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  • Question 1 - A 42-year-old multiparous woman undergoes an 11-week gestation dating scan revealing a live...

    Correct

    • A 42-year-old multiparous woman undergoes an 11-week gestation dating scan revealing a live fetus with several abnormalities such as choroid plexus cysts, clenched hands, rocker bottom feet, and a small placenta. What is the probable abnormality?

      Your Answer: Edwards syndrome (Trisomy 18)

      Explanation:

      A newborn has micrognathia, low-set ears, rocker bottom feet, and overlapping fingers, which are indicative of Edwards Syndrome. This condition, also known as Trisomy 18, is the second most common trisomy after Down Syndrome. Unfortunately, the outcome for infants with Edwards Syndrome is poor, with many dying in-utero and few surviving beyond one week. There are several ultrasound markers that suggest Edwards Syndrome, including cardiac malformations, choroid plexus cysts, neural tube defects, abnormal hand and feet position, exomphalos, growth restriction, single umbilical artery, polyhydramnios, and small placenta. While these markers are not specific to Edwards Syndrome, they increase the likelihood of diagnosis when present together. To confirm the diagnosis, karyotype analysis of placental or amniotic fluid should be performed with patient consent. Infections such as rubella, cytomegalovirus, and varicella zoster should also be considered in the differential diagnosis of multiple fetal abnormalities, and maternal viral serology may be helpful in diagnosis.

      Childhood syndromes are a group of medical conditions that affect children and are characterized by a set of common features. Patau syndrome, also known as trisomy 13, is a syndrome that is characterized by microcephaly, small eyes, cleft lip/palate, polydactyly, and scalp lesions. Edward’s syndrome, also known as trisomy 18, is characterized by micrognathia, low-set ears, rocker bottom feet, and overlapping of fingers. Fragile X syndrome is characterized by learning difficulties, macrocephaly, long face, large ears, and macro-orchidism. Noonan syndrome is characterized by a webbed neck, pectus excavatum, short stature, and pulmonary stenosis. Pierre-Robin syndrome is characterized by micrognathia, posterior displacement of the tongue, and cleft palate. Prader-Willi syndrome is characterized by hypotonia, hypogonadism, and obesity. William’s syndrome is characterized by short stature, learning difficulties, friendly, extrovert personality, and transient neonatal hypercalcaemia. Cri du chat syndrome, also known as chromosome 5p deletion syndrome, is characterized by a characteristic cry, feeding difficulties and poor weight gain, learning difficulties, microcephaly and micrognathism, and hypertelorism. It is important to note that Treacher-Collins syndrome is similar to Pierre-Robin syndrome, but it is autosomal dominant and usually has a family history of similar problems.

    • This question is part of the following fields:

      • Paediatrics
      11.2
      Seconds
  • Question 2 - A 28-year-old woman presents to her GP with a range of symptoms that...

    Correct

    • A 28-year-old woman presents to her GP with a range of symptoms that have been progressively worsening over the past 6 months. Despite no changes in her diet, she has gained over 3 stone of weight, with a concentration on her face and neck. She has also noticed stretch marks on her abdomen and excessive hair growth on her body and face. Upon referral to an endocrinologist, she is diagnosed with a pituitary adenoma causing an increased secretion of adrenocorticotropic hormone.
      What is the best description of this condition?

      Your Answer: Cushing's disease

      Explanation:

      The patient is experiencing Cushing’s disease, which is caused by excessive secretion of adrenocorticotropic hormone (ACTH) from the anterior pituitary gland, often due to a pituitary adenoma. Addison’s disease and acromegaly can be ruled out based on the patient’s symptoms. It is important to differentiate between Cushing’s triad, which includes irregular breathing, bradycardia, and systolic hypertension caused by increased intracranial pressure, and Cushing’s syndrome, a collection of symptoms resulting from prolonged exposure to cortisol. Cushing’s disease is a specific type of Cushing’s syndrome characterized by increased ACTH production due to a pituitary adenoma or excess production of hypothalamus CRH.

      Understanding the Causes of Cushing’s Syndrome

      Cushing’s syndrome is a condition that occurs when the body is exposed to high levels of cortisol for an extended period. While exogenous causes of Cushing’s syndrome, such as glucocorticoid therapy, are more common, endogenous causes can also occur. The causes of Cushing’s syndrome can be divided into two categories: ACTH dependent and ACTH independent.

      ACTH dependent causes of Cushing’s syndrome include Cushing’s disease, which is caused by a pituitary tumor secreting ACTH and producing adrenal hyperplasia. Ectopic ACTH production, which is caused by small cell lung cancer, is another ACTH dependent cause. On the other hand, ACTH independent causes of Cushing’s syndrome include iatrogenic causes such as steroid use, adrenal adenoma, adrenal carcinoma, Carney complex, and micronodular adrenal dysplasia.

      In addition to these causes, there is also a condition called Pseudo-Cushing’s, which mimics Cushing’s syndrome. This condition is often caused by alcohol excess or severe depression and can cause false positive dexamethasone suppression tests or 24-hour urinary free cortisol tests. To differentiate between Cushing’s syndrome and Pseudo-Cushing’s, an insulin stress test may be used. Understanding the causes of Cushing’s syndrome is crucial in diagnosing and treating this condition.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      48
      Seconds
  • Question 3 - What is a risk factor for developmental dysplasia of the hip in infants?...

    Incorrect

    • What is a risk factor for developmental dysplasia of the hip in infants?

      Your Answer: Male sex

      Correct Answer: Oligohydramnios

      Explanation:

      Developmental dysplasia of the hip (DDH) is a condition that affects 1-3% of newborns and is more common in females, firstborn children, and those with a positive family history or breech presentation. It used to be called congenital dislocation of the hip (CDH). DDH is more often found in the left hip and can be bilateral in 20% of cases. Screening for DDH is recommended for infants with certain risk factors, and all infants are screened using the Barlow and Ortolani tests at the newborn and six-week baby check. Clinical examination includes testing for leg length symmetry, restricted hip abduction, and knee level when hips and knees are flexed. Ultrasound is used to confirm the diagnosis if clinically suspected, but x-ray is the first line investigation for infants over 4.5 months. Management includes the use of a Pavlik harness for children under 4-5 months and surgery for older children with unstable hips.

    • This question is part of the following fields:

      • Paediatrics
      26.7
      Seconds
  • Question 4 - A 50-year-old man arrives at the emergency department complaining of severe chest pain...

    Correct

    • A 50-year-old man arrives at the emergency department complaining of severe chest pain that radiates to his left arm, accompanied by nausea and sweating. His ECG reveals widespread ST depression with T wave inversion, and his blood tests show a haemoglobin level of 75g/L. What is the appropriate treatment for his anaemia?

