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Question 1
Correct
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A 50-year-old man presents to his GP with concerns about erectile dysfunction. He has been experiencing this for the past year and is feeling embarrassed and anxious about it, as it is causing issues in his marriage. On examination, the GP notes that the patient is overweight with a BMI of 27 kg/m2, but does not find any other abnormalities. The GP orders HbA1c and lipid tests. What other steps should the GP take at this point?
Your Answer: Morning testosterone
Explanation:The appropriate test to be conducted on all men with erectile dysfunction is the morning testosterone level check. Checking for Chlamydia and gonorrhoeae NAAT is not necessary. Prolactin and FSH/LH should only be checked if the testosterone level is low. Referring for counseling may be considered if psychological factors are suspected, but other tests should be conducted first. Endocrinology referral is not necessary at this stage, but may be considered if the testosterone level is found to be reduced.
Erectile dysfunction (ED) is a condition where a man is unable to achieve or maintain an erection that is sufficient for sexual activity. It is not a disease but a symptom that can be caused by organic, psychogenic, or mixed factors. It is important to differentiate between the causes of ED, with gradual onset of symptoms, lack of tumescence, and normal libido favoring an organic cause, while sudden onset of symptoms, decreased libido, and major life events favoring a psychogenic cause. Risk factors for ED include cardiovascular disease, alcohol use, and certain medications.
To assess for ED, it is recommended to measure lipid and fasting glucose serum levels to calculate cardiovascular risk, as well as free testosterone levels in the morning. If free testosterone is low or borderline, further assessment may be needed. PDE-5 inhibitors, such as sildenafil, are the first-line treatment for ED and should be prescribed to all patients regardless of the cause. Vacuum erection devices can be used as an alternative for those who cannot or will not take PDE-5 inhibitors.
For young men who have always had difficulty achieving an erection, referral to urology is appropriate. Additionally, people with ED who cycle for more than three hours per week should be advised to stop. Overall, ED is a common condition that can be effectively managed with appropriate treatment.
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This question is part of the following fields:
- Surgery
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Question 2
Correct
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A 15-year-old female patient has been referred for primary amenorrhoea. Upon investigation, it is found that she has a 46 XY karyotype. What is a true statement regarding this condition?
Your Answer: The diagnosis is likely to be androgen insensitivity syndrome
Explanation:Gender-related Disorders and their Causes
Gender-related disorders can arise due to various factors. Androgen insensitivity syndrome, also known as testicular feminisation syndrome, is caused by an androgen receptor defect that leads to a female phenotype. Stilboestrol therapy, on the other hand, has been linked to the activation of latent tumours and changes in sexual behaviour, but it does not cause any abnormalities in sexual identity.
Noonan’s syndrome is a condition where male infants exhibit physical features similar to those found in Turner’s syndrome. However, they are still biologically male. In contrast, neither prednisolone nor maternal thyrotoxicosis can cause gender malassignment problems. It is important to understand the causes of gender-related disorders to provide appropriate treatment and support to those affected. Proper diagnosis and management can help individuals lead fulfilling lives.
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This question is part of the following fields:
- Clinical Sciences
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Question 3
Incorrect
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A 28-year-old woman presents at 12 weeks’ gestation for her dating scan. The radiographer calls you in to speak to the patient, as the gestational sac is small for dates and she is unable to demonstrate a fetal heart rate. On further questioning, the patient reports an episode of bleeding while abroad at nine weeks’ gestation, which settled spontaneously.
Which of the following is the most likely diagnosis?Your Answer: Complete miscarriage
Correct Answer: Missed miscarriage
Explanation:Different Types of Miscarriage: Symptoms and Diagnosis
Miscarriage is the loss of pregnancy before 20 weeks’ gestation. There are several types of miscarriage, each with its own symptoms and diagnosis.
Missed miscarriage is an incidental finding where the patient presents without symptoms, but the ultrasound shows a small gestational sac and no fetal heart rate.
Complete miscarriage is when all products of conception have been passed, and the uterus is empty and contracted.
Incomplete miscarriage is when some, but not all, products of conception have been expelled, and the patient experiences vaginal bleeding with an open or closed os.
Inevitable miscarriage is when the pregnancy will inevitably be lost, and the patient presents with active bleeding, abdominal pain, and an open cervical os.
Threatened miscarriage is when there is an episode of bleeding, but the pregnancy is unaffected, and the patient experiences cyclical abdominal pain and dark red-brown bleeding. The cervical os is closed, and ultrasound confirms the presence of a gestational sac and fetal heart rate.
It is important to seek medical attention if any symptoms of miscarriage occur.
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This question is part of the following fields:
- Obstetrics
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Question 4
Incorrect
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A 23-year-old male presents to the emergency department with complaints of testicular pain. The pain has been gradually increasing over the past 24 hours and is localized to the left testicle. On examination, the patient appears uncomfortable. His heart rate is 68/min, blood pressure is 118/92 mmHg, respiratory rate is 18/min, and temperature is 38.5 ºC. The left testicle is swollen and erythematosus, and lifting the scrotal skin provides relief. There is no discharge reported. What is the most appropriate next step given the likely diagnosis?
Your Answer: Order a testicular ultrasound
Correct Answer: Send a urine first void sample for nucleic acid amplification tests (NAATs)
Explanation:The appropriate investigation for suspected epididymo-orchitis depends on the patient’s age and sexual history. For sexually active young adults, a nucleic acid amplification test (NAAT) for sexually transmitted infections (STIs) is recommended. For older adults with a low-risk sexual history, a mid-stream urine (MSU) for microscopy and culture is appropriate.
In the given scenario, the patient is a young, sexually active individual with symptoms of epididymo-orchitis. Therefore, the correct investigation is to send a urine first void sample for NAATs to identify Chlamydia trachomatis and Neisseria gonorrhoeae. Ordering a testicular ultrasound is not necessary at this stage, as it is used to investigate testicular masses and would delay treatment time. Similarly, taking bloods and testing for alpha-fetoprotein is not relevant, as this is used to investigate testicular cancer, which presents differently from epididymo-orchitis. Finally, sending an MSU for microscopy and culture is not the primary investigation in this case, as STIs are more likely to be the cause of the infection.
