-
Question 1
Incorrect
-
A 70-year-old man arrives at the emergency department with abrupt onset of numbness on the right side of his body, without any other accompanying symptoms. He has a medical history of uncontrolled hypertension and diabetes mellitus. A CT scan of his head was conducted, which revealed no signs of bleeding or tumors. The diagnosis is a lacunar stroke. Which area of the brain is impacted by a lacunar stroke?
Your Answer: Posterior inferior cerebellar artery
Correct Answer: The basal ganglia, thalamus and internal capsule
Explanation:The basal ganglia, thalamus, and internal capsule are common sites for lacunar strokes. Amaurosis fugax affects (1), ‘locked-in’ syndrome affects (2), Wallenberg syndrome affects (4), and lateral pontine syndrome affects (5).
When a stroke occurs, the location of the lesion in the brain can determine the specific effects on the body. Depending on which artery is affected, different symptoms may arise. For example, a stroke in the anterior cerebral artery can lead to contralateral hemiparesis and sensory loss, with the lower extremity being more affected than the upper. On the other hand, a stroke in the middle cerebral artery can cause contralateral hemiparesis and sensory loss, with the upper extremity being more affected than the lower, as well as contralateral homonymous hemianopia and aphasia.
If the stroke occurs in the posterior cerebral artery, the individual may experience contralateral homonymous hemianopia with macular sparing and visual agnosia. In the case of Weber’s syndrome, which involves branches of the posterior cerebral artery that supply the midbrain, the person may have an ipsilateral CN III palsy and contralateral weakness of the upper and lower extremities.
Other types of strokes include those affecting the posterior inferior cerebellar artery, which can lead to ipsilateral facial pain and temperature loss and contralateral limb/torso pain and temperature loss, as well as ataxia and nystagmus. A stroke in the anterior inferior cerebellar artery can cause similar symptoms to Wallenberg’s syndrome, but with the addition of ipsilateral facial paralysis and deafness.
Finally, lacunar strokes are small, localized strokes that often occur in individuals with hypertension. They typically present with isolated hemiparesis, hemisensory loss, or hemiparesis with limb ataxia, and commonly affect the basal ganglia, thalamus, and internal capsule.
-
This question is part of the following fields:
- Neurology
-
-
Question 2
Incorrect
-
A 25-year-old female is prescribed varenicline to aid in smoking cessation. What is the most probable adverse effect that may occur?
Your Answer: Constipation
Correct Answer: Nausea
Explanation:NICE guidance recommends offering nicotine replacement therapy (NRT), varenicline, or bupropion to patients for smoking cessation, with no preference for one medication over another. NRT should be offered in combination for those with high nicotine dependence or inadequate response to single forms. Varenicline should be started a week before the target stop date and monitored for adverse effects, including nausea and suicidal behavior. Bupropion should also be started before the target stop date and is contraindicated in epilepsy, pregnancy, and breastfeeding. Pregnant women should be tested for smoking and referred to NHS Stop Smoking Services, with first-line interventions being cognitive behavior therapy, motivational interviewing, or structured self-help and support. NRT may be used if other measures fail, but varenicline and bupropion are contraindicated.
-
This question is part of the following fields:
- Pharmacology/Therapeutics
-
-
Question 3
Incorrect
-
A 68-year-old man has been taking medication for psoriasis with arthropathy for a prolonged period. He has recently experienced a dry cough and worsening shortness of breath with minimal activity.
Which of the following medications is the most probable cause of his symptoms?
Choose ONE option from the list provided.Your Answer: Hydroxychloroquine
Correct Answer: Methotrexate
Explanation:Identifying the Probable Cause of Pulmonary Fibrosis
Methotrexate is the correct answer as it is a well-known drug-related cause of pulmonary fibrosis, which is the probable cause of the patient’s symptoms. Hydroxychloroquine, azathioprine, ciclosporin, and penicillamine are not known to cause pulmonary fibrosis, although some of them have the potential to cause pneumonitis. Ciclosporin has been studied as a treatment for the disease, but it is not recommended by NICE. Therefore, it is important to identify the probable cause of pulmonary fibrosis to provide appropriate treatment and prevent further complications.
