00
Correct
00
Incorrect
00 : 00 : 00
Session Time
00 : 00
Average Question Time ( Secs)
  • Question 1 - A 25-year-old patient with a history of well-controlled epilepsy visits the general practice...

    Incorrect

    • A 25-year-old patient with a history of well-controlled epilepsy visits the general practice with her partner. They have been attempting to conceive through regular sexual intercourse for the past 10 months. The patient is currently taking omeprazole, levetiracetam, folic acid 400 micrograms, and paracetamol as needed. What medication adjustments would be most suitable?

      Your Answer: No medications required until >12 months of regular sexual intercourse

      Correct Answer: Folic acid 5 milligrams

      Explanation:

      Women on antiepileptics trying to conceive should receive 5mg folic acid. Letrozole and clomiphene are not appropriate for this patient. Adequate control of epilepsy is important and medication changes should be made by a specialist. This patient should be started on a high dose of folic acid due to the risk of neural tube defects.

      Folic Acid: Importance, Deficiency, and Prevention

      Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

      To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.

      In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.

    • This question is part of the following fields:

      • Obstetrics
      49.7
      Seconds
  • Question 2 - A 32-year-old woman who has recently returned from holiday to Australia presents to...

    Incorrect

    • A 32-year-old woman who has recently returned from holiday to Australia presents to the Emergency Department with sudden-onset chest pain and shortness of breath. The patient has no medical history of note and takes no medication, apart from the combined oral contraceptive pill (COCP).
      On examination, the patient is significantly breathless at rest, with a respiratory rate of 30 breaths/min. Oxygen saturations are 91% on high-flow oxygen; her blood pressure is 105/65 mmHg, and her heart rate is 110 bpm and regular. Her temperature is 37.5 °C.
      On examination of the chest, breath sounds are normal, with good air entry. No focal signs are found.
      Which of the following investigations would be the most appropriate to confirm the likely diagnosis?

      Your Answer: Electrocardiogram (ECG)

      Correct Answer: Computed tomography pulmonary angiography (CTPA)

      Explanation:

      Diagnostic Tests for Pulmonary Embolism

      Pulmonary embolism (PE) is a serious medical condition that requires prompt diagnosis and treatment. There are several diagnostic tests available to confirm or rule out the presence of PE.

      Computed tomography pulmonary angiography (CTPA) is the most commonly used test for patients with a high clinical probability of PE or those with a positive D-dimer test. Chest X-ray may be helpful in excluding alternative diagnoses, but specific signs of PE are rarely found. Electrocardiogram (ECG) may show signs of right heart strain and tachycardia, but it is not the most appropriate test to confirm the diagnosis. D-dimer test is non-specific and less useful in patients with a high clinical suspicion of PE. Ventilation-perfusion scanning may be useful when CT scanning is not available or contraindicated, but CTPA remains the method of choice to confirm the diagnosis.

      In summary, a combination of clinical assessment and appropriate diagnostic tests is necessary to diagnose PE accurately and promptly.

    • This question is part of the following fields:

      • Cardiothoracic
      63.1
      Seconds
  • Question 3 - A 65-year-old man from a nursing home was brought in by ambulance to...

    Incorrect

    • A 65-year-old man from a nursing home was brought in by ambulance to the Emergency Department feeling generally unwell. He was recently treated with amoxicillin for community acquired pneumonia by his GP. The nursing staff said yesterday he was complaining of some muscle pain and weakness and tiredness. He has been vomiting over the last few days. He has a past medical history of asthma, type II diabetes, gout, hypercholesterolaemia and osteoarthritis. Medication includes simvastatin, co-codamol, allopurinol, metformin and a salbutamol inhaler. On examination:
      Investigation Result Normal
      Respiratory rate (RR) 23 breaths/min 12–18 breaths/min
      Sats 96% on air 94–98%
      Blood pressure (BP) 126/68 mmHg <120/80 mmHg
      Heart rate (HR) 98 beats/min 60–100 beats/min
      Temperature 36.8ºC 36.1–37.2°C
      He is drowsy but nothing remarkable otherwise. An arterial blood gas (ABG) on air showed:
      Investigation Result Normal
      pH 7.28 7.35–7.45
      pO2 12.0 kPa 10.5–13.5 kPa
      pCO2 5.5 kPa 4.7–6.0 kPa
      Bicarbonate 18 mmol/l 22–26 mmol/l
      BE 1.0 –2 +2
      What is the most likely cause of the above presentation and investigation results?

      Your Answer: Allopurinol

      Correct Answer: Metformin

      Explanation:

      Analysis of Possible Causes for Metabolic Acidosis in an Elderly Patient

      The arterial blood gas (ABG) results of an elderly patient showed metabolic acidosis, which could be explained by several factors. One possible cause is metformin, a medication commonly used to treat type 2 diabetes. Metformin can cause gastrointestinal (GI) upset and lactic acidosis in patients with impaired renal function, which may be aggravated by dehydration caused by vomiting. Therefore, it is important to monitor renal function and fluid balance in patients taking metformin.

      Another medication that the patient is taking is simvastatin, a statin used to lower cholesterol levels. Although statins can cause rhabdomyolysis and myalgia, they are unlikely to cause metabolic acidosis. Therefore, simvastatin is not a likely cause for the ABG results.

      The patient’s history does not suggest unresolved pneumonia, which could cause respiratory acidosis or failure. Therefore, pneumonia is an unlikely cause for the ABG results.

      Allopurinol, a medication used to treat gout and kidney stones, is inconsistent with the presentation and ABG results. Therefore, allopurinol is an unlikely cause for the ABG results.

      Co-codamol, a combination of codeine and paracetamol, may cause drowsiness in elderly patients, but it is not likely to cause metabolic acidosis. Therefore, co-codamol is an unlikely cause for the ABG results.

      In summary, the most likely cause for the metabolic acidosis in the elderly patient is metformin, which should be monitored and adjusted accordingly. Other possible causes should be ruled out or addressed as needed.

    • This question is part of the following fields:

      • Pharmacology
      131.8
      Seconds
  • Question 4 - What condition would make exercise testing completely unsafe? ...

    Incorrect

    • What condition would make exercise testing completely unsafe?

      Your Answer: Severe left anterior descending coronary stenosis

      Correct Answer: Severe aortic stenosis

      Explanation:

      Contraindications for Exercise Testing

      Exercise testing is a common diagnostic tool used to evaluate a patient’s cardiovascular health. However, there are certain conditions that make exercise testing unsafe or inappropriate. These conditions are known as contraindications.

      Absolute contraindications for exercise testing include acute myocardial infarction (heart attack) within the past two days, unstable angina, uncontrolled cardiac arrhythmias, symptomatic severe aortic stenosis, uncontrolled heart failure, acute pulmonary embolism or pulmonary infarction, acute myocarditis or pericarditis, and acute aortic dissection. These conditions are considered absolute contraindications because they pose a significant risk to the patient’s health and safety during exercise testing.

      Relative contraindications for exercise testing include left main coronary stenosis, moderate stenotic valvular heart disease, electrolyte abnormalities, severe arterial hypertension, tachyarrhythmias or bradyarrhythmias, hypertrophic cardiomyopathy, mental or physical impairment leading to an inability to exercise adequately, and high-degree atrioventricular (AV) block. These conditions are considered relative contraindications because they may increase the risk of complications during exercise testing, but the benefits of testing may outweigh the risks in certain cases.

      It is important for healthcare providers to carefully evaluate a patient’s medical history and current health status before recommending exercise testing. If contraindications are present, alternative diagnostic tests may be necessary to ensure the safety and well-being of the patient.

