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Question 1
Correct
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What structures are located inside the carpal tunnel?
Your Answer: Flexor pollicis longus
Explanation:Anatomy of the Carpal Tunnel
The carpal tunnel is a narrow passageway located in the wrist that contains several important structures. These include the median nerve, which provides sensation to the thumb, index, middle, and half of the ring finger, as well as motor function to some of the muscles in the hand. Additionally, the carpal tunnel houses the tendons of the flexor digitorum profundus and superficialis muscles, which are responsible for flexing the fingers. The flexor pollicis longus, which controls movement of the thumb, is also found within the carpal tunnel, along with its synovium.
In the most radial (first) dorsal wrist compartment, the abductor pollicis longus and extensor pollicis brevis are located. These structures are responsible for abduction and extension of the thumb, respectively.
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This question is part of the following fields:
- Clinical Sciences
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Question 2
Correct
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A nursing student faints in the dissection room, falling straight backwards and hitting her head hard on the floor. She admits that she had no breakfast prior to attending dissection, and a well-meaning technician gives her a piece of chocolate. She complains that the chocolate tastes funny and vomits afterwards. Formal neurological assessment reveals anosmia, and computerised tomography (CT) of the head and neck reveals an anterior base of skull fracture affecting the cribriform plate of the ethmoid bone.
What is the level of interruption to the olfactory pathway likely to be in a nursing student?Your Answer: The first-order sensory neurones
Explanation:The Olfactory Pathway: Neuronal Path and Potential Disruptions
The olfactory pathway is responsible for our sense of smell and is composed of several neuronal structures. The first-order sensory neurones begin at the olfactory receptors in the nasal cavity and pass through the cribriform plate of the ethmoid bone to synapse with second-order neurones at the olfactory bulb. A fracture of the cribriform plate can disrupt these first-order neurones, leading to anosmia and a loss of taste sensation. However, the olfactory bulb is supported and protected by the ethmoid bone, making it less likely to be affected by the fracture. The second-order neurones arise in the olfactory bulb and form the olfactory tract, which divides into medial and lateral branches. The lateral branch terminates in the piriform cortex of the frontal lobe, which is further from the ethmoid bone and less likely to be disrupted. Understanding the neuronal path of the olfactory pathway can help identify potential disruptions and their effects on our sense of smell and taste.
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This question is part of the following fields:
- Trauma
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Question 3
Incorrect
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A 73-year-old man comes to the Emergency department after experiencing an injury while playing tennis. He felt something snap in his forearm while hitting a forehand shot. Upon examination, there is a noticeable lump above his elbow, about the size of an orange, and he has difficulty flexing his elbow. What type of injury is he likely to have sustained?
Your Answer: Distal biceps rupture
Correct Answer: Proximal biceps rupture
Explanation:The Biceps Brachii Muscle and Tendon Rupture
The biceps brachii muscle is located in the anterior compartment of the arm and is responsible for flexion. It has two heads, the short head attaching to the tip of the coracoid process of the scapula and the long head attaching to the supraglenoid tubercle of the scapula. The tendon of the long head crosses the head of the humerus within the glenohumeral joint and descends in the intertubercular groove of the humerus.
Rupture of the biceps tendon is usually caused by wear and tear of an inflamed tendon as it moves back and forth in the intertubercular groove of the humerus. This injury is common in older athletes, particularly baseball pitchers. The tendon is typically torn from its attachment to the supraglenoid tubercle of the scapula, resulting in a dramatic snap or pop and a ball-like bulge in the distal part of the arm.
While forceful flexion of the arm against excessive resistance can also cause biceps tendon rupture, it more commonly occurs as a result of repetitive overhead motions, such as those performed by swimmers. Conservative treatment is typically the best option, with patients becoming asymptomatic after four to six weeks. Surgical intervention is usually only necessary for cosmetic reasons or if shoulder reconstruction is required.
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This question is part of the following fields:
- Clinical Sciences
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Question 4
Incorrect
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A 52-year-old male construction worker has been admitted with haematemesis and is scheduled for an urgent upper GI endoscopy. According to the Rockall score, which feature would classify him as being in the high-risk category for a patient presenting with GI bleeding?
Your Answer: His age
Correct Answer: A history of ischaemic heart disease
Explanation:Scoring Systems for Gastrointestinal Bleed Risk Stratification
There are several scoring systems available to categorize patients with gastrointestinal bleeding into high and low-risk groups. The Rockall scoring system considers age, comorbidities such as ischaemic heart disease, presence of shock, and endoscopic abnormalities. Similarly, the Canadian Consensus Conference Statement incorporates endoscopic factors such as active bleeding, major stigmata of recent haemorrhage, ulcers greater than 2 cm in diameter, and the location of ulcers in proximity to large arteries. The Baylor bleeding score assigns a score to pre- and post-endoscopic features. On the other hand, the Blatchford score is based on clinical parameters alone, including elevated blood urea nitrogen, reduced haemoglobin, a drop in systolic blood pressure, raised pulse rate, the presence of melaena or syncope, and evidence of hepatic or cardiac disease.
These scoring systems are useful in determining the severity of gastrointestinal bleeding and identifying patients who require urgent intervention. By stratifying patients into high and low-risk groups, healthcare providers can make informed decisions regarding management and treatment options. The use of these scoring systems can also aid in predicting outcomes and mortality rates, allowing for appropriate monitoring and follow-up care. Overall, the implementation of scoring systems for gastrointestinal bleed risk stratification is an important tool in improving patient outcomes and reducing morbidity and mortality rates.
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This question is part of the following fields:
- Gastroenterology
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Question 5
Correct
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A 25-year-old female patient complains of a painful red eye with a tearing sensation. On a scale of 1 to 10, she rates the pain as 7. She mentions that she wears contact lenses regularly. What would be the most suitable course of action?
Your Answer: Same-day ophthalmology referral
Explanation:If a contact lens wearer experiences a painful red eye, it is important to refer them to an eye casualty immediately to rule out microbial keratitis. Due to the complexity of assessing red eye in contact lens wearers, a specialist should assess the patient on the same day to determine the cause and provide appropriate treatment. While acyclovir is effective in treating viral keratitis, other microbes may be responsible for this condition. Therefore, specialist referral is necessary. The patient should be advised to temporarily discontinue contact lens use and practice good hygiene. Reassurance is not appropriate as microbial keratitis can lead to vision loss if left untreated. It is important to make an urgent referral, which is typically offered to suspected cancer patients within two weeks.
