 33.2 °C.
Under what circumstances is extracorporeal membrane oxygenation (ECMO) considered as a treatment option for drowning patients?Your Answer:
Correct Answer: Persistent hypothermia from cold water drowning
Explanation:When to Consider Extracorporeal Membrane Oxygenation (ECMO) for Drowning Patients
Drowning can lead to respiratory compromise and persistent hypothermia, which may require advanced medical intervention. Extracorporeal membrane oxygenation (ECMO) is a treatment option that can be considered for selected patients who have drowned. However, it is important to understand the indications for ECMO and when it may not be appropriate.
ECMO may be considered in cases where conventional mechanical ventilation or high-frequency ventilation have failed to improve respiratory function. Additionally, there should be a reasonable probability of the patient recovering neurological function. Persistent hypothermia from cold water drowning is another indication for ECMO.
On the other hand, altered level of consciousness alone is not an indication for ECMO. Patients who respond well to conventional mechanical ventilation or high-frequency ventilation may not require ECMO. Similarly, haemodynamic instability can be managed with inotropes and fluids, and ECMO should only be considered for patients who are resistant to conventional organ support.
It is important to note that ECMO has a high complication rate, with a 15% risk of bleeding. Therefore, it should only be used in selected cases where the potential benefits outweigh the risks.
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This question is part of the following fields:
- Acute Medicine And Intensive Care
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Question 21
Incorrect
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A 55-year-old male patient reports experiencing excessive thirst and frequent urination for the past three months. What diagnostic measurement would confirm a diagnosis of diabetes mellitus?
Your Answer:
Correct Answer: A fasting plasma glucose of 7.5 mmol/L
Explanation:Diabetes mellitus is diagnosed based on symptoms and a random glucose level above 11.1 mmol/L or fasting plasma glucose above 7 mmol/L or the two hour oral glucose tolerance test. Impaired glucose tolerance is indicated by a post OGTT plasma glucose between 7.7 and 11.1 or a fasting plasma glucose between 6.1 and 7. HbA1c of 48 mmol/mol (6.5%) is recommended as the cut point for diagnosing diabetes for suitable groups. A value of less than 48 mmol/mol (6.5%) does not exclude diabetes diagnosed using glucose test.
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This question is part of the following fields:
- Clinical Sciences
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Question 22
Incorrect
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A 55-year-old man with a history of hypertension presents with pruritus and lethargy. His serum biochemistry results show low calcium, high phosphate, and raised parathyroid hormone levels. His blood test results are as follows:
Investigation Result Normal value
Sodium (Na+) 138 mmol/l 135–145 mmol/l
Potassium (K+) 4.8 mmol/l 3.5–5.0 mmol/l
Urea 15.5 mmol/l 2.5–6.5 mmol/l
Creatinine 590 μmol/l 50–120 mmol/l
What is the most likely diagnosis for this patient?Your Answer:
Correct Answer: Secondary hyperparathyroidism
Explanation:Causes of Secondary Hyperparathyroidism in a Patient with Chronic Renal Failure
Secondary hyperparathyroidism can occur in patients with chronic renal failure due to imbalances in phosphorus and calcium levels. In this case, the patient has hyperphosphatemia and hypocalcemia, leading to overproduction of parathyroid hormone (PTH) by the parathyroid gland.
Loop diuretic overuse can also affect PTH levels, but it would result in additional electrolyte imbalances such as hyponatremia and hypokalemia. The role of hypertension in causing chronic renal failure is unclear in this patient.
Primary hyperparathyroidism, where the parathyroid gland overproduces PTH resulting in high serum calcium, is not present in this case. Tertiary hyperparathyroidism, which occurs after a chronic period of secondary hyperparathyroidism and results in dysregulation of calcium homeostasis and high serum calcium levels, is also not present.