Epididymo-orchitis is a condition where the epididymis and/or testes become infected, leading to pain and swelling. It is commonly caused by infections spreading from the genital tract or bladder, with Chlamydia trachomatis and Neisseria gonorrhoeae being the usual culprits in sexually active young adults, while E. coli is more commonly seen in older adults with a low-risk sexual history. Symptoms include unilateral testicular pain and swelling, with urethral discharge sometimes present. Testicular torsion, which can cause ischaemia of the testicle, is an important differential diagnosis and needs to be excluded urgently, especially in younger patients with severe pain and an acute onset.
Investigations are guided by the patient’s age, with sexually transmitted infections being assessed in younger adults and a mid-stream urine (MSU) being sent for microscopy and culture in older adults with a low-risk sexual history. Management guidelines from the British Association for Sexual Health and HIV (BASHH) recommend ceftriaxone 500 mg intramuscularly as a single dose, plus doxycycline 100 mg orally twice daily for 10-14 days if the organism causing the infection is unknown. Further investigations are recommended after treatment to rule out any underlying structural abnormalities.
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This question is part of the following fields:
- Surgery
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Question 5
Correct
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For which disease is isolation of the patient necessary?
Your Answer: Measles
Explanation:Infectious Diseases and Their Modes of Transmission
Children who have chicken pox and measles should be kept away from others as there is a high chance of spreading the infection to others. This is because these diseases are highly contagious and can easily spread from one person to another. It is important to isolate these children to prevent the spread of the disease.
Post streptococcal GN and rheumatic fever are caused by immune complexes that develop after an initial infection. These diseases are not contagious and cannot be spread from one person to another. However, it is important to treat the initial infection to prevent the development of these diseases.
Herpetic gingivostomatitis is a disease that is spread through direct contact with infected secretions. This means that the disease can be transmitted when infected secretions come into contact with the skin of an uninfected person. There is no risk of aerosol spread, which means that the disease cannot be spread through the air.
HSP is a disease that is not infectious and cannot be spread from one person to another. This disease is caused by an abnormal immune response and is not contagious.
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This question is part of the following fields:
- Infectious Diseases
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Question 6
Incorrect
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Which of the following is not involved in managing chronic pain caused by cancer?
Your Answer: Nifedipine
Correct Answer: Pinaverium
Explanation:Medications for Pain Relief in Various Conditions
Pinaverium is a medication that is commonly used to reduce the duration of pain in individuals with irritable bowel syndrome (IBS). On the other hand, carbamazepine is used to treat neuropathic pain that is associated with malignancy, diabetes, and other disorders. Clodronate is another medication that is used to treat malignant bone pain and hypercalcaemia by inhibiting osteoclastic bone resorption.
Corticosteroids are also used to treat pain caused by central nervous system tumours. These medications work by reducing inflammation and oedema, which in turn relieves the pain caused by neural compression. Nifedipine is another medication that is used to relieve painful oesophageal spasm and tenesmus that is associated with gastrointestinal tumours.
Lastly, oxybutynin is a medication that is used to relieve painful bladder spasm. Overall, these medications are used to treat pain in various conditions and can provide relief to individuals who are experiencing discomfort.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 7
Correct
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A 47-year-old man presents to his GP complaining of facial swelling and pain following a recent upper respiratory tract infection. Upon examination, the right eye is surrounded by erythema and swelling, and there is discomfort when moving the eye. The patient's left eye has a visual acuity of 6/6, while the right eye has a visual acuity of 6/24.
What would be the best course of action in this case?Your Answer: Admit to hospital for IV antibiotics
Explanation:Patients who exhibit symptoms of orbital cellulitis should be admitted to the hospital for IV antibiotics due to the potential risks of cavernous sinus thrombosis and intracranial spread. Prescribing high-dose oral steroids and checking thyroid function is not the appropriate course of action, as these symptoms are more indicative of orbital cellulitis resulting from the spread of infection from the upper respiratory tract. Referring to Rheumatology and prescribing high-dose oral steroids is also not recommended, as this would be more appropriate for suspected giant cell arthritis, which is rare in patients under 65 years old. Supportive management and nasal decongestants are not recommended at this stage, as the facial pain and swelling with painful eye movements suggest that the condition has progressed to orbital cellulitis and requires IV antibiotics.
Understanding Orbital Cellulitis: Causes, Symptoms, and Management
Orbital cellulitis is a serious infection that affects the fat and muscles behind the orbital septum within the orbit, but not the globe. It is commonly caused by upper respiratory tract infections that spread from the sinuses and can lead to a high mortality rate. On the other hand, periorbital cellulitis is a less severe infection that occurs in the superficial tissues anterior to the orbital septum. However, it can progress to orbital cellulitis if left untreated.
Risk factors for orbital cellulitis include childhood, previous sinus infections, lack of Haemophilus influenzae type b (Hib) vaccination, recent eyelid infections or insect bites, and ear or facial infections. Symptoms of orbital cellulitis include redness and swelling around the eye, severe ocular pain, visual disturbance, proptosis, ophthalmoplegia, eyelid edema, and ptosis. In rare cases, meningeal involvement can cause drowsiness, nausea, and vomiting.
To differentiate between orbital and preseptal cellulitis, doctors look for reduced visual acuity, proptosis, and ophthalmoplegia, which are not consistent with preseptal cellulitis. Full blood count and clinical examination involving complete ophthalmological assessment are necessary to determine the severity of the infection. CT with contrast can also help identify inflammation of the orbital tissues deep to the septum and sinusitis. Blood culture and microbiological swab are also necessary to determine the organism causing the infection.
Management of orbital cellulitis requires hospital admission for IV antibiotics. It is a medical emergency that requires urgent senior review. Early diagnosis and treatment are crucial to prevent complications and reduce the risk of mortality.