Understanding Keratitis: Inflammation of the Cornea
Keratitis is a condition that refers to the inflammation of the cornea. While conjunctivitis is a common eye infection that is not usually serious, microbial keratitis can be sight-threatening and requires urgent evaluation and treatment. The causes of keratitis can vary, with bacterial infections typically caused by Staphylococcus aureus and Pseudomonas aeruginosa commonly seen in contact lens wearers. Fungal and amoebic infections can also cause keratitis, with acanthamoebic keratitis accounting for around 5% of cases. Parasitic infections such as onchocercal keratitis can also cause inflammation of the cornea.
Other factors that can cause keratitis include viral infections such as herpes simplex keratitis, environmental factors like photokeratitis (e.g. welder’s arc eye), and exposure keratitis. Clinical features of keratitis include a red eye with pain and erythema, photophobia, a foreign body sensation, and the presence of hypopyon. Referral is necessary for contact lens wearers who present with a painful red eye, as an accurate diagnosis can only be made with a slit-lamp examination.
Management of keratitis involves stopping the use of contact lenses until symptoms have fully resolved, as well as the use of topical antibiotics such as quinolones. Cycloplegic agents like cyclopentolate can also be used for pain relief. Complications of keratitis can include corneal scarring, perforation, endophthalmitis, and visual loss. Understanding the causes and symptoms of keratitis is important for prompt diagnosis and treatment to prevent serious complications.
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This question is part of the following fields:
- Ophthalmology
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Question 6
Incorrect
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A woman was brought to the Emergency Department after being stabbed in the abdomen, one inch (2.54 cm) superior to the umbilicus in the midline.
Assuming the knife entered the peritoneal cavity, which one of the following abdominal wall structures would the knife penetrate first?Your Answer: Aponeurosis of the transversus abdominis muscle
Correct Answer: Aponeurosis of the external oblique and internal oblique muscles
Explanation:Layers of the Anterior Abdominal Wall
The anterior abdominal wall is composed of several layers that provide support and protection to the abdominal organs. Understanding the layers of the abdominal wall is important for surgical procedures and diagnostic imaging.
Skin and Superficial Fascia
The outermost layer of the abdominal wall is the skin, followed by the superficial fascia. The superficial fascia contains adipose tissue and is important for insulation and energy storage.Anterior Rectus Sheath
The anterior rectus sheath is formed by the fusion of the aponeuroses of the external oblique and internal oblique muscles. It covers the rectus muscle and provides additional support to the abdominal wall.Rectus Muscle
The rectus muscle is located deep to the anterior rectus sheath and is responsible for flexing the trunk. It is an important muscle for maintaining posture and stability.Posterior Rectus Sheath
The posterior rectus sheath is formed by the fusion of the aponeuroses of the internal oblique and transversus muscles. It provides additional support to the rectus muscle and helps to maintain the integrity of the abdominal wall.Transversalis Fascia
The transversalis fascia is a thin layer of connective tissue that lies deep to the posterior rectus sheath. It separates the abdominal wall from the peritoneum and provides additional support to the abdominal organs.Extraperitoneal Fat and Peritoneum
The extraperitoneal fat is a layer of adipose tissue that lies deep to the transversalis fascia. It provides insulation and energy storage. The peritoneum is a thin layer of tissue that lines the abdominal cavity and covers the abdominal organs.Conclusion
Understanding the layers of the anterior abdominal wall is important for surgical procedures and diagnostic imaging. Each layer provides important support and protection to the abdominal organs. -
This question is part of the following fields:
- Colorectal
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Question 7
Incorrect
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A 42-year-old man visits his GP complaining of heel pain that has been bothering him for four months. He mentions that the pain intensifies when he walks to and from work. The man has a BMI of 29 kg/m² and is being evaluated for diabetes mellitus. He has a medical history of asthma, generalized anxiety disorder, and Peyronie's disease.
What is the most appropriate initial course of action for his heel pain?Your Answer: Suggest simple stretch exercises, prescribe ibuprofen and review in 6 weeks
Correct Answer: Suggest weight loss, simple stretch exercises and resting the heel
Explanation:To manage plantar fasciitis, it is recommended to start with rest, stretching, and weight loss if the patient is overweight. Stretching exercises targeting the plantar fascia and Achilles tendon should be done three times a day. Orthotics and NSAIDs can be used, but only after trying the initial measures. It is important to note that the patient has asthma, so prescribing ibuprofen would not be appropriate. While a 6 week review is appropriate, it should also include monitoring weight loss as a key factor in managing the condition. Therefore, weight loss should be considered as the best initial step, given the patient’s BMI of 29.
Understanding Plantar Fasciitis
Plantar fasciitis is a prevalent condition that causes heel pain in adults. The pain is typically concentrated around the medial calcaneal tuberosity, which is the bony bump on the inside of the heel. This condition occurs when the plantar fascia, a thick band of tissue that runs along the bottom of the foot, becomes inflamed or irritated.
To manage plantar fasciitis, it is essential to rest the feet as much as possible. Wearing shoes with good arch support and cushioned heels can also help alleviate the pain. Insoles and heel pads may also be beneficial in providing additional support and cushioning. It is important to note that plantar fasciitis can take time to heal, and it is crucial to be patient and consistent with treatment. By taking these steps, individuals can effectively manage their plantar fasciitis and reduce their discomfort.
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This question is part of the following fields:
- Musculoskeletal
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Question 8
Incorrect
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A 16-year-old girl and her mother rush to the Emergency department due to the girl's sudden onset of breathlessness and facial puffiness. The girl has a history of eczema and is currently taking oral contraceptives. Despite being well prior to this incident, she is now visibly distressed and experiencing laboured breathing with stridor but no wheezing. What is the most probable reason for her breathlessness?