    • This question is part of the following fields:

      • Cardiology
      27.5
      Seconds
  • Question 5 - As a locum GP, you have been presented with blood results for five...

    Incorrect

    • As a locum GP, you have been presented with blood results for five patients you have never met before. Your task is to review the results and identify which patient is likely to have nephrotic syndrome. The results are as follows:

      Patient A: Adjusted calcium - 2.3 mmol/L, Phosphate - 0.9 mmol/L, PTH - 8.09 pmol/L, Urea - 7.8 mmol/L, Creatinine - 132 μmol/L, Albumin - 36 g/L.

      Patient B: Adjusted calcium - 2.9 mmol/L, Phosphate - 0.5 mmol/L, PTH - 7.2 pmol/L, Urea - 5 mmol/L, Creatinine - 140 μmol/L, Albumin - 38 g/L.

      Patient C: Adjusted calcium - 2.0 mmol/L, Phosphate - 2.8 mmol/L, PTH - 12.53 pmol/L, Urea - 32.8 mmol/L, Creatinine - 540 μmol/L, Albumin - 28 g/L.

      Patient D: Adjusted calcium - 2.5 mmol/L, Phosphate - 1.6 mmol/L, PTH - 2.05 pmol/L, Urea - 32.8 mmol/L, Creatinine - 190 μmol/L, Albumin - 40 g/L.

      Patient E: Adjusted calcium - 2.2 mmol/L, Phosphate - 0.7 mmol/L, PTH - 5.88 pmol/L, Urea - 4.6 mmol/L, Creatinine - 81 μmol/L, Albumin - 18 g/L.

      It is important to note that the normal values for each of these parameters are also provided. With this information, you must determine which patient is likely to have nephrotic syndrome.

      Your Answer: Patient D

      Correct Answer: Patient E

      Explanation:

      Nephrotic Syndrome

      Nephrotic syndrome is a condition characterized by heavy proteinuria, low serum albumin, and peripheral edema. Patients with this condition may also have severe hyperlipidemia and altered clotting due to the loss of clotting factors in the urine. It is important to note that in the early stages of nephrotic syndrome, the levels of urea and creatinine may appear normal despite underlying renal pathology.

      One of the key indicators of nephrotic syndrome is proteinuria, which is the presence of excessive protein in the urine. Patients with this condition typically have proteinuria greater than 3-3.5 g/24 hours. Additionally, low serum albumin levels, which are less than 25 g/L, are also common in patients with nephrotic syndrome. Peripheral edema, or swelling in the extremities, is another hallmark of this condition.

      Patients with nephrotic syndrome may also experience severe hyperlipidemia, which is characterized by high levels of total cholesterol, often exceeding 10 mmol/L. The loss of clotting factors in the urine can also cause altered clotting, leading to a procoagulant effect. This can be treated with antiplatelet agents and/or low molecular weight heparin.

      Overall, the key features of nephrotic syndrome is important for proper diagnosis and treatment. Further investigation, such as urinalysis, may be necessary to confirm the presence of heavy proteinuria.

    • This question is part of the following fields:

      • Nephrology
      84.1
      Seconds
  • Question 6 - A 28-year-old man presents with right-sided pleuritic chest pain. He reports feeling a...

    Incorrect

    • A 28-year-old man presents with right-sided pleuritic chest pain. He reports feeling a sudden ‘pop’ followed by the onset of pain and shortness of breath.
      Upon examination, the patient appears to be struggling to breathe with a respiratory rate of 40 breaths per minute. Diminished breath sounds are heard on the right side of the chest during auscultation.
      Diagnostic tests reveal a PaO2 of 8.2 kPa (normal range: 10.5-13.5 kPa) and a PaCO2 of 3.3 kPa (normal range: 4.6-6.0 kPa). A chest X-ray shows a 60% right-sided pneumothorax.
      What is the most appropriate course of treatment for this patient?

      Your Answer: 32F chest drain insertion with a cut-down

      Correct Answer: 14F chest drain insertion over a Seldinger wire

      Explanation:

      Safe and Effective Chest Drain Insertion Techniques for Pneumothorax Management

      Pneumothorax, the presence of air in the pleural cavity, can cause significant respiratory distress and requires prompt management. Chest drain insertion is a common procedure used to treat pneumothorax, but the technique used depends on the size and cause of the pneumothorax. Here are some safe and effective chest drain insertion techniques for managing pneumothorax:

      1. Narrow-bore chest drain insertion over a Seldinger wire: This technique is appropriate for large spontaneous pneumothorax without trauma. It involves inserting a narrow-bore chest drain over a Seldinger wire, which is a minimally invasive technique that reduces the risk of complications.

      2. Portex chest drain insertion: Portex chest drains are a safer alternative to surgical chest drains in traumatic cases. This technique involves inserting a less traumatic chest drain that is easier to manage and less likely to cause complications.

      3. Avoid chest drain insertion using a trochar: Chest drain insertion using a trochar is a dangerous technique that can cause significant pressure damage to surrounding tissues. It should be avoided.

      4. Avoid repeated air aspiration: Although needle aspiration is a management option for symptomatic pneumothorax, repeated air aspiration is not recommended. It can cause complications and is less effective than chest drain insertion.

      In conclusion, chest drain insertion is an effective technique for managing pneumothorax, but the technique used should be appropriate for the size and cause of the pneumothorax. Narrow-bore chest drain insertion over a Seldinger wire and Portex chest drain insertion are safer alternatives to more invasive techniques. Chest drain insertion using a trochar and repeated air aspiration should be avoided.

    • This question is part of the following fields:

      • Respiratory
      107
      Seconds
  • Question 7 - A General Practitioner refers a 6-week-old infant to the neurosurgery clinic due to...

    Correct

    • A General Practitioner refers a 6-week-old infant to the neurosurgery clinic due to observing an exponential increase in the child's head circumference. What signs would indicate that the infant is suffering from hydrocephalus?

      Your Answer: Impaired upward gaze

      Explanation:

      Infants suffering from hydrocephalus will exhibit an enlarged head size, a protruding soft spot on the skull, and downward deviation of the eyes.

      Understanding Hydrocephalus

      Hydrocephalus is a medical condition characterized by an excessive amount of cerebrospinal fluid (CSF) in the ventricular system of the brain. This is caused by an imbalance between the production and absorption of CSF. Patients with hydrocephalus experience symptoms due to increased intracranial pressure, such as headaches, nausea, vomiting, and papilloedema. In severe cases, it can lead to coma. Infants with hydrocephalus have an increase in head circumference, and their anterior fontanelle bulges and becomes tense. Failure of upward gaze is also common in children with severe hydrocephalus.

      Hydrocephalus can be classified into two categories: obstructive and non-obstructive. Obstructive hydrocephalus is caused by a structural pathology that blocks the flow of CSF, while non-obstructive hydrocephalus is due to an imbalance of CSF production and absorption. Normal pressure hydrocephalus is a unique form of non-obstructive hydrocephalus characterized by large ventricles but normal intracranial pressure. The classic triad of symptoms is dementia, incontinence, and disturbed gait.

      To diagnose hydrocephalus, a CT head is used as a first-line imaging investigation. MRI may be used to investigate hydrocephalus in more detail, particularly if there is a suspected underlying lesion. Lumbar puncture is both diagnostic and therapeutic since it allows you to sample CSF, measure the opening pressure, and drain CSF to reduce the pressure. Treatment for hydrocephalus involves an external ventricular drain (EVD) in acute, severe cases, and a ventriculoperitoneal shunt (VPS) for long-term CSF diversion. In obstructive hydrocephalus, the treatment may involve surgically treating the obstructing pathology. It is important to note that lumbar puncture must not be used in obstructive hydrocephalus since it can cause brain herniation.