      Your Answer: Transfusion of packed red cells

      Explanation:

      For patients with ACS, the recommended transfusion threshold is a haemoglobin level of 80 g/L. In this case, the patient is presenting with symptoms of ACS and his ECG confirms this. However, his haemoglobin level is below the threshold, indicating severe anaemia. Therefore, an immediate transfusion is necessary to alleviate the anaemia. Anaemia can exacerbate ischaemia in ACS, leading to increased strain on the heart and reduced oxygen supply. The guidelines suggest aiming for a haemoglobin concentration of 80-100 g/L after transfusion. Oral or IV iron would not provide immediate relief, and IV Hartmann’s solution is not a suitable treatment for anaemia and would not address the underlying issue. This highlights the importance of prompt and appropriate treatment for patients with ACS. This information is based on the NICE guideline [NG24].

      Guidelines for Red Blood Cell Transfusion

      In 2015, NICE released guidelines for the use of blood products, specifically red blood cells. These guidelines recommend different transfusion thresholds for patients with and without acute coronary syndrome (ACS). For patients without ACS, the transfusion threshold is 70 g/L, while for those with ACS, it is 80 g/L. The target hemoglobin level after transfusion is 70-90 g/L for patients without ACS and 80-100 g/L for those with ACS. It is important to note that these thresholds should not be used for patients with ongoing major hemorrhage or those who require regular blood transfusions for chronic anemia.

      When administering red blood cells, it is crucial to store them at 4°C prior to infusion. In non-urgent scenarios, a unit of RBC is typically transfused over a period of 90-120 minutes. By following these guidelines, healthcare professionals can ensure that red blood cell transfusions are administered safely and effectively.

    • This question is part of the following fields:

      • Cardiovascular
      6.1
      Seconds
  • Question 5 - A concerned parent brings her 4-month-old to your clinic with a bright red...

    Correct

    • A concerned parent brings her 4-month-old to your clinic with a bright red lump on their scalp that has been gradually increasing in size over the past 6 weeks. What is the probable diagnosis?

      Your Answer: Capillary haemangioma

      Explanation:

      Port wine stain and naevus flammeus are two different conditions that are often confused with each other. While they both present as red or purple birthmarks, port wine stains are caused by a malformation of blood vessels in the skin, while naevus flammeus is a type of capillary malformation.

      Understanding Strawberry Naevus

      Strawberry naevus, also known as capillary haemangioma, is a type of skin condition that usually develops in infants within the first month of life. It is characterized by raised, erythematous, and multilobed tumours that commonly appear on the face, scalp, and back. While it is not present at birth, it can grow rapidly and reach its peak size at around 6-9 months before regressing over the next few years. In fact, around 95% of cases resolve before the child reaches 10 years of age. However, there are potential complications that may arise, such as obstructing visual fields or airway, bleeding, ulceration, and thrombocytopaenia.

      Capillary haemangiomas are more common in white infants, particularly in female and premature infants, as well as those whose mothers have undergone chorionic villous sampling. In cases where treatment is necessary, propranolol is now the preferred choice over systemic steroids. Topical beta-blockers like timolol may also be used. It is important to note that there is a deeper type of capillary haemangioma called cavernous haemangioma. Understanding the nature of strawberry naevus is crucial in managing its potential complications and providing appropriate treatment.

    • This question is part of the following fields:

      • Dermatology
      9.1
      Seconds
  • Question 6 - A 50-year-old female patient arrives at the emergency department via ambulance after experiencing...

    Correct

    • A 50-year-old female patient arrives at the emergency department via ambulance after experiencing a sudden onset of facial droop and speech impairment. Upon examination, she is conscious but displays both expressive and receptive aphasia. The patient's GP summary record indicates that she is only taking tamoxifen. Based on this information, what is the most probable medical condition in her past medical history?

      Your Answer: Oestrogen receptor-positive breast cancer

      Explanation:

      Pre-menopausal women with oestrogen receptor-positive breast cancer are managed using Tamoxifen.
      Tamoxifen is ineffective in treating oestrogen receptor-negative breast cancer or ovarian cancer.
      However, Tamoxifen may increase the risk of endometrial cancer.
      Colorectal cancer is not treated with Tamoxifen.

      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 flushes, 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 flushes, arthralgia, myalgia, and insomnia. NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer.

    • This question is part of the following fields:

      • Neurology
      21.2
      Seconds
  • Question 7 - A 35-year-old patient is admitted with vomiting and abdominal pain. He was noted...

    Correct

    • A 35-year-old patient is admitted with vomiting and abdominal pain. He was noted to have marked buccal pigmentation.
      On examination, he is dehydrated. His pulse is 95 beats per minute, while his blood pressure (BP) is 100/70 mmHg.
      Investigations reveal the following:
      Investigation Result Normal values
      Glucose 3.5 mmol/l 3.9–7.1 mmol/l
      Sodium (Na+) 130 mmol/l 135–145 mmol/l
      Potassium (K+) 4.2 mmol/l 3.5–5.0 mmol/l
      Urea 7.8 mmol/l 2.5–7.1 mmol/l
      Creatinine (Cr) 95 µmol/l 50–120 µmol/l
      Which of the following is the most likely diagnosis?

      Your Answer: Addison’s disease

      Explanation:

      Endocrine Disorders: Addison’s Disease, Cushing Syndrome, and Conn Syndrome

      Addison’s Disease:
      Addison’s disease, or primary hypoadrenalism, is a condition characterized by chronic adrenal insufficiency. It is most commonly caused by autoimmune destruction of the adrenals in the UK, while tuberculosis is the most common cause worldwide. Other causes include long-term exogenous steroid use, cancer, or hemorrhage damage. Symptoms develop gradually, but patients can present in Addisonian crisis if there is a sudden deterioration in adrenal function or a physiological stress that the residual adrenal function cannot cope with. Treatment is with long-term replacement of corticosteroids and aldosterone.

      Cushing Syndrome:
      Cushing syndrome is a result of excess corticosteroid. It can be caused by exogenous steroids, primary hyperadrenalism, or secondary hyperadrenalism. Signs and symptoms include weight gain with moon facies and buffalo hump, hypertension, hyperglycemia, mood changes, hirsutism, baldness, and sleep disturbance.

      Conn Syndrome:
      Conn syndrome, also known as primary hyperaldosteronism, is caused most commonly by adrenal hyperplasia or adenomas. It results in excess aldosterone release, causing difficult-to-treat hypertension, hypernatremia, and hypokalemia.

      Other Disorders:
      Hypoglycemia occurs in insulinoma, but the other features are absent. Peutz-Jeghers syndrome is an autosomal dominant condition characterized by perioral freckling and small bowel polyps, which may present with vomiting secondary to intussusception from the small polyps but does not explain the hypoglycemia.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      13.7
      Seconds
  • Question 8 - A 50-year-old woman comes in for a check-up. Her mother was recently released...

