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Question 1
Correct
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You are working in a GP surgery and you meet a 25-year-old newly qualified healthcare assistant who has come in to see you as she would like to know more about the BCG vaccination and whether she needs to have it. You advise her that she will need the BCG as she is at risk of occupational exposure. She would also like to know more about who needs to have the BCG vaccination.
Who needs a BCG vaccination assuming they have not had one before?Your Answer: A 22-year-old man who has started work as a prison officer
Explanation:Children born in areas with a high prevalence of tuberculosis (TB) or with parents/grandparents from such areas, as well as individuals under the age of 35 at high risk of occupational exposure to TB, are administered the BCG vaccine. However, there is no evidence to support the effectiveness of the BCG vaccine for individuals over the age of 35, and therefore it is not administered to them.
The BCG Vaccine: Who Should Get It and How It’s Administered
The Bacille Calmette-Guérin (BCG) vaccine is a vaccine that provides limited protection against tuberculosis (TB). In the UK, it is given to high-risk infants and certain groups of people who are at risk of contracting TB. The vaccine contains live attenuated Mycobacterium bovis and also offers limited protection against leprosy.
The Greenbook provides guidelines on who should receive the BCG vaccine. It is recommended for all infants living in areas of the UK where the annual incidence of TB is 40/100,000 or greater, as well as infants with a parent or grandparent who was born in a country with a high incidence of TB. The vaccine is also recommended for previously unvaccinated tuberculin-negative contacts of cases of respiratory TB, new entrants under 16 years of age who were born in or have lived for a prolonged period in a high-risk country, healthcare workers, prison staff, staff of care homes for the elderly, and those who work with homeless people.
Before receiving the BCG vaccine, any person being considered must first be given a tuberculin skin test, except for children under 6 years old who have had no contact with tuberculosis. The vaccine is given intradermally, normally to the lateral aspect of the left upper arm. It can be given at the same time as other live vaccines, but if not administered simultaneously, there should be a 4-week interval.
There are some contraindications for the BCG vaccine, including previous BCG vaccination, a past history of tuberculosis, HIV, pregnancy, and a positive tuberculin test (Heaf or Mantoux). It is not given to anyone over the age of 35, as there is no evidence that it works for people of this age group.
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This question is part of the following fields:
- Infectious Diseases
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Question 2
Correct
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You are summoned to the examination room of a pediatric clinic as a 15-month-old girl has developed a rash and difficulty breathing after receiving a routine vaccination. Upon assessment, she is exhibiting swelling in the mouth and neck area. What is the best initial course of action?
Your Answer: IM adrenaline 150 mcg (0.15ml of 1 in 1,000)
Explanation:For children between 6 months and 6 years old, the recommended dose of adrenaline for anaphylaxis is 150 mcg (0.15ml of 1 in 1,000 solution).
Anaphylaxis is a severe and potentially life-threatening allergic reaction that affects the entire body. It can be caused by various triggers, including food, drugs, and insect venom. The symptoms of anaphylaxis typically occur suddenly and progress rapidly, affecting the airway, breathing, and circulation. Common signs include swelling of the throat and tongue, hoarse voice, respiratory wheeze, dyspnea, hypotension, and tachycardia. In addition, around 80-90% of patients experience skin and mucosal changes, such as generalized pruritus, erythematous rash, or urticaria.
The management of anaphylaxis requires prompt and decisive action, as it is a medical emergency. The Resuscitation Council guidelines recommend intramuscular adrenaline as the most important drug for treating anaphylaxis. The recommended doses of adrenaline vary depending on the patient’s age, ranging from 100-150 micrograms for infants under 6 months to 500 micrograms for adults and children over 12 years. Adrenaline can be repeated every 5 minutes if necessary, and the best site for injection is the anterolateral aspect of the middle third of the thigh. In cases of refractory anaphylaxis, IV fluids and expert help should be sought.
Following stabilisation, patients may be given non-sedating oral antihistamines to manage persisting skin symptoms. It is important to refer all patients with a new diagnosis of anaphylaxis to a specialist allergy clinic and provide them with an adrenaline injector as an interim measure before the specialist assessment. Patients should also be prescribed two adrenaline auto-injectors and trained on how to use them. A risk-stratified approach to discharge should be taken, as biphasic reactions can occur in up to 20% of patients. The Resus Council UK recommends a fast-track discharge for patients who have had a good response to a single dose of adrenaline and complete resolution of symptoms, while those who require two doses of IM adrenaline or have a history of biphasic reaction should be observed for at least 12 hours following symptom resolution.
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This question is part of the following fields:
- Immunology/Allergy
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Question 3
Correct
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A 26-year-old female presents for follow-up. She was diagnosed with asthma four years ago and is currently utilizing a salbutamol inhaler 100mcg as needed in combination with beclometasone dipropionate inhaler 200 mcg twice daily. However, her asthma remains poorly controlled. Upon examination, her chest is clear and she demonstrates proper inhaler technique. In accordance with NICE recommendations, what is the most suitable course of action for further management?
Your Answer: Add a leukotriene receptor antagonist
Explanation:According to NICE 2017 guidelines, if a patient with asthma is not effectively managed with a SABA + ICS, the first step should be to add a LTRA rather than a LABA.
The management of asthma in adults has been updated by NICE in 2017, following the 2016 BTS guidelines. One of the significant changes is in ‘step 3’, where patients on a SABA + ICS whose asthma is not well controlled should be offered a leukotriene receptor antagonist instead of a LABA. NICE does not follow the stepwise approach of the previous BTS guidelines, but to make the guidelines easier to follow, we have added our own steps. The steps range from newly-diagnosed asthma to SABA +/- LTRA + one of the following options, including increasing ICS to high-dose, a trial of an additional drug, or seeking advice from a healthcare professional with expertise in asthma. Maintenance and reliever therapy (MART) is a form of combined ICS and LABA treatment that is only available for ICS and LABA combinations in which the LABA has a fast-acting component. It should be noted that NICE does not recommend changing treatment in patients who have well-controlled asthma simply to adhere to the latest guidance. The definitions of what constitutes a low, moderate, or high-dose ICS have also changed, with <= 400 micrograms budesonide or equivalent being a low dose, 400 micrograms - 800 micrograms budesonide or equivalent being a moderate dose, and > 800 micrograms budesonide or equivalent being a high dose for adults.
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This question is part of the following fields:
- Respiratory Medicine
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Question 4
Correct
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A 25-year-old man presents with a complaint of generalised swelling that has affected his legs, arm and face, worsening over the last three weeks. Upon investigation, the following results were obtained: Sodium (Na+) 139 mmol/l (normal range: 135–145 mmol/l), Potassium (K+) 4.2 mmol/l (normal range: 3.5–5.0 mmol/l), Creatinine (Cr) 190 μmol/l (normal range: 50–120 μmol/l), Urea 14.8 mmol/l (normal range: 7–20 mmol/l), Alanine aminotransferase (ALT) 20 IU/l (normal range: 29–33 IU/l), Bilirubin 16 μmol/l (normal range: < 20.5 μmol/l), Albumin 19 g/l (normal range: 35–50 g/l), Total Cholesterol 9.2 mmol/l (normal range: < 5.2 mmol/l), Prothrombin time (PT) 10 s. What is the most likely diagnosis?