Your Answer: Pulmonary embolism
Correct Answer: Angio-oedema
Explanation:Noisy Breathing and Atopy in Adolescents
The presence of noisy breathing in an adolescent may indicate the possibility of stridor, which can be caused by an allergic reaction even in an otherwise healthy individual. The history of atopy, or a tendency to develop allergic reactions, further supports the diagnosis of angio-oedema. The sudden onset of symptoms also adds to the likelihood of this diagnosis.
While asthma is a possible differential diagnosis, it typically presents with expiratory wheezing. However, if the chest is silent, it may indicate a severe and life-threatening form of asthma. Therefore, it is important to consider all possible causes of noisy breathing and atopy in adolescents to ensure prompt and appropriate treatment.
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This question is part of the following fields:
- Emergency Medicine
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Question 9
Incorrect
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A 27-year-old female patient complains of pain and swelling in her hand joints that have persisted for the past four months. She reports experiencing stiffness in her joints in the morning, which lasts for about an hour. The patient denies any pain or swelling in her elbows, ankles, or knees.
During the physical examination, the doctor observes swelling and tenderness in the second and third metacarpophalangeal (MCP) joints of both hands. Laboratory tests reveal an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels.
Which investigation has NICE recommended to be performed on all patients with similar symptoms?Your Answer: Antinuclear antibodies (ANA)
Correct Answer: X-ray of hands and feet
Explanation:The patient’s symptoms suggest rheumatoid arthritis, and according to NICE guidelines, x-rays of the hands and feet should be performed for all suspected cases. Additionally, tests for rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (anti-CCP) should be conducted. The presence of anti-neutrophil cytoplasmic antibody (ANCA) is more indicative of vasculitic syndromes, which this patient does not exhibit. Antinuclear antibody (ANA) testing is typically reserved for suspected cases of systemic lupus erythematosus (SLE) and should not be routinely performed for rheumatoid arthritis. Serum uric acid monitoring is more relevant for gout diagnosis.
Rheumatoid arthritis is a condition that can be diagnosed through initial investigations, including antibody tests and x-rays. One of the first tests recommended is the rheumatoid factor (RF) test, which detects a circulating antibody that reacts with the patient’s own IgG. This test can be done through the Rose-Waaler test or the latex agglutination test, with the former being more specific. A positive RF result is found in 70-80% of patients with rheumatoid arthritis, and high levels are associated with severe progressive disease. However, it is not a marker of disease activity. Other conditions that may have a positive RF result include Felty’s syndrome, Sjogren’s syndrome, infective endocarditis, SLE, systemic sclerosis, and the general population.
Another antibody test that can aid in the diagnosis of rheumatoid arthritis is the anti-cyclic citrullinated peptide antibody test. This test can detect the antibody up to 10 years before the development of rheumatoid arthritis and has a sensitivity similar to RF (around 70%) but a much higher specificity of 90-95%. NICE recommends that patients with suspected rheumatoid arthritis who are RF negative should be tested for anti-CCP antibodies.
In addition to antibody tests, x-rays of the hands and feet are also recommended for all patients with suspected rheumatoid arthritis. These x-rays can help detect joint damage and deformities, which are common in rheumatoid arthritis. Early detection and treatment of rheumatoid arthritis can help prevent further joint damage and improve overall quality of life for patients.
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This question is part of the following fields:
- Musculoskeletal
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Question 10
Correct
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A 56-year-old patient presents for an annual review. He has no significant past medical history. He is a smoker and has a family history of ischaemic heart disease: body mass index (BMI) 27.4, blood pressure (BP) 178/62 mmHg, fasting serum cholesterol 7.9 mmol/l (normal value < 5.17 mmol/l), triglycerides 2.2 mmol/l (normal value < 1.7 mmol/l), fasting glucose 5.8 mmol/l (normal value 3.9–5.6 mmol/l).
Which of the following would be the most appropriate treatment for his cholesterol?Your Answer: Start atorvastatin
Explanation:Treatment Options for Primary Prevention of Cardiovascular Disease
The primary prevention of cardiovascular disease (CVD) involves identifying and managing risk factors such as high cholesterol, smoking, hypertension, and family history of heart disease. The National Institute for Health and Care Excellence (NICE) provides guidelines for the treatment of these risk factors.
Start Atorvastatin: NICE recommends offering atorvastatin 20 mg to people with a 10% or greater 10-year risk of developing CVD. Atorvastatin is preferred over simvastatin due to its superior efficacy and side-effect profile.
Reassure and Repeat in One Year: NICE advises using the QRISK2 risk assessment tool to assess CVD risk and starting treatment if the risk is >10%.
Dietary Advice and Repeat in Six Months: Dietary advice should be offered to all patients, including reducing saturated fat intake, increasing mono-unsaturated fat intake, choosing wholegrain varieties of starchy food, reducing sugar intake, eating fruits and vegetables, fish, nuts, seeds, and legumes.
Start Bezafibrate: NICE advises against routinely offering fibrates for the prevention of CVD to people being treated for primary prevention.
Start Ezetimibe: Ezetimibe is not a first-line treatment for hyperlipidaemia, but people with primary hypercholesterolaemia should be considered for ezetimibe treatment.
Overall, a combination of lifestyle changes and medication can effectively manage cardiovascular risk factors and prevent the development of CVD.
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This question is part of the following fields:
- Cardiology
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Question 11
Correct
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A 35-year-old intravenous drug user has been diagnosed with osteomyelitis of the right tibia. What organism is most likely responsible for this infection?
Your Answer: Staphylococcus aureus
Explanation:Understanding Osteomyelitis: Types, Causes, and Treatment
Osteomyelitis is a bone infection that can be classified into two types: haematogenous and non-haematogenous. Haematogenous osteomyelitis is caused by bacteria that enter the bloodstream and is usually monomicrobial. It is more common in children, with vertebral osteomyelitis being the most common form in adults. Risk factors include sickle cell anaemia, intravenous drug use, immunosuppression, and infective endocarditis. On the other hand, non-haematogenous osteomyelitis results from the spread of infection from adjacent soft tissues or direct injury to the bone. It is often polymicrobial and more common in adults, with risk factors such as diabetic foot ulcers, pressure sores, diabetes mellitus, and peripheral arterial disease.