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This question is part of the following fields:
- Ophthalmology
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Question 8
Incorrect
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A 50-year-old male visits his GP complaining of bilateral sore eyes that feel gritty. He has tried using over-the-counter eye drops, but the symptoms returned the next day. During the examination, the doctor notices erythematosus eyelid margins and a small stye on the right side. The patient has no known allergies. What is the initial management that should be taken?
Your Answer: Hot compress and topical sodium cromoglycate
Correct Answer: Hot compress and mechanical removal of debris
Explanation:The patient is displaying symptoms that are typical of blepharitis, such as bilateral grittiness. This condition is caused by inflammation of the eyelid margins due to meibomian gland dysfunction, seborrhoeic dermatitis, or infection. Common symptoms include sticky eyes, erythematosus eyelid margins, and an increased risk of styes, chalazions, and secondary conjunctivitis.
To manage blepharitis, hot compresses should be applied to soften the eyelid margin, and debris should be removed with cotton buds dipped in cooled boiled water. Artificial tears may also be used if the patient reports dry eyes.
If the patient were suffering from allergic conjunctivitis, topical sodium cromoglycate would be appropriate. This condition would present with bilateral red eyes, itchiness, swelling, rhinitis, and clear discharge. On the other hand, if the patient had anterior uveitis, topical steroids would be indicated. This condition would present with rapid onset blurred vision, photosensitivity, floaters, eye pain, and redness in one or both eyes.
Blepharitis is a condition where the eyelid margins become inflamed. This can be caused by dysfunction of the meibomian glands (posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (anterior blepharitis). It is more common in patients with rosacea. The meibomian glands secrete oil to prevent rapid evaporation of the tear film, so any problem affecting these glands can cause dryness and irritation of the eyes. Symptoms of blepharitis are usually bilateral and include grittiness, discomfort around the eyelid margins, sticky eyes in the morning, and redness of the eyelid margins. Styes and chalazions are also more common in patients with blepharitis, and secondary conjunctivitis may occur.
Management of blepharitis involves softening the lid margin with hot compresses twice a day and practicing lid hygiene to remove debris from the lid margins. This can be done using cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo or sodium bicarbonate in cooled boiled water. Artificial tears may also be given for symptom relief in people with dry eyes or an abnormal tear film.
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This question is part of the following fields:
- Ophthalmology
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Question 9
Incorrect
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A 42-year-old mechanic visits his GP complaining of intermittent jaundice that has been occurring for the past 5 months. He has been feeling fatigued lately and occasionally experiences mild itching on his arms. He denies any pain or weight loss. The patient has a history of ulcerative colitis, which was diagnosed 13 years ago and has been managed with mesalazine, anti-diarrhoeals, and steroids. The GP orders liver function tests, which reveal the following results:
total bilirubin 38 mmol/l
aspartate aminotransferase (AST) 32 iu/l
alanine aminotransferase (ALT) 34 iu/l
alkaline phosphatase 310 u/l.
What is the most probable diagnosis?Your Answer: Chronic cholecystitis
Correct Answer: Primary sclerosing cholangitis (PSC)
Explanation:Differential Diagnosis for Cholestatic Jaundice in a Patient with UC
Primary sclerosing cholangitis (PSC) is a condition that should be considered in a patient with UC who presents with a raised alkaline phosphatase level. This is because approximately two-thirds of patients with PSC also have coexisting UC, and between 3% and 8% of UC sufferers will develop PSC. Chronic cholecystitis would present with pain, which is not present in this patient, making PSC the more likely diagnosis. Acute cholecystitis would present with right upper quadrant pain and obstructive liver function tests, which are not present in this case. Primary biliary cholangitis is more likely to affect women aged 30-60, and given the patient’s history of UC, PSC is more likely. Pancreatic carcinoma would be associated with weight loss and obstructive liver function tests. Therefore, in a patient with UC presenting with cholestatic jaundice, PSC should be considered as a possible diagnosis.
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This question is part of the following fields:
- Gastroenterology
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Question 10
Incorrect
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A 28-year-old primigravida 1+0 arrives at 35 weeks gestation with a blood pressure reading of 165/120 mmHg and 3+ proteinuria on dipstick testing. She had a stable blood pressure of approximately 115/75mmHg before becoming pregnant, and her only medical history is well-managed asthma. Which of the following statements is correct regarding her treatment?
Your Answer: IV magnesium sulphate is the only curative treatment for her condition
Correct Answer: In induced labour, epidural anaesthesia should help reduce blood pressure
Explanation:1. The only effective treatment for pre-eclampsia is delivery, while IV magnesium sulphate is administered to prevent seizures in eclampsia.
2. Delivery on the same day is a viable option after 34 weeks.
3. Nifedipine is considered safe for breastfeeding mothers. (However, labetalol is the preferred antihypertensive medication, as beta-blockers should be avoided in patients with a history of asthma.)
4. Epidural anaesthesia can help lower blood pressure.
5. It is important to continue hypertension treatment during labour to manage blood pressure levels. Please refer to the NICE guideline on the diagnosis and management of hypertension in pregnancy for further information.Pre-eclampsia is a condition that occurs during pregnancy and is characterized by high blood pressure, proteinuria, and edema. It can lead to complications such as eclampsia, neurological issues, fetal growth problems, liver involvement, and cardiac failure. Severe pre-eclampsia is marked by hypertension, proteinuria, headache, visual disturbances, and other symptoms. Risk factors for pre-eclampsia include hypertension in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension, first pregnancy, and age over 40. Aspirin may be recommended for women with high or moderate risk factors. Treatment involves emergency assessment, admission for observation, and medication such as labetalol, nifedipine, or hydralazine. Delivery of the baby is the most important step in management, with timing depending on the individual case.
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This question is part of the following fields:
- Obstetrics
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Question 11
Incorrect
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Before undergoing general anaesthesia, which regular medications need to be stopped?