    • This question is part of the following fields:

      • Surgery
      24.2
      Seconds
  • Question 8 - An 80-year-old woman comes to the emergency department complaining of a headache that...

    Incorrect

    • An 80-year-old woman comes to the emergency department complaining of a headache that has persisted for the past week. She reports feeling pain on her left temple, which intensifies when she touches her head or brushes her hair, and discomfort in her jaw when eating. She is anxious because she recently had a brief episode of vision loss, which she describes as a dark curtain descending. What is the probable observation on fundoscopy?

      Your Answer: Macula oedema

      Correct Answer: Swollen pale disc with blurred margins

      Explanation:

      The correct fundoscopy finding for anterior ischemic optic neuropathy (AION) is a swollen pale disc with blurred margins. This occurs due to a loss of blood supply to the optic nerve, which is commonly caused by temporal arthritis. It is important to recognize this finding as urgent IV steroids are required to prevent permanent visual loss. A cherry red spot on the macula is not associated with temporal arthritis, as it is a sign of central retinal artery occlusion. Macula edema and cupping of the optic disc are also not typically associated with temporal arthritis.

      Temporal arthritis, also known as giant cell arthritis, is a condition that affects medium and large-sized arteries and is of unknown cause. It typically occurs in individuals over the age of 50, with the highest incidence in those in their 70s. Early recognition and treatment are crucial to minimize the risk of complications, such as permanent loss of vision. Therefore, when temporal arthritis is suspected, urgent referral for assessment by a specialist and prompt treatment with high-dose prednisolone is necessary.

      Temporal arthritis often overlaps with polymyalgia rheumatica, with around 50% of patients exhibiting features of both conditions. Symptoms of temporal arthritis include headache, jaw claudication, and tender, palpable temporal artery. Vision testing is a key investigation in all patients, as anterior ischemic optic neuropathy is the most common ocular complication. This results from occlusion of the posterior ciliary artery, leading to ischemia of the optic nerve head. Fundoscopy typically shows a swollen pale disc and blurred margins. Other symptoms may include aching, morning stiffness in proximal limb muscles, lethargy, depression, low-grade fever, anorexia, and night sweats.

      Investigations for temporal arthritis include raised inflammatory markers, such as an ESR greater than 50 mm/hr and elevated CRP. A temporal artery biopsy may also be performed, and skip lesions may be present. Treatment for temporal arthritis involves urgent high-dose glucocorticoids, which should be given as soon as the diagnosis is suspected and before the temporal artery biopsy. If there is no visual loss, high-dose prednisolone is used. If there is evolving visual loss, IV methylprednisolone is usually given prior to starting high-dose prednisolone. Urgent ophthalmology review is necessary, as visual damage is often irreversible. Other treatments may include bone protection with bisphosphonates and low-dose aspirin.

    • This question is part of the following fields:

      • Musculoskeletal
      50.3
      Seconds
  • Question 9 - An 80-year-old woman has been experiencing jaw pain and difficulty chewing for the...

    Incorrect

    • An 80-year-old woman has been experiencing jaw pain and difficulty chewing for the past 2 months. She describes her jaw as feeling heavy, but there is no clicking or locking, and no changes to her vision or scalp tenderness. She has a history of well-controlled polymyalgia rheumatica and depression, and recalls a medical student mentioning that this could be a side effect of one of her medications. Her current medications include vitamin D and calcium supplements, prednisolone, alendronic acid, and sertraline. What is the most probable cause of her symptoms?

      Your Answer: Temporomandibular joint (TMJ) dysfunction

      Correct Answer: Bisphosphonate use

      Explanation:

      Bisphosphonates: Uses and Adverse Effects

      Bisphosphonates are drugs that mimic the action of pyrophosphate, a molecule that helps prevent bone demineralization. They work by inhibiting osteoclasts, which are cells that break down bone tissue. This reduces the risk of bone fractures and can be used to treat conditions such as osteoporosis, hypercalcemia, Paget’s disease, and pain from bone metastases.

      However, bisphosphonates can have adverse effects, including oesophageal reactions such as oesophagitis and ulcers, osteonecrosis of the jaw, and an increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate. Patients may also experience an acute phase response, which can cause fever, myalgia, and arthralgia. Hypocalcemia, or low calcium levels, can also occur due to reduced calcium efflux from bone, but this is usually not clinically significant.

      To minimize the risk of adverse effects, patients taking oral bisphosphonates should swallow the tablets whole with plenty of water while sitting or standing. They should take the medication on an empty stomach at least 30 minutes before breakfast or other oral medications and remain upright for at least 30 minutes after taking the tablet. Hypocalcemia and vitamin D deficiency should be corrected before starting bisphosphonate treatment, and calcium supplements should only be prescribed if dietary intake is inadequate. The duration of bisphosphonate treatment varies depending on the patient’s level of risk, and some authorities recommend stopping treatment after five years for low-risk patients with a femoral neck T-score of > -2.5.

    • This question is part of the following fields:

      • Musculoskeletal
      37.6
      Seconds
  • Question 10 - A 50-year-old male with type 2 diabetes presents for his annual review. Despite...

    Incorrect

    • A 50-year-old male with type 2 diabetes presents for his annual review. Despite following a diet plan, his glycaemic control is not optimal and his most recent HbA1c is 63 mmol/mol (20-46). You decide to initiate treatment with metformin 500 mg bd. As per NICE NG28 guidelines for diabetes management, what is the recommended interval for rechecking his HbA1c after each intensification of treatment?

      Your Answer: Two to three weeks

      Correct Answer: Three to six months

      Explanation:

      HbA1c as a Tool for Glycaemic Control

      The glycated haemoglobin (HbA1c) is a measure of the glucose levels in the blood over a period of time. It reflects the glycosylation of the haemoglobin molecule by glucose, and there is a strong correlation between the glycosylation of this molecule and average plasma glucose concentrations. This makes it a widely used tool in clinical practice to assess glycaemic control. Studies have also shown that HbA1c has prognostic significance in both microvascular and macrovascular risk.

      The life span of a red blood cell is 120 days, and HbA1c reflects the average blood glucose levels during the half-life of the red cell, which is about 60 days. According to NICE guidelines, it is recommended to re-check HbA1c with each treatment intensification at 3/6 monthly intervals. HbA1c as a tool for glycaemic control is crucial in managing diabetes and reducing the risk of complications.

    • This question is part of the following fields:

      • Endocrinology
      26.9
      Seconds
  • Question 11 - A 65-year-old female comes to see her GP for a check-up. She is...

    Incorrect

    • A 65-year-old female comes to see her GP for a check-up. She is currently taking multiple medications. Her recent blood test reveals that her INR has fallen below the necessary therapeutic level. Upon reviewing her medications, which one is most likely responsible for the decrease in her INR?

      Your Answer: Sodium valproate

      Correct Answer: Phenytoin

      Explanation:

      Phenytoin induces the activity of P450 enzymes.

      The P450 enzyme system plays a crucial role in the metabolism of various foreign substances. Phenytoin is known to induce the activity of two families of P450 enzymes, namely CYP3A4 and CYP2C9. On the other hand, P450 inhibitors such as sodium valproate, ciprofloxacin, omeprazole, and fluoxetine can inhibit the activity of these enzymes. Warfarin is primarily metabolized by CYP1A2, CYP2C9, and CYP3A4. Therefore, the induction of metabolism by phenytoin can lead to a decrease in INR levels.