Staphylococcus aureus is the most common cause of osteomyelitis, except in patients with sickle-cell anaemia where Salmonella species predominate. To diagnose osteomyelitis, MRI is the imaging modality of choice, with a sensitivity of 90-100%. Treatment for osteomyelitis involves a six-week course of flucloxacillin. Clindamycin is an alternative for patients who are allergic to penicillin.
In summary, osteomyelitis is a bone infection that can be caused by bacteria entering the bloodstream or spreading from adjacent soft tissues or direct injury to the bone. It is more common in children and adults with certain risk factors. Staphylococcus aureus is the most common cause, and MRI is the preferred imaging modality for diagnosis. Treatment involves a six-week course of flucloxacillin or clindamycin for penicillin-allergic patients.
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This question is part of the following fields:
- Musculoskeletal
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Question 12
Correct
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A 26-year-old woman presents to the Eye Casualty with a sudden onset of painful reduction in vision in her left eye. She denies any other symptoms and has no significant medical history.
Upon examination, her right eye has a visual acuity of 6/6 while her left eye has a visual acuity of 6/36 with reduced color vision. Eye movements are normal, but the pain worsens. The swinging torch test reveals left pupil dilation when the torch light swings from the right eye to the left. Dilated fundoscopy shows a swollen optic disc in her left eye.
What is the recommended first-line treatment for this condition?Your Answer: Intravenous methylprednisolone
Explanation:Treatment Options for Optic Neuritis in Multiple Sclerosis Patients
Optic neuritis is a common symptom of multiple sclerosis (MS) and can cause vision loss or pain. While the condition may improve on its own, treatment with steroids is often recommended. Intravenous methylprednisolone is the preferred route of administration for this medication, although it can cause side effects such as mood changes and weight gain.
Glatiramer acetate and interferon beta are first-line treatments for MS, but are not typically used for isolated episodes of optic neuritis. Natalizumab is a second-line treatment option for MS, but may not be appropriate for all patients.
It is important to note that oral prednisolone alone is not recommended for optic neuritis in MS patients due to an increased risk of recurrence. Overall, treatment options for optic neuritis in MS patients should be carefully considered based on individual patient needs and medical history.
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This question is part of the following fields:
- Ophthalmology
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Question 13
Incorrect
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A 55-year-old male patient complains of swelling and is diagnosed with nephrotic syndrome. What is a frequently occurring complication of this condition?
Your Answer: Increased risk of bleeding
Correct Answer: Increased risk of pneumococcal pneumonia
Explanation:Nephrotic Syndrome and its Complications
Nephrotic syndrome is a condition characterized by three main symptoms: hypoalbuminemia, proteinuria, and edema. Patients with this condition are at an increased risk of developing complications such as thrombosis, infections, and hyperlipidemia. Chronic kidney disease (CKD) is also a possible complication of nephrotic syndrome, although not all patients with the condition will have a history of established renal disease prior to presentation. The risk of developing CKD depends on the underlying cause of the nephrotic syndrome.
One unusual complication of nephrotic syndrome is hypercalcemia, which is not commonly seen in this condition. Abnormal plasma protein proportions can cause changes in the binding of electrolytes, drugs, and other solutes, leading to low ionized calcium levels. In severe cases, this may result in symptoms of hypocalcemia. However, in CKD, hypocalcemia is a common occurrence and can cause secondary hyperparathyroidism.
In summary, the symptoms and complications of nephrotic syndrome is crucial for proper management and treatment of the condition. While hypercalcemia is not a common complication, patients with nephrotic syndrome are at an increased risk of developing thrombosis, infections, and hyperlipidemia. Additionally, the risk of developing CKD depends on the underlying cause of the condition.
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This question is part of the following fields:
- Nephrology
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Question 14
Incorrect
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Sarah, a 12-year-old girl with Down's syndrome, visits her GP complaining of fatigue. What medical condition is commonly linked to Down's syndrome?
Your Answer: Type-2-diabetes
Correct Answer: Hypothyroidism
Explanation:Hypothyroidism is commonly found in individuals with Down syndrome, while the risk of hyperthyroidism is also increased. Type-1 diabetes is more prevalent in those with Down syndrome, but there is no association with ADHD. Fragile X is linked to ADHD, and male breast cancer is not associated with Down syndrome but has been linked to Klinefelter’s syndrome.
Down’s syndrome is a genetic disorder that is characterized by various clinical features. These features include an upslanting of the palpebral fissures, epicanthic folds, Brushfield spots in the iris, a protruding tongue, small low-set ears, and a round or flat face. Additionally, individuals with Down’s syndrome may have a flat occiput, a single palmar crease, and a pronounced sandal gap between their big and first toe. Hypotonia, congenital heart defects, duodenal atresia, and Hirschsprung’s disease are also common in individuals with Down’s syndrome.
Cardiac complications are also prevalent in individuals with Down’s syndrome, with multiple cardiac problems potentially present. The most common cardiac defect is the endocardial cushion defect, also known as atrioventricular septal canal defects, which affects 40% of individuals with Down’s syndrome. Other cardiac defects include ventricular septal defect, secundum atrial septal defect, tetralogy of Fallot, and isolated patent ductus arteriosus.
Later complications of Down’s syndrome include subfertility, learning difficulties, short stature, repeated respiratory infections, hearing impairment from glue ear, acute lymphoblastic leukaemia, hypothyroidism, Alzheimer’s disease, and atlantoaxial instability. Males with Down’s syndrome are almost always infertile due to impaired spermatogenesis, while females are usually subfertile and have an increased incidence of problems with pregnancy and labour.
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This question is part of the following fields:
- Paediatrics
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Question 15
Correct
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A 55-year-old man is scheduled for colorectal carcinoma resection and has type 2 diabetes. He is currently well-controlled on 5 mg glibenclamide daily. What is the best pre-operative plan for managing his blood sugar levels?
Your Answer: Stop glibenclamide on the morning of surgery and commence insulin by intravenous infusion
Explanation:Management of Glibenclamide in a Patient Undergoing Major Surgery
During major surgery, it is crucial to maintain optimal glycaemic control in patients with diabetes. In the case of a patient taking glibenclamide, the most appropriate course of action is to discontinue the medication on the morning of surgery. Instead, the patient should be started on intravenous (IV) insulin and dextrose with potassium. This approach allows for frequent blood glucose measurements and adjustment of the insulin infusion rate as needed.