    Correct

    • A 50-year-old woman comes in for a check-up. Her mother was recently released from the hospital after fracturing her hip. The patient is worried that she may have inherited osteoporosis and wants to know what steps she should take. She has no significant medical history, does not take any regular medications, and has never experienced any fractures. She is a smoker, consuming approximately 20 cigarettes per day, and drinks 3-4 units of alcohol daily.

      What is the best course of action for this patient?

      Your Answer: Use the FRAX tool

      Explanation:

      Due to her positive family history, smoking, and excess alcohol intake, this woman is at a higher risk of developing osteoporosis. Therefore, it is recommended that she undergo a FRAX assessment without delay, rather than waiting until the age of 65 as typically recommended for women without such risk factors.

      Assessing the Risk of Osteoporosis

      Osteoporosis is a concern due to the increased risk of fragility fractures. To determine which patients require further investigation, NICE produced guidelines in 2012 for assessing the risk of fragility fracture. Women aged 65 years and older and men aged 75 years and older should be assessed, while younger patients should be assessed in the presence of risk factors such as previous fragility fracture, history of falls, and low body mass index.

      NICE recommends using a clinical prediction tool such as FRAX or QFracture to assess a patient’s 10-year risk of developing a fracture. FRAX estimates the 10-year risk of fragility fracture and is valid for patients aged 40-90 years. QFracture estimates the 10-year risk of fragility fracture and includes a larger group of risk factors.

      If the FRAX assessment was done without a bone mineral density (BMD) measurement, the results will be categorised into low, intermediate, or high risk. If the FRAX assessment was done with a BMD measurement, the results will be categorised into reassurance, consider treatment, or strongly recommend treatment. Patients assessed using QFracture are not automatically categorised into low, intermediate, or high risk.

      NICE recommends reassessing a patient’s risk if the original calculated risk was in the region of the intervention threshold for a proposed treatment and only after a minimum of 2 years or when there has been a change in the person’s risk factors.

    • This question is part of the following fields:

      • Musculoskeletal
      18.5
      Seconds
  • Question 9 - A 68-year-old man presents with confusion and evidence of right lower lobe pneumonia...

    Incorrect

    • A 68-year-old man presents with confusion and evidence of right lower lobe pneumonia on Chest X-Ray. He appears unwell to you. His urea level is 8 mmol/l, and respiratory rate is 38 breaths per minute. His pulse rate is 89, and blood pressure is 120/58 mmHg.

      What is the patient's CURB 65 score?

      Your Answer: 4

      Correct Answer: 5

      Explanation:

      Pneumonia is a serious respiratory infection that requires prompt assessment and management. In the primary care setting, the CRB65 criteria are used to stratify patients based on their risk of mortality. Patients with a score of 0 are considered low risk and may be treated at home, while those with a score of 3 or 4 are high risk and require urgent admission to hospital. The use of a point-of-care CRP test can help guide antibiotic therapy. In the secondary care setting, the CURB65 criteria are used, which includes an additional criterion of urea > 7 mmol/L. Chest x-rays and blood and sputum cultures are recommended for intermediate or high-risk patients. Treatment for low-severity community acquired pneumonia typically involves a 5-day course of amoxicillin, while moderate and high-severity cases may require dual antibiotic therapy for 7-10 days. Discharge criteria and advice post-discharge are also provided, including information on expected symptom resolution timeframes and the need for a repeat chest x-ray at 6 weeks.

    • This question is part of the following fields:

      • Respiratory Medicine
      22.2
      Seconds
  • Question 10 - A 32-year-old woman reports experiencing discomfort in the plantar midfoot area between the...

    Incorrect

    • A 32-year-old woman reports experiencing discomfort in the plantar midfoot area between the third and fourth toes while wearing high heels.
      What is the most probable reason for her symptoms?

      Your Answer: Plantar fasciitis

      Correct Answer: Morton’s neuroma

      Explanation:

      Common Foot Conditions and Their Symptoms

      Morton’s Neuroma: This condition is characterized by perineural fibrosis and common digital nerve degeneration, resulting in neuropathic pain in the forefoot and interdigital space. The third web space is most commonly affected, and pain is aggravated by narrow, tight, high-heeled shoes. Treatment involves local steroid injections and footwear advice.

      Claw Toe: In this condition, there is MTP dorsiflexion with PIP and DIP flexion affecting any of the second to fifth toes. Patients often report pain at the PIP joint due to pressure from a shoe on the toe.

      Achilles Tendonitis: This results in activity-related pain and swelling of the Achilles tendon, felt at the lower calf. The toes are unaffected. Management includes rest, NSAIDs, heel padding, physiotherapy, and steroid injections.

      Hammer Toe: This is a deformity of the second, third, or fourth toe, characterized by progressive PIP flexion deformity and compensatory hyperextension of the MTP and DIP joints. The PIP joint becomes prominent dorsally, causing pain when rubbing against the shoe.

      Plantar Fasciitis: This is a pain in the inferior heel at the attachment of the medial band of the plantar fascia to the medial calcaneal tubercle. It is a chronic inflammatory process and an overuse injury, with pain worst in the morning. Treatment involves shoes with arch support, soft heels and heel padding, regular stretching exercises, NSAIDs, and local steroid injections.

      Understanding Common Foot Conditions and Their Symptoms

    • This question is part of the following fields:

      • Musculoskeletal
      6.2
      Seconds
  • Question 11 - A 50-year-old man presents to the emergency department with right upper quadrant pain,...

    Correct

    • A 50-year-old man presents to the emergency department with right upper quadrant pain, fatigue, and anorexia that has been going on for a few weeks and is getting gradually worse. His past medical history includes heavy alcohol intake, gastroesophageal reflux disease (GORD) and a hiatus hernia. He only takes omeprazole and has no known allergies.

      On examination, he looks jaundiced.

      A liver function test is done which shows:

      Bilirubin 50 µmol/L (3 - 17)
      ALT 150 u/L (3 - 40)
      AST 300 u/L (8 - 33)
      Albumin 35 g/L (35 - 50)

      What is the most likely diagnosis?

      Your Answer: Alcoholic hepatitis

      Explanation:

      Understanding Alcoholic Liver Disease and its Management

      Alcoholic liver disease is a range of conditions that includes alcoholic fatty liver disease, alcoholic hepatitis, and cirrhosis. One of the characteristic findings in this disease is an elevated gamma-GT level. Additionally, a ratio of AST:ALT greater than 2, and especially greater than 3, strongly suggests acute alcoholic hepatitis.