      P450 Enzyme System and its Inducers and Inhibitors

      The P450 enzyme system is responsible for metabolizing drugs in the body. Induction of this system usually requires prolonged exposure to the inducing drug, unlike P450 inhibitors, which have rapid effects. Some drugs that induce the P450 system include antiepileptics like phenytoin and carbamazepine, barbiturates such as phenobarbitone, rifampicin, St John’s Wort, chronic alcohol intake, griseofulvin, and smoking, which affects CYP1A2 and is the reason why smokers require more aminophylline.

      On the other hand, some drugs inhibit the P450 system, including antibiotics like ciprofloxacin and erythromycin, isoniazid, cimetidine, omeprazole, amiodarone, allopurinol, imidazoles such as ketoconazole and fluconazole, SSRIs like fluoxetine and sertraline, ritonavir, sodium valproate, and acute alcohol intake. It is important to be aware of these inducers and inhibitors as they can affect the metabolism and efficacy of drugs in the body. Proper dosing and monitoring can help ensure safe and effective treatment.

    • This question is part of the following fields:

      • Pharmacology
      54.7
      Seconds
  • Question 12 - During a routine GP check-up, a 33-year-old woman is found to have a...

    Incorrect

    • During a routine GP check-up, a 33-year-old woman is found to have a mid-diastolic rumbling murmur accompanied by a loud first heart sound. What valvular abnormality is likely causing this?

      Your Answer: Aortic regurgitation

      Correct Answer: Mitral stenosis

      Explanation:

      Valvular Murmurs

      Valvular murmurs are a common topic in medical exams, and it is crucial to have a good of them. The easiest way to approach them is by classifying them into systolic and diastolic murmurs. If the arterial valves, such as the aortic or pulmonary valves, are narrowed, ventricular contraction will cause turbulent flow, resulting in a systolic murmur. On the other hand, if these valves are incompetent, blood will leak back through the valve during diastole, causing a diastolic murmur.

      Similarly, the atrioventricular valves, such as the mitral and tricuspid valves, can be thought of in the same way. If these valves are leaky, blood will be forced back into the atria during systole, causing a systolic murmur. If they are narrowed, blood will not flow freely from the atria to the ventricles during diastole, causing a diastolic murmur.

      Therefore, a diastolic murmur indicates either aortic/pulmonary regurgitation or mitral/tricuspid stenosis. The loud first heart sound is due to increased force in closing the mitral or tricuspid valve, which suggests stenosis. the different types of valvular murmurs and their causes is essential for medical professionals to diagnose and treat patients accurately.

    • This question is part of the following fields:

      • Cardiology
      85.4
      Seconds
  • Question 13 - What are the clinical signs that indicate a child has acute rheumatic fever...

    Incorrect

    • What are the clinical signs that indicate a child has acute rheumatic fever carditis?

      Your Answer: Shortened PR interval on ECG

      Correct Answer: Pericardial rub

      Explanation:

      Acute Rheumatic Fever

      Acute rheumatic fever is a condition that occurs after a bacterial infection and is caused by pathogenic antibodies. It is characterized by a systemic inflammatory response that affects the heart, joints, and skin. The condition is triggered by antibodies that cross-react with cardiac tissue, which can lead to pancarditis, arthritis, and intra-dermal inflammation. The diagnosis of acute rheumatic fever is based on a combination of clinical and investigatory findings, which are known as the revised Jones criteria.

      The pancarditis associated with acute rheumatic fever can cause a sustained tachycardia, which is particularly prominent at night. Conduction abnormalities, including prolonged PR interval, are also common. Pericarditis may be detected clinically with a pericardial rub, and patients may exhibit features of congestive cardiac failure, such as cardiomegaly. Several murmurs are recognized in patients with acute rheumatic fever, including aortic regurgitation, mitral regurgitation, and the Carey Coombs murmur.

      In summary, acute rheumatic fever is a serious condition that can have significant effects on the heart, joints, and skin. Early diagnosis and treatment are essential to prevent complications and improve outcomes. The revised Jones criteria provide guidance for clinicians in making an accurate diagnosis and initiating appropriate treatment.

    • This question is part of the following fields:

      • Cardiology
      45.3
      Seconds
  • Question 14 - A 56-year-old male has presented to the GP diabetic clinic for a medication...

    Correct

    • A 56-year-old male has presented to the GP diabetic clinic for a medication and blood result review. He has been well-controlled on metformin 1g twice-a-day for his type 2 diabetes. However, his recent HbA1c result is 60 mmol/mol. The patient has a history of heart failure and the GP emphasizes the significance of lifestyle and dietary advice.

      What would be the most suitable course of action for managing this patient?

      Your Answer: Prescribe DPP-4 inhibitor

      Explanation:

      If the HbA1c level in type 2 diabetes mellitus is above 58 mmol/mol, a second drug should be added.

      When a patient’s HbA1c result indicates poor glucose control, it may be due to various factors such as tolerance, adherence, or lifestyle issues. In such cases, the next step is to prescribe a second medication, which could be a DPP-4 inhibitor, sulfonylurea, or SGLT-2 inhibitor, based on the patient’s needs and after weighing the risks and benefits of each option.

      The standard dose of metformin is 500g daily, which can be increased up to a maximum of 2g daily, divided into separate doses. However, if the patient is already on 2g, the dose cannot be increased further. Thiazolidinediones like pioglitazone are not recommended for patients with heart failure and are rarely used as first or second-line therapies.

      Since the patient’s HbA1c levels exceed 58 mmol/mol, an additional intervention is necessary, along with reinforcing lifestyle and dietary advice. Insulin is typically reserved for patients who do not respond to double or triple therapy.

      NICE updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022, reflecting advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. The first-line drug of choice remains metformin, which should be titrated up slowly to minimize gastrointestinal upset. HbA1c targets should be agreed upon with patients and checked every 3-6 months until stable, with consideration for relaxing targets on a case-by-case basis. Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates and controlling intake of foods containing saturated fats and trans fatty acids. Blood pressure targets are the same as for patients without type 2 diabetes, and antiplatelets should not be offered unless a patient has existing cardiovascular disease. Only patients with a 10-year cardiovascular risk > 10% should be offered a statin, with atorvastatin 20 mg as the first-line choice.

    • This question is part of the following fields:

      • Medicine
      93.5
      Seconds
  • Question 15 - A 29-year-old woman presents to the Emergency Department at 36-weeks gestation with vaginal...

    Correct

    • A 29-year-old woman presents to the Emergency Department at 36-weeks gestation with vaginal bleeding and lower abdominal pain. She is conscious and responsive. During the physical examination, her heart rate was 110 bpm, blood pressure was 95/60 mmHg, and O2 saturation was 98%. Neurological examination revealed dilated pupils and brisk reflexes. Laboratory results showed Hb of 118 g/l, platelets of 240 * 109/l, WBC of 6 * 109/l, PT of 11 seconds, and APTT of 28 seconds. What underlying condition could best explain the observed physical exam findings?

      Your Answer: Cocaine abuse

      Explanation:

      The symptoms described in the question suggest that the patient is experiencing placental abruption, which can be caused by cocaine abuse, pre-eclampsia, and HELLP syndrome. The presence of hyperreflexia on physical examination indicates placental abruption, while ruling out HELLP syndrome due to normal blood count results. Dilated pupils and hyperreflexia are consistent with cocaine abuse, while pinpointed pupils are more commonly associated with heroin abuse. Although pre-eclampsia can also lead to placental abruption, the physical exam findings suggest cocaine abuse as the underlying cause. Disseminated intravascular coagulopathy is a complication of placental abruption, not a cause, and the normal PTT and APTT results make it less likely to be present.