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This question is part of the following fields:
- Endocrinology
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Question 23
Incorrect
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A 50-year-old woman comes to see her GP for a follow-up on her Dupuytren's contracture. She has been experiencing more difficulty lately with her job, which involves a lot of typing. Despite taking Naproxen, she has not found much relief. During the examination, the GP observes that the metacarpophalangeal joints on her right hand's little finger and ring finger are bent forward by 30 degrees, and she is unable to place her hand flat on the table. What should be the GP's next appropriate step in managing her condition?
Your Answer:
Correct Answer: Make a routine referral to orthopaedics to be seen by a hand specialist
Explanation:When a patient with Dupuytren’s contracture is unable to straighten their metacarpophalangeal joints and place their hand flat on a table, surgical treatment should be considered. This condition occurs when the palmar fascia becomes stiff and fibroses, causing the affected fingers to contract, typically the ring and little finger of the right hand.
The severity of the condition will determine the appropriate management approach. In cases where the condition is severe and impacting the patient’s quality of life, referral to a hand specialist for secondary intervention is recommended. This may involve either surgical intervention or injectable enzyme therapy, which should only be initiated by a specialist.
For minor cases where the condition is not significantly affecting the patient’s quality of life, primary care management may be appropriate. This will involve reassurance that the condition may improve over time, regular reviews, and advice on when to return for referral if necessary.
It is important to note that corticosteroid injections are not effective in treating Dupuytren’s contracture. Additionally, as this is not an acute problem, patients should not be advised to attend the emergency department.
Understanding Dupuytren’s Contracture
Dupuytren’s contracture is a condition that affects about 5% of the population. It is more common in older men and those with a family history of the condition. The causes of Dupuytren’s contracture include manual labor, phenytoin treatment, alcoholic liver disease, diabetes mellitus, and trauma to the hand.
The condition typically affects the ring finger and little finger, causing them to become bent and difficult to straighten. In severe cases, the hand may not be able to be placed flat on a table.
Surgical treatment may be necessary when the metacarpophalangeal joints cannot be straightened.
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This question is part of the following fields:
- Musculoskeletal
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Question 24
Incorrect
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What feature is typical of the early stages of Alzheimer's disease?
Your Answer:
Correct Answer: Impaired short term memory
Explanation:Identifying Dementia: Symptoms and Differential Diagnosis
Dementia is a progressive neurological disorder that affects cognitive function, including memory, language, and decision-making abilities. Alzheimer’s disease is the most common form of dementia, and it is characterised by short-term memory loss in the early stages. However, other symptoms may suggest an alternative diagnosis.
For instance, gait ataxia and urinary incontinence may indicate normal pressure hydrocephalus, while myoclonic jerks may suggest Creutzfeldt-Jakob disease. Visual hallucinations and delirium are common in Lewy body dementia.
It is important to differentiate between different types of dementia to provide appropriate treatment and care. Early diagnosis and intervention can help slow down the progression of the disease and improve the quality of life for patients and their families. Healthcare professionals should be aware of the various symptoms and differential diagnosis of dementia to provide accurate diagnosis and management.
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This question is part of the following fields:
- Miscellaneous
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Question 25
Incorrect
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A 25-year-old man comes to you with a history of back pain that has been getting worse over the past year. The pain and stiffness are more severe in the morning but improve with exercise. During your examination, you notice a flexural rash with poorly defined areas of erythema, dry skin, and lichenification. All observations appear normal. The blood test results show an ESR of 84 mm/hr (normal range: 0-22) and a CRP of 6 mg/L (normal range: 0-10). ANA, RhF, and Anti-CCP tests are all negative. What is the most likely diagnosis?
Your Answer:
Correct Answer: Ankylosing spondylitis
Explanation:Exercise is typically beneficial for inflammatory back pain, such as that seen in ankylosing spondylitis. The patient’s symptoms, including morning stiffness and improvement with exercise, suggest an inflammatory cause, which is supported by the significantly elevated ESR. While there are several possible diagnoses, including seropositive and seronegative spondyloarthropathies, the most likely explanation is ankylosing spondylitis. Psoriatic arthritis is an incorrect answer, as the patient’s rash is more consistent with dermatitis than psoriasis. Osteoarthritis is also unlikely given the patient’s age and clinical history, while reactive arthritis is less likely due to the duration of symptoms and lack of urethritis or conjunctivitis.