      When it comes to managing alcoholic hepatitis, glucocorticoids such as prednisolone are often used during acute episodes. The Maddrey’s discriminant function (DF) is used to determine who would benefit from glucocorticoid therapy. This function is calculated using prothrombin time and bilirubin concentration. Pentoxyphylline is also sometimes used as a treatment option.

      A study called STOPAH compared the two common treatments for alcoholic hepatitis, pentoxyphylline and prednisolone. The study showed that prednisolone improved survival at 28 days, while pentoxyphylline did not improve outcomes. Understanding the different types of alcoholic liver disease and their management options is crucial for healthcare professionals in providing effective care for patients.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      43
      Seconds
  • Question 12 - A 19-year-old man with a history of anxiety and depression is being managed...

    Incorrect

    • A 19-year-old man with a history of anxiety and depression is being managed by the Child and Adolescent Mental Health Service. They have suggested prescribing an SSRI. What is the most suitable medication to prescribe?

      Your Answer: Sertraline

      Correct Answer: Fluoxetine

      Explanation:

      Fluoxetine is the preferred SSRI for children and adolescents.

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

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

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

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

    • This question is part of the following fields:

      • Psychiatry
      13.6
      Seconds
  • Question 13 - A 62-year-old woman visits the clinic complaining of unpleasant breath and gurgling sounds...

    Correct

    • A 62-year-old woman visits the clinic complaining of unpleasant breath and gurgling sounds while swallowing. She reports no other symptoms or changes in her health.
      What is the MOST probable diagnosis?

      Your Answer: Pharyngeal pouch

      Explanation:

      Pharyngeal Pouch and Hiatus Hernia: Two Common Causes of Oesophageal Symptoms

      Pharyngeal pouch and hiatus hernia are two common conditions that can cause symptoms related to the oesophagus. A pharyngeal pouch is a diverticulum that forms in the posterior aspect of the oesophagus due to herniation between two muscles that constrict the inferior part of the pharynx. This pouch can trap food and cause halitosis, regurgitation of food or gurgling noises, and sometimes a palpable lump on the side of the neck. Treatment involves surgery to correct the herniation or sometimes to close the diverticulum.

      Hiatus hernia, on the other hand, occurs when part of the stomach protrudes through the diaphragm into the chest cavity, leading to a retrosternal burning sensation, gastro-oesophageal reflux, and dysphagia. This condition is more common in older people and those with obesity or a history of smoking. Treatment may involve lifestyle changes, such as weight loss and avoiding trigger foods, as well as medications to reduce acid production or strengthen the lower oesophageal sphincter.

      Other possible causes of oesophageal symptoms include gastro-oesophageal reflux disease (GORD), oesophageal candidiasis, and oesophageal carcinoma. GORD is a chronic condition that involves reflux of gastric contents into the oesophagus, causing symptoms of heartburn and acid regurgitation. Oesophageal candidiasis is a fungal infection that usually affects people with weakened immune systems. Oesophageal carcinoma is a type of cancer that can develop in the lining of the oesophagus, often with symptoms such as weight loss, dysphagia, abdominal pain, and dyspepsia. However, based on the history provided, pharyngeal pouch and hiatus hernia are more likely causes of the patient’s symptoms.

    • This question is part of the following fields:

      • ENT
      15
      Seconds
  • Question 14 - A 38-year-old man with a history of Wilson’s disease and mild osteoarthritis presents...

    Incorrect

    • A 38-year-old man with a history of Wilson’s disease and mild osteoarthritis presents with features of nephrotic syndrome.
      Which medication is the most likely cause for his condition?

      Your Answer: Topical non-steroidal anti-inflammatory drugs (NSAIDs)

      Correct Answer: d-Penicillamine

      Explanation:

      Pharmacologic Treatments and Complications: A Review

      Secondary membranous nephropathy can be caused by autoimmune diseases, infectious diseases, malignancy, and exposure to certain drugs such as captopril, gold, lithium, or penicillamine. Treatment with chelating agents like D-penicillamine is the mainstay of treatment for Wilson’s disease, but it can cause proteinuria in up to 30% of patients. Hydroxychloroquine is used for active rheumatoid arthritis but can cause ocular toxicity. Methotrexate is used for severe Crohn’s disease and rheumatoid arthritis but can cause bone marrow suppression. Topical NSAIDs are unlikely to cause systemic side-effects, while sulfasalazine can cause rare but serious side-effects in patients with G6PD deficiency. It is important to monitor patients closely for complications when using these pharmacologic treatments.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      6.4
      Seconds
  • Question 15 - A 45-year-old woman, who is a non-smoker, presents with back pain. A bone...

    Correct

    • A 45-year-old woman, who is a non-smoker, presents with back pain. A bone scan shows multiple lesions highly suggestive of metastases. Clinical examination is normal apart from unilateral axillary lymphadenopathy. Excision biopsy of an affected lymph node shows adenocarcinoma. Which of the following investigations should be prioritised to find the site of the primary?

      Your Answer: Mammography

      Explanation:

      When a patient presents with metastatic bone disease from an unknown primary, it is important to identify the primary source in order to guide treatment and determine prognosis. Tumours that commonly metastasize to bone include those of the lungs, prostate, breast, kidney, and thyroid.

      In cases where the patient has unilateral axillary lymphadenopathy, metastatic breast carcinoma is highly likely. Other potential causes of unilateral axillary lymphadenopathy include lymphoma, primary malignancy, melanoma, or metastases from non-breast primary malignancy.

      While there are various investigations that can be performed, mammography should be the first examination of choice. If the mammogram is negative, other investigations may be pursued to identify alternative occult sites.

      It is important to note that identifying the primary source is useful even in cases of metastatic disease, as it can guide treatment and provide insight into prognosis. Therefore, mammography plays a crucial role in the diagnosis of metastatic breast cancer.

    • This question is part of the following fields:

      • Haematology/Oncology
      25.6
      Seconds
  • Question 16 - A 4-year-old boy is brought to the Paediatric Emergency Department with a fever...

    Incorrect

    • A 4-year-old boy is brought to the Paediatric Emergency Department with a fever of one week. On evaluation, the child appears unwell, erythema of the palms and soles are noted, along with bilateral conjunctivitis. Examination of the oral cavity reveals cracked lips.
      In addition to the above findings, which one of the following features would prompt an urgent referral for echocardiography?