      Risks of Smoking, Alcohol, and Illegal Drugs During Pregnancy

      During pregnancy, drug use can have serious consequences for both the mother and the developing fetus. Smoking during pregnancy increases the risk of miscarriage, preterm labor, stillbirth, and sudden unexpected death in infancy. Alcohol consumption can lead to fetal alcohol syndrome, which can cause learning difficulties, characteristic facial features, and growth restrictions. Binge drinking is a major risk factor for fetal alcohol syndrome. Cannabis use poses similar risks to smoking due to the tobacco content. Cocaine use can lead to hypertension in pregnancy, including pre-eclampsia, and placental abruption. Fetal risks include prematurity and neonatal abstinence syndrome. Heroin use can result in neonatal abstinence syndrome. It is important for pregnant women to avoid drug use to ensure the health and well-being of both themselves and their unborn child.

    • This question is part of the following fields:

      • Obstetrics
      101.4
      Seconds
  • Question 16 - A 58-year-old male presents with black tarry stools. He has a history of...

    Incorrect

    • A 58-year-old male presents with black tarry stools. He has a history of chronic alcoholism for 30 years, consuming approximately a litre of vodka daily. During an upper gastrointestinal endoscopy, oesophageal varices with bleeding and a small gastric ulcer were discovered. Due to active gastrointestinal bleeding, he was kept nil by mouth and given intravenous infusions of 5% glucose plus 0.45% sodium chloride solution at a rate of 60 ml/hour and 60 ml of 50% glucose water every 6 hours. Initially, he showed no signs of confusion, and his ammonia levels were normal. However, he later developed polymorphic VT, and refeeding syndrome is suspected. What electrolyte changes would you anticipate?

      Your Answer: Low Phosphate, low potassium, high magnesium

      Correct Answer: Low Phosphate, low potassium, low magnesium

      Explanation:

      Refeeding Syndrome

      Refeeding syndrome is a condition that occurs when nutrition is reintroduced to individuals who have been starved, severely malnourished, or metabolically stressed due to severe illness. This syndrome is characterized by metabolic disturbances that can be attributed to the resumption of glycaemia, which leads to increased insulin and decreased secretion of glucagon. As a result, insulin stimulates glycogen, fat, and protein synthesis, which requires minerals such as phosphate and magnesium, as well as cofactors such as thiamine. Furthermore, insulin stimulates the uptake of potassium into the cell, which can lead to low levels of potassium, magnesium, and phosphate.

      To treat refeeding syndrome, it is essential to correct the electrolyte imbalances that occur. This can be achieved through careful monitoring of the patient’s electrolyte levels and providing appropriate supplementation as needed. By the underlying mechanisms of refeeding syndrome and taking appropriate measures to correct electrolyte imbalances, healthcare professionals can effectively manage this condition and prevent potential complications.

    • This question is part of the following fields:

      • Clinical Sciences
      98.3
      Seconds
  • Question 17 - A 67-year-old patient visits his primary care physician complaining of a recent exacerbation...

    Incorrect

    • A 67-year-old patient visits his primary care physician complaining of a recent exacerbation of his chronic cough. He reports experiencing similar episodes in the past, during which his typically yellow sputum becomes thicker and slightly tinged with blood. The patient has a history of hypertension and bronchiectasis, and has received multiple courses of antibiotics for these exacerbations. Upon examination, the patient appears relatively healthy but continues to cough. Crackles are heard upon chest auscultation. Given the patient's medical history and likely diagnosis, the physician decides to obtain a sputum sample. What organism is most likely to be observed upon culturing?

      Your Answer: Streptococcus pneumoniae

      Correct Answer: Haemophilus influenzae

      Explanation:

      The most common organism associated with bronchiectasis is Haemophilus influenzae, making it the correct answer for an acute exacerbation of this condition. While Klebsiella pneumonia is also a possibility, it is less frequently seen and typically associated with pneumonia in patients with alcohol dependence. Pseudomonas aeruginosa is an incorrect answer, as it is more commonly found in patients with cystic fibrosis than bronchiectasis. Staphylococcus aureus is also less commonly isolated in bronchiectasis, and is more commonly associated with other infective conditions such as infective endocarditis and skin infections, as well as being a secondary bacterial cause of pneumonia following influenzae.

      Managing Bronchiectasis

      Bronchiectasis is a condition where the airways become permanently dilated due to chronic inflammation or infection. Before starting treatment, it is important to identify any underlying causes that can be treated, such as immune deficiency. The management of bronchiectasis includes physical training, such as inspiratory muscle training, which has been shown to be effective for patients without cystic fibrosis. Postural drainage, antibiotics for exacerbations, and long-term rotating antibiotics for severe cases are also recommended. Bronchodilators may be used in selected cases, and immunizations are important to prevent infections. Surgery may be considered for localized disease. The most common organisms isolated from patients with bronchiectasis include Haemophilus influenzae, Pseudomonas aeruginosa, Klebsiella spp., and Streptococcus pneumoniae.

      Spacing:

      Bronchiectasis is a condition where the airways become permanently dilated due to chronic inflammation or infection. Before starting treatment, it is important to identify any underlying causes that can be treated, such as immune deficiency.

      The management of bronchiectasis includes physical training, such as inspiratory muscle training, which has been shown to be effective for patients without cystic fibrosis. Postural drainage, antibiotics for exacerbations, and long-term rotating antibiotics for severe cases are also recommended. Bronchodilators may be used in selected cases, and immunizations are important to prevent infections. Surgery may be considered for localized disease.

      The most common organisms isolated from patients with bronchiectasis include Haemophilus influenzae, Pseudomonas aeruginosa, Klebsiella spp., and Streptococcus pneumoniae.

    • This question is part of the following fields:

      • Medicine
      38.2
      Seconds
  • Question 18 - A 65-year-old patient presents to their GP with a general feeling of unwellness....

    Incorrect

    • A 65-year-old patient presents to their GP with a general feeling of unwellness. The following blood results are obtained:

      - Adjusted calcium 2.1 mmol/L (2.2-2.4)
      - Phosphate 0.7 mmol/L (0.7-1.0)
      - PTH 15.21 pmol/L (1.05-6.83)
      - Urea 4.6 mmol/L (2.5-7.8)
      - Creatinine 81 µmol/L (60-120)
      - 25 OH Vit D 12 nmol/L (optimal >75)

      What is the most likely diagnosis?

      Your Answer: Primary hyperparathyroidism

      Correct Answer: Vitamin D deficiency

      Explanation:

      Vitamin D Deficiency and its Effects on the Body

      Vitamin D deficiency is a common condition that can be caused by a lack of dietary vitamin D or insufficient exposure to sunlight. This deficiency is more common in certain populations, such as the elderly, institutionalized patients, and ethnic groups with dark skin tones. Additionally, reduced sunlight exposure due to cultural dress codes, poor intake of dairy foods, and malabsorption states affecting fat-soluble vitamins can also contribute to vitamin D deficiency.

      When the kidneys are functioning normally, they activate vitamin D through the 1-alpha hydroxylase mechanism. The actions of 1,25(OH)2 Vitamin D have various effects on the body. It has a direct effect on the gut, increasing the absorption of calcium and phosphate. It also has a direct effect on the kidney, inhibiting its own synthesis by reducing 1-alpha hydroxylase activity. Furthermore, it has a direct effect on the parathyroids, inhibiting PTH synthesis. At high concentrations, activated vitamin D increases osteoclastic activity, promoting bone resorption.