Your Answer: Nephrotic syndrome
Explanation:Differential Diagnosis for a Patient with Generalized Edema, Low Albumin, Renal Impairment, and Elevated Cholesterol
The patient presents with generalized edema, low albumin, renal impairment, and elevated cholesterol. The most likely diagnosis is nephrotic syndrome. Anorexia nervosa is unlikely to cause such a low albumin level. Cirrhosis of the liver is less likely due to normal liver function tests and PT. Cystic fibrosis typically presents with bronchiectasis, pancreatic insufficiency, malabsorption, or diabetes. Nephritic syndrome causes hypertension, haematuria, and oliguria.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 5
Correct
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A 28-year-old female patient presents to her GP complaining of a foul-smelling vaginal discharge that has persisted for 5 days after having unprotected sex. She reports feeling generally well and denies any fever or urinary symptoms. The patient also confirms that she is not pregnant. During the examination, the doctor observes multiple punctate lesions on her cervix and a green discharge with a strong odor. What is the probable diagnosis?
Your Answer: Trichomoniasis
Explanation:The patient is likely suffering from trichomoniasis caused by Trichomonas vaginalis, a sexually transmitted disease that results in a yellow/green discharge with a foul odor, vulval itching, and dysuria. During a speculum examination, the cervix may appear as a strawberry cervix due to multiple punctate haemorrhages. Bacterial vaginosis, which is not a sexually transmitted disease and can be caused by various factors, is less likely to be the diagnosis due to the recent unprotected sexual intercourse and the presence of an offensive discharge. Chlamydia and gonorrhoea, both sexually transmitted diseases, can also cause dysuria and vaginal discharge, but the punctate cervical haemorrhages and malodorous green discharge make them less likely diagnoses. Syphilis, which presents in three stages, is unlikely due to the acute onset of symptoms and the absence of genital lesions.
Understanding Trichomonas vaginalis and its Comparison to Bacterial Vaginosis
Trichomonas vaginalis is a type of protozoan parasite that is highly motile and flagellated. It is known to cause trichomoniasis, which is a sexually transmitted infection. The infection is characterized by symptoms such as offensive, yellow/green, frothy vaginal discharge, vulvovaginitis, and strawberry cervix. The pH level is usually above 4.5, and in men, it may cause urethritis.
To diagnose trichomoniasis, a wet mount microscopy is conducted to observe the motile trophozoites. The treatment for trichomoniasis involves oral metronidazole for 5-7 days, although a one-off dose of 2g metronidazole may also be used.
When compared to bacterial vaginosis, trichomoniasis has distinct differences. Bacterial vaginosis is caused by an overgrowth of bacteria in the vagina, while trichomoniasis is caused by a protozoan parasite. The symptoms of bacterial vaginosis include a thin, grayish-white vaginal discharge with a fishy odor, and a pH level above 4.5. Unlike trichomoniasis, bacterial vaginosis is not considered a sexually transmitted infection.
In conclusion, understanding the differences between trichomoniasis and bacterial vaginosis is crucial in diagnosing and treating these conditions effectively. Proper diagnosis and treatment can help prevent complications and improve overall health and well-being.
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This question is part of the following fields:
- Reproductive Medicine
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Question 6
Correct
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A 26 year-old woman, who is 36 weeks pregnant, presents to her GP with a blood pressure reading of 170/110 mmHg. She is feeling well otherwise and is currently taking 250 mg labetalol. Urinalysis shows 3+ proteinuria. Fetal monitoring is normal. Her blood tests reveal a hemoglobin level of 135 g/l, platelet count of 280 * 109/l, white blood cell count of 6.0 * 109/l, sodium level of 142 mmol/l, potassium level of 4.0 mmol/l, urea level of 2.8 mmol/l, and creatinine level of 24 µmol/l. What is the most appropriate course of action for her management?
Your Answer: Admit the patient to hospital as an emergency
Explanation:Despite the absence of symptoms, the patient’s blood pressure remains elevated at a level exceeding 160/100 mmHg, and there is also significant proteinuria, despite receiving labetalol treatment. As a result, emergency admission is necessary to monitor and manage the hypertension in a controlled setting. If there is no improvement, delivery may be considered as an option.
Hypertension during pregnancy is a common occurrence that requires careful management. In normal pregnancies, blood pressure tends to decrease in the first trimester and then gradually increase to pre-pregnancy levels by term. However, in cases of hypertension during pregnancy, the systolic blood pressure is usually above 140 mmHg or the diastolic blood pressure is above 90 mmHg. Additionally, an increase of more than 30 mmHg systolic or 15 mmHg diastolic from the initial readings may also indicate hypertension.
There are three categories of hypertension during pregnancy: pre-existing hypertension, pregnancy-induced hypertension (PIH), and pre-eclampsia. Pre-existing hypertension refers to a history of hypertension before pregnancy or elevated blood pressure before 20 weeks gestation. PIH occurs in the second half of pregnancy and resolves after birth. Pre-eclampsia is characterized by hypertension and proteinuria, and may also involve edema.
The management of hypertension during pregnancy involves the use of antihypertensive medications such as labetalol, nifedipine, and hydralazine. In cases of pre-existing hypertension, ACE inhibitors and angiotensin II receptor blockers should be stopped immediately and alternative medications should be prescribed. Women who are at high risk of developing pre-eclampsia should take aspirin from 12 weeks until the birth of the baby. It is important to carefully monitor blood pressure and proteinuria levels during pregnancy to ensure the health of both the mother and the baby.
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This question is part of the following fields:
- Reproductive Medicine
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Question 7
Correct
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A geriatric patient presents with chronic heart failure.
Which of the following drugs should be used as a first-line treatment for heart failure?
Your Answer: Enalapril
Explanation:Heart Failure Medications: Uses and Recommendations
Heart failure is a serious condition that requires proper management and treatment. There are several medications available for heart failure, each with its own specific uses and recommendations.
Enalapril is an ACE inhibitor that works by reducing levels of angiotensin II, a potent vasoconstrictor, resulting in reduced vasoconstriction and a reduction in left ventricular afterload. It is recommended as a first-line treatment for all patients with heart failure due to left ventricular systolic dysfunction.
Digoxin is recommended for worsening or severe heart failure due to left ventricular systolic dysfunction despite first- and second-line treatment for heart failure.
Aspirin should be prescribed for patients with heart failure and atherosclerotic arterial disease, including coronary heart disease. It is not useful in monotherapy for the treatment of heart failure.
Furosemide is a diuretic that is routinely used for the relief of congestive symptoms and fluid retention in patients with heart failure. It should be titrated according to need after the initiation of subsequent heart failure therapies.
