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Question 1
Correct
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A 29-year-old man with valvular heart disease is urgently admitted with fever, worsening shortness of breath and a letter from his GP confirming the presence of a new murmur. During examination, a harsh pansystolic murmur and early diastolic murmur are detected, along with a temperature of 38.3 °C and bilateral fine basal crepitations. Initial blood cultures have been collected.
What is the most pressing concern that needs to be addressed immediately?Your Answer: Administration of intravenous antibiotics
Explanation:Prioritizing Interventions in Suspected Infective Endocarditis
When dealing with suspected infective endocarditis, time is of the essence. The following interventions should be prioritized in order to limit valve destruction and improve patient outcomes.
Administration of Intravenous Antibiotics
Prompt initiation of intravenous antibiotics is crucial. An empirical regime of gentamicin and benzylpenicillin may be used until microbiological advice suggests any alternative.Electrocardiogram (ECG)
An ECG provides important diagnostic information and should be performed as part of the initial work-up. However, it does not take priority over antibiotic administration.Echocardiogram (ECHO)
An ECHO should be performed in all patients with suspected infective endocarditis, but it does not take priority over administration of antibiotics. A transoesophageal ECHO is more sensitive and should be considered if necessary.Throat Swab
While a throat swab may be useful in identifying the causative organism of infective endocarditis, it should not take precedence over commencing antibiotics. Careful examination of a patient’s dentition is also crucial to evaluate for a possible infectious source.Administration of Paracetamol
Symptomatic relief is important, but administration of paracetamol should not take priority over antibiotic delivery. Both interventions should be given as soon as possible to improve patient outcomes. -
This question is part of the following fields:
- Cardiology
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Question 2
Incorrect
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A 72-year-old woman experiences severe lumbar back pain that radiates around to the waist after a coughing fit. She is not taking any medications and her clinical observations are normal. What is the most probable diagnosis?
Your Answer: Mechanical back pain
Correct Answer: Osteoporotic wedge fracture
Explanation:Differential Diagnosis for Back Pain in a 72-Year-Old Woman
Back pain is a common complaint in primary care, and its differential diagnosis can be challenging. In this case, a 72-year-old woman presents with back pain after a coughing fit. The following conditions are considered and ruled out based on the available information:
– Osteoporotic wedge fracture: postmenopausal women are at increased risk of osteoporosis, which can lead to vertebral fractures from minor trauma. This possibility should be considered in any older patient with back pain, especially if there is a history of osteoporosis or low-trauma injury.
– Herniated lumbar disc prolapse: This condition typically causes sciatica, which is pain that radiates down the leg to the ankle. The absence of this symptom makes it less likely.
– Mechanical back pain: This is a common cause of back pain, especially in older adults. It is usually aggravated by heavy lifting and prolonged standing or sitting, but not necessarily by coughing.
– Osteoarthritis: This condition can cause back pain, especially in the lower back, but it is not typically associated with coughing. It tends to worsen with activity and improve with rest.
– Osteomyelitis: This is a serious infection of the bone that can cause severe pain and fever. It is less likely in this case because the patient’s clinical observations are normal.In summary, the differential diagnosis for back pain in a 72-year-old woman includes several possibilities, such as osteoporotic fracture, herniated disc, mechanical pain, osteoarthritis, and osteomyelitis. A thorough history and physical examination, along with appropriate imaging and laboratory tests, can help narrow down the possibilities and guide the management plan.
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This question is part of the following fields:
- Orthopaedics
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Question 3
Incorrect
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A 63-year-old man presents to his GP with a complaint of increasing blood in his urine over the past two weeks. He denies any pain or difficulty while urinating but reports feeling fatigued and possibly losing some weight over the last few months. He has a history of smoking with a 48 pack-year history. On examination, he has a heart rate of 70 bpm, blood pressure of 155/78 mmHg, oxygen saturation of 97% on air, and a temperature of 37.0ºC. There is tenderness in the left renal angle, and a palpable mass is felt on the left side. His abdomen is soft without anterior tenderness. Digital rectal exam reveals a non-enlarged and non-tender prostate. The urine dip results show leucocytes ++, blood +++, protein +, nitrites negative, glucose trace, and ketones negative. What is the most likely diagnosis?
Your Answer: Transitional cell carcinoma of the bladder
Correct Answer: Renal cell carcinoma
Explanation:Frank haematuria can be caused by various conditions, including cancer, stones, and infection. However, in this case, the absence of lower urinary tract symptoms and pain makes infection or stones less likely. The patient’s constitutional symptoms and absence of sepsis signs suggest an underlying malignancy. Additionally, the absence of nitrites on the dip test rules out a urinary tract infection. The presence of a ballotable mass and renal angle tenderness is more indicative of renal cell carcinoma than bladder tumour.
Understanding Renal Cell Cancer
Renal cell cancer, also known as hypernephroma, is a primary renal neoplasm that accounts for 85% of cases. It typically arises from the proximal renal tubular epithelium, with the clear cell subtype being the most common. This type of cancer is more prevalent in middle-aged men and is associated with smoking, von Hippel-Lindau syndrome, and tuberous sclerosis. While renal cell cancer is only slightly increased in patients with autosomal dominant polycystic kidney disease, it can present with a classical triad of haematuria, loin pain, and abdominal mass. Other features include pyrexia of unknown origin, endocrine effects, and paraneoplastic hepatic dysfunction syndrome.
The T category criteria for renal cell cancer are based on the size and extent of the tumour. For confined disease, a partial or total nephrectomy may be recommended depending on the tumour size. Patients with a T1 tumour are typically offered a partial nephrectomy, while those with larger tumours may require a total nephrectomy. Treatment options for renal cell cancer include alpha-interferon, interleukin-2, and receptor tyrosine kinase inhibitors such as sorafenib and sunitinib. These medications have been shown to reduce tumour size and treat patients with metastases. It is important to note that renal cell cancer can have paraneoplastic effects, such as Stauffer syndrome, which is associated with cholestasis and hepatosplenomegaly. Overall, early detection and prompt treatment are crucial for improving outcomes in patients with renal cell cancer.
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This question is part of the following fields:
- Surgery
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Question 4
Incorrect
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Which feature is not associated with Down's syndrome?
Your Answer: A third fontanelle
Correct Answer: Ataxic gait
Explanation:Down’s Syndrome and Cognitive Decline
Cerebellar dysfunction is not a characteristic of Down’s syndrome. However, individuals with this condition may experience a decline in memory and cognitive abilities similar to Alzheimer’s disease as they approach their mid-thirties. This syndrome is characterized by a gradual loss of cognitive function, including memory, attention, and problem-solving skills. It is important to note that this decline is not universal and may vary in severity among individuals with Down’s syndrome. Despite this, it is crucial to monitor cognitive function in individuals with Down’s syndrome to ensure early detection and intervention if necessary.
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This question is part of the following fields:
- Paediatrics
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Question 5
Incorrect
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In what type of tissue do bones that develop in tendons form?