      Your Answer: Tonsillar exudate

      Correct Answer: Rash on the trunk and extremities

      Explanation:

      Clinical Features and Differential Diagnoses of Kawasaki Disease

      Kawasaki disease is a rare but serious condition that primarily affects children under the age of five. To diagnose Kawasaki disease, a patient must have a fever for at least five days and four out of five classical features: bilateral, non-exudative conjunctival injection, changes in lips and oral cavity, oedema and erythema in the hands and feet, polymorphous rash, and cervical lymphadenopathy. However, tonsillar exudate, leukopenia, neck stiffness, and small submental lymph nodes are not classical features of Kawasaki disease and should prompt consideration of other differential diagnoses. Patients with confirmed Kawasaki disease should undergo echocardiographic examination to detect potential coronary artery aneurysms. Early diagnosis and treatment are crucial to prevent serious complications.

    • This question is part of the following fields:

      • Musculoskeletal
      34.6
      Seconds
  • Question 17 - A 6-month-old boy is brought to the emergency department with a 24-hour history...

    Incorrect

    • A 6-month-old boy is brought to the emergency department with a 24-hour history of cough and wheeze, following a week of mild fever and coryzal symptoms. The infant appears otherwise healthy and has no significant medical history. Upon respiratory examination, diffuse wheezing is noted. Vital signs reveal:
      Respiratory rate 52/min
      Blood pressure 92/54 mmHg
      Temperature 38.2ºC
      Heart rate 120 bpm
      Oxygen saturation 96% on room air
      What is the most appropriate course of action for managing this infant's symptoms?

      Your Answer: Nebulised salbutamol

      Correct Answer: Supportive management only

      Explanation:

      If the patient’s respiratory distress worsened or their feeding was impacted, they would be admitted. It is important to note that amoxicillin is not effective in treating bronchiolitis, but may be used for uncomplicated community-acquired pneumonia or acute otitis media. Dexamethasone is commonly used for croup, but this diagnosis is unlikely as the patient does not have a barking cough, hoarse voice, or inspiratory stridor. Inhaled racemic adrenaline is also used for croup. Nebulised salbutamol is not necessary for this patient as they are stable and require only supportive management.

      Bronchiolitis is a condition where the bronchioles become inflamed, and it is most commonly caused by respiratory syncytial virus (RSV). This virus is responsible for 75-80% of cases, with other causes including mycoplasma and adenoviruses. Bronchiolitis is most prevalent in infants under one year old, with 90% of cases occurring in those aged 1-9 months. The condition is more serious in premature babies, those with congenital heart disease or cystic fibrosis. Symptoms include coryzal symptoms, dry cough, increasing breathlessness, and wheezing. Hospital admission is often necessary due to feeding difficulties associated with increasing dyspnoea.

      Immediate referral is recommended if the child has apnoea, looks seriously unwell, has severe respiratory distress, central cyanosis, or persistent oxygen saturation of less than 92% when breathing air. Clinicians should consider referral if the child has a respiratory rate of over 60 breaths/minute, difficulty with breastfeeding or inadequate oral fluid intake, or clinical dehydration. Immunofluorescence of nasopharyngeal secretions may show RSV, and management is largely supportive. Humidified oxygen is given via a head box if oxygen saturations are persistently low, and nasogastric feeding may be necessary if children cannot take enough fluid/feed by mouth. Suction may also be used for excessive upper airway secretions. NICE released guidelines on bronchiolitis in 2015 for more information.

    • This question is part of the following fields:

      • Paediatrics
      26.4
      Seconds
  • Question 18 - A 62-year-old man is being evaluated for cognitive impairment with concerns about a...

    Correct

    • A 62-year-old man is being evaluated for cognitive impairment with concerns about a movement disorder. As part of his evaluation, he undergoes cross-sectional brain imaging and a dopamine Transporter Scan (DaTscan). The results show reduced dopaminergic activity in the substantia nigra bilaterally on the DaTscan and age-related changes on the MRI head. What is the most probable diagnosis?

      Your Answer: Parkinson’s disease

      Explanation:

      Differentiating Neurodegenerative Disorders: A Comparison of Parkinson’s Disease, Alzheimer’s Dementia, Frontotemporal Dementia, Huntington’s Disease, and Vascular Dementia

      Neurodegenerative disorders can be difficult to differentiate due to overlapping symptoms. Parkinson’s disease, for example, involves the death of neurones in the substantia nigra and is often confirmed through the use of DaTscan, which visualises dopamine transporter levels in the brain. Dementia is a common complication of Parkinson’s disease, affecting 20-40% of patients and causing cognitive, mood, and behavioural changes.

      Alzheimer’s dementia, on the other hand, is characterised by cortical atrophy visible on CT and MRI scans and is not typically associated with movement disorders. Frontotemporal dementia primarily affects behaviour and language and is also not typically associated with movement disorders.

      Huntington’s disease is another basal ganglia disorder, but it primarily involves cell loss in the striatum, leading to chorea – uncontrollable limb movements. CT and MRI scans can show loss of striatal volume in moderate-to-severe cases, but early scans may appear normal.

      Vascular dementia, the second most common cause of dementia after Alzheimer’s, often has a history of cerebral vascular disease and is not typically associated with movement disorders. Understanding the unique characteristics of each neurodegenerative disorder is crucial for accurate diagnosis and treatment.

    • This question is part of the following fields:

      • Neurology
      42.5
      Seconds
  • Question 19 - A 26-year-old woman comes in for her routine medical check-up before starting her...

    Correct

    • A 26-year-old woman comes in for her routine medical check-up before starting her new job as a soccer player. She reports feeling healthy and has no notable medical history in her family.

      During the physical examination, her lungs sound clear and her heart has a normal rhythm. Her pulse rate is 62 beats per minute. However, her ECG reveals sinus rhythm with a prolonged PR interval of 215ms.

      What is the appropriate course of action for managing her ECG results?

      Your Answer: No intervention needed

      Explanation:

      First-degree heart block is a common occurrence in athletes and does not require any intervention. This patient’s ECG shows a prolonged PR interval, which is the defining characteristic of first-degree heart block. As it is a normal variant, there is no need for any referral or further investigations. The patient can continue to play football without any concerns.

      Normal Variants in Athlete ECGs

      Athletes may exhibit certain ECG changes that are considered normal variants. These include sinus bradycardia, junctional rhythm, first degree heart block, and Mobitz type 1 (Wenckebach phenomenon). Sinus bradycardia refers to a slower than normal heart rate originating from the sinus node, which is the natural pacemaker of the heart. Junctional rhythm occurs when the heart’s electrical impulses originate from the junction between the atria and ventricles, rather than the sinus node. First degree heart block is a delay in the electrical conduction between the atria and ventricles, resulting in a prolonged PR interval on the ECG. Mobitz type 1, also known as Wenckebach phenomenon, is a type of heart block where there is a progressive lengthening of the PR interval until a beat is dropped. These ECG changes are considered normal in athletes and do not necessarily indicate any underlying cardiac pathology.

    • This question is part of the following fields:

      • Cardiovascular
      30
      Seconds
  • Question 20 - A 35-year-old woman who is 8 weeks pregnant visits the early pregnancy unit...