Spironolactone is an aldosterone antagonist that forms the second-line treatment in patients with heart failure. It is important to closely monitor potassium and creatinine levels and the estimated glomerular filtration rate (eGFR). Specialist advice should be sought if the patient develops hyperkalaemia or renal function deteriorates.
In summary, the appropriate medication for heart failure depends on the individual patient’s condition and needs. It is important to consult with a healthcare professional for proper diagnosis and treatment.
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This question is part of the following fields:
- Cardiovascular
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Question 8
Correct
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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.
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This question is part of the following fields:
- Cardiovascular
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Question 9
Correct
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A 35-year-old man presents to his General Practitioner with weight loss, dry eyes and palpitations. He reports feeling jittery and nervous for the past few weeks. Upon examination, a fine tremor, regular pulse of 105 bpm, exophthalmos and a moderate, smooth goitre are noted. The results of his thyroid function tests are as follows:
Investigation Result Normal Value
Thyroid-stimulating hormone (TSH) 0.03 mU/l 0.25–4.0 mU/l
Free T4 38.5 pmol/l 12.0–22.0 pmol/l
Free T3 11.8 pmol/l 3.1–6.8 pmol/l
Thyroid peroxidase (TPO) antibodies Positive
What is the most likely diagnosis?Your Answer: Graves' disease
Explanation:Differentiating Causes of Thyrotoxicosis: A Brief Overview
Thyrotoxicosis, or hyperthyroidism, can be caused by various conditions, including Graves’ disease, De Quervain’s thyroiditis, Hashimoto’s thyroiditis, hypothyroidism, and toxic multinodular goitre. Among these, Graves’ disease is the most common cause, characterized by autoimmune dysfunction and typical hyperthyroid symptoms. About a third of patients with Graves’ disease also develop eye signs, while pretibial myxoedema or clubbing of the fingers may occur rarely. De Quervain’s thyroiditis, on the other hand, is associated with transient hyperthyroidism following a viral infection and neck pain. Hashimoto’s thyroiditis, an autoimmune condition, causes hypothyroidism instead of hyperthyroidism. Hypothyroidism presents with weight gain, fatigue, constipation, dry skin, and depression, and is characterized by raised TSH and reduced T4 or T3. Finally, toxic multinodular goitre is the second most common cause of hyperthyroidism in the UK, presenting with a multinodular goitre and hyperthyroidism without Graves’ disease symptoms. However, in the case presented, the positive TPO antibodies and typical Graves’ disease symptoms make it the most likely diagnosis.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 10
Correct
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A 45-year-old woman, with a history of gallstones, arrives at the emergency department complaining of central abdominal pain that radiates to her back. Upon conducting blood tests, you observe the following result:
Amylase 480 U/L (30 - 110). The patient is diagnosed with acute pancreatitis and inquires about the severity of her condition. What is the primary factor in determining the clinical severity of acute pancreatitis?Your Answer: Presence of any systemic or local complications
Explanation:When determining the severity of pancreatitis, the presence of systemic or local complications is the most important factor to consider. Mild acute pancreatitis is characterized by the absence of both organ failure and local complications. Local complications in severe cases may include peripancreatic fluid collections, pancreatic or peripancreatic necrosis, pseudocysts, and walled-off areas of necrosis. The Atlanta classification system categorizes acute pancreatitis as mild, moderate, or severe. Mild cases have no organ failure, local or systemic complications, and typically resolve within a week. Pain level and initial CRP levels are not used to classify severity, but a high white blood cell count may indicate an increased risk of severe pancreatitis. Serum amylase levels and pancreatic calcification on CT scans are also not reliable indicators of severity.
Managing Acute Pancreatitis in a Hospital Setting
Acute pancreatitis is a serious condition that requires management in a hospital setting. The severity of the condition can be stratified based on the presence of organ failure and local complications. Key aspects of care include fluid resuscitation, aggressive early hydration with crystalloids, and adequate pain management with intravenous opioids. Patients should not be made ‘nil-by-mouth’ unless there is a clear reason, and enteral nutrition should be offered within 72 hours of presentation. Antibiotics should not be used prophylactically, but may be indicated in cases of infected pancreatic necrosis. Surgery may be necessary for patients with acute pancreatitis due to gallstones or obstructed biliary systems, and those with infected necrosis may require radiological drainage or surgical necrosectomy.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 11
Correct
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In an elderly patient, which of the following is the single most likely statement indicating an increased risk of suicide?
Your Answer: A direct statement of intent to attempt suicide
Explanation:Understanding Suicide Risk Factors
Suicide is a complex issue with various risk factors that can contribute to its occurrence. One of the most obvious warning signs is a direct statement of intent to attempt suicide. It is important to take these statements seriously and seek help immediately.
Physical illness, especially if it is prolonged and associated with pain and/or a poor prognosis, is also a well-recognized risk factor for suicide. Additionally, caring for a dying friend or relative can increase the risk, albeit to a lesser extent.
Unemployment is another risk factor, as it can lead to feelings of hopelessness and financial strain. Living alone, particularly after a bereavement, can also indicate a higher risk, especially if the person was dependent on the deceased.
While paranoid delusions can occur in depressive illness, they do not have any special significance in assessing suicide risk. However, approximately one in twenty people with schizophrenia attempt suicide, with a higher risk at the onset of the illness and if there is associated depressive illness.
It is important to understand these risk factors and seek help if you or someone you know is struggling with suicidal thoughts. Remember, there is always hope and help available.
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This question is part of the following fields:
- Psychiatry
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Question 12
Correct
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A 55-year-old woman seeks guidance on managing her menopausal symptoms. She has experienced cessation of her menstrual cycle and is bothered by hot flashes and night sweats. Due to her sister's breast cancer, she is not interested in hormone replacement therapy. What is the most suitable treatment option to suggest?
Your Answer: Citalopram
Explanation:Managing Menopause: Lifestyle Modifications, Hormone Replacement Therapy, and Non-Hormone Replacement Therapy
Menopause is a natural biological process that marks the end of a woman’s reproductive years. It is diagnosed when a woman has not had a period for 12 consecutive months. Menopausal symptoms are common and can last for up to 7 years, with varying degrees of severity and duration. The management of menopause can be divided into three categories: lifestyle modifications, hormone replacement therapy (HRT), and non-hormone replacement therapy.
Lifestyle modifications can help manage menopausal symptoms such as hot flushes, sleep disturbance, mood changes, and cognitive symptoms. Regular exercise, weight loss, stress reduction, and good sleep hygiene are recommended. For women who cannot or do not want to take HRT, non-hormonal treatments such as fluoxetine, citalopram, or venlafaxine for vasomotor symptoms, vaginal lubricants or moisturizers for vaginal dryness, and cognitive behavior therapy or antidepressants for psychological symptoms can be prescribed.