Your Answer: Morphine sulphate
Correct Answer: Phenelzine
Explanation:Medication Management in Perioperative Period
Phenelzine and tranylcypromine are monoamine oxidase inhibitors that need to be discontinued at least two weeks before elective surgery due to their potential life-threatening interactions with pethidine and indirect sympathomimetics. Additionally, they can prolong the action of suxamethonium by decreasing the concentration of plasma cholinesterase. Carbamazepine, an anticonvulsant, should be continued throughout the perioperative period. Gliclazide, a short-acting oral hypoglycemic, can be taken if the surgery’s anticipated duration is short.
Lisinopril, an angiotensin-converting enzyme inhibitor (ACEi), and digoxin, a cardiac glycoside, should be continued pre-operatively. Morphine sulfate tablets should also be continued pre-operatively, and a morphine infusion (PCA) should be considered for postoperative analgesia. Pyridostigmine is used in the management of myasthenia gravis and should be continued before minor surgery. However, if perioperative muscle relaxation is required, omitting one or more doses of pyridostigmine would allow a reduction in the dose of the muscle relaxant. Proper medication management in the perioperative period is crucial to ensure patient safety and optimal surgical outcomes.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 12
Incorrect
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An older man comes in with a severe headache, nausea, vomiting and a painful, red right eye. He has reduced visual acuity in the right eye and normal visual acuity in the left eye. During the examination, he had a stony hard eye with marked pericorneal reddening and a hazy corneal reflex. Tonometry revealed a raised intraocular pressure. The patient reports that he has recently been prescribed a new medication by his general practitioner.
What medication could be responsible for this sudden onset of symptoms?Your Answer: Montelukast
Correct Answer: Ipratropium nebuliser
Explanation:Understanding Acute Closed Angle Glaucoma and its Treatment Options
Acute closed angle glaucoma is a serious eye condition that can cause sudden vision loss, severe eye pain, and nausea. It occurs when the angle between the iris and cornea is reduced, leading to a blockage of the aqueous humour flow and increased intraocular pressure. Risk factors include female sex, Asian ethnicity, and hypermetropia.
Certain drugs, such as nebulised ipratropium and tricyclic antidepressants, can induce angle closure due to their antimuscarinic effects. Other antimuscarinic drug side-effects include dry eyes, xerostomia, bronchodilation, decreased gut motility, urinary outflow obstruction, and hallucinations.
Acetazolamide is a carbonic anhydrase inhibitor that is given intravenously to treat acute closed angle glaucoma. It helps to reduce intraocular pressure and prevent damage to the optic nerve. Bisoprolol is a β-blocker that does not precipitate an episode of acute closed angle glaucoma, while montelukast is used in the long-term management of asthma and does not increase the risk of acute closed angle glaucoma.
Topical pilocarpine is a miotic that is used to treat acute angle closure glaucoma by constricting the pupil and promoting aqueous humour flow. It is important to understand the causes and treatment options for acute closed angle glaucoma to prevent vision loss and other serious complications.
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This question is part of the following fields:
- Ophthalmology
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Question 13
Incorrect
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A 50-year-old male with schizophrenia is being evaluated by his psychiatrist. During the consultation, the psychiatrist observes that the patient appears disinterested and unresponsive when discussing recent and upcoming events in his life, such as his upcoming trip to Hawaii and his recent separation from his spouse.
What is the most appropriate term to describe the abnormality exhibited by the patient?Your Answer:
Correct Answer: Blunting of affect
Explanation:Emotional and Cognitive Symptoms in Mental Health
Blunting of affect is a condition where an individual experiences a loss of normal emotional expression towards events. This can be observed in people with schizophrenia, depression, and post-traumatic stress disorder. Anhedonia, on the other hand, is the inability to derive pleasure from activities that were once enjoyable. Depersonalisation is a feeling of detachment from oneself, where an individual may feel like they are not real. Labile affect is characterized by sudden and inappropriate changes in emotional expression. Lastly, thought blocking is a sudden interruption in the flow of thought.
These symptoms are commonly observed in individuals with mental health conditions and can significantly impact their daily lives. It is important to recognize and address these symptoms to provide appropriate treatment and support. By these symptoms, mental health professionals can better assess and diagnose their patients, leading to more effective treatment plans. Additionally, individuals experiencing these symptoms can seek help and support to manage their condition and improve their quality of life.
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This question is part of the following fields:
- Psychiatry
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Question 14
Incorrect
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A 65-year-old patient is suspected of having ingested a substance with anticholinesterase effects. What combination of signs, if present, would most likely confirm this effect?
Your Answer:
Correct Answer: Bradycardia and miosis
Explanation:Acetylcholinesterase Inhibitors and Muscarinic Effects
An acetylcholinesterase inhibitor, also known as an anticholinesterase, is a chemical that prevents the breakdown of acetylcholine (ACh) by inhibiting the cholinesterase enzyme. This leads to an increase in both the level and duration of action of ACh, a neurotransmitter that stimulates postganglionic receptors to produce various effects such as salivation, lacrimation, defecation, micturition, sweating, miosis, bradycardia, and bronchospasm. These effects are referred to as muscarinic effects, and the postganglionic receptors are called muscarinic receptors since muscarine produces these effects.
One pathological syndrome associated with excessive stimulation of the parasympathetic nervous system is SLUD, which stands for Salivation, Lacrimation, Urination, Defecation, and emesis. SLUD is not likely to occur naturally and is usually encountered only in cases of drug overdose or exposure to nerve gases. Nerve gases irreversibly inhibit the acetylcholinesterase enzyme, leading to a chronically high level of ACh at cholinergic synapses throughout the body. This, in turn, chronically stimulates ACh receptors throughout the body, resulting in SLUD and other muscarinic effects.