    Correct

    • A 35-year-old woman who is 8 weeks pregnant visits the early pregnancy unit drop-in clinic complaining of dysuria and increased urinary frequency for the past 2 days. The results of her urine dipstick test are as follows: Leucocytes +++, Nitrites +, Protein -, pH 5.0, Blood +, Ketones -, Glucose -. What is the recommended treatment for her condition?

      Your Answer: 7-day course of nitrofurantoin

      Explanation:

      The recommended first-line treatment for lower UTI in pregnant women who are not at term is a 7-day course of nitrofurantoin. However, nitrofurantoin should be avoided in women who are close to term due to the risk of neonatal haemolysis. It is important to promptly and appropriately treat UTI in pregnancy as it is associated with pre-term delivery and low-birthweight. Amoxicillin and cefalexin are second-line options, but local guidelines may vary. It is important to note that a 3-day course of nitrofurantoin is not recommended according to NICE guidelines.

      Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is teratogenic in the first trimester. Asymptomatic bacteriuria in pregnant women should also be treated to prevent progression to acute pyelonephritis. Men with UTIs should be offered a seven-day course of trimethoprim or nitrofurantoin unless prostatitis is suspected. A urine culture should be sent before antibiotics are started. Catheterised patients should not be treated for asymptomatic bacteria, but if symptomatic, a seven-day course of antibiotics should be given. Acute pyelonephritis requires hospital admission and treatment with a broad-spectrum cephalosporin or quinolone for 10-14 days. Referral to urology is not routinely required for men who have had one uncomplicated lower UTI.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      27.6
      Seconds
  • Question 21 - A father is worried about a swelling he has noticed on his two-day-old...

    Incorrect

    • A father is worried about a swelling he has noticed on his two-day-old baby's head. The baby was delivered using forceps due to a prolonged second stage of labor. Upon examination, there is a swelling in the parietal region that does not cross the suture lines. The doctor informs him that it may take several weeks to resolve. What type of head injury is most likely responsible for this?

      Your Answer: Caput succedaneum

      Correct Answer: Cephalohaematoma

      Explanation:

      A cephalohaematoma is a swelling that appears on a newborn’s head, usually a few hours after delivery. It is caused by bleeding between the skull and periosteum, with the parietal region being the most commonly affected site. This condition may lead to jaundice as a complication and can take up to three months to resolve.

      In comparison to caput succedaneum, which is another type of swelling that can occur on a newborn’s head, cephalohaematoma is more localized and does not cross suture lines. Caput succedaneum, on the other hand, is a diffuse swelling that can cross suture lines and is caused by fluid accumulation in the scalp tissue. Both conditions are usually harmless and resolve on their own, but medical attention may be necessary in severe cases.

    • This question is part of the following fields:

      • Paediatrics
      20.2
      Seconds
  • Question 22 - As a general practice doctor, you see a 35-year-old plumber who complains of...

    Correct

    • As a general practice doctor, you see a 35-year-old plumber who complains of shooting pains down his left leg for the past 3 weeks. The pain has been increasing in intensity and over the counter analgesia has not helped. The patient has no past medical history and takes no regular medications. During examination, you find normal power in both legs but altered sensation over the great toe on his left. There are no urinary symptoms or perianal sensation issues. An MRI scan of his lumbar spine shows a small left paracentral L4/5 disc prolapse causing compression of the transiting L5 nerve root. There is no compression of the cauda equina with CSF visible around all nerve roots. What is the most appropriate next step in managing this patient?

      Your Answer: Start treatment with NSAIDs and refer for physiotherapy

      Explanation:

      Most cases of sciatica can be resolved within 3 months through conservative treatment, and specialist referral is rarely necessary. However, if the pain persists after 4-6 weeks of physiotherapy and anti-neuropathic medication, referral to spinal surgery may be considered. Discharging the patient without proper intervention is not recommended as there is a risk of symptoms worsening and developing cauda equina syndrome. Patients should be advised to seek emergency care if they experience peri-anal or saddle sensory changes, difficulty urinating, or symptoms affecting both legs. Opiates are not recommended for neuropathic pain and may lead to dependence. Instead, a more appropriate and effective pain reliever for the patient’s age would be a non-steroidal anti-inflammatory drug (NSAID) like naproxen.

      Understanding Prolapsed Disc and its Features

      A prolapsed lumbar disc is a common cause of lower back pain that can lead to neurological deficits. It is characterized by clear dermatomal leg pain, which is usually worse than the back pain. The pain is often aggravated when sitting. The features of the prolapsed disc depend on the site of compression. For instance, L3 nerve root compression can cause sensory loss over the anterior thigh, weak quadriceps, reduced knee reflex, and a positive femoral stretch test. On the other hand, L4 nerve root compression can lead to sensory loss in the anterior aspect of the knee, weak quadriceps, reduced knee reflex, and a positive femoral stretch test.

      The management of prolapsed disc is similar to that of other musculoskeletal lower back pain. It involves analgesia, physiotherapy, and exercises. According to NICE, the first-line treatment for back pain without sciatica symptoms is NSAIDs +/- proton pump inhibitors, rather than neuropathic analgesia. If the symptoms persist after 4-6 weeks, referral for consideration of MRI is appropriate. Understanding the features of prolapsed disc can help in the diagnosis and management of this condition.

    • This question is part of the following fields:

      • Musculoskeletal
      40.6
      Seconds
  • Question 23 - A 62-year-old female presents with a red eye on one side that is...

    Correct

    • A 62-year-old female presents with a red eye on one side that is watering but not causing any pain. She has a history of well-managed Crohn's disease and reports feeling generally healthy. Her vital signs are normal. Upon examination, a small area of redness is observed, but there is no vision impairment, and the patient does not display any sensitivity to light. Eye drops are given, resulting in a brief whitening of the blood vessels. What is the probable diagnosis?

      Your Answer: Episcleritis

      Explanation:

      Episcleritis is a condition that can cause redness in the eye, but it is typically not accompanied by pain.

      Both episcleritis and scleritis can cause unilateral redness in the eye, tearing, and no sensitivity to light. However, a key difference between the two is that the use of phenylephrine or neosynephrine eye drops will cause the blood vessels in episcleritis to become pale, while this will not occur in scleritis.

      In contrast, closed-angle glaucoma often presents with a painful, red eye that is unilateral. The cornea may appear hazy, and the pupil may be mid-dilated. Patients may also experience nausea, vomiting, and see halos around lights.

      A stye, or hordeolum, is a bacterial infection of one of the glands in the eyelid. This can cause a tender, red bump on the edge of the eyelid.