HRT is a treatment option for women with moderate to severe menopausal symptoms. However, it is contraindicated in women with current or past breast cancer, any estrogen-sensitive cancer, undiagnosed vaginal bleeding, or untreated endometrial hyperplasia. HRT brings certain risks, including venous thromboembolism, stroke, coronary heart disease, breast cancer, and ovarian cancer. Women should be advised of these risks and the fact that symptoms typically last for 2-5 years.
When stopping HRT, it is important to gradually reduce the dosage to limit recurrence of symptoms in the short term. However, in the long term, there is no difference in symptom control. Women who experience ineffective treatment, ongoing side effects, or unexplained bleeding should be referred to secondary care. Overall, managing menopause requires a personalized approach that takes into account a woman’s medical history, preferences, and individual symptoms.
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This question is part of the following fields:
- Reproductive Medicine
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Question 13
Incorrect
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A 26-year-old woman is recuperating from a kidney transplant. Within 24 hours of the surgery, she complains of increased discomfort at the transplant site. Upon examination, she has a fever, tenderness at the transplant site, and has not produced urine since the procedure. Her creatinine levels have significantly increased in the past 24 hours. What is the fundamental mechanism behind her rejection?
Your Answer: Cell-mediated (cytotoxic T cell) induced rejection
Correct Answer: Pre-existing antibodies against ABO or HLA antigens
Explanation:Understanding HLA Typing and Graft Failure in Renal Transplants
The human leucocyte antigen (HLA) system, also known as the major histocompatibility complex (MHC), is located on chromosome 6 and plays a crucial role in renal transplants. The HLA system includes class 1 antigens (A, B, and C) and class 2 antigens (DP, DQ, and DR), with DR being the most important for HLA matching in renal transplants. Graft survival rates for cadaveric transplants are 90% at 1 year and 60% at 10 years, while living-donor transplants have a 95% survival rate at 1 year and 70% at 10 years.
Post-operative problems may include acute tubular necrosis of the graft, vascular thrombosis, urine leakage, and urinary tract infections. Hyperacute rejection, which occurs within minutes to hours, is caused by pre-existing antibodies against ABO or HLA antigens and leads to widespread thrombosis of graft vessels, resulting in the need for graft removal. Acute graft failure, which occurs within 6 months, is usually due to mismatched HLA and is picked up by a rising creatinine, pyuria, and proteinuria. Chronic graft failure, which occurs after 6 months, is caused by both antibody and cell-mediated mechanisms and leads to fibrosis of the transplanted kidney, with recurrence of the original renal disease being a common cause.
In summary, understanding the HLA system and its role in renal transplants is crucial for successful outcomes. Monitoring for post-operative problems and early detection of graft failure can help improve long-term survival rates.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 14
Correct
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A 62-year-old man has been referred due to a tremor and bradykinesia, leading to a diagnosis of Parkinson's disease. These symptoms are now interfering with his work as an accountant and overall quality of life. What initial treatment is he likely to receive?
Your Answer: Levodopa
Explanation:Patients with newly diagnosed Parkinson’s who experience motor symptoms that negatively impact their quality of life should be provided with levodopa.
Management of Parkinson’s Disease: Medications and Considerations
Parkinson’s disease is a complex condition that requires specialized expertise in movement disorders for diagnosis and management. However, all healthcare professionals should be familiar with the medications used to treat Parkinson’s disease due to its prevalence. The National Institute for Health and Care Excellence (NICE) published guidelines in 2017 to aid in the management of Parkinson’s disease.
For first-line treatment, levodopa is recommended if motor symptoms are affecting the patient’s quality of life. If motor symptoms are not affecting the patient’s quality of life, dopamine agonists (non-ergot derived), levodopa, or monoamine oxidase B (MAO-B) inhibitors may be used. NICE provides tables to aid in decision-making regarding the use of these medications, taking into account their effects on motor symptoms, activities of daily living, motor complications, and adverse events.
If a patient continues to have symptoms despite optimal levodopa treatment or has developed dyskinesia, NICE recommends the addition of a dopamine agonist, MAO-B inhibitor, or catechol-O-methyl transferase (COMT) inhibitor as an adjunct. Other considerations in Parkinson’s disease management include the risk of acute akinesia or neuroleptic malignant syndrome if medication is not taken or absorbed, the potential for impulse control disorders with dopaminergic therapy, and the need to adjust medication if excessive daytime sleepiness or orthostatic hypotension develops.
Specific medications used in Parkinson’s disease management include levodopa, dopamine receptor agonists, MAO-B inhibitors, amantadine, COMT inhibitors, and antimuscarinics. Each medication has its own set of benefits and potential adverse effects, which should be carefully considered when selecting a treatment plan. Overall, the management of Parkinson’s disease requires a comprehensive approach that takes into account the individual needs and circumstances of each patient.
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This question is part of the following fields:
- Neurology
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Question 15
Correct
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A 59 year old man with a history of aortic stenosis presents to his cardiology clinic with complaints of worsening shortness of breath and fainting episodes. His recent ECHO reveals a mean gradient of 45 mmHg and mild aortic regurgitation, while his ECG shows left ventricular hypertrophy, left bundle branch block, and a prolonged PR interval. What factor is most indicative of the need for valve replacement surgery?
Your Answer: Presence of symptoms
Explanation:Aortic valve replacement is typically recommended for patients with severe aortic stenosis who are experiencing symptoms such as dyspnea, chest pain, and syncope. Without treatment, these symptoms can lead to a mortality rate of 2-3 years. However, the decision to perform valve replacement on asymptomatic patients is a topic of debate.
Aortic Stenosis: Symptoms, Causes, and Management
Aortic stenosis is a condition characterized by the narrowing of the aortic valve, which can lead to various symptoms. These symptoms include chest pain, dyspnea, syncope, and a characteristic ejection systolic murmur that radiates to the carotids. Severe aortic stenosis can also cause a narrow pulse pressure, slow rising pulse, delayed ESM, soft/absent S2, S4, thrill, and left ventricular hypertrophy or failure. The most common causes of aortic stenosis are degenerative calcification in older patients and bicuspid aortic valve in younger patients.
If a patient is asymptomatic, observation is usually recommended. However, if the patient is symptomatic or has a valvular gradient greater than 40 mmHg with features such as left ventricular systolic dysfunction, valve replacement is necessary. Surgical AVR is the preferred treatment for young, low/medium operative risk patients, while TAVR is used for those with a high operative risk. Balloon valvuloplasty may be used in children without aortic valve calcification and in adults with critical aortic stenosis who are not fit for valve replacement.
In summary, aortic stenosis is a condition that can cause various symptoms and requires prompt management to prevent complications. The causes of aortic stenosis vary, and treatment options depend on the patient’s age, operative risk, and overall health.
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This question is part of the following fields:
- Cardiovascular
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Question 16
Correct
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A 30-year-old male with a history of ankylosing spondylitis presents to his GP with complaints of eye pain and sensitivity to light. He wears glasses for nearsightedness and this is his first occurrence, affecting only his right eye. Upon examination, his right eye has a visual acuity of 6/6 while his left eye is corrected to 6/18. The left pupil is misshapen and the eye is red, but the cornea appears clear. What is the most likely diagnosis for this patient?