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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 25-year-old female graduate student presents to her primary care physician with complaints of weight gain and excessive hair growth on her face and upper chest. She reports having irregular periods, with only one occurring every 2-3 months. Upon examination, the patient is found to have elevated levels of testosterone at 3.5 nmol/l and an elevated LH:FSH ratio. Additionally, she is overweight with a BMI of 28 and has acne. What is the most probable diagnosis?
Your Answer:
Correct Answer: Polycystic ovarian syndrome (PCOS)
Explanation:Differential diagnosis for a woman with typical PCOS phenotype and biochemical markers
Polycystic ovarian syndrome (PCOS) is a common endocrine disorder that affects reproductive-aged women. Its diagnosis is based on the presence of at least two of the following criteria: oligo-ovulation or anovulation, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries on ultrasound. However, other conditions can mimic or coexist with PCOS, making the differential diagnosis challenging. Here are some possible explanations for a woman who presents with the typical PCOS phenotype and biochemical markers:
– Cushing syndrome: This rare disorder results from chronic exposure to high levels of cortisol, either endogenously (e.g., due to a pituitary or adrenal tumour) or exogenously (e.g., due to long-term glucocorticoid therapy). Cushing syndrome can cause weight gain, central obesity, moon face, buffalo hump, purple striae, hypertension, glucose intolerance, and osteoporosis. However, it is not associated with a high LH: FSH ratio, which is a hallmark of PCOS.
– Androgen-secreting tumour: This is a rare cause of hyperandrogenism that can arise from the ovary, adrenal gland, or other tissues. The excess production of androgens can lead to virilization, hirsutism, acne, alopecia, menstrual irregularities, and infertility. However, the testosterone level in this case would be expected to be higher than 3.5 nmol/l, which is the upper limit of the normal range for most assays.
– Simple obesity: This is a common condition that can affect women of any age and ethnicity. Obesity can cause insulin resistance, hyperinsulinemia, dyslipidemia, inflammation, and oxidative stress, which can contribute to the development of PCOS. However, the abnormal testosterone and LH: FSH ratio suggest an underlying pathology that is not solely related to excess adiposity. Moreover, at a BMI of 28, the patient’s weight is not within the range for a clinical diagnosis of obesity (BMI ≥ 30).
– Complete androgen insensitivity syndrome: This is a rare genetic disorder that affects the androgen receptor, leading to a lack of response to androgens in target tissues. As a result, affected individuals have a female phenotype despite having XY chromosomes. They typically present with primary amenorrhea -
This question is part of the following fields:
- Gynaecology
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Question 16
Incorrect
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A 35-year-old woman who has given birth before is experiencing advanced labour at 37 weeks gestation. An ultrasound reveals that the baby is in a breech presentation. Despite pushing for one and a half hours, the buttocks are still not visible. What is the appropriate course of action in this scenario?
Your Answer:
Correct Answer: Caesarean section
Explanation:A vaginal delivery is expected to be challenging due to the foetal presentation and station. Singleton pregnancies are not recommended for breech extraction, which also demands expertise. Hence, it is advisable to opt for a Caesarean section.
Breech presentation occurs when the caudal end of the fetus is in the lower segment, and it is more common at 28 weeks than near term. Risk factors include uterine malformations, placenta praevia, and fetal abnormalities. Management options include spontaneous turning, external cephalic version (ECV), planned caesarean section, or vaginal delivery. The RCOG recommends informing women that planned caesarean section reduces perinatal mortality and early neonatal morbidity, but there is no evidence that the long-term health of babies is influenced by how they are born. ECV is contraindicated in certain cases, such as where caesarean delivery is required or there is an abnormal cardiotocography.
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This question is part of the following fields:
- Obstetrics
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Question 17
Incorrect
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A 36-year-old head trauma patient who is in Critical Care is having difficulty consuming enough calories due to bilateral limb fractures that are non-weight-bearing and previous blunt trauma to the chest causing multiple rib fractures. The medical team decides to administer supplemental feeding through a nasogastric (NG) tube. The junior doctor successfully inserts the NG tube but seeks guidance from their senior on the most effective way to verify its correct placement.
What is the appropriate method for confirming the proper positioning of the NG tube?Your Answer:
Correct Answer: Perform a CXR and look for midline descent to below the diaphragm before crossing to the patient’s left-hand side in the stomach.
Explanation:Confirming Correct Placement of Nasogastric (NG) Tube
To ensure correct placement of an NG tube, a chest X-ray (CXR) should be performed to confirm midline descent below the diaphragm before crossing to the left-hand side in the stomach. Misplacement of an NG tube is a never event due to the high mortality rate associated with feeding through a misplaced tube. Seeking radiological support to confirm placement is recommended, and the tip of the NG tube should be visualized ideally. Monitoring oxygen saturations or aspirating and checking the aspirate’s appearance or pH level are not reliable methods for confirming placement. The minimum requirement for confirming placement is ensuring the NG tube progresses below the diaphragm and moves to the left-hand side to sit in the stomach.
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This question is part of the following fields:
- Trauma
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Question 18
Incorrect
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A 55-year-old man, who has been a heavy drinker for many years, arrives at the Emergency Department with intense abdominal pain. During the abdominal examination, caput medusae is observed. Which vessels combine to form the obstructed blood vessel in this patient?
Your Answer:
Correct Answer: Superior mesenteric and splenic veins
Explanation:Understanding the Hepatic Portal Vein and Caput Medusae
The hepatic portal vein is formed by the union of the superior mesenteric and splenic veins. When this vein is obstructed, it can lead to caput medusae, a clinical sign characterized by dilated varicose veins that emanate from the umbilicus, resembling Medusa’s head. This condition is often seen in patients with cirrhotic livers, particularly those who are alcoholics.
While the inferior mesenteric vein can sometimes contribute to the formation of the hepatic portal vein, this is only true for about one-third of individuals. The left gastric vein, on the other hand, does not play a role in the formation of the hepatic portal vein.
It’s important to note that the right and left common iliac arteries are not involved in this condition. Additionally, neither the inferior mesenteric artery nor the paraumbilical veins contribute to the formation of the hepatic portal vein.