      Retrobulbar hemorrhage can occur due to various factors, such as AV malformation, trauma, or increased venous pressure. Symptoms include a painful, red eye that may protrude, particularly at night. Patients may also experience reduced vision, nausea, vomiting, and double vision.

      Understanding Episcleritis

      Episcleritis is a condition that involves the sudden onset of inflammation in the episclera of one or both eyes. While the majority of cases are idiopathic, there are some associated conditions such as inflammatory bowel disease and rheumatoid arthritis. Symptoms of episcleritis include a red eye, mild pain or irritation, watering, and mild photophobia. However, unlike scleritis, episcleritis is typically not painful.

      One way to differentiate between the two conditions is by applying gentle pressure on the sclera. If the injected vessels are mobile, it is likely episcleritis. In contrast, scleritis involves deeper vessels that do not move. Phenylephrine drops may also be used to distinguish between the two conditions. If the eye redness improves after phenylephrine, a diagnosis of episcleritis can be made.

      Approximately 50% of cases of episcleritis are bilateral. Treatment for episcleritis is typically conservative, with artificial tears sometimes being used. Understanding the symptoms and differences between episcleritis and scleritis can help individuals seek appropriate treatment and management for their eye condition.

    • This question is part of the following fields:

      • Ophthalmology
      28.5
      Seconds
  • Question 24 - During a routine opticians appointment, corneal opacities are observed in a 65-year-old woman....

    Correct

    • During a routine opticians appointment, corneal opacities are observed in a 65-year-old woman. Her vision is not affected. Which medication is the most probable culprit for this condition?

      Your Answer: Amiodarone

      Explanation:

      Both corneal opacities and optic neuritis can be caused by amiodarone therapy.

      There are certain drugs that can cause problems with the eyes. For example, steroids can lead to the development of cataracts, while amiodarone and indomethacin can cause corneal opacities. Ethambutol, amiodarone, and metronidazole are known to cause optic neuritis. Additionally, chloroquine and quinine can result in retinopathy. It’s important to note that sildenafil, a medication used to treat erectile dysfunction, can cause both blue discoloration and non-arteritic anterior ischemic neuropathy. It’s crucial to be aware of these potential side effects and to speak with a healthcare provider if any ocular problems arise while taking these medications.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      9.3
      Seconds
  • Question 25 - A 45-year-old man visits his doctor complaining of difficulty lifting heavy objects and...

    Incorrect

    • A 45-year-old man visits his doctor complaining of difficulty lifting heavy objects and describes a feeling of weakness when climbing stairs. He has noticed occasional muscle twitches and spasms that seem to be increasing in frequency.
      Which of the following is the most likely diagnosis?

      Your Answer: Myasthenia gravis

      Correct Answer: Polymyositis

      Explanation:

      Based on the patient’s symptoms, the most likely diagnosis is polymyositis. This is a connective tissue disease that affects the striated muscles, causing symmetrical weakness in the proximal muscles. Patients may have difficulty rising from chairs and experience muscle tenderness. Creatine kinase levels are elevated, and a muscle biopsy can confirm the diagnosis. This presentation is not suggestive of Guillain-Barré syndrome, which typically presents with distal weakness that progresses proximally. Mononeuritis multiplex, which involves neuropathy of multiple peripheral and/or cranial nerves, is unlikely given the symmetrical distribution of symptoms affecting proximal muscles. Multiple sclerosis is also unlikely, as it tends to present with distal rather than proximal limb weakness or paraesthesia. Myasthenia gravis, which is associated with antibodies to acetylcholine receptors and causes fatigability, is not suggested by the patient’s symptoms.

    • This question is part of the following fields:

      • Neurology
      32.8
      Seconds
  • Question 26 - A 68-year-old woman visits her GP with a complaint of urine leakage when...

    Correct

    • A 68-year-old woman visits her GP with a complaint of urine leakage when she coughs, sneezes, or laughs. She has been experiencing this for the past year intermittently, but it has become more severe over the last two months. She has no dysuria or haematuria and is in good health with no abdominal symptoms. All three of her children were delivered vaginally. A urine dip and culture test came back negative. What is the probable diagnosis?

      Your Answer: Stress incontinence

      Explanation:

      The most probable cause of urinary incontinence while coughing is stress incontinence. This occurs when the bladder neck drops below the levator ani sling, which can happen when there is increased intra-abdominal pressure, such as when coughing, laughing, or sneezing. Stress incontinence is characterized by leakage of urine during these activities. Neurogenic bladder, on the other hand, typically presents with overflow incontinence or retention, which is not limited to increased intra-abdominal pressure. Detrusor instability is associated with urgency and increased urinary frequency. Urinary tract infections and pyelonephritis are characterized by increased frequency, dysuria, pyrexia, and loin pain. In this case, the negative urine dip makes infection an unlikely cause.

      Understanding Urinary Incontinence: Causes, Classification, and Management

      Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

      Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

      In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      9.6
      Seconds
  • Question 27 - A 55-year-old woman is brought into the Emergency Department with a sudden onset...

    Correct

    • A 55-year-old woman is brought into the Emergency Department with a sudden onset of severe back pain lasting 30 minutes. The pain is constant and not exacerbated by coughing or sneezing.
      On examination, the patient is in shock, with a palpable 7 cm mass deep in the epigastrium above the umbilicus. Her past medical history includes a 5 cm abdominal aortic aneurysm diagnosed three years ago at the time of appendectomy. The patient is a non-smoker and drinks one glass of wine a week.
      What is the most likely diagnosis?

      Your Answer: Rupturing abdominal aortic aneurysm

      Explanation:

      Possible Causes of Sudden-Onset Severe Back Pain: A Differential Diagnosis

      Sudden-onset severe back pain can be a sign of various medical conditions. In the case of a male patient with increasing age and a known history of abdominal aortic aneurysm, a rupturing aortic aneurysm should be suspected until proven otherwise. This suspicion is supported by the presence of shock, a large palpable mass deep in the epigastrium, and severe back pain that may radiate to the abdomen. The risk of rupture increases with the size of the aneurysm, and blood initially leaks into the retroperitoneal space before spilling into the peritoneal cavity.

      Other possible causes of sudden-onset severe back pain include acute cholecystitis, which is unlikely in a patient who had a previous cholecystectomy. Acute pancreatitis may also cause epigastric pain that radiates to the back, but this condition is usually accompanied by vomiting and diarrhea, and the patient does not have significant risk factors for it. Renal colic, which is characterized by acute severe pain that radiates from the loin to the groin, may cause tachycardia but is less likely in a patient who is haemodynamically unstable and has a known large AAA. Herniated lumbar disc, which may cause back pain that worsens with coughing or sneezing and radiates down the leg, is also less likely in this case.