Your Answer: Cartilage
Correct Answer: Sesamoid bone
Explanation:Classification of Bones by Shape
Bones can be classified based on their shape. The first type is flat bones, which include the bones of the skull, sternum, pelvis, and ribs. The second type is tubular bones, which can be further divided into long tubular bones, such as those found in the limbs, and short tubular bones, such as the phalanges, metacarpals, and metatarsals in the hands and feet. The third type is irregular bones, which include the bones of the face and vertebral column. The fourth type is sesamoid bones, which develop in specific tendons, with the largest example being the patella. Finally, there are accessory or supernumerary bones, which are extra bones that develop in additional ossification centers or bones that failed to fuse with the main parts during development. Accessory bones are common in the foot and may be mistaken for bone chips or fractures.
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This question is part of the following fields:
- Surgery
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Question 6
Correct
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A 32-year-old male with type 1 diabetes presents with pain, swelling, and redness in his left middle finger for the past two days. He experienced this after pricking his finger while gardening and pruning a bush. Despite his diabetic control being reasonable with a HbA1c of 54 mmol/mol (20-46) on basal bolus insulin consisting of Lispro tds and Humulin I in the evenings, he is now diagnosed with cellulitis. On examination, his middle finger is painful, red, and swollen, with the redness extending to the metacarpophalangeal joint. However, his hand movements are intact, and he is clinically stable with normal observations.
What is the most appropriate initial treatment for this patient?Your Answer: Oral flucloxacillin
Explanation:The patient has digital cellulitis likely caused by Strep. pyogenes or Staph. aureus. Flucloxacillin is the initial treatment, but if there is tendon involvement, IV antibiotics should be initiated. Clindamycin can be used in combination with flucloxacillin for rapid control or in severe cases. Oral antibiotics can be tried if hand movements are intact. The patient should be closely monitored and readmitted for IV antibiotics if there is no improvement within 48 hours.
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This question is part of the following fields:
- Endocrinology
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Question 7
Incorrect
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A 48-year-old man is recovering on the ward after a cholecystectomy. Upon examination, there are no concerns, and it is decided to prescribe pain relief. However, he has been experiencing nausea and has been unable to keep down food or fluids for the past hour. His drug chart shows that he has taken eight 500 mg tablets of paracetamol today, and he weighs 75 kg. There are no recorded allergies. What is the most suitable form of analgesia to offer?
Your Answer: 30mg oral codeine maximum 4-hourly as required
Correct Answer: IV morphine controlled by patient-controlled analgesia (PCA)
Explanation:Patient-controlled analgesia (PCA) using IV morphine is a suitable choice for managing post-operative pain. Since the patient has already received the maximum dose of paracetamol and is still experiencing pain, stronger analgesia is necessary. Additionally, the patient has been vomiting, making oral analgesia unsuitable. PCA allows the patient to regulate their pain relief based on their level of discomfort, and as their pain subsides, they may reduce their PCA usage.
Administering 1g of IV paracetamol over 15 minutes is not recommended since the patient has already reached their daily maximum dose of paracetamol. Similarly, prescribing 30mg of oral codeine every 4 hours as needed is not ideal due to the patient’s recent vomiting. While 400mg of oral ibuprofen three times a day with 20 mg of omeprazole once daily is a viable option, IV analgesia is preferred in this case due to the patient’s vomiting.
Pain management can be achieved through various methods, including the use of analgesic drugs and local anesthetics. The World Health Organisation (WHO) recommends a stepwise approach to pain management, starting with peripherally acting drugs such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs). If pain control is not achieved, weak opioid drugs such as codeine or dextropropoxyphene can be introduced, followed by strong opioids such as morphine as a final option. Local anesthetics can also be used to provide pain relief, either through infiltration of a wound or blockade of plexuses or peripheral nerves.
For acute pain management, the World Federation of Societies of Anaesthesiologists (WFSA) recommends a similar approach, starting with strong analgesics in combination with local anesthetic blocks and peripherally acting drugs. The use of strong opioids may no longer be required once the oral route can be used to deliver analgesia, and peripherally acting agents and weak opioids can be used instead. The final step is when pain can be controlled by peripherally acting agents alone.
Local anesthetics can be administered through infiltration of a wound with a long-acting agent such as Bupivacaine, providing several hours of pain relief. Blockade of plexuses or peripheral nerves can also provide selective analgesia, either for surgery or postoperative pain relief. Spinal and epidural anesthesia are other options, with spinal anesthesia providing excellent analgesia for lower body surgery and epidural anesthesia providing continuous infusion of analgesic agents. Transversus Abdominal Plane block (TAP) is a technique that uses ultrasound to identify the correct muscle plane and injects local anesthetic to block spinal nerves, providing a wide field of blockade without the need for indwelling devices.
Patient Controlled Analgesia (PCA) allows patients to administer their own intravenous analgesia and titrate the dose to their own end-point of pain relief using a microprocessor-controlled pump. Opioids such as morphine and pethidine are commonly used, but caution is advised due to potential side effects and toxicity. Non-opioid analgesics such as paracetamol and NSAIDs can also be used, with NSAIDs being more useful for superficial pain and having relative contraindications for certain medical conditions.
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This question is part of the following fields:
- Pharmacology
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Question 8
Incorrect
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A 22-year-old female with paranoid schizophrenia is currently admitted as an inpatient and receiving treatment with antipsychotic medication under section 3 of the Mental Health Act. She has recently reported experiencing breast tenderness and enlargement. As the current antipsychotic regimen is not being well-tolerated, what would be the most suitable alternative antipsychotic medication to minimize these side effects?
Your Answer: Risperidone
Correct Answer: Aripiprazole
Explanation:Compared to other atypical antipsychotics, aripiprazole is known for having a more tolerable side effect profile, particularly when it comes to causing hyperprolactinemia. This condition, which can result in breast tenderness, enlargement, and lactation, is a common side effect of most typical and some atypical antipsychotics such as risperidone and amisulpride.
Atypical antipsychotics are now recommended as the first-line treatment for patients with schizophrenia, as per the 2005 NICE guidelines. These medications have the advantage of significantly reducing extrapyramidal side-effects. However, they can also cause adverse effects such as weight gain, hyperprolactinaemia, and in the case of clozapine, agranulocytosis. The Medicines and Healthcare products Regulatory Agency has issued warnings about the increased risk of stroke and venous thromboembolism when antipsychotics are used in elderly patients. Examples of atypical antipsychotics include clozapine, olanzapine, risperidone, quetiapine, amisulpride, and aripiprazole.
Clozapine, one of the first atypical antipsychotics, carries a significant risk of agranulocytosis and requires full blood count monitoring during treatment. Therefore, it should only be used in patients who are resistant to other antipsychotic medication. The BNF recommends introducing clozapine if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs, one of which should be a second-generation antipsychotic drug, each for at least 6-8 weeks. Adverse effects of clozapine include agranulocytosis, neutropaenia, reduced seizure threshold, constipation, myocarditis, and hypersalivation. Dose adjustment of clozapine may be necessary if smoking is started or stopped during treatment.