By stopping glibenclamide, the risk of hypoglycaemia during surgery is reduced. IV insulin and dextrose with potassium provide a more controlled and predictable method of glycaemic control during the stress of surgery. This approach ensures that the patient’s blood glucose levels remain within a safe range, reducing the risk of complications such as infection, delayed wound healing, and poor surgical outcomes.
In summary, the management of glibenclamide in a patient undergoing major surgery involves discontinuing the medication on the morning of surgery and starting the patient on IV insulin and dextrose with potassium. This approach allows for optimal glycaemic control during the stress of surgery and reduces the risk of complications.
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This question is part of the following fields:
- Endocrinology
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Question 16
Incorrect
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An 80-year-old woman has been suffering from Paget's disease of bone for over a decade. Lately, she has been experiencing increased pain in her lower back and hip region even when at rest. Upon conducting an X-ray, a destructive mass is observed in her bony pelvis. What is the probable diagnosis?
Your Answer: Osteoma
Correct Answer: Osteosarcoma
Explanation:Paget’s Disease of Bone
Paget’s disease of bone is a condition that typically affects individuals in their later years. It is characterized by a disruption in the normal process of bone repair, resulting in the formation of weak bones that are prone to fractures. Specifically, the repair process ends at the stage of vascular osteoid bone, which is not as strong as fully mineralized bone.
Unfortunately, Paget’s disease of bone can also lead to complications such as osteogenic sarcoma, which occurs in approximately 5% of cases. As such, it is important for individuals with this condition to receive appropriate medical care and monitoring to prevent further complications.
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This question is part of the following fields:
- Oncology
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Question 17
Incorrect
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A 39-year-old patient with a history of peripheral vascular disease presents to the emergency department with complaints of rest pain in their left leg. Despite being a smoker, their BMI is 25 kg/m² and they have no other medical issues. Upon examination, the patient has absent foot pulses and lower limb pallor. A CT angiogram is performed and reveals a long segmental obstruction, leading to suspicion of critical limb ischaemia. What is the best course of treatment?
Your Answer: Balloon angioplasty
Correct Answer: Open bypass graft
Explanation:Open surgical revascularization is more appropriate for low-risk patients with long-segment/multifocal lesions who have peripheral arterial disease with critical limb ischaemia.
Peripheral arterial disease (PAD) is a condition that is strongly associated with smoking. Therefore, patients who still smoke should be provided with assistance to quit smoking. It is also important to treat any comorbidities that the patient may have, such as hypertension, diabetes mellitus, and obesity. All patients with established cardiovascular disease, including PAD, should be taking a statin, with Atorvastatin 80 mg being the recommended dosage. In 2010, NICE published guidance recommending the use of clopidogrel as the first-line treatment for PAD patients instead of aspirin. Exercise training has also been shown to have significant benefits, and NICE recommends a supervised exercise program for all PAD patients before other interventions.
For severe PAD or critical limb ischaemia, there are several treatment options available. Endovascular revascularization and percutaneous transluminal angioplasty with or without stent placement are typically used for short segment stenosis, aortic iliac disease, and high-risk patients. On the other hand, surgical revascularization, surgical bypass with an autologous vein or prosthetic material, and endarterectomy are typically used for long segment lesions, multifocal lesions, lesions of the common femoral artery, and purely infrapopliteal disease. Amputation should only be considered for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty or bypass surgery.
There are also drugs licensed for use in PAD, including naftidrofuryl oxalate, a vasodilator sometimes used for patients with a poor quality of life. Cilostazol, a phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects, is not recommended by NICE.
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This question is part of the following fields:
- Surgery
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Question 18
Incorrect
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What is the most suitable vitamin D supplement for a patient with liver and kidney failure, considering the need for enzymatic conversion of naturally occurring analogues?
Your Answer: Cholecalciferol (vitamin D3)
Correct Answer: Calcitriol (1,25 dihydroxycholecalciferol)
Explanation:Vitamin D Activation
Vitamin D is an essential nutrient that plays a crucial role in maintaining bone health and immune function. However, not all forms of vitamin D are active and readily available for use by the body.
Alphacalcidol, a partly activated form of vitamin D, is not the correct answer as it still requires further hydroxylation by the liver. Similarly, cholecalciferol (vitamin D3) and ergocalciferol (vitamin D2) are naturally occurring analogues that require activation by both the liver and kidneys.
The correct answer is calcitriol (1,25 dihydroxycholecalciferol), an active form of vitamin D that has undergone the necessary hydroxylation by both the kidneys and liver.
It is important to understand the different forms of vitamin D and their activation processes in order to ensure adequate intake and absorption for optimal health.
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This question is part of the following fields:
- Endocrinology
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Question 19
Incorrect
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What is the absolute risk reduction of stroke in elderly subjects treated with aspirin compared to those not treated, and how many elderly subjects would need to be treated with aspirin to prevent one stroke?
Your Answer: 25
Correct Answer: 50
Explanation:Number Needed to Treat
Number needed to treat (NNT) is a statistical measure used in medical research to estimate the number of patients who need to receive a particular treatment in order to prevent a specific outcome. In simpler terms, it is a way of determining the effectiveness of a treatment by calculating how many patients need to be treated to prevent one negative event from occurring. For example, if two out of every 100 patients who take aspirin are prevented from having a stroke, the NNT would be 50, meaning that 50 patients would need to be treated with aspirin to prevent one stroke.
NNT is an important tool for healthcare professionals as it helps them to make informed decisions about which treatments are most effective for their patients. By the NNT for a particular treatment, doctors can weigh the potential benefits against the risks and side effects of the treatment, and make a more informed decision about whether or not to prescribe it. Overall, NNT is a valuable measure that helps to ensure that patients receive the most effective treatments possible.
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This question is part of the following fields:
- Clinical Sciences
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Question 20
Incorrect
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A 67-year-old man, who had recently undergone a full bone marrow transplantation for acute myeloid leukaemia (AML), presented with progressive dyspnoea over the past 2 weeks. He also had a dry cough, but no fever. During examination, scattered wheeze and some expiratory high-pitched sounds were observed. The C-reactive protein (CRP) level was normal, and the Mantoux test was negative. Spirometry results showed a Forced expiratory volume in 1 second (FEV1) of 51%, Forced vital capacity (FVC) of 88%, and FEV1/FVC of 58%. What is the most likely diagnosis?