      Therefore, a rupturing abdominal aortic aneurysm is the most probable cause of the patient’s sudden-onset severe back pain, and urgent management is necessary to prevent further complications.

    • This question is part of the following fields:

      • Cardiovascular
      16.7
      Seconds
  • Question 28 - A 6-year-old boy is presented for surgery after the appearance of multiple small,...

    Correct

    • A 6-year-old boy is presented for surgery after the appearance of multiple small, umbilicated lesions on his right leg. He has no prior history of such lesions and is generally healthy, except for a history of allergies. What is the best course of action for management?

      Your Answer: Reassure

      Explanation:

      Understanding Molluscum Contagiosum

      Molluscum contagiosum is a viral skin infection that is commonly seen in children, particularly those with atopic eczema. It is caused by the molluscum contagiosum virus and can be transmitted through direct contact or contaminated surfaces. The infection presents as pinkish or pearly white papules with a central umbilication, which can appear anywhere on the body except for the palms of the hands and soles of the feet. In children, lesions are commonly seen on the trunk and in flexures, while in adults, sexual contact may lead to lesions developing on the genitalia, pubis, thighs, and lower abdomen.

      While molluscum contagiosum is a self-limiting condition that usually resolves within 18 months, it is important to avoid sharing towels, clothing, and baths with uninfected individuals to prevent transmission. Scratching the lesions should also be avoided, and treatment may be considered if the itch is problematic. However, treatment is not usually recommended, and if necessary, simple trauma or cryotherapy may be used. In some cases, referral may be necessary, such as for individuals who are HIV-positive with extensive lesions or those with eyelid-margin or ocular lesions and associated red eye.

      Overall, understanding molluscum contagiosum and taking appropriate precautions can help prevent transmission and alleviate symptoms.

    • This question is part of the following fields:

      • Dermatology
      37.7
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  • Question 29 - A 48-year-old male patient comes to the GP clinic complaining of pain and...

    Correct

    • A 48-year-old male patient comes to the GP clinic complaining of pain and redness on his left upper eyelid. Upon examination, a tender papule with erythema is found at the left eyelid margin, with a small area of pus discharge. Additionally, there is slight redness of the conjunctiva. What is the probable diagnosis?

      Your Answer: Hordeolum externum

      Explanation:

      The individual is experiencing an infection in the glands of their external eyelid, which is classified as a type of stye known as hordeolum externum. It should be noted that a chalazion, also referred to as a meibomian cyst, typically occurs on the internal eyelid. Blepharitis, on the other hand, is characterized by inflammation of the eyelid margins and does not typically result in a lump. Ectropion refers to the outward turning of the eyelids, while acne vulgaris does not typically impact the eyelids.

      Eyelid problems are quite common and can include a variety of issues. One such issue is blepharitis, which is inflammation of the eyelid margins that can cause redness in the eye. Another problem is a stye, which is an infection of the glands in the eyelids. Chalazion, also known as Meibomian cyst, is another eyelid problem that can occur. Entropion is when the eyelids turn inward, while ectropion is when they turn outward.

      Styes can come in different forms, such as external or internal. An external stye is an infection of the glands that produce sebum or sweat, while an internal stye is an infection of the Meibomian glands. Treatment for styes typically involves hot compresses and pain relief, with topical antibiotics only being recommended if there is also conjunctivitis present. A chalazion, on the other hand, is a painless lump that can form in the eyelid due to a retention cyst of the Meibomian gland. While most cases will resolve on their own, some may require surgical drainage.

    • This question is part of the following fields:

      • Ophthalmology
      17.2
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  • Question 30 - A 63-year-old woman with metastatic breast cancer complains of worsening dyspnea. She is...

    Incorrect

    • A 63-year-old woman with metastatic breast cancer complains of worsening dyspnea. She is undergoing chemotherapy treatment. During the physical examination, a third heart sound is heard and the apex beat is displaced to the anterior axillary line in the 6th intercostal space. Which chemotherapy drug is most likely causing these symptoms?

      Your Answer: Dactinomycin

      Correct Answer: Doxorubicin

      Explanation:

      Cardiomyopathy can be caused by anthracyclines such as doxorubicin.

      Cytotoxic agents are drugs that are used to kill cancer cells. There are several types of cytotoxic agents, each with their own mechanism of action and adverse effects. Alkylating agents, such as cyclophosphamide, work by causing cross-linking in DNA. However, they can also cause haemorrhagic cystitis, myelosuppression, and transitional cell carcinoma. Cytotoxic antibiotics, like bleomycin, degrade preformed DNA and can lead to lung fibrosis. Anthracyclines, such as doxorubicin, stabilize the DNA-topoisomerase II complex and inhibit DNA and RNA synthesis, but can also cause cardiomyopathy. Antimetabolites, like methotrexate, inhibit dihydrofolate reductase and thymidylate synthesis, leading to myelosuppression, mucositis, liver fibrosis, and lung fibrosis. Fluorouracil (5-FU) is a pyrimidine analogue that induces cell cycle arrest and apoptosis by blocking thymidylate synthase, but can also cause myelosuppression, mucositis, and dermatitis. Cytarabine is a pyrimidine antagonist that interferes with DNA synthesis specifically at the S-phase of the cell cycle and inhibits DNA polymerase, but can also cause myelosuppression and ataxia. Drugs that act on microtubules, like vincristine and vinblastine, inhibit the formation of microtubules and can cause peripheral neuropathy, paralytic ileus, and myelosuppression. Docetaxel prevents microtubule depolymerisation and disassembly, decreasing free tubulin, but can also cause neutropaenia. Topoisomerase inhibitors, like irinotecan, inhibit topoisomerase I which prevents relaxation of supercoiled DNA, but can also cause myelosuppression. Other cytotoxic drugs, such as cisplatin, cause cross-linking in DNA and can lead to ototoxicity, peripheral neuropathy, and hypomagnesaemia. Hydroxyurea (hydroxycarbamide) inhibits ribonucleotide reductase, decreasing DNA synthesis, but can also cause myelosuppression.

    • This question is part of the following fields:

      • Haematology/Oncology
      31.2
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SESSION STATS - PERFORMANCE PER SPECIALTY

Paediatrics (1/4) 25%
Endocrinology/Metabolic Disease (2/2) 100%
Cardiovascular (3/3) 100%
Dermatology (2/2) 100%
Neurology (2/3) 67%
Musculoskeletal (2/4) 50%
Respiratory Medicine (0/1) 0%
Gastroenterology/Nutrition (1/1) 100%
Psychiatry (0/1) 0%
ENT (1/1) 100%
Renal Medicine/Urology (2/3) 67%
Haematology/Oncology (1/2) 50%
Ophthalmology (2/2) 100%
Pharmacology/Therapeutics (1/1) 100%
Passmed