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This question is part of the following fields:
- Psychiatry
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Question 9
Incorrect
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A 30-year-old nulliparous woman arrives at the emergency department with a positive home pregnancy test and symptoms of diarrhoea and mild abdominal discomfort that have been present for 6 hours. She has not been using any regular contraception and her last menstrual period was 8 weeks ago. The patient has a history of pelvic inflammatory disease. A transvaginal ultrasound shows a 40mm foetal sac at the ampulla of the fallopian tube without a visible heartbeat, and her serum B-HCG level is 1200 IU/L. What is the definitive indication for surgical management in this case?
Your Answer:
Correct Answer: Foetal sac size
Explanation:Surgical management is recommended for all ectopic pregnancies with a foetal sac larger than 35mm or a serum B-hCG level exceeding 5,000 IU/L, as per NICE guidelines. Foetal sacs larger than 35mm are at a higher risk of spontaneous rupture, making expectant or medical management unsuitable. The size of the foetal sac is measured using transvaginal ultrasound. Detection of a foetal heartbeat on transvaginal ultrasound requires urgent surgical management. A history of pelvic inflammatory disease is not an indication for surgical management, although it is a risk factor for ectopic pregnancy. Serum HCG levels between 1,500IU/L and 5,000 IU/L may be managed medically if the patient can return for follow-up and has no significant abdominal pain or haemodynamic instability. A septate uterus is not an indication for surgical management of ectopic pregnancy, but it may increase the risk of miscarriage.
Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.
There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingostomy, depending on the patient’s risk factors for infertility.
Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.
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This question is part of the following fields:
- Gynaecology
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Question 10
Incorrect
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A 5-year-old girl presents to the emergency department with a fever and a blotchy rash. According to her mother, the rash started behind her ears and has now spread all over her body. During the examination, you observe clusters of white lesions on the buccal mucosa. The child has not received any vaccinations. What is the potential complication that this child may face?
Your Answer:
Correct Answer: Pneumonia
Explanation:Pneumonia is a common complication of measles and can be fatal, especially in children. The measles virus can damage the lower respiratory tract epithelium, which weakens the local immunity in the lungs and leads to pneumonia. Other complications of measles include otitis media, encephalitis, subacute sclerosing panencephalitis, keratoconjunctivitis, corneal ulceration, diarrhea, increased risk of appendicitis, and myocarditis. Treatment for measles involves rest, fluids, and pain relief. It is important to inform the local Health Protection Team (HPT) and avoid school or work for at least four days after the rash appears. Mumps can cause complications such as orchitis, oophoritis, pancreatitis, and viral meningitis. Symptoms of mumps include fever, headache, swelling of the parotid glands, and general malaise. Kawasaki disease, on the other hand, can lead to coronary artery aneurysm and presents with symptoms such as high fever, rash, conjunctival injection, red and cracked hands, feet, and lips, and swollen lymph glands. It is important to note that otitis media, not otitis externa, is a complication of measles.
Measles: A Highly Infectious Viral Disease
Measles is a viral disease caused by an RNA paramyxovirus. It is one of the most infectious known viruses and is spread through aerosol transmission. The disease has an incubation period of 10-14 days and is infective from the prodromal phase until four days after the rash starts. Measles is now rare in developed countries due to immunization programs, but outbreaks can occur when vaccination rates drop, such as during the MMR controversy of the early 2000s.
The disease is characterized by a prodromal phase, which includes irritability, conjunctivitis, fever, and Koplik spots. The latter typically develop before the rash and are white spots on the buccal mucosa. The rash starts behind the ears and then spreads to the whole body, becoming a discrete maculopapular rash that may become blotchy and confluent. Desquamation may occur after a week, typically sparing the palms and soles. Diarrhea occurs in around 10% of patients.
Measles is mainly managed through supportive care, and admission may be considered in immunosuppressed or pregnant patients. The disease is notifiable, and public health should be informed. Complications of measles include otitis media, pneumonia (the most common cause of death), encephalitis (typically occurring 1-2 weeks following the onset of the illness), subacute sclerosing panencephalitis (very rare, may present 5-10 years following the illness), febrile convulsions, keratoconjunctivitis, corneal ulceration, diarrhea, increased incidence of appendicitis, and myocarditis.
If an unimmunized child comes into contact with measles, MMR should be offered within 72 hours. Vaccine-induced measles antibody develops more rapidly than that following natural infection.
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This question is part of the following fields:
- Paediatrics
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Question 11
Incorrect
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A 65-year-old male is admitted to the respiratory ward for severe community-acquired pneumonia and is being treated with amoxicillin. He has a medical history of a heart attack 2 years ago, hypertension, and type 2 diabetes. His current medications include aspirin 75 mg, atorvastatin 40 mg, ramipril 5mg, bendroflumethiazide 5mg, and metformin 500 mg BD. On the third day of treatment, the medical team noticed that the patient's creatinine levels increased from a baseline of 67 micromol/litre to 190 micromol/litre. His eGFR is found to be 25 ml/min, and he is diagnosed with acute kidney injury. Which of the patient's current medications can he continue taking in his current condition?
Your Answer:
Correct Answer: Aspirin
Explanation:In cases of acute kidney injury (AKI), it is important to identify drugs that may worsen renal function and those that can result in toxicity. AKI is defined as a 50% or greater rise in serum creatinine within the past 7 days or a fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours.
For patients on aspirin for secondary prevention of acute coronary syndrome, the cardioprotective dose of 75 mg per day should be continued as there is strong evidence supporting its use. Aspirin is a COX-inhibitor that inhibits thromboxane synthesis via the COX-1 pathway, exhibiting antithrombotic effects.
Drugs that should be stopped in AKI as they may worsen renal function include diuretics, aminoglycosides, ACE inhibitors/ARBs, and NSAIDs that are not at cardioprotective doses. On the other hand, drugs that do not worsen renal function but can result in toxicity include metformin, lithium, and digoxin. A helpful mnemonic to remember the drugs to stop in AKI is DAMN AKI: Diuretics, Aminoglycosides and ACE inhibitors, Metformin, and NSAIDs.
Understanding Acute Kidney Injury: A Basic Overview
Acute kidney injury (AKI) is a condition where the kidneys experience a reduction in function due to an insult. In the past, the kidneys were often neglected in acute medicine, resulting in slow recognition and limited action. However, around 15% of patients admitted to the hospital develop AKI. While most patients recover their renal function, some may have long-term impaired kidney function due to AKI, which can result in acute complications, including death. Identifying patients at increased risk of AKI is crucial in reducing its incidence. Risk factors for AKI include chronic kidney disease, other organ failure/chronic disease, a history of AKI, and the use of drugs with nephrotoxic potential.