Understanding the anatomy and physiology of the hepatic portal vein and caput medusae can aid in the diagnosis and treatment of patients with liver disease.
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This question is part of the following fields:
- Gastroenterology
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Question 19
Incorrect
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An 80-year-old woman presents to the Emergency Department with a 3-day history of fever, anorexia, and right upper quadrant pain. She appears lethargic and confused about her surroundings. Upon examination, there is significant tenderness in the abdomen, particularly in the right upper quadrant. What is the probable bacterial source of her infection?
Your Answer:
Correct Answer: Escherichia
Explanation:Common Bacteria Associated with Cholecystitis
Cholecystitis is a condition characterized by inflammation of the gallbladder. The most likely cause of this condition is Escherichia, a Gram-negative bacilli belonging to the Enterobacteriaceae family. Although Enterococcus can also cause cholecystitis, E Coli is more common. Bacteroides, an obligate anaerobic, Gram-negative bacterium, is a significant component of bacterial flora on mucous membranes but is not a common cause of cholecystitis. Pseudomonas, a Gram-negative aerobic bacterium, is a far less likely cause of acute cholecystitis and is associated with lung infections in those with underlying chronic lung pathology. Proteus, another member of the Enterobacteriaceae family, is a less likely cause of acute cholecystitis and is commonly associated with urinary tract infections. Understanding the common bacteria associated with cholecystitis can aid in the diagnosis and treatment of this condition.
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This question is part of the following fields:
- Microbiology
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Question 20
Incorrect
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A GP registrar has diagnosed a urinary tract infection in a 3-year-old child.
Urine cultures and sensitivity show the organism is sensitive to amoxicillin.
The child weighs 12 kg. The dose of amoxicillin is 20 mg/kg three times daily in a pharmacological preparation which contains 125 mg/5 ml.
What is the appropriate dose to be prescribed?
Choose the correct dosing schedule:Your Answer:
Correct Answer: 4 ml twice daily
Explanation:Dosage Calculation for a 10 kg Child
When administering medication to a child, it is important to calculate the correct dosage based on their weight. For a 10 kg child, the recommended dose is 4 mg/kg twice daily. This means that the child would require 40 mg twice daily.
To determine the amount of medication needed, it is important to know the concentration of the medication. If the medication contains 50 mg per 5 ml, then the child would need 4 ml twice daily to receive the correct dosage of 40 mg. It is important to carefully measure the medication and follow the instructions provided by the healthcare provider to ensure the child receives the correct amount of medication.
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This question is part of the following fields:
- Pharmacology
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Question 21
Incorrect
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A previously healthy 72-year-old man reports experiencing intermittent flashes and a curtain-like loss of lateral vision in his right eye upon waking up this morning, which has since worsened. What is the most probable cause of his symptoms?
Your Answer:
Correct Answer: Retinal detachment
Explanation:Retinal Detachment
Retinal detachment is a serious eye emergency that occurs when the retina’s sensory and pigment layers separate. This condition can be caused by various factors such as congenital malformations, metabolic disorders, trauma, vascular disease, high myopia, vitreous disease, and degeneration. It is important to note that retinal detachment is a time-critical condition that requires immediate medical attention.
Symptoms of retinal detachment include floaters, a grey curtain or veil moving across the field of vision, and sudden decrease of vision. Early diagnosis and treatment can help prevent permanent vision loss. Therefore, it is crucial to be aware of the risk factors and symptoms associated with retinal detachment to ensure prompt medical attention and treatment.
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This question is part of the following fields:
- Neurology
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Question 22
Incorrect
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A 10-year-old girl injures her leg while playing soccer at the park. Her mother takes her to the emergency doctor at their GP clinic later that day as the bleeding has not stopped. The cut is not very big and is on the girl's calf. They immediately applied pressure to the wound and then a bandage, however on examination the wound is still bleeding a little bit. The girl's mother knows that there is a bleeding disorder in her family.
What is the most suitable course of action for this patient, given the probable diagnosis?Your Answer:
Correct Answer: Give desmopressin and tranexamic acid
Explanation:Treatment Options for Bleeding Disorders: Haemophilia A and Von Willebrand Disease
Haemophilia A, a genetic bleeding disorder affecting men, is characterized by a propensity to bleed with minor injuries. Diagnosis is made through a prolonged APTT on a background of normal PT and bleeding time. Treatment for minor bleeds includes desmopressin and tranexamic acid, while major bleeds require infusion with recombinant factor 8. Fresh-frozen plasma and platelets are used in major trauma as replacement therapy, while heparin is an anticoagulant and should be avoided. Von Willebrand factor is given once the diagnosis of Von Willebrand disease is confirmed. Children with severe haemophilia A should receive prophylactic infusion of factor 8 at least once a week until physical maturity, and those undergoing elective surgery or pregnant women will require prophylactic treatment.
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This question is part of the following fields:
- Haematology
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Question 23
Incorrect
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A 30-year-old woman with a history of recurrent spontaneous miscarriages and DVT / PEs comes for a follow-up appointment at your clinic. During the examination, you observe the presence of purpuric rashes, splinter haemorrhages, and livedo reticularis. Considering the probable diagnosis, what would be the most suitable auto-immune antibody test to conduct?
Your Answer:
Correct Answer: Anti-cardiolipin antibodies
Explanation:The antibodies associated with antiphospholipid syndrome are lupus anticoagulant (LA) and anti-cardiolipin antibodies (aCL).
Antiphospholipid syndrome is a condition that can be acquired and is characterized by a higher risk of both venous and arterial thrombosis, recurrent fetal loss, and thrombocytopenia. It can occur as a primary disorder or as a secondary condition to other diseases, with systemic lupus erythematosus being the most common. One important point to remember for exams is that antiphospholipid syndrome can cause a paradoxical increase in the APTT. This is due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with phospholipids involved in the coagulation cascade. Other features of this condition include livedo reticularis, pre-eclampsia, and pulmonary hypertension.