      In conclusion, the risk factors and effects of vitamin D deficiency is crucial for maintaining overall health and preventing related conditions. Adequate exposure to sunlight and a balanced diet can help prevent vitamin D deficiency.

    • This question is part of the following fields:

      • Nephrology
      75.9
      Seconds
  • Question 19 - A 57-year-old man arrives at the Emergency Department with sudden onset central crushing...

    Correct

    • A 57-year-old man arrives at the Emergency Department with sudden onset central crushing chest pain. The patient reports feeling pain in his neck and jaw as well. He has no significant medical history, but he does smoke socially and consumes up to 60 units of alcohol per week. An ECG is performed, revealing widespread ST elevation indicative of an acute coronary syndrome.
      What is the earliest point at which the microscopic changes of acute MI become apparent?

      Your Answer: 12-24 hours after the infarct

      Explanation:

      The Pathological Progression of Myocardial Infarction: A Timeline of Changes

      Myocardial infarction, commonly known as a heart attack, is a serious medical condition that occurs when blood flow to the heart is blocked, leading to tissue damage and potentially life-threatening complications. The pathological progression of myocardial infarction follows a predictable sequence of events, with macroscopic and microscopic changes occurring over time.

      Immediately after the infarct occurs, there are usually no visible changes to the myocardium. However, within 3-6 hours, maximal inflammatory changes occur, with the most prominent changes occurring between 24-72 hours. During this time, coagulative necrosis and acute inflammatory responses are visible, with marked infiltration by neutrophils.

      Between 3-10 days, the infarcted area begins to develop a hyperaemic border, and the process of organisation and repair begins. Granulation tissue replaces dead muscle, and dying neutrophils are replaced by macrophages. Disintegration and phagocytosis of dead myofibres occur during this time.

      If a patient survives an acute infarction, the infarct heals through the formation of scar tissue. However, scar tissue does not possess the usual contractile properties of normal cardiac muscle, leading to contractile dysfunction or congestive cardiac failure. The entire process from coagulative necrosis to the formation of well-formed scar tissue takes 6-8 weeks.

      In summary, understanding the timeline of changes that occur during myocardial infarction is crucial for early diagnosis and effective treatment. By recognising the macroscopic and microscopic changes that occur over time, healthcare professionals can provide appropriate interventions to improve patient outcomes.

    • This question is part of the following fields:

      • Cardiology
      38.9
      Seconds
  • Question 20 - A 58-year-old man presents to the Emergency Department with increasing shortness of breath...

    Incorrect

    • A 58-year-old man presents to the Emergency Department with increasing shortness of breath and cough for the last two days. The patient reports feeling fevers and chills and although he has a chronic cough, this has now become productive of yellow sputum over the last 36 hours. He denies chest pain. His past medical history is significant for chronic obstructive pulmonary disease (COPD) for which he has been prescribed various inhalers that he is not compliant with. He currently smokes 15 cigarettes per day and does not drink alcohol.
      His observations and blood tests results are shown below:
      Investigation Result Normal value
      Temperature 36.9 °C
      Blood pressure 143/64 mmHg
      Heart rate 77 beats per minute
      Respiratory rate 32 breaths per minute
      Sp(O2) 90% (room air)
      White cell count 14.9 × 109/l 4–11 × 109/l
      C-reactive protein 83 mg/l 0–10 mg/l
      Urea 5.5 mmol/l 2.5–6.5 mmol/l
      Physical examination reveals widespread wheeze throughout his lungs without other added sounds. There is no dullness or hyperresonance on percussion of the chest. His trachea is central.
      Which of the following is the most appropriate next investigation?

      Your Answer: Sputum culture

      Correct Answer: Chest plain film

      Explanation:

      The patient is experiencing shortness of breath, cough with sputum production, and widespread wheeze, along with elevated inflammatory markers. This suggests an infective exacerbation of COPD or community-acquired pneumonia. A chest X-ray should be ordered urgently to determine the cause and prescribe appropriate antibiotics. Treatment for COPD exacerbation includes oxygen therapy, nebulizers, oral steroids, and antibiotics. Blood cultures are not necessary at this stage unless the patient has fevers. A CTPA is not needed as the patient’s symptoms are not consistent with PE. Pulmonary function tests are not necessary in acute management. Sputum culture may be necessary if the patient’s CURB-65 score is ≥3 or if the score is 2 and antibiotics have not been given yet. The patient’s CURB-65 score is 1.

    • This question is part of the following fields:

      • Respiratory
      96.3
      Seconds
  • Question 21 - With which malignancy is HTLV-1 infection linked? ...

    Incorrect

    • With which malignancy is HTLV-1 infection linked?

      Your Answer: Burkitt's lymphoma

      Correct Answer: Adult T cell leukaemia

      Explanation:

      Risk of Malignancy Associated with HTLV-1

      Between the time frame of 1:10 and 1:20, it is believed that individuals may develop malignancy associated with HTLV-1, specifically adult T cell leukaemia/lymphoma. This suggests that a small percentage of individuals infected with HTLV-1 may be at risk for developing this type of cancer. It is important for individuals who are infected with HTLV-1 to be aware of this potential risk and to regularly monitor their health for any signs or symptoms of malignancy. Early detection and treatment can greatly improve the chances of successful outcomes for those affected.

    • This question is part of the following fields:

      • Oncology
      25.3
      Seconds
  • Question 22 - A 29-year-old female patient comes in with a complaint of excessive menstrual bleeding....

    Incorrect

    • A 29-year-old female patient comes in with a complaint of excessive menstrual bleeding. She reports having to change her pads every hour due to saturation with blood. She is not experiencing any other symptoms and has no plans of having children in the immediate future. After a routine examination, what is the best course of action for management?

      Your Answer: Combined oral contraceptive pill

      Correct Answer: Intrauterine system

      Explanation:

      According to NICE CG44, when heavy menstrual bleeding is not caused by any structural or histological abnormality, the first recommended treatment is the intrauterine system, also known as Mirena.

      Managing Heavy Menstrual Bleeding

      Heavy menstrual bleeding, also known as menorrhagia, is a condition where a woman experiences excessive blood loss during her menstrual cycle. While it was previously defined as total blood loss of over 80 ml per cycle, the management of menorrhagia now depends on the woman’s perception of what is excessive. In the past, hysterectomy was a common treatment for heavy periods, but the approach has changed significantly since the 1990s.

      To manage menorrhagia, a full blood count should be performed in all women. If symptoms suggest a structural or histological abnormality, a routine transvaginal ultrasound scan should be arranged. For women who do not require contraception, mefenamic acid or tranexamic acid can be used. If there is no improvement, other drugs can be tried while awaiting referral.

      For women who require contraception, options include the intrauterine system (Mirena), combined oral contraceptive pill, and long-acting progestogens. Norethisterone can also be used as a short-term option to rapidly stop heavy menstrual bleeding. The flowchart below shows the management of menorrhagia.

      [Insert flowchart here]

    • This question is part of the following fields:

      • Gynaecology
      18.1
      Seconds
  • Question 23 - A 25 year old patient presents to the accident and emergency department after...

    Incorrect

    • A 25 year old patient presents to the accident and emergency department after being involved in a fight an hour ago. Due to being intoxicated, the patient is unable to provide much history. Upon examination, the patient has significant facial swelling on the lower left side and bruising around the left eye. The patient does not experience tenderness when palpated on either side of the nose. However, when asked to bite down, the patient complains of an unusual sensation in their mouth, and the left side teeth come together before the right side. Additionally, two teeth are missing on the left side. What would be the most appropriate next investigation?