AKI has three main causes: prerenal, intrinsic, and postrenal. Prerenal causes are due to a lack of blood flow to the kidneys, while intrinsic causes relate to intrinsic damage to the kidneys themselves. Postrenal causes occur when there is an obstruction to the urine coming from the kidneys. Symptoms of AKI include reduced urine output, fluid overload, arrhythmias, and features of uraemia. Diagnosis of AKI is made through blood tests, urinalysis, and imaging.
The management of AKI is largely supportive, with careful fluid balance and medication review being crucial. Loop diuretics and low-dose dopamine are not recommended, but hyperkalaemia needs prompt treatment to avoid life-threatening arrhythmias. Renal replacement therapy may be necessary in severe cases. Prompt review by a urologist is required for patients with suspected AKI secondary to urinary obstruction, while specialist input from a nephrologist is necessary for cases where the cause is unknown or the AKI is severe.
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This question is part of the following fields:
- Medicine
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Question 12
Incorrect
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A 42-year-old man is referred to an otolaryngologist with vertigo and hearing loss. A magnetic resonance imaging (MRI) scan of the cranial region reveals a tumour at the cerebellopontine angle. A working diagnosis of acoustic neuroma is made. In light of the progressive symptoms, the surgeon plans to remove the tumour.
With regard to the vestibulocochlear nerve, which of the following is correct?Your Answer:
Correct Answer: Vestibular fibres pass to the vestibular nuclear complex, located in the floor of the fourth ventricle
Explanation:Anatomy of the Vestibulocochlear Nerve
The vestibulocochlear nerve, also known as the eighth cranial nerve, is responsible for carrying special sensory afferent fibers from the inner ear. It is composed of two portions: the vestibular nerve and the cochlear nerve. The vestibular fibers pass to the vestibular nuclear complex, located in the floor of the fourth ventricle, while the cochlear fibers pass to the cochlear nuclear complex, located across the junction between the pons and medulla.
Acoustic neuromas, which are tumors that commonly arise from the vestibular portion of the nerve, are also known as vestibular schwannomas. The efferent nerve supply to the tensor tympani, a muscle in the middle ear, is provided by the mandibular branch of the fifth cranial nerve.
The vestibulocochlear nerve enters the brainstem at the pontomedullary junction, lateral to the facial nerve. It then passes into the temporal bone via the internal auditory meatus, along with the facial nerve. It does not exit the cranium through the jugular foramen, which is where the ninth, tenth, and eleventh cranial nerves exit. Understanding the anatomy of the vestibulocochlear nerve is important in diagnosing and treating disorders related to hearing and balance.
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This question is part of the following fields:
- ENT
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Question 13
Incorrect
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A 28-year-old patient presents to the Emergency Department with fresh red vaginal bleeding and lower abdominal pain.
The patient is at 36 weeks gestation and gravida 3, para 2. She is rhesus positive and a current smoker. Access to her current maternity notes is unavailable. She tells you she has pre-eclampsia for which she takes labetalol.
Maternal observations are normal and there are no concerns with foetal movements. A cardiotocograph (CTG) demonstrates that the foetal heart rate is 140 beats/min, variability is 15 beats/min, accelerations are present and there are no decelerations noted.
On examination, the uterus is hard and tender to palpation. The doctor suspects that the foetus may be in a transverse lie. The patient's pad is partially soaked but there is no active bleeding noted on a quick inspection.
What would the most appropriate first course of action be in this scenario?Your Answer:
Correct Answer: Administer corticosteroids and arrange admission to the ward
Explanation:When a pregnant patient presents with painful bleeding and a hard, tender uterus, it may indicate placental abruption. In this case, the patient has risk factors such as being a smoker, having pre-eclampsia, and a transverse lie. The management of placental abruption depends on the gestation, maternal condition, and fetal condition. In this scenario, the patient is stable, at 34 weeks gestation, and the fetus is not showing signs of distress. Therefore, the appropriate plan is to admit the patient and administer steroids for observation.
Administering anti-D and performing a Kleihauer test is unnecessary as the patient is already known to be rhesus positive. Induction of labor is not indicated as the fetus has not matured to term. Emergency caesarean section would only be necessary if fetal distress was present. Performing a sterile speculum examination is not appropriate as it could cause or worsen hemorrhage, especially if the patient has placenta previa. The best course of action is to admit the patient to the ward until access to notes becomes available or an ultrasound is performed.
Placental Abruption: Causes, Management, and Complications
Placental abruption is a condition where the placenta separates from the uterine wall, leading to maternal haemorrhage. The severity of the condition depends on the extent of the separation and the gestational age of the fetus. Management of placental abruption is crucial to prevent maternal and fetal complications.
If the fetus is alive and less than 36 weeks, immediate caesarean delivery is recommended if there is fetal distress. If there is no fetal distress, close observation, administration of steroids, and no tocolysis are recommended. The decision to deliver depends on the gestational age of the fetus. If the fetus is alive and more than 36 weeks, immediate caesarean delivery is recommended if there is fetal distress. If there is no fetal distress, vaginal delivery is recommended. If the fetus is dead, vaginal delivery should be induced.
Placental abruption can lead to various maternal complications, including shock, disseminated intravascular coagulation (DIC), renal failure, and postpartum haemorrhage (PPH). Fetal complications include intrauterine growth restriction (IUGR), hypoxia, and death. The condition is associated with a high perinatal mortality rate and is responsible for 15% of perinatal deaths.
In conclusion, placental abruption is a serious condition that requires prompt management to prevent maternal and fetal complications. Close monitoring and timely intervention can improve the prognosis for both the mother and the baby.
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This question is part of the following fields:
- Obstetrics
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Question 14
Incorrect
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A 55-year-old diabetic man experiences a gradual burning and tingling sensation in his right hand. He observes that his symptoms are more severe at night, frequently waking him up, and can only be alleviated by hanging his arm outside of the bed. Which nerve compression is likely responsible for this man's symptoms?
Your Answer:
Correct Answer: Median nerve
Explanation:Understanding Nerve Compression: Symptoms and Special Tests
Nerve compression can cause a range of symptoms, from pain and weakness to numbness and tingling. Here are some key things to know about nerve compression and how it affects different nerves in the body.
The Median Nerve: Carpal Tunnel Syndrome
The median nerve runs through the carpal tunnel, and compression of this nerve can cause pain, paraesthesiae, and weakness in the distribution of the median nerve. Carpal tunnel syndrome is a common condition that can be caused by pregnancy, diabetes, and other factors. Special tests to detect carpal tunnel syndrome include TINel’s sign, Phalen’s test, and motor assessment.
The Radial Nerve: Hand and Arm Pain
Compression of the radial nerve can lead to pain in the back of your hand, near your thumb, and you may not be able to straighten your arm.
The Lateral Cutaneous Nerve: Reduced Sensation
Compression of the lateral cutaneous nerve can lead to reduced sensation on the lateral aspect of the forearm.