Your Answer: Drug induced lung disorder
Correct Answer: Bronchiolitis obliterans
Explanation:Understanding Bronchiolitis Obliterans: Symptoms, Causes, and Treatment Options
Bronchiolitis obliterans (BO) is a condition that can occur in patients who have undergone bone marrow, heart, or lung transplants. It is characterized by an obstructive picture on spirometry, which may be accompanied by cough, cold, dyspnea, tachypnea, chest wall retraction, and cyanosis. The pulmonary defect is usually irreversible, and a CT scan may show areas of air trapping. Common infections associated with bronchiolitis include influenzae, adenovirus, Mycoplasma, and Bordetella. In adults, bronchiolitis is mainly caused by Mycoplasma, while among connective tissue disorders, BO is found in rheumatoid arthritis and, rarely, in Sjögren’s syndrome or systemic lupus erythematosus. Treatment options include corticosteroids, with variable results. Lung biopsy reveals concentric inflammation and fibrosis around bronchioles. Other conditions, such as acute respiratory distress syndrome (ARDS), drug-induced lung disorder, fungal infection, and pneumocystis pneumonia, have different clinical findings and require different treatment approaches.
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This question is part of the following fields:
- Respiratory
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Question 21
Correct
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A 32-year-old female with a history of depression is being evaluated. She is presently using St John's Wort, which she purchased from a nearby health food store, and a combination oral contraceptive pill. What is the probable outcome of taking both drugs simultaneously?
Your Answer: Reduced effectiveness of combined oral contraceptive pill
Explanation:St John’s Wort: An Alternative Treatment for Mild-Moderate Depression
St John’s Wort has been found to be as effective as tricyclic antidepressants in treating mild-moderate depression. Its mechanism of action is thought to be similar to SSRIs, although it has also been shown to inhibit noradrenaline uptake. However, the National Institute for Health and Care Excellence (NICE) advises against its use due to uncertainty about appropriate doses, variation in the nature of preparations, and potential serious interactions with other drugs.
In clinical trials, the adverse effects of St John’s Wort were similar to those of a placebo. However, it can cause serotonin syndrome and is an inducer of the P450 system, which can lead to decreased levels of drugs such as warfarin and ciclosporin. Additionally, the effectiveness of the combined oral contraceptive pill may be reduced.
Overall, St John’s Wort may be a viable alternative treatment for those with mild-moderate depression. However, caution should be exercised due to potential interactions with other medications and the lack of standardization in dosing and preparation. It is important to consult with a healthcare professional before starting any new treatment.
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This question is part of the following fields:
- Pharmacology
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Question 22
Correct
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A 27-year-old woman presents at 18 weeks’ gestation, seeking advice. She was collecting her son from school the other day when the teacher alerted the parents that a few children had developed ‘slapped cheek syndrome’. One of those children was at her house with his parents for dinner over the weekend.
She is concerned she may have been infected and is worried about her baby. She had all her paediatric vaccinations, as per the National Health Service (NHS) schedule.
Which of the following should be the next step in the investigation of this patient?Your Answer: Parvovirus B19 immunoglobulin G (IgG) and immunoglobulin M (IgM) serology
Explanation:Serology Testing for Parvovirus B19 and Rubella During Pregnancy
During pregnancy, it is important to investigate exposure to certain viruses, such as parvovirus B19 and rubella, as they can have detrimental effects on the fetus. Serology testing for immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies is used to determine if a patient has had a previous infection or if there is a recent or acute infection.
Parvovirus B19 is a DNA virus that commonly affects children and can cause slapped cheek syndrome. If a patient has had significant exposure to parvovirus B19, IgG and IgM serology testing is performed. A positive IgG and negative IgM result indicates an old infection, while a negative IgG and IgM result requires repeat testing in one month. A positive IgM result indicates a recent infection, which requires further confirmation and referral to a specialist center for fetal monitoring.
Varicella IgG serology is performed if there was exposure to chickenpox during pregnancy. A positive result indicates immunity to the virus, and no further investigation is required.
Rubella IgG and IgM serology is used to investigate exposure to rubella during pregnancy. A positive IgG indicates previous exposure or immunity from vaccination, while a positive IgM indicates a recent or acute infection.
In conclusion, serology testing is an important tool in investigating viral exposure during pregnancy and can help guide appropriate management and monitoring.
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This question is part of the following fields:
- Obstetrics
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Question 23
Incorrect
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A 35-year-old male is being seen on the surgical ward round, four days after his abdominal surgery. He complains of a peculiar sensation over the wound while shifting in bed. Upon removing the dressings, it is discovered that the wound is gaping open, with visible internal organs. Despite this, his vital signs are all normal, and he does not seem to be bothered by the situation. The wound is covered with gauze impregnated with saline. While waiting for additional surgical assistance, what other urgent treatment should be provided?
Your Answer: IV flucloxacillin
Correct Answer: IV ceftriaxone and metronidazole
Explanation:The initial management for abdominal wound dehiscence involves covering the wound with saline impregnated gauze and administering broad-spectrum antibiotics intravenously. In this case, a combination of ceftriaxone and metronidazole would be appropriate. Flucloxacillin is not broad enough to cover the range of organisms that may be present. While fluids are important, a 1 L stat bolus is excessive at this stage. Analgesia should be provided, but it is less urgent than antibiotics. Oxygen is not indicated based on the patient’s current condition.
Abdominal wound dehiscence is a serious issue that surgeons who perform abdominal surgery frequently encounter. It occurs when all layers of an abdominal mass closure fail, resulting in the protrusion of the viscera externally. This condition is associated with a 30% mortality rate and can be classified as either superficial or complete, depending on the extent of the wound failure.
Several factors increase the risk of abdominal wound dehiscence, including malnutrition, vitamin deficiencies, jaundice, steroid use, major wound contamination (such as faecal peritonitis), and poor surgical technique. To prevent this condition, the preferred method is the mass closure technique, also known as the Jenkins Rule.