Antiphospholipid syndrome can also be associated with other autoimmune disorders, lymphoproliferative disorders, and, rarely, phenothiazines. Management of this condition is based on EULAR guidelines. Primary thromboprophylaxis involves low-dose aspirin, while secondary thromboprophylaxis depends on the type of thromboembolic event. Initial venous thromboembolic events require lifelong warfarin with a target INR of 2-3, while recurrent venous thromboembolic events require lifelong warfarin and low-dose aspirin. Arterial thrombosis should be treated with lifelong warfarin with a target INR of 2-3.
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This question is part of the following fields:
- Musculoskeletal
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Question 24
Incorrect
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A 30-year-old woman presents with a breast lump and is referred to secondary care. Imaging reveals ductal carcinoma in situ that is oestrogen receptor-positive, progesterone receptor-negative, and HER2-negative. The recommended treatment plan includes lumpectomy, adjuvant radiotherapy, and endocrine therapy. The patient has no medical history and does not use hormonal contraceptives. Her menstrual cycle is regular with a 28-day cycle. What is the mechanism of action of the drug that will likely be prescribed?
Your Answer:
Correct Answer: Partial antagonism of the oestrogen receptor
Explanation:Tamoxifen is the preferred treatment for premenopausal women with oestrogen receptor-positive breast cancer. It is a selective oestrogen receptor modulator (SERM) that partially antagonizes the oestrogen receptor. Other options for endocrine therapy include aromatase inhibitors and GnRH agonists, but these are not typically used as first-line treatment for premenopausal women with breast cancer. GnRH antagonists and complete antagonists of the oestrogen receptor are not used in the management of breast cancer.
Anti-oestrogen drugs are used in the management of oestrogen receptor-positive breast cancer. Selective oEstrogen Receptor Modulators (SERM) such as Tamoxifen act as an oestrogen receptor antagonist and partial agonist. However, Tamoxifen can cause adverse effects such as menstrual disturbance, hot flashes, venous thromboembolism, and endometrial cancer. On the other hand, aromatase inhibitors like Anastrozole and Letrozole reduce peripheral oestrogen synthesis, which is important in postmenopausal women. Anastrozole is used for ER +ve breast cancer in this group. However, aromatase inhibitors can cause adverse effects such as osteoporosis, hot flashes, arthralgia, myalgia, and insomnia. NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer.
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This question is part of the following fields:
- Surgery
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Question 25
Incorrect
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A 59-year-old man, a bus driver, with a history of angina, is admitted to hospital with chest pain. He is diagnosed and successfully treated for a STEMI, and discharged one week later.
Which of the following activities is permitted during the first month of his recovery?Your Answer:
Correct Answer: Drinking alcohol (up to 14 units)
Explanation:Post-Myocardial Infarction (MI) Precautions: Guidelines for Alcohol, Machinery, Driving, Sex, and Exercise
After experiencing a myocardial infarction (MI), also known as a heart attack, it is crucial to take precautions to prevent further complications. Here are some guidelines to follow:
Alcohol Consumption: Patients should be advised to keep their alcohol consumption within recommended limits, which is now 14 units per week for both men and women.
Operating Heavy Machinery: Patients should avoid operating heavy machinery for four weeks post MI.
Bus Driving: Patients should refrain from driving a bus or lorry for six weeks post MI. If the patient had angioplasty, driving is not allowed for one week if successful and four weeks if unsuccessful or not performed.
Sexual Intercourse: Patients should avoid sexual intercourse for four weeks post MI.
Vigorous Exercise: Patients should refrain from vigorous exercise for four weeks post MI.
Following these guidelines can help prevent further complications and aid in the recovery process after a myocardial infarction.
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This question is part of the following fields:
- Cardiology
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Question 26
Incorrect
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A 5-year-old patient is referred to the Paediatric Unit after having presented to her General Practitioner (GP) twice over the course of the week with fever and a red tongue and throat. A course of penicillin V has so far been ineffective. She is fully immunised and has not been in contact with any other children with notifiable infectious diseases. Her parents report that she has not been well for around 7 days with a high fever, which they have been unable to bring down with paracetamol and ibuprofen. She has had a cough with coryzal symptoms and has now developed conjunctivitis.
On examination, she looks unwell. Temperature is 38 °C, heart rate 124 bpm and respiratory rate 28. Capillary refill time is 2 s centrally. She has bilateral conjunctivitis. She has a red oropharynx and a red tongue. There is cervical lymphadenopathy and a widespread maculopapular rash. Her hands and feet are red and there is some peeling of the skin around the toes.
Which of the following diagnoses should be made?Your Answer:
Correct Answer: Kawasaki disease
Explanation:The child in question is suffering from Kawasaki disease, a febrile vasculitis that affects small to medium-sized arteries and primarily affects children under the age of 5, with males being more commonly affected. Symptoms include sudden-onset fever lasting at least 5 days, nonexudative conjunctivitis, polymorphous rash, lymphadenopathy, mucositis, and cardiovascular manifestations such as coronary artery aneurysms. Diagnosis is based on the presence of fever lasting for >5 days and at least four or five of the following: bilateral conjunctivitis, changes in the lips and oral mucosal cavities, lymphadenopathy, polymorphous rash, and changes in the extremities. Treatment involves inpatient care, intravenous immunoglobulins (IVIG), aspirin, and monitoring of cardiovascular function. If left untreated, Kawasaki disease can lead to arterial aneurysms and congestive heart disease. Other potential causes of the child’s symptoms, such as Coxsackie infection, measles, viral upper respiratory tract infection with exanthema, and scarlet fever, have been ruled out based on the child’s symptoms and medical history.
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This question is part of the following fields:
- Paediatrics
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Question 27
Incorrect
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A 68-year-old man is seen in the Cardiology Clinic. He has been on a cardiac glycoside for atrial fibrillation for a while. The cardiologist is worried about the medication's toxicity and wants to switch to a different one.