The Ulnar Nerve: Numbness and Tingling
Compression of the ulnar nerve can lead to numbness and tingling in the fifth finger and half of the fourth finger.
The Medial Cutaneous Nerve: Elbow and Forearm Pain
Compression of the medial cutaneous nerve can lead to pain at the elbow and forearm.
By understanding the symptoms and special tests associated with nerve compression, you can better identify and manage these conditions.
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This question is part of the following fields:
- Orthopaedics
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Question 15
Incorrect
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A 65-year-old man comes to the vascular clinic with a complaint of leg pain during exercise. He reports that the pain occurs in both calves, with the left side being slightly worse than the right. The pain starts after walking a few meters and subsides when he sits down. The patient has a medical history of type II diabetes mellitus, hypercholesterolemia, hypertension, and glaucoma. He has a 40 pack-year smoking history but quit smoking ten years ago when he was diagnosed with diabetes.
You conduct an Ankle: Brachial Pressure Index (ABPI) test on the man and find that his left leg ABPI is 0.8, while his right leg ABPI is 0.9. What would be your initial approach to managing this patient?Your Answer:
Correct Answer: Optimise control of diabetes, ensure he is compliant with his statin, supervised exercise programme for 3 month and prescribe 75 mg of clopidogrel daily
Explanation:Management of Intermittent Claudication in a Patient with Multiple Risk Factors
Intermittent claudication is a common symptom of arterial disease and can be caused by multiple risk factors, including smoking, diabetes, and hypercholesterolaemia. In managing a patient with intermittent claudication, it is important to first assess their ankle-brachial pressure index (ABPI) measurement to determine the severity of their arterial disease.
For patients with ABPI measurements between 0.6-0.9, first-line treatment involves managing risk factors and encouraging supervised exercise for three months. This patient should be optimally controlled for diabetes and compliant with their statin medication. Additionally, they should be prescribed 75 mg of clopidogrel daily to reduce the risk of blood clots.
A duplex USS arteriogram of both legs should be conducted to assess the extent of arterial disease. If necessary, a contrast-enhanced MRI may be used to plan revascularisation. However, surgery is typically only considered as a third-line treatment option.
It is important to note that analgesia is not the first-line treatment for intermittent claudication. Instead, addressing risk factors and enrolling in a supervised exercise programme for three months should be prioritised. Patients should be encouraged to exercise for two hours a week, to the maximum point of pain.
In summary, managing intermittent claudication in a patient with multiple risk factors involves a comprehensive approach that addresses risk factors, encourages exercise, and may involve further diagnostic testing and medication.
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This question is part of the following fields:
- Vascular
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Question 16
Incorrect
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A 85-year-old woman with a history of dementia is discovered on the floor of her nursing home. She is taken to the Emergency Department and reports experiencing pain in her left hip and is unable to put weight on it. X-rays of the hip and pelvis show no abnormalities. Despite receiving sufficient pain relief, she continues to complain of severe hip pain and remains unable to bear weight. What is the most suitable course of action to take next?
Your Answer:
Correct Answer: MRI Hip
Explanation:When a patient presents with clinical symptoms of a hip fracture, it is necessary to conduct further imaging. Repeating plain films is unlikely to yield any new information. While radioisotope bone scans can detect areas of high bone turnover and osteoblastic activity, they are not very sensitive. Although CT scans are widely available, the recommended first line investigation for occult hip fractures is an MRI, as per NICE guidelines.
Hip fractures are a common occurrence, particularly in elderly women with osteoporosis. The femoral head’s blood supply runs up the neck, making avascular necrosis a potential risk in displaced fractures. Symptoms of a hip fracture include pain and a shortened and externally rotated leg. Patients with non-displaced or incomplete neck of femur fractures may still be able to bear weight. Hip fractures can be classified as intracapsular or extracapsular, with the Garden system being a commonly used classification system. Blood supply disruption is most common in Types III and IV fractures.
Intracapsular hip fractures can be treated with internal fixation or hemiarthroplasty if the patient is unfit. Displaced fractures are recommended for replacement arthroplasty, such as total hip replacement or hemiarthroplasty, according to NICE guidelines. Total hip replacement is preferred over hemiarthroplasty if the patient was able to walk independently outdoors with the use of a stick, is not cognitively impaired, and is medically fit for anesthesia and the procedure. Extracapsular hip fractures can be managed with a dynamic hip screw for stable intertrochanteric fractures or an intramedullary device for reverse oblique, transverse, or subtrochanteric fractures.
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This question is part of the following fields:
- Musculoskeletal
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Question 17
Incorrect
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A 38-year-old construction worker complains of sudden onset groin pain on the left side that radiates from the flank. The pain is intermittent but excruciating when it occurs and is not related to movement. The patient's examination, observations, and blood tests are normal, but a urine dip reveals ++ blood. The patient reports that his job involves heavy lifting and he rarely takes breaks. What is the probable diagnosis?
Your Answer:
Correct Answer: Ureteric calculus
Explanation:The young man is experiencing pain on his right side, from his lower back to his groin, and has microscopic blood in his urine. It is suggested that he may be frequently dehydrated due to his job. Based on these symptoms, it is highly likely that he has a kidney stone on his right side, which is causing the colicky pain. Although his job involves heavy lifting, there is no indication of a visible lump during examination, making a hernia unlikely.
The management of renal stones involves initial medication and investigations, including an NSAID for analgesia and a non-contrast CT KUB for imaging. Stones less than 5mm may pass spontaneously, but more intensive treatment is needed for ureteric obstruction or renal abnormalities. Treatment options include shockwave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy. Prevention strategies include high fluid intake, low animal protein and salt diet, and medication such as thiazides diuretics for hypercalciuria and allopurinol for uric acid stones.
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This question is part of the following fields:
- Surgery
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Question 18
Incorrect
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A 72-year-old man with atrial fibrillation and heart failure is initiated on digoxin. What is the mode of action of digoxin?
Your Answer:
Correct Answer: Inhibits the Na+/K+ ATPase pump
Explanation:Understanding Digoxin and Its Toxicity
Digoxin is a medication used for rate control in atrial fibrillation and for improving symptoms in heart failure patients. It works by decreasing conduction through the atrioventricular node and increasing the force of cardiac muscle contraction. However, it has a narrow therapeutic index and requires monitoring for toxicity.
Toxicity may occur even when the digoxin concentration is within the therapeutic range. Symptoms of toxicity include lethargy, nausea, vomiting, anorexia, confusion, yellow-green vision, arrhythmias, and gynaecomastia. Hypokalaemia is a classic precipitating factor, as it allows digoxin to more easily bind to the ATPase pump and increase its inhibitory effects. Other factors that may contribute to toxicity include increasing age, renal failure, myocardial ischaemia, electrolyte imbalances, hypoalbuminaemia, hypothermia, hypothyroidism, and certain medications such as amiodarone, quinidine, and verapamil.