Ankylosing spondylitis is a type of spondyloarthropathy that is associated with HLA-B27. It is more commonly seen in young males, with a sex ratio of 3:1, and typically presents with lower back pain and stiffness that develops gradually. The stiffness is usually worse in the morning and improves with exercise, while pain at night may improve upon getting up. Clinical examination may reveal reduced lateral and forward flexion, as well as reduced chest expansion. Other features associated with ankylosing spondylitis include apical fibrosis, anterior uveitis, aortic regurgitation, Achilles tendonitis, AV node block, amyloidosis, cauda equina syndrome, and peripheral arthritis (more common in females).
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This question is part of the following fields:
- Musculoskeletal
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Question 26
Incorrect
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A 75-year-old man presents with fatigue. His complete blood count and iron studies are provided below.
Hemoglobin: 95g/L (normal range: 135-180g/L)
Mean Corpuscular Volume: 58fL (normal range: 78-100fL)
Platelets: 210* 109/L (normal range: 150-400* 109/L)
White Blood Cells: 7* 109/L (normal range: 4-11* 109/L)
Ferritin: 14 ug/L (normal range: 41-400 ug/L)
Total Iron Binding Capacity: 80 micromoles/L (normal range: 45-66 micromoles/L)
What is the most appropriate next investigation?Your Answer:
Correct Answer: Colonoscopy
Explanation:The complete blood count results indicate that the patient has microcytic anemia, which is caused by iron deficiency according to the iron studies. In men over 60 years old, iron deficiency anemia is often linked to colorectal cancer, so urgent referral to colorectal services is necessary for suspected cancer cases. A colonoscopy and OGD are likely to be performed. CEA is a tumor marker for colon cancer, but it is not used for diagnosis due to its poor specificity. B12 and folate deficiency would result in an increased MCV, so they are not the cause of this patient’s anemia. If bone marrow failure were suspected, a bone marrow biopsy might be performed, but the patient’s platelets and white cell count would be reduced in such cases.
Understanding Colorectal Cancer
Colorectal cancer is a prevalent type of cancer in the UK, ranking third in terms of frequency and second in terms of mortality rates. Every year, approximately 150,000 new cases are diagnosed, and 50,000 people die from the disease. The cancer can occur in different parts of the colon, with the rectum being the most common location, accounting for 40% of cases. The sigmoid colon follows closely, with 30% of cases, while the descending colon has only 5%. The transverse colon has 10% of cases, and the ascending colon and caecum have 15%. Understanding the location of the cancer is crucial in determining the appropriate treatment and management plan. With early detection and proper medical care, the prognosis for colorectal cancer can be improved.
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This question is part of the following fields:
- Surgery
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Question 27
Incorrect
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You are with the on-call anaesthetist who has been asked to see a 30-year-old man blue-lighted into the Emergency Department. The patient complains of being stung by a wasp while running and reports his arm becoming immediately swollen and red. He kept running but, within a few minutes, began to feel very light-headed and had difficulty breathing. On examination, the patient looks flushed and has a widespread wheeze on auscultation. Blood pressure 76/55 mmHg, heart rate 150 bpm, respiratory rate 32 breaths/minute.
Which of the following is the best initial treatment?Your Answer:
Correct Answer: Intramuscular (IM) 1 : 1000 adrenaline 500 micrograms
Explanation:Management of Anaphylaxis: Initial Treatment and Beyond
Anaphylaxis is a life-threatening condition that requires prompt and appropriate management. The Resuscitation Council has established three criteria for diagnosing anaphylaxis: sudden onset and rapid progression of symptoms, life-threatening airway, breathing, and circulatory problems, and skin changes. The initial management for anaphylaxis is IM 1 : 1000 adrenaline 500 micrograms, even before equipment or IV access is available. Once expertise and equipment are available, the airway should be stabilized, high-flow oxygen given, the patient fluid-challenged, and IV hydrocortisone and chlorphenamine given. Ephedrine has no role in anaphylaxis, and IV adrenaline is not the first-line management. Prompt intubation may be necessary, but IM adrenaline must be given before a full ABCDE assessment is made. Nebulized adrenaline may help with airway swelling, but it will not treat the underlying immunological phenomenon. Proper management of anaphylaxis requires a comprehensive approach that addresses both the immediate and long-term needs of the patient.