      Your Answer: CT facial skeleton

      Correct Answer: Mandible radiography with (orthopantogram)

      Explanation:

      Imaging for Mandibular Fractures: Options and Considerations

      Mandibular fractures are less common now with the use of seat belts in motor vehicles, but they still occur, especially in young males. A standard mandible series, including a PA view, Towne view, and left and right oblique views, along with an orthopantogram (OPG), can provide a full evaluation of the mandible and teeth. If further imaging is needed, a CT of the facial skeleton and mandible may be necessary.

      In cases of suspected mandibular fractures, it is important to document the function of the marginal mandibular nerve and sensation over the chin. If teeth are missing, a chest X-ray may be necessary to check for inhaled foreign bodies. Lateral facial radiographs are not typically used for the facial skeleton, and MRI is not the first choice for bony injuries but can be useful for evaluating TMJ pathology.

      It is important to consider the potential risks and benefits of each imaging option, especially in terms of ionizing radiation exposure. Chest radiographs and CT scans involve higher doses of radiation and should not be the first choice unless necessary. Overall, a thorough evaluation of mandibular fractures requires careful consideration of the patient’s individual needs and circumstances.

    • This question is part of the following fields:

      • Plastics
      37.5
      Seconds
  • Question 24 - A 31-year-old woman who is 39 weeks pregnant reaches out to you seeking...

    Incorrect

    • A 31-year-old woman who is 39 weeks pregnant reaches out to you seeking details about the newborn hearing screening program. She expresses concerns about potential harm to her baby's ears and is uncertain about giving consent for the screening. What specific test is provided to all newborns as part of this screening program?

      Your Answer: Pure tone audiometry

      Correct Answer: Automated otoacoustic emission test

      Explanation:

      The automated otoacoustic emission test is the appropriate method for screening newborns for hearing problems. This test involves inserting a soft-tipped earpiece into the baby’s outer ear and emitting clicking sounds to detect a healthy cochlea. The auditory brainstem response test may be used if the baby does not pass the automated otoacoustic emission test. Play audiometry is only suitable for children between two and five years old, while pure tone audiometry is used for older children and adults and is not appropriate for newborns.

      Hearing Tests for Children

      Hearing tests are important for children to ensure that they are developing normally. There are several tests that may be performed on children of different ages. For newborns, an otoacoustic emission test is typically done as part of the Newborn Hearing Screening Programme. This test involves playing a computer-generated click through a small earpiece and checking for the presence of a soft echo, which indicates a healthy cochlea. If the results of this test are abnormal, an Auditory Brainstem Response test may be done.

      For infants between 6-9 months, a Distraction test may be performed by a health visitor with the help of two trained staff members. For children between 18 months to 2.5 years, a Recognition of familiar objects test may be used, which involves using familiar objects like a teddy or cup and asking the child simple questions like where is the teddy? For children over 2.5 years, Performance testing and Speech discrimination tests may be used, such as the Kendall Toy test or McCormick Toy Test. Pure tone audiometry is typically done at school entry in most areas of the UK for children over 3 years old.

      In addition to these tests, there is also a questionnaire for parents in the Personal Child Health Records called Can your baby hear you? It is important for parents to be aware of these tests and to have their child’s hearing checked regularly to ensure proper development.

    • This question is part of the following fields:

      • Paediatrics
      34.9
      Seconds
  • Question 25 - A 27-year-old woman named Priya, who moved to the UK from India 8...

    Correct

    • A 27-year-old woman named Priya, who moved to the UK from India 8 years ago, visited her GP with her husband. She was 32 weeks pregnant with her first child. Priya had experienced mild hyperemesis until week 16 but had an otherwise uneventful pregnancy. She reported feeling slightly feverish and unwell, and had developed a rash the previous night.

      Upon examination, Priya appeared healthy, with a temperature of 37.8ºC, oxygen saturation of 99% in air, heart rate of 92 beats per minute, respiratory rate of 18 breaths per minute, and blood pressure of 112/74 mmHg. She had a macular rash with some early papular and vesicular lesions.

      Further questioning revealed that Priya had attended a family gathering two weeks ago, where she spent time with her young cousins. One of her cousins was later diagnosed with chickenpox. Priya's husband confirmed that she had never had chickenpox before.

      What is the appropriate next step in managing chickenpox in this case?

      Your Answer: Prescribe oral acyclovir

      Explanation:

      Pregnant women who are at least 20 weeks pregnant and contract chickenpox are typically treated with oral acyclovir if they seek medical attention within 24 hours of developing the rash. Women who were not born and raised in the UK are at a higher risk of contracting chickenpox when they move to the country. The RCOG recommends prescribing oral acyclovir to pregnant women with chickenpox who are at least 20 weeks pregnant and have developed the rash within 24 hours. acyclovir may also be considered for women who are less than 20 weeks pregnant. If a woman contracts chickenpox before 28 weeks of pregnancy, she should be referred to a fetal medicine specialist five weeks after the infection. The chickenpox vaccine cannot be administered during pregnancy, and VZIG is not effective once the rash has developed. In cases where there is clear clinical evidence of chickenpox infection, antibody testing is unnecessary. Pregnant women with chickenpox should be monitored daily, and if they exhibit signs of severe or complicated chickenpox, they should be referred to a specialist immediately. Adults with chickenpox are at a higher risk of complications such as pneumonia, hepatitis, and encephalitis, and in rare cases, death, so proper assessment and management are crucial.

      Chickenpox exposure in pregnancy can pose risks to both the mother and fetus, including fetal varicella syndrome. Post-exposure prophylaxis (PEP) with varicella-zoster immunoglobulin (VZIG) or antivirals should be given to non-immune pregnant women, with timing dependent on gestational age. If a pregnant woman develops chickenpox, specialist advice should be sought and oral acyclovir may be given if she is ≥ 20 weeks and presents within 24 hours of onset of the rash.

    • This question is part of the following fields:

      • Obstetrics
      21.1
      Seconds
  • Question 26 - A 50-year-old man presents to the Emergency Department with a 2-day history of...

    Correct

    • A 50-year-old man presents to the Emergency Department with a 2-day history of an increasingly painful and swollen left eye. He complains of blurring of vision and pain, especially with eye movements.
      On examination, visual acuity is 6/18 in the left and 6/6 in the right. The periorbital area of the left eye is very swollen and erythematosus. The eye itself is red and proptosed. The conjunctiva is chemosed. Eye movements in the left eye are quite restricted in all directions. There is relative afferent pupillary defect on the left. Fundoscopy shows a swollen optic disc in the left eye. Computed tomography (CT) scan shows some opacities in the ethmoid sinuses.
      Vital observations are as follows:
      Blood pressure 120/70 mmHg
      Heart rate 75 bpm
      Respiratory rate 18 per minute
      Oxygen saturation 98% on air
      Temperature 37.9 °C
      What is the definitive treatment for this eye problem?

      Your Answer: Drainage of the ethmoid sinuses

      Explanation:

      Treatment Options for Ethmoidal Sinusitis and Orbital Cellulitis

      Ethmoidal sinusitis is a common cause of orbital cellulitis, which requires prompt treatment to prevent complications. The most effective treatment for ethmoidal sinusitis is surgical drainage of the sinuses to remove the pus and debris. Antibiotics are also necessary to aid recovery, but they should be administered after the drainage procedure.