Management of digoxin toxicity involves the use of Digibind, correction of arrhythmias, and monitoring of potassium levels. It is important to recognize the potential for toxicity and monitor patients accordingly to prevent adverse outcomes.
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This question is part of the following fields:
- Pharmacology
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Question 19
Incorrect
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A Cardiotocogram (CTG) is conducted on a 32-year-old woman at 39 weeks gestation who has arrived at the labor ward in spontaneous labor. The CTG reveals a fetal heart rate of 150 bpm with good variability, and it is a low-risk pregnancy. The midwife contacts you with worries about the presence of late decelerations on the CTG trace. What is the most suitable course of action for management?
Your Answer:
Correct Answer: Fetal blood sampling
Explanation:When late decelerations are observed on a CTG, it is considered a pathological finding and requires immediate fetal blood sampling to check for fetal hypoxia and acidosis. A pH level of over 7.2 during labor is considered normal, but if fetal acidosis is detected, urgent delivery should be considered. Despite the reassuring normal fetal heart rate and variability, the presence of late decelerations is a worrisome sign that requires prompt investigation and management.
Cardiotocography (CTG) is a medical procedure that measures pressure changes in the uterus using either internal or external pressure transducers. It is used to monitor the fetal heart rate, which normally ranges between 100-160 beats per minute. There are several features that can be observed during a CTG, including baseline bradycardia (heart rate below 100 beats per minute), which can be caused by increased fetal vagal tone or maternal beta-blocker use. Baseline tachycardia (heart rate above 160 beats per minute) can be caused by maternal pyrexia, chorioamnionitis, hypoxia, or prematurity. Loss of baseline variability (less than 5 beats per minute) can be caused by prematurity or hypoxia. Early deceleration, which is a decrease in heart rate that starts with the onset of a contraction and returns to normal after the contraction, is usually harmless and indicates head compression. Late deceleration, on the other hand, is a decrease in heart rate that lags behind the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction. This can indicate fetal distress, such as asphyxia or placental insufficiency. Variable decelerations, which are independent of contractions, may indicate cord compression.
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This question is part of the following fields:
- Obstetrics
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Question 20
Incorrect
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You are summoned to the death of an 80-year-old male on the geriatric care unit. He has a lengthy record of breathlessness linked with heart failure and the nursing staff reports that he abruptly collapsed and passed away. No resuscitation was attempted. What is the most suitable single cause of death that you can record on the death certificate?
Your Answer:
Correct Answer: Ischaemic heart disease
Explanation:Guidelines for Filling out Death Certificates
When filling out a death certificate, it is important to note that modes of death such as cardiac arrest, syncope, and respiratory arrest are not acceptable as underlying causes of death. Instead, the cause of death should be a pathological condition such as heart disease or a heart attack. Only in limited circumstances should old age, senility, or frailty of old age be given as the sole cause of death. These circumstances include personally caring for the deceased over a long period, observing a gradual decline in the patient’s health, not being aware of any identifiable disease or injury that contributed to the death, and being certain that there is no reason to report the death to the coroner.
If old age or frailty is mentioned, it should only be as a contributory cause and not the sole cause of death. It is important to have supporting information from the patient’s medical records and any relevant investigations. Additionally, the patient’s family may request further investigation if they do not believe old age is an adequate explanation for their relative’s death. If a death is certified as due to old age or senility alone, it will usually be referred to the coroner unless the deceased was 80 or older, all the conditions listed above are fulfilled, and there is no other reason to refer the death. It is important to follow these guidelines to ensure accurate and appropriate reporting of causes of death.
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This question is part of the following fields:
- Miscellaneous
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Question 21
Incorrect
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A 32-year-old obese man presents to Accident and Emergency with a 2-day history of nausea, frank haematuria and sharp, persistent left-sided flank pain, radiating from the loin to the groin. On examination, he has left renal angle tenderness.
Urine dip shows:
frank haematuria
blood 2+
protein 2+.
He has a history of hypertension, appendicitis 10 years ago and gout. You order a non-contrast computerised tomography (CT) for the kidney–ureter–bladder (KUB), which shows a 2.2 cm calculus in the proximal left (LT) ureter.
Which of the following is the definitive treatment for this patient’s stone?Your Answer:
Correct Answer: Percutaneous ureterolithotomy
Explanation:Treatment Options for Large Kidney Stones
Large kidney stones, typically those over 2 cm in diameter, require surgical intervention as they are unlikely to pass spontaneously. Here are some treatment options for such stones:
1. Percutaneous Ureterolithotomy/Nephrolithotomy: This procedure involves using a nephroscope to remove or break down the stone into smaller pieces before removal. It is highly effective for stones between 21 and 30 mm in diameter and is indicated for staghorn calculi, cystine stones, or when ESWL is not suitable.
2. Extracorporeal Shock Wave Lithotripsy (ESWL): This option uses ultrasound shock waves to break up stones into smaller fragments, which can be passed spontaneously in the urine. It is appropriate for stones up to 2 cm in diameter that fail to pass spontaneously.
3. Medical Expulsive Therapy: In some cases, calcium channel blockers or a blockers may be used to help pass the stone. A corticosteroid may also be added. However, this option is not suitable for stones causing severe symptoms.
It is important to note that admission and treatment with diclofenac, antiemetic, and rehydration therapy is only the initial management for an acute presentation and that sending the patient home with paracetamol and advice to drink water is only appropriate for small stones. Open surgery is rarely used and is reserved for complicated cases.
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This question is part of the following fields:
- Urology
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Question 22
Incorrect
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A man in his thirties receives a punch to the left side of his face resulting in a black eye. He reports experiencing numbness in his left cheek and upper teeth on that side.
Which nerve is likely to have been affected?Your Answer:
Correct Answer: Infraorbital nerve
Explanation:Nerves and their Functions in Facial Sensation and Movement
The face is innervated by several nerves that serve different functions. The infraorbital nerve supplies sensation to the upper teeth and cheek, but is vulnerable to direct trauma and pressure. The supratrochlear nerve provides sensation to the upper eyelid, conjunctiva, and lower middle forehead. The mental nerve supplies sensation to the lower lip and chin, while the zygomatic branch of the facial nerve gives motor innervation to the orbicularis oculi. Lastly, the chorda tympani is responsible for taste sensation in the anterior two-thirds of the tongue. Understanding the functions of these nerves is crucial in diagnosing and treating facial injuries and disorders.
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This question is part of the following fields:
- Trauma
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Question 23
Incorrect
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A 60-year-old patient presents with abnormal liver function tests, including elevated bilirubin, alanine transaminase, aspartate transaminase, alkaline phosphatase, and gamma glutamyl transferase, as well as decreased albumin and an elevated INR. What is the probable underlying cause of these findings?