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This question is part of the following fields:
- Acute Medicine And Intensive Care
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Question 28
Incorrect
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A 68-year-old woman presents with acute lower back pain of one week duration. The pain is localized to her lower back, rates 9/10 in severity, and has not improved with paracetamol and ibuprofen. She has a medical history significant for stage 3 chronic kidney disease, hypertension, osteoporosis, and hypercholesterolemia. The patient has a 30-pack-year smoking history and is currently taking bendroflumethiazide, amlodipine, alendronic acid, vitamin D supplements, calcium tablets, omeprazole, and atorvastatin. On physical examination, the patient has lumbar lordosis, decreased mobility, and spasm of the paravertebral muscles. Tenderness to palpation is noted at L4-L5. A previous DEXA scan taken 6 months ago shows a T-score of −3.0 in the lumbosacral spine and −3.2 in the left hip. What is the recommended first-line investigation?
Your Answer:
Correct Answer: X-ray spine
Explanation:X-ray of the spine is the first-line investigation for a suspected osteoporotic vertebral fracture, while CT spine, MRI spine, repeat DEXA scan, and skeletal survey are not indicated or necessary.
Understanding Osteoporotic Vertebral Fractures
Osteoporotic vertebral fractures are a common consequence of osteoporosis, a condition where bones gradually decrease in bone mineral density, leading to an increased risk of fragility fractures. These fractures often present with acute onset back pain, but patients can also be asymptomatic. Osteoporosis is more prevalent in females than males, with a male-to-female ratio of 1:6. Advancing age is a major risk factor for osteoporotic fractures, with women over 65 and men over 75 being at increased risk. Other risk factors include a previous history of fragility fractures, frequent or prolonged use of glucocorticoids, history of falls, family history of hip fracture, alternative causes of secondary osteoporosis, low BMI, tobacco smoking, and high alcohol intake.
Patients with osteoporotic vertebral fractures may present with acute back pain, breathing difficulties, gastrointestinal problems, loss of height, kyphosis, and localised tenderness on palpation of spinous processes at the fracture site. X-ray of the spine is the first investigation ordered, which may show wedging of the vertebra due to compression of the bone. Other investigations such as CT spine and MRI spine may be used to visualise the extent/features of the fracture more clearly and differentiate osteoporotic fractures from those caused by another pathology.
To assess the likelihood of future fractures, risk factors are taken into account, and a dual-energy X-ray absorptiometry (DEXA) scan should be considered. The FRAX tool or QFracture tool can be used to estimate the 10-year risk of a fracture. These tools require the clinician to input patient information into a form, which is then used by the programme to calculate the risk. Understanding osteoporotic vertebral fractures and their risk factors is crucial in preventing and managing this condition.
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This question is part of the following fields:
- Musculoskeletal
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Question 29
Incorrect
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At 1700 h, you are tasked with seeing a 15-year-old girl who has recently been diagnosed with leukaemia and admitted to a major hospital in England. The patient's current vital signs include a heart rate of 120 per minute, a gallop rhythm, and a soft murmur. Additionally, her Hb level is at 6.5. However, the patient's parents are refusing a blood transfusion due to their religious beliefs. What course of action do you take?
Your Answer:
Correct Answer: Ask for a court order
Explanation:Legal and Medical Considerations in the Case of a Child Refusing Blood Transfusion
In the case of a child with leukaemia who requires a blood transfusion but whose parents refuse due to religious beliefs, there are legal and medical considerations to take into account. While parental rights are recognized, they are not absolute and must be balanced with the duty to ensure the child’s health, safety, and wellbeing. If treatment refusal results in a child’s suffering, parents may be criminally liable, and the courts may exercise their power under the doctrine of parens patriae to protect the child’s welfare.