When sudden full dehiscence occurs, the wound should be covered with saline impregnated gauze, and the patient should receive IV broad-spectrum antibiotics, analgesia, and IV fluids. Arrangements should also be made for a return to the operating theatre.
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This question is part of the following fields:
- Surgery
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Question 24
Incorrect
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A 40-year-old asthmatic has been admitted to the hospital with a worsening wheeze that has persisted for 24 hours. You are urgently called as the patient has become acutely short of breath despite receiving three sets of salbutamol nebulisers. The patient is now hypotensive and desaturating. Upon examination, you notice reduced air entry with a resonant percussion note in the left lung field and a trachea deviated to the right. Based on these symptoms, what is the most likely diagnosis?
Your Answer: Simple pneumothorax
Correct Answer: Tension pneumothorax
Explanation:Urgent Treatment for Evolving Pneumothorax
This patient is showing clinical signs of a developing pneumothorax, which requires urgent treatment. While a tension pneumothorax is typically associated with a deviated trachea and hyper-resonance, these signs may not appear until later stages. It is possible that the patient has a simple pneumothorax, but given their hypotension, urgent needle decompression is necessary to treat a potential tension pneumothorax. In such cases, chest imaging should not be prioritized over immediate intervention. The procedure involves inserting a large bore needle in the second intercostal space in the mid-clavicular line, followed by a chest drain.
Pneumonia can often trigger asthma exacerbations, which can lead to severe chest sepsis and SIRS criteria evolving into severe sepsis. In such cases, ARDS may be the predominant clinical picture with wet lung fields. While massive pulmonary embolism can also cause desaturation and hypotension, there are no other apparent risk factors in this patient’s case. It is important to note that while acute asthma exacerbations can cause anxiety, the diagnosis of panic attacks should only be made after excluding other potential causes.
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This question is part of the following fields:
- Emergency Medicine
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Question 25
Incorrect
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A 65-year-old man comes to the Emergency Department with severe abdominal pain and haematemesis. Following initial resuscitation, an urgent CT scan shows a perforated duodenal ulcer. The surgical team schedules an emergency laparotomy, and he is transferred to the operating room. Due to his non-fasted state, the anaesthetist intends to perform a rapid sequence induction (RSI) using a depolarising muscle relaxant to minimize airway obstruction.
What is the appropriate drug to use in this situation?Your Answer: Mivacurium
Correct Answer: Suxamethonium
Explanation:Suxamethonium belongs to the category of depolarising muscle relaxants, which is one of the two main categories of muscle relaxants used in anaesthesia. The other category is non-depolarising muscle relaxants. Therefore, suxamethonium is the correct answer out of the given options. Rocuronium, mivacurium, and pancuronium are all examples of non-depolarising muscle relaxants and are incorrect options. Sugammadex is used for reversing neuromuscular blockade caused by rocuronium and vecuronium and is also an incorrect answer.
Muscle relaxants are drugs that can be used to induce paralysis in patients undergoing surgery or other medical procedures. Suxamethonium is a type of muscle relaxant that works by inhibiting the action of acetylcholine at the neuromuscular junction. It is broken down by plasma cholinesterase and acetylcholinesterase and has the fastest onset and shortest duration of action of all muscle relaxants. However, it can cause adverse effects such as hyperkalaemia, malignant hyperthermia, and lack of acetylcholinesterase.
Atracurium is another type of muscle relaxant that is a non-depolarising neuromuscular blocking drug. It usually has a duration of action of 30-45 minutes and may cause generalised histamine release on administration, which can produce facial flushing, tachycardia, and hypotension. Unlike suxamethonium, atracurium is not excreted by the liver or kidney but is broken down in tissues by hydrolysis. Its effects can be reversed by neostigmine.
Vecuronium is also a non-depolarising neuromuscular blocking drug that has a duration of action of approximately 30-40 minutes. Its effects may be prolonged in patients with organ dysfunction as it is degraded by the liver and kidney. Similarly, its effects can be reversed by neostigmine.
Pancuronium is a non-depolarising neuromuscular blocker that has an onset of action of approximately 2-3 minutes and a duration of action of up to 2 hours. Its effects may be partially reversed with drugs such as neostigmine. Overall, muscle relaxants are important drugs in medical practice, but their use requires careful consideration of their potential adverse effects and appropriate monitoring of patients.
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This question is part of the following fields:
- Surgery
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Question 26
Incorrect
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What is the mechanism of action of nicotinic acid in the management of hyperlipidaemia?
Your Answer: Stimulate increased action of the enzyme lipoprotein lipase
Correct Answer: Inhibit hepatic secretion of VLDL
Explanation:The Benefits and Limitations of Nicotinic Acid as a Lipid-Lowering Agent
Nicotinic acid, also known as niacin, is a B-group vitamin that has been found to have several beneficial effects on the lipid profile. It can reduce triglycerides by decreasing the secretion of very low-density lipoproteins (VLDL) by the liver, lower low-density lipoprotein (LDL) cholesterol, and increase high-density lipoprotein (HDL) cholesterol. However, the use of nicotinic acid as a drug has been limited due to its side effects.
The most common side effect of nicotinic acid is facial flushing, which can be disabling for some patients. To address this issue, the HPS2-THRIVE Trial was conducted using extended-release niacin with a prostaglandin receptor blocker called laropiprant. The goal was to minimize flushing and enable hyperlipidemic patients to benefit more from niacin usage.
However, the study found that the addition of extended-release niacin-laropiprant to statin-based LDL cholesterol-lowering therapy did not significantly reduce the risk of major vascular events. Instead, it increased the risk of serious adverse events. Therefore, while nicotinic acid has several beneficial effects on the lipid profile, its use as a drug is limited by its side effects and the need for further research to minimize these effects.
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This question is part of the following fields:
- Pharmacology
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Question 27
Incorrect
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A 28-year-old woman has been experiencing severe dysmenorrhoea for a prolonged period and seeks consultation at the gynaecological clinic. The consultant suspects adenomyosis as the underlying cause but wants to confirm the diagnosis and exclude other possible pathologies before initiating treatment. What is the most appropriate imaging modality for diagnosing this condition?