Your Answer:
Correct Answer: Paracetamol overdose
Explanation:Liver Function Tests
Liver function tests are important diagnostic tools that help doctors assess the health of a patient’s liver. Elevated levels of transaminases, specifically AST and ALT, indicate a hepatitic picture, which may be caused by conditions such as hepatitis or paracetamol overdose. ALT is specific to hepatocytes, while AST is also found in other parts of the body. An AST:ALT ratio of >2 may suggest alcoholic hepatitis. However, the magnitude of transaminase elevations is not used in standard scoring systems of severity.
Elevated INR levels, which indicate a loss of liver synthetic function, are important indicators of severity and prognosis in patients with liver failure. Cholestasis, reflected in elevated ALP and GGT, may also be seen in a predominantly hepatitic process. This is partly due to blockage of intrahepatic bile canaliculi by dead hepatocytes. On the other hand, primary biliary cirrhosis, cholecystitis, and head of pancreas tumor would lead to a cholestatic picture.
Dubin Johnson syndrome is an inherited disorder of bilirubin metabolism that leads to a conjugated hyperbilirubinemia without elevations in other liver enzymes. It is a benign condition. liver function tests and their interpretation is crucial in diagnosing and managing liver diseases.
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This question is part of the following fields:
- Clinical Sciences
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Question 24
Incorrect
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A child is born with a genetic condition that is inherited in an autosomal dominant manner. The parents are informed of this. What is the most likely condition that the child has?
Your Answer:
Correct Answer: Myotonic dystrophy
Explanation:Inherited Genetic Disorders: Myotonic Dystrophy, Homocystinuria, Sickle-Cell Anaemia, Phenylketonuria, and Cystic Fibrosis
Myotonic dystrophy, homocystinuria, sickle-cell anaemia, phenylketonuria, and cystic fibrosis are all inherited genetic disorders that affect various bodily functions. Myotonic dystrophy is an autosomal dominant disorder that causes progressive muscle weakness and loss of muscle mass. Homocystinuria is an autosomal recessive disorder that leads to the accumulation of homocysteine and its metabolites in the blood and urine. Sickle-cell anaemia is an autosomal recessive disorder that causes deformed red blood cells that can block small capillaries and cause pain crises. Phenylketonuria is an autosomal recessive disorder that leads to intellectual disability due to the inability to convert phenylalanine to tyrosine. Cystic fibrosis is an autosomal recessive disorder that affects the chloride ion channel, leading to excessively viscous mucous secretions.
Although there is no cure for these disorders, early detection and treatment can improve outcomes. Support measures such as leg braces and muscle relaxants can assist with mobility in myotonic dystrophy. Low-protein diets and vitamin supplements can help manage homocystinuria. Pain management and regular monitoring can help manage sickle-cell anaemia. Dietary protein restriction and tyrosine supplementation can help manage phenylketonuria. A multidisciplinary team can provide specialized care for cystic fibrosis patients. It is important to be aware of these inherited genetic disorders and seek medical attention if symptoms arise.
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This question is part of the following fields:
- Genetics
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Question 25
Incorrect
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A 60-year-old man is seen at cardiology outpatients 6 weeks after an anterior myocardial infarction. His wife complains that she cannot sleep at night due to his constant coughing and throat clearing.
Which medication is likely causing these symptoms?Your Answer:
Correct Answer: Perindopril
Explanation:Common Side-Effects of Cardiovascular Medications
Cardiovascular medications are commonly prescribed to manage various heart conditions. However, they can also cause side-effects that can affect a patient’s quality of life. Here are some common side-effects of popular cardiovascular medications:
Perindopril: This medication can cause a dry, persistent cough, as well as hyperkalaemia, fatigue, dizziness, and hypotension.
Amiodarone: Side-effects of this medication include dizziness, visual disturbance, unco-ordination, tremors, paraesthesia, deranged liver function tests (LFTs), deranged thyroid function tests (TFTs), and lung fibrosis.
Atenolol: β-blockers like atenolol can cause fatigue, Raynaud’s phenomenon, bronchospasm, change in bowel habit, and sexual dysfunction.
Atorvastatin: Statins like atorvastatin can cause myopathy/myositis, derangement of glucose control, and deranged LFTs.
Candesartan: Angiotensin receptor blockers like candesartan can cause dizziness, headache, hyperkalaemia, and first-dose orthostatic hypotension. They are often prescribed to patients who are intolerant of ACE inhibitors due to dry cough.
In conclusion, patients taking cardiovascular medications should be aware of these potential side-effects and report any concerns to their healthcare provider.
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This question is part of the following fields:
- Cardiology
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Question 26
Incorrect
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A 60-year-old active builder presents to the emergency department with left-sided scrotal pain and swelling accompanied by fever for the past two days. He had a urinary tract infection 10 days ago, which improved after taking antibiotics. He has a medical history of benign prostatic hyperplasia and is waiting for transurethral resection of the prostate. Despite his age, he is still sexually active with his wife and denies ever having a sexually transmitted disease. What is the probable pathogen responsible for his current condition?
Your Answer:
Correct Answer: Escherichia coli
Explanation:Epididymo-orchitis is probable in individuals with a low risk of sexually transmitted infections, such as a married man in his 50s who only has one sexual partner, and is most likely caused by enteric organisms like E. coli due to the presence of pain, swelling, and a history of urinary tract infections.
Epididymo-orchitis is a condition where the epididymis and/or testes become infected, leading to pain and swelling. It is commonly caused by infections spreading from the genital tract or bladder, with Chlamydia trachomatis and Neisseria gonorrhoeae being the usual culprits in sexually active younger adults, while E. coli is more commonly seen in older adults with a low-risk sexual history. Symptoms include unilateral testicular pain and swelling, with urethral discharge sometimes present. Testicular torsion, which can cause ischaemia of the testicle, is an important differential diagnosis and needs to be excluded urgently, especially in younger patients with severe pain and an acute onset.
Investigations are guided by the patient’s age, with sexually transmitted infections being assessed in younger adults and a mid-stream urine (MSU) being sent for microscopy and culture in older adults with a low-risk sexual history. Management guidelines from the British Association for Sexual Health and HIV (BASHH) recommend ceftriaxone 500 mg intramuscularly as a single dose, plus doxycycline 100 mg orally twice daily for 10-14 days if the organism causing the infection is unknown. Further investigations are recommended after treatment to rule out any underlying structural abnormalities.
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This question is part of the following fields:
- Surgery
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Question 27
Incorrect
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A 55-year-old man comes to his GP complaining of tingling in both hands that began a month ago and has been progressively worsening. He has no significant medical history. During the examination, you observe that the man has large hands, widely spaced teeth, and a prominent brow. You suspect that he may have acromegaly.