      While there are several antibiotics that can be used to treat orbital cellulitis, such as cefuroxime, metronidazole, co-amoxiclav, and Tazocin®, they are not sufficient to address the underlying cause of the condition. Therefore, drainage of the ethmoid sinuses is the definitive treatment for ethmoidal sinusitis and orbital cellulitis.

      In summary, the treatment options for ethmoidal sinusitis and orbital cellulitis include surgical drainage of the sinuses followed by antibiotics. Antibiotics alone are not enough to treat the condition, and the choice of antibiotic may vary depending on the patient’s age and other factors.

    • This question is part of the following fields:

      • Ophthalmology
      67.8
      Seconds
  • Question 27 - What substances or factors prevent osteoclast activity? ...

    Correct

    • What substances or factors prevent osteoclast activity?

      Your Answer: Calcitonin

      Explanation:

      The Role of Calcitonin in Bone Health

      Calcitonin is a peptide consisting of 32 amino acids that is derived from a larger prohormone. It is produced by the parafollicular or C cells in the thyroid gland and has a direct effect on osteoclasts. Calcitonin binds to receptors on the surface of osteoclasts, causing them to shrink and stop breaking down bone tissue. This process is important for maintaining bone health and preventing conditions such as osteoporosis. The peptide contains a single disulfide bond, which contributes to its stability and effectiveness. Overall, calcitonin plays a crucial role in regulating bone metabolism and maintaining skeletal integrity.

    • This question is part of the following fields:

      • Surgery
      9.3
      Seconds
  • Question 28 - An 18 year old girl comes to the clinic with a complaint of...

    Incorrect

    • An 18 year old girl comes to the clinic with a complaint of never having started her menstrual cycle. Upon further inquiry, she reports having developed secondary sexual characteristics like breast tissue growth and pubic hair. Additionally, she experiences pelvic pain and bloating. What is the probable cause of her symptoms?

      Your Answer: Polycystic ovarian syndrome (PCOS)

      Correct Answer: Imperforate hymen

      Explanation:

      When a teenage girl experiences regular painful cycles but has not yet started menstruating, an imperforate hymen is a likely cause. This condition blocks the flow of menstrual blood, leading to primary amenorrhoea while allowing for normal development of secondary sexual characteristics like pubic hair and breast growth. The accumulation of menstrual blood in the vagina can cause discomfort and bloating due to pressure. Other potential causes of amenorrhoea include chemotherapy during childhood, Turner’s syndrome, and polycystic ovary syndrome, which can all interfere with the production of estrogen and the development of secondary sexual characteristics.

      Understanding Amenorrhoea: Causes, Investigations, and Management

      Amenorrhoea is a condition characterized by the absence of menstrual periods in women. It can be classified into two types: primary and secondary. Primary amenorrhoea occurs when menstruation fails to start by the age of 15 in girls with normal secondary sexual characteristics or by the age of 13 in girls without secondary sexual characteristics. On the other hand, secondary amenorrhoea is the cessation of menstruation for 3-6 months in women with previously normal and regular menses or 6-12 months in women with previous oligomenorrhoea.

      There are various causes of amenorrhoea, including gonadal dysgenesis, testicular feminization, congenital malformations of the genital tract, functional hypothalamic amenorrhoea, congenital adrenal hyperplasia, imperforate hymen, hypothalamic amenorrhoea, polycystic ovarian syndrome, hyperprolactinemia, premature ovarian failure, Sheehan’s syndrome, Asherman’s syndrome, and thyrotoxicosis. To determine the underlying cause of amenorrhoea, initial investigations such as full blood count, urea & electrolytes, coeliac screen, thyroid function tests, gonadotrophins, prolactin, and androgen levels are necessary.

      The management of amenorrhoea depends on the underlying cause. For primary amenorrhoea, it is important to investigate and treat any underlying cause. Women with primary ovarian insufficiency due to gonadal dysgenesis may benefit from hormone replacement therapy to prevent osteoporosis. For secondary amenorrhoea, it is important to exclude pregnancy, lactation, and menopause in women 40 years of age or older and treat the underlying cause accordingly. It is important to note that hypothyroidism may also cause amenorrhoea.

    • This question is part of the following fields:

      • Gynaecology
      18.1
      Seconds
  • Question 29 - What is the most frequently occurring infectious agent linked to acute pyelonephritis? ...

    Incorrect

    • What is the most frequently occurring infectious agent linked to acute pyelonephritis?

      Your Answer: Hepatitis B virus

      Correct Answer: Escherichia coli

      Explanation:

      Common Pathogens in Acute Pyelonephritis

      Acute pyelonephritis is commonly caused by Escherichia coli, which accounts for more than 80% of cases. Other pathogens that can cause this condition include Enterococcus faecalis, Klebsiella, and Proteus species. The infection typically begins in the bladder and then spreads to the renal parenchyma. At first, the bacteria multiply within the tubules. However, within 48 hours, damage to the tubular epithelium begins to occur.

    • This question is part of the following fields:

      • Infectious Diseases
      15.8
      Seconds
  • Question 30 - A 25-year-old man is brought to the Emergency Department by ambulance following a...

    Incorrect

    • A 25-year-old man is brought to the Emergency Department by ambulance following a fall from a roof where he was repairing shingles. He is conscious and complains of back and neck pain. He is breathing spontaneously and has a blood pressure of 110/70 mmHg and a pulse rate of 75 bpm. He has deformity in the right thigh, which he says does not hurt. He is managed as a multiple trauma and is noted to have priapism as a urinary catheter is inserted. Initially, he has no movement, reflexes or sensation in his lower limbs, but when examined several days later, he is found to have spastic paresis and hyperreflexia in the lower limbs affecting all muscle groups. The lower limbs remain insensate. The upper limbs move normally both proximally and distally, and reflexes are normal.
      What is the most likely level of his spinal cord injury?

      Your Answer: S5

      Correct Answer: T8

      Explanation:

      Determining the Level of Spinal Cord Injury

      When assessing a patient with a suspected spinal cord injury, it is important to determine the level of the injury in order to understand the extent of neurological deficits. The initial phase of injury is known as spinal shock, which refers to the loss of all neurological activity below the level of injury. This phase typically lasts up to 6 weeks post-injury. Once spinal shock passes, upper motor neuron signs become apparent.

      In the case of a patient with priapism and sensory loss in the lower limbs but unaffected upper limbs, the injury must be below T1. The lower limbs are innervated by the femoral, obturator, and sciatic nerves, which all arise above the fifth sacral segment of the cord. A lesion at L4 would spare some proximal lower limb muscle function and sensation over the anterior thigh, which is not consistent with the patient’s symptoms. An injury at S5 would not cause additional neurological signs and symptoms in the lower limbs.

      Therefore, the most likely level of injury is T8. It is important to rule out higher-level injuries, such as C3 or C8, which would also affect the upper limbs and breathing. By determining the level of spinal cord injury, healthcare professionals can better understand the extent of neurological deficits and provide appropriate treatment and management.

    • This question is part of the following fields:

      • Trauma
      81.8
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Obstetrics (2/3) 67%
Cardiothoracic (0/1) 0%
Pharmacology (0/2) 0%
Cardiology (1/4) 25%
Nephrology (0/2) 0%
Respiratory (0/2) 0%
Surgery (2/2) 100%
Musculoskeletal (0/2) 0%
Endocrinology (0/1) 0%
Medicine (1/2) 50%
Clinical Sciences (0/1) 0%
Oncology (0/1) 0%
Gynaecology (0/2) 0%
Plastics (0/1) 0%
Paediatrics (0/1) 0%
Ophthalmology (1/1) 100%
Infectious Diseases (0/1) 0%
Trauma (0/1) 0%
Passmed