One option is to obtain a Section 8 (Children Act 1989) specific issue order, which allows the court to exercise its power over a specific issue of parental responsibility, such as the issue of blood transfusion. In urgent cases, such an order can be obtained over the phone from a High Court judge in as little as 30 minutes. Judges may visit sick children to ascertain their wishes and preferences and assess their decision-making competence. An independent arbitration system can also help defuse conflict and provide all parties with the opportunity to give their views.
If there is not enough time to obtain a court order and an independent clinician deems that the child will die without a blood transfusion, then blood must be given to save the child’s life. However, if chemotherapy is given without transfusion, the child is likely to become more anaemic and be placed at significant risk.
Obtaining a Police Protection Order does not transfer parental authority and would not give the police the power to make a decision regarding blood transfusion. Instead, a psychiatric assessment can be helpful in determining the child’s decision-making capacity, but legal review may still be necessary if the family persists in refusing treatment. Ultimately, the best interests of the child must be the guiding principle in making any decisions regarding their medical treatment.
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This question is part of the following fields:
- Ethics And Legal
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Question 30
Incorrect
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Samantha is a 52-year-old female who visits her doctor with complaints of dysuria and increased urinary frequency for the past day. She has a medical history of hypertension and is currently taking candesartan and spironolactone. During her teenage years, she had two simple urinary tract infections. Upon examination, a urinary dipstick reveals leukocytes ++, nitrites ++ and microscopic haematuria. The doctor diagnoses her with a urinary tract infection and prescribes trimethoprim 200mg BD for three days.
After three days, Samantha returns to the clinic with improved urinary tract infection symptoms but complains of decreased urine output, nausea, and swelling in both legs. To investigate further, the doctor orders a full blood count and renal function bloods. What electrolyte disturbances might be expected to be found on Samantha's bloods?Your Answer:
Correct Answer: Hyperkalaemia
Explanation:Trimethoprim can lead to tubular dysfunction, which can result in hyperkalemia and an increase in serum creatinine levels.
This statement is accurate, as trimethoprim can block the ENaC channel in the distal nephron, causing a type 4 hyperkalemic distal renal tubular acidosis. In this patient’s case, the use of trimethoprim, along with her regular medications, has caused acute kidney injury. It is important to avoid using trimethoprim in patients taking renin angiotensin antagonist drugs or potassium-sparing diuretics, or to monitor renal function closely.
However, the statement that hypercalcemia is a common occurrence in acute kidney injury is incorrect. Hypocalcemia is more commonly seen in this condition. Similarly, hypernatremia is not a common finding in acute kidney injury, as hyponatremia is more frequently observed. On the other hand, hyperphosphatemia is a common occurrence in acute kidney injury due to phosphate retention.
Understanding Trimethoprim: Mechanism of Action, Adverse Effects, and Use in Pregnancy
Trimethoprim is an antibiotic that is commonly used to treat urinary tract infections. Its mechanism of action involves interfering with DNA synthesis by inhibiting dihydrofolate reductase. This can potentially interact with methotrexate, which also inhibits dihydrofolate reductase. However, the use of trimethoprim can also lead to adverse effects such as myelosuppression and a transient rise in creatinine. The drug can competitively inhibit the tubular secretion of creatinine, resulting in a temporary increase that reverses upon stopping the drug. Additionally, trimethoprim can block the ENaC channel in the distal nephron, causing a hyperkalaemic distal RTA (type 4). It can also inhibit creatinine secretion, often leading to an increase in creatinine by around 40 points, but not necessarily causing AKI.
When it comes to the use of trimethoprim in pregnancy, caution is advised. The British National Formulary (BNF) warns of a teratogenic risk in the first trimester due to its folate antagonist properties. As such, manufacturers advise avoiding the use of trimethoprim during pregnancy. It is important to understand the potential risks and benefits of using this antibiotic and to consult with a healthcare provider before taking any medication.
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This question is part of the following fields:
- Medicine
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