Your Answer: Anterior uveitis
Explanation:Ankylosing spondylitis is commonly associated with anterior uveitis, which presents with symptoms such as a misshapen pupil, red eye, and reduced vision. This condition involves both eyes and is more likely than other eye conditions. Retinal detachment does not cause eye pain.
Anterior uveitis, also known as iritis, is a type of inflammation that affects the iris and ciliary body in the front part of the uvea. It is a common cause of red eye and is associated with HLA-B27, which may also be linked to other conditions. Symptoms of anterior uveitis include sudden onset of eye discomfort and pain, small or irregular pupils, intense sensitivity to light, blurred vision, redness, tearing, and the presence of pus and inflammatory cells in the front part of the eye. This condition may be associated with ankylosing spondylitis, reactive arthritis, ulcerative colitis, Crohn’s disease, Behcet’s disease, and sarcoidosis. Urgent review by an ophthalmologist is necessary, and treatment may involve the use of cycloplegics and steroid eye drops.
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This question is part of the following fields:
- Ophthalmology
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Question 17
Correct
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A 48-year-old type 2 diabetic man has an annual review; bloods show creatinine 109 μmol/l (reference range 53–106 μmol/l) and estimated glomerular filtration rate (eGFR) 64 (reference range >90 ml/min/1.73 m2). Urinary albumin : creatinine ratio (ACR) test = 37 mg/mmol (reference range <3 mg/mmol- 30 mg/mmol). The results are repeated 4 weeks later and the results are very similar.
Which class of chronic kidney disease (CKD) does this fit?
Select the SINGLE most appropriate class from the list below.
Select ONE option only.Your Answer: CKD stage 2
Explanation:Understanding the Stages of Chronic Kidney Disease
Chronic kidney disease (CKD) is a condition in which the kidneys gradually lose function over time. To help diagnose and manage CKD, healthcare professionals use a staging system based on the glomerular filtration rate (GFR), which measures how well the kidneys are filtering waste from the blood.
The stages of CKD are as follows:
– Stage 1: GFR >90 ml/min/1.73 m2 (normal or high)
– Stage 2: GFR 60–89 ml/min/1.73 m2 (mildly decreased)
– Stage 3a: GFR 45–59 ml/min/1.73 m2 (mildly to moderately decreased)
– Stage 3b: GFR 30–44 ml/min/1.73 m2 (moderately to severely decreased)
– Stage 4: GFR 15–29 ml/min/1.73 m2 (severely decreased)
– Stage 5: GFR <15 ml/min/1.73 m2 (kidney failure) The 2008 National Institute for Health and Care Excellence (NICE) guideline on CKD recommends subdividing stage 3 into 3a and 3b, and adding the suffix P to denote significant proteinuria at any stage. Significant proteinuria is defined as a urinary albumin-to-creatinine ratio (ACR) of 30 mg/mmol or higher. Understanding the stage of CKD can help healthcare professionals determine appropriate treatment and management strategies to slow the progression of the disease and prevent complications. -
This question is part of the following fields:
- Renal Medicine/Urology
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Question 18
Correct
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Sarah is a 30-year-old woman who has been admitted under Section 2 of the Mental Health Act. She has a history of depression and was recently referred for a Mental Health Act assessment because her family were concerned about her. She has been talking about her insides rotting and believes that she is going to die in her sleep. She cannot be convinced otherwise. She is not eating, barely drinking and lacks energy, concentration and motivation. Just prior to the Assessment she used a biro pen to cut into her forearm to 'prove that there is nothing inside that will bleed', and this required reconstructive surgery.
She is admitted to a psychiatric hospital and is commenced on an SSRI and an antipsychotic. One week into her admission the nurses call you because she is scoring highly on the Early Warning Score.
On examination you find Sarah to be confused. She has a temperature of 39ºC and is sweating. Her heart rate is 130 beats/min and her blood pressure is 80/50 mmHg. She complains of muscle stiffness but is not sure when this began. Cogwheel rigidity is present.
Urgent blood tests reveal the following:
Hb 155 g/L Male: (135-180) Female: (115 - 160)
Platelets 200 * 109/L (150 - 400)
WBC 18 * 109/L (4.0 - 11.0)
Creatine Kinase 2032 9/L (32-294)
Na+ 135 mmol/L (135 - 145)
K+ 4.9 mmol/L (3.5 - 5.0)
Urea 3.0 mmol/L (2.0 - 7.0)
Creatinine 118 µmol/L (55 - 120)
What is the likely cause of her symptoms?Your Answer: Neuroleptic malignant syndrome
Explanation:Neuroleptic malignant syndrome is a severe reaction that can occur in response to antipsychotic medication and can be life-threatening. The patient is exhibiting symptoms consistent with NMS, including muscle rigidity and elevated creatine kinase levels. Amphetamine intoxication is an unlikely cause as there is no history of drug use and the patient is under Section 2 of the MHA. Encephalitis and sepsis are important differential diagnoses to consider, but cogwheel rigidity would not be expected in encephalitis and sepsis would not typically cause muscle rigidity or elevated creatine kinase levels.
Understanding Neuroleptic Malignant Syndrome
Neuroleptic malignant syndrome is a rare but serious condition that can occur in patients taking antipsychotic medication. It can also happen with dopaminergic drugs used for Parkinson’s disease. The exact cause of this condition is unknown, but it is believed that dopamine blockade induced by antipsychotics triggers massive glutamate release, leading to neurotoxicity and muscle damage. Symptoms of neuroleptic malignant syndrome typically appear within hours to days of starting an antipsychotic and include fever, muscle rigidity, autonomic lability, and agitated delirium with confusion.
A raised creatine kinase is present in most cases, and acute kidney injury may develop in severe cases. Management of neuroleptic malignant syndrome involves stopping the antipsychotic medication and transferring the patient to a medical ward or intensive care unit. Intravenous fluids may be given to prevent renal failure, and dantrolene or bromocriptine may be used in selected cases. It is important to differentiate neuroleptic malignant syndrome from serotonin syndrome, which has similar symptoms but is caused by excessive serotonin activity.
In summary, neuroleptic malignant syndrome is a rare but potentially life-threatening condition that can occur in patients taking antipsychotic medication or dopaminergic drugs. Early recognition and management are crucial to prevent complications and improve outcomes.
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This question is part of the following fields:
- Neurology
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Question 19
Correct
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A 28-year-old woman comes to the doctor complaining of lower abdominal pain, pain during sexual intercourse, and an abnormal vaginal discharge. A vaginal swab reveals a positive chlamydia infection. She has no known allergies and is generally healthy. What is the most appropriate next step in managing this patient?