Your Answer: Laparoscopy
Correct Answer: MRI Pelvis
Explanation:MRI is the most effective imaging technique for diagnosing adenomyosis, which is the presence of endometrial tissue in the myometrium. While ultrasound can also aid in diagnosis, it is not as reliable as MRI. Laparoscopy is used to diagnose endometriosis, but it cannot detect adenomyosis as it occurs within the uterine wall. CT is not a suitable imaging technique for adenomyosis as it cannot differentiate between different types of tissue. Hysterosalpingography is used for imaging the uterine lining and fallopian tubes, typically during fertility treatment, but it cannot provide an image of the myometrium.
Understanding Adenomyosis
Adenomyosis is a medical condition that occurs when endometrial tissue grows within the muscular walls of the uterus. This condition is more common in women who have had multiple pregnancies and are nearing the end of their reproductive years. Symptoms of adenomyosis include painful menstrual cramps, heavy menstrual bleeding, and an enlarged and tender uterus.
To diagnose adenomyosis, doctors typically use magnetic resonance imaging (MRI) as it is the most effective method. Treatment options for adenomyosis include managing symptoms with pain relief medication, using tranexamic acid to control heavy bleeding, and administering gonadotropin-releasing hormone (GnRH) agonists to reduce estrogen levels. In severe cases, uterine artery embolization or hysterectomy may be necessary. Hysterectomy is considered the definitive treatment for adenomyosis.
In summary, adenomyosis is a condition that affects the uterus and can cause painful menstrual cramps, heavy bleeding, and an enlarged uterus. It is more common in women who have had multiple pregnancies and are nearing the end of their reproductive years. Diagnosis is typically done through MRI, and treatment options include managing symptoms, medication, and surgery.
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This question is part of the following fields:
- Gynaecology
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Question 28
Incorrect
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A 14-year-old girl came to the clinic with several erythematosus lesions on her trunk. The lesions had a collarette of scales at their periphery and were asymptomatic. What is the most probable diagnosis?
Your Answer: Psoriasis
Correct Answer: Pityriasis rosea
Explanation:Pityriasis Rosea: Symptoms, Causes, and Treatment
Pityriasis rosea is a skin condition that typically begins with a single patch, known as the herald or mother patch. This is followed by smaller patches that appear in clusters, resembling a Christmas tree pattern on the upper trunk of the body. These patches have a fine ring of scales around their edges, known as a collarette. The condition is believed to be caused by a viral infection and typically lasts for six to eight weeks. While there is no specific treatment for pityriasis rosea, symptoms can be managed with over-the-counter medications and topical creams.
Pityriasis rosea is a common skin condition that can cause discomfort and embarrassment for those affected. the symptoms, causes, and treatment options can help individuals manage the condition and alleviate symptoms.
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This question is part of the following fields:
- Dermatology
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Question 29
Incorrect
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A 42-year-old woman, who had a hysterectomy to treat fibroids in the past, visits the Preoperative Gynaecology Clinic for sacrospinous fixation to address a vault prolapse. The surgeon discusses the potential risks and complications of the procedure before obtaining consent. What nerve is in danger of being harmed during sacrospinous fixation for vault prolapse treatment?
Your Answer: Inguinal
Correct Answer: Sciatic
Explanation:Nerve Damage in Obstetric and Surgical Procedures
During obstetric and surgical procedures, nerve damage can occur in various parts of the body. One such instance is a total vault prolapse, which can occur following a hysterectomy. Two surgical options for management include sacrocolpopexy and sacrospinous fixation. While sacrocolpopexy involves suturing the vaginal vault to the sacrum, sacrospinous fixation requires suturing the top of the vaginal vault to the sacrospinous ligament. However, complications such as damage to the sciatic nerve and pudendal vessels can occur with the latter procedure.
Damage to the common peroneal nerve is most common during total knee arthroplasties when the patient is placed in the lithotomy and lateral positions for extended periods of time. On the other hand, the femoral nerve can be injured during abdomino-pelvic surgery, aortic cross-clamp, invasive procedures to access the femoral vessels, and hip arthroplasty. Inguinal hernia repair is the most common cause of damage to the inguinal nerve.
Lastly, isolated damage to the posterior cutaneous nerve of the thigh is not associated with obstetric surgery. However, damage to the main femoral nerve is commonly seen in abdominal hysterectomies due to compression by retractor blades. It is important for healthcare professionals to be aware of these potential complications and take necessary precautions to prevent nerve damage during procedures.
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This question is part of the following fields:
- Gynaecology
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Question 30
Incorrect
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A 67-year-old man is admitted to the colorectal ward after undergoing resection of a large adenocarcinoma in his descending colon. The surgery involved a left hemicolectomy and removal of two loops of small bowel and a partial cystectomy due to tumour invasion. He is currently five days post-operation and is managing well with adequate pain control. However, his catheter has drained 2000ml in the last 24 hours, and his abdominal surgical drain is still producing 200-300 ml of clear yellow fluid per day. There is a concern that his bladder wall repair may be leaking urine. What investigation should be ordered to provide the most definitive result in assessing the healing of the bladder suture line?
Your Answer: Ultrasound of the kidneys, ureters and bladder
Correct Answer: Cystogram
Explanation:To perform a cystogram, a radiopaque dye is injected into the bladder and radiographs are taken to examine the movement of the bladder contents. This helps to determine if there is any radiopaque fluid that has leaked from the bladder and is now present in the abdominal cavity.
Functional renal imaging techniques are used to assess the structure and function of the kidneys. One such technique is dimercaptosuccinic acid (DMSA) scintigraphy, which localizes to the renal cortex and is useful for identifying cortical defects and ectopic or abhorrent kidneys. However, it does not provide information on the ureter or collecting system. Diethylene-triamine-penta-acetic acid (DTPA) is primarily a glomerular filtration agent and provides information on the glomerular filtration rate (GFR). MAG 3 renogram is an agent that is primarily secreted by tubular cells and is useful for imaging the kidneys of patients with existing renal impairment. Micturating cystourethrogram (MCUG scan) provides information on bladder reflux, while intravenous urography may provide evidence of renal stones or other structural lesions. PET/CT may be used to evaluate structurally indeterminate lesions in the staging of malignancy.
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This question is part of the following fields:
- Surgery
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