What aspect of this medication is causing the most concern for the cardiologist?Your Answer:
Correct Answer: Narrow therapeutic index
Explanation:Digoxin is a medication used to treat atrial fibrillation, but it has a narrow therapeutic index, meaning that even small changes in dosage or interactions with other medications can cause harmful side effects. Other drugs with a narrow therapeutic index include lithium, gentamicin, and vancomycin. High protein binding is also important in toxicology, as medications can compete for the same binding sites, leading to increased levels of free medication in the body. Amiodarone, if used long-term, can cause pulmonary toxicity, limiting its use in younger patients who may require it for extended periods. Variable first-pass metabolism can make it difficult to determine the appropriate dosage for a desired drug concentration, as the amount of drug metabolized can vary. Propranolol is an example of a drug affected by variable first-pass metabolism. Finally, zero-order kinetics refers to a constant rate of drug metabolism that is not related to drug concentration. Drugs affected by zero-order kinetics include phenytoin and ethanol.
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This question is part of the following fields:
- Pharmacology
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Question 28
Incorrect
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A 4-year-old child is brought to the General Practice by his mother. She informs you that her son has had a fever and has not been as active during play sessions. She decided to bring him into the surgery when he erupted in a rash two days ago. On examination, he has a vesicular rash which is widely disseminated and intensely pruritic. He has a temperature of 38 °C. You diagnose him with a common childhood infection. The next day, a patient, who is 14 weeks’ pregnant, reports that she briefly baby sat for the child before she knew about his infection. She has no recollection of having the infection as a child and she is well in herself.
Given that the patient has been exposed to the infected child, what is the next best step in her management?Your Answer:
Correct Answer: Check for varicella antibodies
Explanation:Management of Varicella in Pregnancy
Explanation:
When a pregnant woman presents with a vesicular pruritic rash, it is important to consider the possibility of varicella zoster virus infection. Varicella is a teratogenic virus that can harm the fetus, so prompt management is necessary. The first step is to check the woman’s immune status by testing for varicella antibodies. If the results are not available within two working days, referral to secondary services for prophylaxis should be considered. Watching and waiting is not appropriate in this situation. Administering a varicella zoster vaccine is not recommended due to the theoretical risk to the fetus. Immunoglobulins for rubella are not indicated. acyclovir may be used for symptomatic patients, but informed consent is required as the evidence for its safety in pregnancy is not strong. Overall, prompt and appropriate management is crucial in protecting the health of both the mother and the fetus. -
This question is part of the following fields:
- Infectious Diseases
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Question 29
Incorrect
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A 58-year-old man comes to the clinic for his regular follow-up of psoriasis. He had been managing it well with phototherapy six months ago, but recently his condition has worsened. He is currently using topical calcipotriol (Dovonex), topical coal tar ointment, and topical hydromol ointment, and is taking amoxicillin for a recent respiratory infection. He is in good health otherwise.
During the examination, he has an erythematosus rash that covers most of his torso, with widespread plaques on his limbs and neck. The rash is tender and warm, and he is shivering. There are no oral lesions. His heart rate is 101 bpm, blood pressure is 91/45 mmHg, and temperature is 37.7 °C.
What is the most crucial next step in treating this man?Your Answer:
Correct Answer: Arrange hospital admission
Explanation:Emergency Management of Erythrodermic Psoriasis
Erythrodermic psoriasis is a dermatological emergency that requires urgent hospital admission. This is evident in a patient presenting with a drop in blood pressure, tachycardia, borderline pyrexia, and rigors. Supportive care, including IV fluids, cool wet dressings, and a systemic agent, is necessary. The choice of systemic agent depends on the patient and may involve rapid-acting therapies like ciclosporin or slower agents like methotrexate. Discontinuing amoxicillin is crucial as it can cause Stevens–Johnson syndrome/toxic epidermal necrolysis. However, admission is essential in both emergency presentations. Starting ciclosporin or methotrexate orally is not appropriate without investigations. Repeat phototherapy should be avoided as it can worsen erythroderma.
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This question is part of the following fields:
- Dermatology
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Question 30
Incorrect
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As a healthcare professional, you are requested to address a family who have recently been informed of a diagnosis of pulmonary hypoplasia on fetal MRI. What is the most frequent cause of pulmonary hypoplasia?
Your Answer:
Correct Answer: Congenital diaphragmatic hernia
Explanation:Pulmonary hypoplasia in CDH is not a direct result of hernial development but rather occurs alongside it as part of a sequence. It is caused by oligohydramnios, which reduces the size of the intrathoracic cavity and prevents foetal lung growth. Other less common causes of pulmonary hypoplasia include diaphragm agenesis, tetralogy of Fallot, and osteogenesis imperfecta.
Understanding Pulmonary Hypoplasia in Newborns
Pulmonary hypoplasia is a condition that affects newborn infants, where their lungs are underdeveloped. This means that the lungs are smaller than they should be, and they may not function properly. There are several causes of pulmonary hypoplasia, including oligohydramnios and congenital diaphragmatic hernia.
Oligohydramnios is a condition where there is a low level of amniotic fluid in the womb. This can happen for a variety of reasons, such as a problem with the placenta or a leak in the amniotic sac. When there is not enough amniotic fluid, the baby may not have enough room to move around and develop properly. This can lead to pulmonary hypoplasia, as the lungs do not have enough space to grow.
Congenital diaphragmatic hernia is a condition where there is a hole in the diaphragm, which is the muscle that separates the chest cavity from the abdominal cavity. This can allow the organs in the abdomen to move up into the chest cavity, which can put pressure on the lungs and prevent them from developing properly. This can also lead to pulmonary hypoplasia.
In summary, pulmonary hypoplasia is a condition where newborn infants have underdeveloped lungs. It can be caused by a variety of factors, including oligohydramnios and congenital diaphragmatic hernia. It is important to diagnose and treat this condition as soon as possible, as it can lead to serious health problems for the baby.
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This question is part of the following fields:
- Paediatrics
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