Your Answer: Prescribe a 7-day course of doxycycline
Explanation:Treatment Options for Chlamydia Infections
Chlamydia trachomatis is a common sexually transmitted infection that can be effectively treated with antibiotics. The National Institute for Health and Care Excellence (NICE) provides guidance on the appropriate antimicrobial prescribing for chlamydia infections.
The first-line treatment for chlamydia is a 7-day course of doxycycline. This medication is highly effective against Chlamydia trachomatis and is well-tolerated by most patients. If doxycycline cannot be used, such as in cases of pregnancy or allergy, a 7-day course of azithromycin can be given as a second-line option.
It is important for patients to complete their full course of antibiotics and to avoid sexual intercourse until treatment is complete. If the treatment is completed, there is no need for a test of cure to be carried out.
Other antibiotics, such as oral penicillin and cefalexin, are not effective against chlamydia infections. A one-off dose of intramuscular ceftriaxone is the treatment of choice for gonorrhoea infections, but it is not indicated for the treatment of chlamydia.
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This question is part of the following fields:
- Infectious Diseases
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Question 20
Incorrect
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A mother brings her 2-year-old daughter to your clinic with a similar concern about a mass around her belly button that seems to increase in size when she coughs or strains. Upon examination, you diagnose an unobstructed umbilical hernia that is soft, nontender, and reducible.
What is the recommended course of action for managing this patient?Your Answer: Routine referral to paediatric surgeon
Correct Answer: Reassure mum that umbilical hernias usually resolve but if persisting at 2-3 years of age surgery may be considered
Explanation:It is important to reassure the mother that umbilical hernias in newborns usually resolve on their own by the age of 3. However, if the hernia persists beyond this age, surgery may be considered. As there are no alarming symptoms currently present, urgent or routine referrals are not necessary. The use of laxatives would only be recommended if there is a history of constipation or faecal loading.
Umbilical Hernia in Children: Causes and Treatment
Umbilical hernias are a common occurrence in children and are often detected during the newborn examination. This condition is characterized by a bulge or protrusion near the belly button, caused by a weakness in the abdominal muscles. While umbilical hernias can occur in any child, they are more common in Afro-Caribbean infants and those with Down’s syndrome or mucopolysaccharide storage diseases.
Fortunately, in most cases, umbilical hernias in children do not require treatment and will resolve on their own by the age of three. However, if the hernia persists beyond this age or becomes painful, surgery may be necessary to repair the abdominal wall. It is important to monitor the hernia and seek medical attention if there are any changes in size or symptoms.
In summary, umbilical hernias are a common condition in children that typically resolve on their own without treatment. However, certain factors such as ethnicity and underlying medical conditions may increase the likelihood of developing an umbilical hernia. Parents should be aware of the signs and symptoms of umbilical hernias and seek medical attention if necessary.
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This question is part of the following fields:
- Paediatrics
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Question 21
Incorrect
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A 27-year-old female patient presents to you for her cervical cancer screening and expresses interest in learning more about HPV (human papillomavirus). What is a true statement regarding HPV?
Your Answer: HPV 6 and 11 are most commonly associated with cervical cancer
Correct Answer: HPV 16 and 18 are most commonly associated with cervical cancer
Explanation:The most significant risk factor for cervical cancer is infection with the human papillomavirus (HPV), particularly types 16, 18, and 33. Among the approximately 15 types of HPV that are considered high-risk for cervical cancer, HPV 16 and 18 are responsible for about 70% of cases. HPV 6 and 11, on the other hand, are associated with the formation of genital warts.
Understanding Cervical Cancer: Risk Factors and Mechanism of HPV
Cervical cancer is a type of cancer that affects the cervix, which is the lower part of the uterus. It is most commonly diagnosed in women under the age of 45, with the highest incidence rates occurring in those aged 25-29. The cancer can be divided into two types: squamous cell cancer and adenocarcinoma. Symptoms may include abnormal vaginal bleeding, postcoital bleeding, intermenstrual bleeding, or postmenopausal bleeding, as well as vaginal discharge.
The most important factor in the development of cervical cancer is the human papillomavirus (HPV), particularly serotypes 16, 18, and 33. Other risk factors include smoking, human immunodeficiency virus, early first intercourse, many sexual partners, high parity, and lower socioeconomic status. While the association between combined oral contraceptive pill use and cervical cancer is sometimes debated, a large study published in the Lancet confirmed the link.
The mechanism by which HPV causes cervical cancer involves the production of oncogenes E6 and E7 by HPV 16 and 18, respectively. E6 inhibits the p53 tumour suppressor gene, while E7 inhibits the RB suppressor gene. Understanding the risk factors and mechanism of HPV in the development of cervical cancer is crucial for prevention and early detection. Regular cervical cancer screening is recommended for all women.
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This question is part of the following fields:
- Reproductive Medicine
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Question 22
Correct
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A 70-year-old man presents with central chest pain that has been ongoing for 2 hours. The pain is radiating to his left arm. He has a medical history of hypertension and hypercholesterolemia.
Upon examination, the patient appears uncomfortable and sweaty. His vital signs are as follows:
- Heart rate: 90 bpm
- Respiratory rate: 20 breaths/min
- Peripheral oxygen saturation: 95% on room air
- Blood pressure: 136/78 mmHg
- Temperature: 37.0ºC
An ECG performed by the paramedics shows ST depression in leads II, III, and aVF, as well as T-wave inversion.
What is the immediate treatment that should be given?Your Answer: Aspirin, nitrate, morphine
Explanation:The appropriate combination in this scenario is aspirin, nitrate, and morphine. The addition of oxygen is not necessary and may even be inappropriate. Ramipril and bisoprolol are not recommended for acute treatment but may be used for long-term management of ACS. Therefore, aspirin, nitrate, and oxygen is an incorrect combination, and morphine should also be included due to the patient’s significant pain. Oxygen should not be administered as the patient’s oxygen saturation levels are already adequate.
Managing Acute Coronary Syndrome: A Summary of NICE Guidelines
Acute coronary syndrome (ACS) is a common and serious medical condition that requires prompt management. The management of ACS has evolved over the years, with the development of new drugs and procedures such as percutaneous coronary intervention (PCI). The National Institute for Health and Care Excellence (NICE) has updated its guidelines on the management of ACS in 2020.
ACS can be classified into three subtypes: ST-elevation myocardial infarction (STEMI), non ST-elevation myocardial infarction (NSTEMI), and unstable angina. The management of ACS depends on the subtype. However, there are common initial drug therapies for all patients with ACS, such as aspirin and nitrates. Oxygen should only be given if the patient has oxygen saturations below 94%, and morphine should only be given for severe pain.
For patients with STEMI, the first step is to assess eligibility for coronary reperfusion therapy, which can be either PCI or fibrinolysis. Patients with NSTEMI/unstable angina require a risk assessment using the Global Registry of Acute Coronary Events (GRACE) tool to determine whether they need coronary angiography (with follow-on PCI if necessary) or conservative management.