What is the most suitable initial investigation for acromegaly?Your Answer:
Correct Answer: Serum IGF1 levels
Explanation:Investigations for Acromegaly: Serum IGF1 Levels, CT/MRI Head, and Visual Field Testing
Acromegaly is a condition caused by excess growth hormone (GH) production, often from a pituitary macroadenoma. To diagnose acromegaly, insulin-like growth factor 1 (IGF1) levels are measured instead of GH levels, as IGF1 has a longer half-life and is more stable in the blood. If IGF1 levels are high, a glucose tolerance test is used to confirm the diagnosis. CT scans of the head are not as sensitive as MRI scans for investigating pituitary tumors, which are a common cause of acromegaly. Visual field testing is also important to assess whether a pituitary tumor is compressing the optic chiasm, but it is not specific to acromegaly and is part of the physical exam.
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This question is part of the following fields:
- Endocrinology
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Question 28
Incorrect
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You review a 56-year-old man with a history of type II diabetes. He was diagnosed 1 year ago and is currently managed with diet and exercise, and additional medication includes ramipril 10 mg po daily, atorvastatin 10 mg and aspirin 75 mg/day. On examination, his blood pressure is measured at 129/75 mmHg. Low-density lipoprotein (LDL) cholesterol is 2.1, HbA1c 62 mmol/mol and creatinine 110 μmol/l.
Which of the following is the most appropriate next treatment step in this case?Your Answer:
Correct Answer: Commence metformin
Explanation:Treatment Recommendations for a Patient with Diabetes and High Cholesterol
To manage a patient with diabetes and high cholesterol, several treatment options are available. If the patient’s HbA1c is above the target level despite diet and exercise, the first-line treatment is metformin. If the patient has poor tolerance or side-effects from metformin, gliclazide may be used as a second-line option. Pioglitazone can be used cautiously in conjunction with metformin if HbA1c is poorly controlled on monotherapy.
However, if the patient’s LDL cholesterol is already adequately controlled, there is no need to increase the dosage of atorvastatin. Similarly, if the patient’s blood pressure is already well-managed, there is no need to add an additional antihypertensive medication. By carefully considering the patient’s individual needs and responses to treatment, healthcare providers can help manage diabetes and high cholesterol effectively.
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This question is part of the following fields:
- Endocrinology
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Question 29
Incorrect
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A 50-year-old man is worried about pain control during his upcoming radical prostatectomy. The consultant goes over various options, including general and regional anesthesia. What is a definite reason to avoid using regional anesthesia, such as spinal, epidural, or plexus block?
Your Answer:
Correct Answer: Concurrent administration of therapeutic dose of warfarin
Explanation:The use of regional anesthesia is not recommended for patients undergoing therapeutic anticoagulation due to the potential risk of bleeding and the severity of hematoma formation within the central nervous system. To prepare for surgery, warfarin is typically discontinued five days prior and replaced with a Low Molecular Weight Heparin, with the dosage determined by the individual’s thrombosis risk stratification (such as CHADs score or time from pulmonary embolism). Additionally, the patient’s INR should be monitored and ideally kept below 1.4, while also ensuring there are no other coagulation abnormalities present.
Pain management can be achieved through various methods, including the use of analgesic drugs and local anesthetics. The World Health Organisation (WHO) recommends a stepwise approach to pain management, starting with peripherally acting drugs such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs). If pain control is not achieved, weak opioid drugs such as codeine or dextropropoxyphene can be introduced, followed by strong opioids such as morphine as a final option. Local anesthetics can also be used to provide pain relief, either through infiltration of a wound or blockade of plexuses or peripheral nerves.
For acute pain management, the World Federation of Societies of Anaesthesiologists (WFSA) recommends a similar approach, starting with strong analgesics in combination with local anesthetic blocks and peripherally acting drugs. The use of strong opioids may no longer be required once the oral route can be used to deliver analgesia, and peripherally acting agents and weak opioids can be used instead. The final step is when pain can be controlled by peripherally acting agents alone.
Local anesthetics can be administered through infiltration of a wound with a long-acting agent such as Bupivacaine, providing several hours of pain relief. Blockade of plexuses or peripheral nerves can also provide selective analgesia, either for surgery or postoperative pain relief. Spinal and epidural anesthesia are other options, with spinal anesthesia providing excellent analgesia for lower body surgery and epidural anesthesia providing continuous infusion of analgesic agents. Transversus Abdominal Plane block (TAP) is a technique that uses ultrasound to identify the correct muscle plane and injects local anesthetic to block spinal nerves, providing a wide field of blockade without the need for indwelling devices.
Patient Controlled Analgesia (PCA) allows patients to administer their own intravenous analgesia and titrate the dose to their own end-point of pain relief using a microprocessor-controlled pump. Opioids such as morphine and pethidine are commonly used, but caution is advised due to potential side effects and toxicity. Non-opioid analgesics such as paracetamol and NSAIDs can also be used, with NSAIDs being more useful for superficial pain and having relative contraindications for certain medical conditions.
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This question is part of the following fields:
- Pharmacology
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Question 30
Incorrect
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A 27-year-old man is brought to the emergency department by a friend who found him confused and drowsy, with his hands over his abdomen. The patient has vomited twice on the way to the hospital and appears to be in pain. An arterial blood gas reveals the following results: pH 7.29 (normal range: 7.35-7.45), HCO3- 17 mmol/L (normal range: 22-26 mmol/L), pCO2 3kPa (normal range: 4.5-6kPa), p02 12kPa (normal range: 10-14kPa), and anion gap 20mEq/L (normal range: 10-14mEq/L). Which diagnostic test would provide the quickest indication of the patient's condition?
Your Answer:
Correct Answer: Blood glucose monitoring (BM)
Explanation:Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus, accounting for around 6% of cases. It can also occur in rare cases of extreme stress in patients with type 2 diabetes mellitus. However, mortality rates have decreased from 8% to under 1% in the past 20 years. DKA is caused by uncontrolled lipolysis, resulting in an excess of free fatty acids that are ultimately converted to ketone bodies. The most common precipitating factors of DKA are infection, missed insulin doses, and myocardial infarction. Symptoms include abdominal pain, polyuria, polydipsia, dehydration, Kussmaul respiration, and acetone-smelling breath. Diagnostic criteria include glucose levels above 13.8 mmol/l, pH below 7.30, serum bicarbonate below 18 mmol/l, anion gap above 10, and ketonaemia.
Management of DKA involves fluid replacement, insulin, and correction of electrolyte disturbance. Most patients with DKA are depleted around 5-8 litres, and isotonic saline is used initially, even if the patient is severely acidotic. Insulin is administered through an intravenous infusion, and correction of electrolyte disturbance is necessary. Long-acting insulin should be continued, while short-acting insulin should be stopped. DKA resolution is defined as pH above 7.3, blood ketones below 0.6 mmol/L, and bicarbonate above 15.0mmol/L. Complications may occur from DKA itself or the treatment, such as gastric stasis, thromboembolism, arrhythmias, acute respiratory distress syndrome, acute kidney injury, and cerebral oedema. Children and young adults are particularly vulnerable to cerebral oedema following fluid resuscitation in DKA and often need 1:1 nursing to monitor neuro-observations.
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This question is part of the following fields:
- Medicine
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