This summary provides an overview of the NICE guidelines for managing ACS. The guidelines are complex and depend on individual patient factors, so healthcare professionals should review the full guidelines for further details. Proper management of ACS can improve patient outcomes and reduce the risk of complications.
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This question is part of the following fields:
- Cardiovascular
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Question 23
Incorrect
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A 7-year-old girl comes to the emergency department with a 2-day history of right-sided otalgia and otorrhoea. Her mother suspects a middle ear infection as she has had them before. During the examination, she is found to be running a fever and has tenderness behind her right ear. The affected ear appears more prominent than the other, and otoscopy reveals a red tympanic membrane with a visible tear and pus discharge. What is the typical initial treatment for this probable diagnosis?
Your Answer: Urgent CT head
Correct Answer: IV antibiotics
Explanation:Mastoiditis is usually diagnosed based on clinical symptoms and requires immediate administration of IV antibiotics.
Upon examination, the patient displays symptoms consistent with mastoiditis, an infection of the mastoid air cells located in the temporal bone. This condition often arises as a complication of untreated or recurrent otitis media, as is the case here. Mastoiditis is the probable diagnosis due to tenderness upon palpation of the mastoid bone, swelling of the affected ear, and accompanying symptoms of otitis media.
The correct answer is IV antibiotics. Mastoiditis is typically diagnosed based on clinical presentation and requires urgent treatment with IV antibiotics.
Oral antibiotics are not the correct answer. Although antibiotics are necessary to treat mastoiditis, this condition is considered an emergency and therefore requires IV antibiotics as the preferred treatment method.
Routine referral to an ENT specialist is not the correct answer. Mastoiditis requires immediate treatment, and therefore a routine referral is not appropriate. The patient needs prompt access to IV antibiotics.
Topical antibiotics are not the correct answer. This treatment is not suitable for mastoiditis and is typically used to treat otitis externa.
Understanding Mastoiditis
Mastoiditis is a condition that occurs when an infection spreads from the middle ear to the mastoid air spaces of the temporal bone. It is characterized by severe pain behind the ear, fever, and a history of recurrent otitis media. Patients with mastoiditis are typically very unwell and may experience swelling, erythema, and tenderness over the mastoid process. In some cases, the external ear may protrude forwards and ear discharge may be present if the eardrum has perforated.
Diagnosis of mastoiditis is typically made based on clinical presentation, although a CT scan may be ordered if complications are suspected. Treatment involves the use of IV antibiotics to combat the infection. If left untreated, mastoiditis can lead to complications such as facial nerve palsy, hearing loss, and even meningitis.
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This question is part of the following fields:
- ENT
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Question 24
Incorrect
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A first-time mother brings her daughter, Lily, who is 7-months old, to the GP surgery. She is worried about Lily's development as she is still unable to sit without support. However, Lily is able to roll from front to back, sit with back straight if being held, and grasp toys when lying on her back. Can you inform the mother at what age Lily will be able to sit without support?
Your Answer: 11-12 months, refer if not achieved by 13 months
Correct Answer: 7-8 months, refer if not achieved by 12 months
Explanation:If sitting without support is not achieved by 12 months, referral is necessary, although it should typically be achieved by 7-8 months.
Gross Motor Developmental Milestones
Gross motor skills refer to the ability to use large muscles in the body for activities such as crawling, walking, running, and jumping. These skills are essential for a child’s physical development and are achieved through a series of developmental milestones.
At 3 months, a baby should have little or no head lag when pulled to sit and should have good head control when lying on their abdomen. By 6 months, they should be able to lift and grasp their feet when lying on their back, pull themselves to a sitting position, and roll from front to back. At 9 months, they should be able to pull themselves to a standing position and crawl. By 12 months, they should be able to cruise and walk with one hand held. At 18 months, they should be able to walk unsupported and squat to pick up a toy. By 2 years, they should be able to run and walk up and down stairs holding onto a rail. At 3 years, they should be able to ride a tricycle using pedals and walk up stairs without holding onto a rail. By 4 years, they should be able to hop on one leg.It is important to note that while the majority of children crawl on all fours before walking, some children may bottom-shuffle, which is a normal variant that runs in families. These milestones serve as a guide for parents and healthcare professionals to monitor a child’s physical development and identify any potential delays or concerns.
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This question is part of the following fields:
- Paediatrics
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Question 25
Correct
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Which infection is most strongly linked to the development of Guillain-Barre syndrome?
Your Answer: Campylobacter jejuni
Explanation:Understanding Guillain-Barre Syndrome and Miller Fisher Syndrome
Guillain-Barre syndrome is a condition that affects the peripheral nervous system and is often triggered by an infection, particularly Campylobacter jejuni. The immune-mediated demyelination of the peripheral nervous system occurs due to the cross-reaction of antibodies with gangliosides. Studies have shown a correlation between the clinical features of the syndrome and the presence of anti-ganglioside antibodies, particularly anti-GM1 antibodies, which are present in 25% of patients.
Miller Fisher syndrome is a variant of Guillain-Barre syndrome that is characterized by ophthalmoplegia, areflexia, and ataxia. Unlike other forms of Guillain-Barre syndrome, Miller Fisher syndrome usually presents as a descending paralysis, with the eye muscles typically affected first. In 90% of cases, anti-GQ1b antibodies are present.
Understanding the pathogenesis and clinical features of Guillain-Barre syndrome and Miller Fisher syndrome is crucial for accurate diagnosis and effective treatment. Further research is needed to fully understand the mechanisms behind these conditions and to develop more targeted therapies.
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This question is part of the following fields:
- Infectious Diseases
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Question 26
Correct
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Which of the following may be linked to a higher risk of venous thromboembolism?
Your Answer: Behcet's syndrome
Explanation:Venous Thromboembolism: Common Risk Factors
Venous thromboembolism (VTE) is a condition where blood clots form in the veins, which can lead to serious complications such as pulmonary embolism (PE). While there are many factors that can increase the risk of VTE, some are more common than others. These include malignancy, pregnancy, and the period following an operation. Other general risk factors include advancing age, obesity, family history of VTE, immobility, hospitalization, anaesthesia, and the use of central venous catheters. Underlying conditions such as heart failure, thrombophilia, and antiphospholipid syndrome can also increase the risk of VTE. Additionally, certain medications like the combined oral contraceptive pill, hormone replacement therapy, raloxifene, tamoxifen, and antipsychotics have been shown to be risk factors.
It is important to note that while these factors can increase the risk of VTE, around 40% of patients diagnosed with a PE have no major risk factors.
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This question is part of the following fields:
- Haematology/Oncology
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Question 27
Incorrect
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A 25-year-old male patient visits the GP clinic with a history of deteriorating vision in both eyes for the past 3 years. He complains of a gradual loss of peripheral vision, as if viewing through a tunnel. He is unable to play basketball due to difficulty seeing the ball. Additionally, he is experiencing increasing difficulty with his vision in low light conditions, causing him to avoid driving at night. Apart from this, he reports feeling healthy. There is no significant medical history to note. What is the probable diagnosis?
Your Answer: Juvenile retinoschisis
Correct Answer: Retinitis pigmentosa
Explanation:Retinitis pigmentosa is responsible for causing tunnel vision, as reported by the patient who is experiencing a gradual decline in their peripheral vision and difficulty seeing at night. These symptoms are typical of retinitis pigmentosa. However, central vision loss is associated with Best disease and juvenile retinoschisis, not retinitis pigmentosa. Glaucoma is improbable in this age range.
Understanding Tunnel Vision and Its Causes
Tunnel vision is a condition where the visual fields become smaller and more concentrated. This means that the person affected can only see what is directly in front of them, while the peripheral vision is diminished. There are several causes of tunnel vision, including papilloedema, glaucoma, retinitis pigmentosa, choroidoretinitis, optic atrophy secondary to tabes dorsalis, and hysteria.
Papilloedema is a condition where there is swelling of the optic nerve head, which can cause pressure on the surrounding tissues. Glaucoma is a condition where there is damage to the optic nerve, which can lead to vision loss. Retinitis pigmentosa is a genetic disorder that affects the retina, causing progressive vision loss. Choroidoretinitis is an inflammation of the choroid and retina, which can cause vision loss. Optic atrophy secondary to tabes dorsalis is a condition where there is damage to the optic nerve due to syphilis. Hysteria is a psychological condition that can cause physical symptoms, including tunnel vision.
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This question is part of the following fields:
- Ophthalmology
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Question 28
Correct
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A 45-year-old man presents to his General Practitioner with a past medical history of type 2 diabetes and a newly diagnosed non-alcoholic fatty liver disease. He has significantly changed his diet and has been reading a lot about liver disease. He realises that he is at increased risk of hepatocellular carcinoma (HCC) due to his liver disease and wanted to know what can be done to monitor him for HCC.
How is HCC screened for in high-risk patients?Your Answer: Abdominal ultrasound (US) is routinely ordered at 6-month intervals
Explanation:Screening for Hepatocellular Carcinoma: Recommended Tests and Intervals
Regular screening for hepatocellular carcinoma (HCC) is recommended in high-risk patients. Abdominal ultrasound (US) is the primary screening tool, with 6-month intervals for follow-up if a lesion of < 1 cm is detected. If there is no growth over 1-2 years, routine 6-monthly surveillance can continue. Alpha-fetoprotein (AFP) levels may be used in conjunction with US, but are not reliable on their own. A triphasic contrast computed tomography (CT) scan is recommended every two years for high-suspicion cases. This article provides an overview of the recommended tests and intervals for HCC screening.
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This question is part of the following fields:
- Haematology/Oncology
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Question 29
Correct
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A 67-year-old man visits his doctor with a complaint of a rash on his face. Upon examination, the doctor observes a vesicular rash around the left orbit and on the bridge of the nose. The patient reports experiencing pain. The eye appears unaffected and is not inflamed. The doctor suspects shingles.
What would be the best course of action?Your Answer: Urgent referral to ophthalmology and start oral aciclovir
Explanation:Immediate ophthalmological assessment and a 7-10 day course of oral antivirals are necessary for the treatment of herpes zoster ophthalmicus. Hutchinson’s sign, which involves the tip of the nose, is a strong indicator of ocular involvement and warrants urgent referral to an ophthalmologist. While oral corticosteroids may help alleviate pain, they are not as crucial as antivirals or ophthalmological evaluation.
Herpes Zoster Ophthalmicus: Symptoms, Treatment, and Complications
Herpes zoster ophthalmicus (HZO) is a condition that occurs when the varicella-zoster virus reactivates in the area supplied by the ophthalmic division of the trigeminal nerve. It is responsible for approximately 10% of shingles cases. The main symptom of HZO is a vesicular rash around the eye, which may or may not involve the eye itself. Hutchinson’s sign, a rash on the tip or side of the nose, is a strong indicator of nasociliary involvement and increases the risk of ocular involvement.
Treatment for HZO involves oral antiviral medication for 7-10 days, ideally started within 72 hours of symptom onset. Intravenous antivirals may be necessary for severe infections or immunocompromised patients. Topical antiviral treatment is not recommended for HZO, but topical corticosteroids may be used to treat any secondary inflammation of the eye. Ocular involvement requires urgent ophthalmology review to prevent complications such as conjunctivitis, keratitis, episcleritis, anterior uveitis, ptosis, and post-herpetic neuralgia.
In summary, HZO is a condition caused by the reactivation of the varicella-zoster virus in the ophthalmic division of the trigeminal nerve. It presents with a vesicular rash around the eye and may involve the eye itself. Treatment involves oral antiviral medication and urgent ophthalmology review is necessary for ocular involvement. Complications of HZO include various eye conditions, ptosis, and post-herpetic neuralgia.
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This question is part of the following fields:
- Ophthalmology
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Question 30
Correct
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A 28-year-old man presents to the colorectal surgeons with recurrent episodes of bright red rectal bleeding over the past 5 months. During examination, a muco-epithelial defect is observed in the posterior midline of the anus. However, a complete digital rectal exam (DRE) could not be performed due to severe pain. Despite trying bulk-forming laxatives, lubricants, and topical glyceryl trinitrate (GTN), the patient has experienced little relief. What is the recommended next step in managing this likely diagnosis?
Your Answer: Sphincterotomy
Explanation:For cases of anal fissures that do not respond to conservative management, sphincterotomy may be considered as the next step. This is likely the case for the patient in question, who has not seen improvement with laxatives, lubricants, and topical GTN. While a high-fibre diet is important in managing anal fissures, it should be initiated alongside other conservative measures. If the patient had a perianal abscess, incision and drainage would be the appropriate treatment. For haemorrhoids, rubber band ligation would be the management, while anal fistulae would require seton insertion.
Understanding Anal Fissures: Causes, Symptoms, and Treatment
Anal fissures are tears in the lining of the distal anal canal that can be either acute or chronic. Acute fissures last for less than six weeks, while chronic fissures persist for more than six weeks. The most common risk factors for anal fissures include constipation, inflammatory bowel disease, and sexually transmitted infections such as HIV, syphilis, and herpes.
Symptoms of anal fissures include painful, bright red rectal bleeding, with around 90% of fissures occurring on the posterior midline. If fissures are found in other locations, underlying causes such as Crohn’s disease should be considered.
Management of acute anal fissures involves softening stool, dietary advice, bulk-forming laxatives, lubricants, topical anaesthetics, and analgesia. For chronic anal fissures, the same techniques should be continued, and topical glyceryl trinitrate (GTN) is the first-line treatment. If GTN is not effective after eight weeks, surgery (sphincterotomy) or botulinum toxin may be considered, and referral to secondary care is recommended.
In summary, anal fissures can be a painful and uncomfortable condition, but with proper management, they can be effectively treated. It is important to identify and address underlying risk factors to prevent the development of chronic fissures.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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