-
This question is part of the following fields:
- Respiratory Medicine
-
-
Question 4
Correct
-
During a routine check-up, a 7 week-old baby boy is seen. His mother has a history of asthma and used inhaled steroids while pregnant. He was delivered via planned Caesarian at 39 weeks due to breech presentation and weighed 3.1kg at birth. What condition is he at a higher risk for?
Your Answer: Developmental dysplasia of the hip
Explanation:If a baby was in a breech presentation, it is important to ensure that they have been referred for screening for developmental dysplasia of the hip (DDH) as it is a risk factor for this condition. The Department of Health recommends that all babies who were breech at any point from 36 weeks (even if not breech at birth), babies born before 36 weeks who were in a breech presentation, and all babies with a first degree relative who had a hip problem in early life, should undergo ultrasound screening for hip dysplasia. If one twin was breech, both should be screened. Some hospitals also refer babies with other conditions such as oligohydramnios, high birth weight, torticollis, congenital talipes calcaneovalgus, and metatarsus adductus for screening. For more information on screening for DDH, please refer to the link provided.
Developmental dysplasia of the hip (DDH) is a condition that affects 1-3% of newborns and is more common in females, firstborn children, and those with a positive family history or breech presentation. It used to be called congenital dislocation of the hip (CDH). DDH is more often found in the left hip and can be bilateral in 20% of cases. Screening for DDH is recommended for infants with certain risk factors, and all infants are screened using the Barlow and Ortolani tests at the newborn and six-week baby check. Clinical examination includes testing for leg length symmetry, restricted hip abduction, and knee level when hips and knees are flexed. Ultrasound is used to confirm the diagnosis if clinically suspected, but x-ray is the first line investigation for infants over 4.5 months. Management includes the use of a Pavlik harness for children under 4-5 months and surgery for older children with unstable hips.
-
This question is part of the following fields:
- Paediatrics
-
-
Question 5
Incorrect
-
A 28-year-old G1P0 woman attends her routine antenatal appointment at 12 weeks gestation and reports experiencing burning retrosternal pain. Omeprazole is prescribed, and a urine sample is taken. The urinalysis shows trace protein with no haematuria, nitrates, or white cells, and the patient denies any urinary symptoms. During the appointment, her blood pressure is measured at 135/88 mmHg. Upon further testing, the urine sample is found to have scant growth of Escherichia coli. What is the most appropriate course of action?
Your Answer: Reassure and advise the woman to reattend for antibiotics if she develops urinary symptoms
Correct Answer: Prescribe a 7 day course of nitrofurantoin
Explanation:Asymptomatic bacteriuria in pregnant women should be treated promptly with antibiotics. The recommended treatment is a 7-day course of nitrofurantoin. This is important to prevent the development of symptomatic urinary tract infection or pyelonephritis. Nitrofurantoin is safe to use in the first and second trimester, but should be avoided in the third trimester due to the risk of neonatal haemolysis. The patient’s blood pressure is within normal range and does not require treatment. The trace of protein in her urine is likely related to her asymptomatic bacteriuria and should be monitored with subsequent urine dips. Antihypertensive treatment is not necessary based on the trace of protein alone. Prescribing a 7-day course of trimethoprim is not recommended as it is contraindicated in the first trimester of pregnancy due to the increased risk of neural-tube defects. Prescribing aspirin, labetalol, and a 7-day course of nitrofurantoin is not necessary as the patient does not meet the diagnostic criteria for pre-eclampsia or pregnancy-induced hypertension. Similarly, prescribing aspirin, labetalol, and a 7-day course of trimethoprim is not recommended for the same reasons.
Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is teratogenic in the first trimester. Asymptomatic bacteriuria in pregnant women should also be treated to prevent progression to acute pyelonephritis. Men with UTIs should be offered a seven-day course of trimethoprim or nitrofurantoin unless prostatitis is suspected. A urine culture should be sent before antibiotics are started. Catheterised patients should not be treated for asymptomatic bacteria, but if symptomatic, a seven-day course of antibiotics should be given. Acute pyelonephritis requires hospital admission and treatment with a broad-spectrum cephalosporin or quinolone for 10-14 days. Referral to urology is not routinely required for men who have had one uncomplicated lower UTI.
-
This question is part of the following fields:
- Renal Medicine/Urology
-
-
Question 6
Correct
-
A patient with a history of heart failure is experiencing discomfort even at rest and is unable to engage in any physical activity without symptoms. What is the New York Heart Association classification that best describes the severity of their condition?
Your Answer: NYHA Class IV
Explanation:NYHA Classification for Chronic Heart Failure
The NYHA classification is a widely used system for categorizing the severity of chronic heart failure. It is based on the symptoms experienced by the patient during physical activity. NYHA Class I indicates no symptoms and no limitations on physical activity. NYHA Class II indicates mild symptoms and slight limitations on physical activity. NYHA Class III indicates moderate symptoms and marked limitations on physical activity. Finally, NYHA Class IV indicates severe symptoms and an inability to carry out any physical activity without discomfort. This classification system is helpful in determining the appropriate treatment and management plan for patients with chronic heart failure.
-
This question is part of the following fields:
- Cardiovascular
-
-
Question 7
Correct
-
A 9-year-old patient is brought to General Practitioner by his parents because he has been disruptive at school. His teachers report that he does not pay attention in class, bullies other classmates and takes their food during lunchtime without their permission. One teacher also reported that the patient was seen hurting the class hamster.
Which of the following is the most likely diagnosis in this patient?Your Answer: Conduct disorder
Explanation:Understanding Different Types of Behavioral Disorders in Children and Adults
Conduct Disorder:
Conduct disorder is a behavioral disorder that affects individuals under the age of 18. It is characterized by repetitive behavior that violates the rights of others, including bullying and torture of animals.Major Depression:
Major depression is a mood disorder that is diagnosed when an individual experiences depressed mood along with at least five of the following symptoms: changes in sleep patterns, loss of interest in activities, feelings of guilt, decreased energy, difficulty concentrating, changes in appetite, sluggishness, and suicidal thoughts.Antisocial Disorder:
Individuals who exhibit signs of conduct disorder and are 18 years or older are diagnosed with antisocial personality disorder.Manic Episode:
Mania is a mood disorder characterized by elevated mood lasting for at least 7 days. Symptoms include increased energy, decreased need for sleep, risky sexual behavior, feelings of invincibility, distractibility, flight of ideas, agitation, and pressured speech.Oppositional Defiant Disorder:
Oppositional defiant disorder is a behavioral disorder characterized by oppositional behavior towards authority figures. However, there is no violation of the rights of others or extreme behavior such as bullying or animal cruelty. -
This question is part of the following fields:
- Psychiatry
-
-
Question 8
Incorrect
-
A 70-year-old man has been diagnosed with active tuberculosis and started on antibiotics. He has a history of chronic kidney disease stage 4 and atrial fibrillation treated with warfarin. His INR taken 2 days after starting treatment is elevated at 7.8. Which antibiotic is the likely cause of this result?
Your Answer: Rifampicin
Correct Answer: Isoniazid
Explanation:The cytochrome p450 system is inhibited by isoniazid, which leads to a decrease in the metabolism of warfarin. This results in an increase in the INR and prolongation of its effects. Although erythromycin is metabolized by the cytochrome p450 system, it is not used in the initial phase of anti-tuberculosis treatment. Levofloxacin is not typically used in the initial phase of anti-tuberculosis treatment, but it may be used in combination with other agents if standard treatment is discontinued due to hepatotoxicity. Pyridoxine, which is vitamin B6, is not utilized in the treatment of tuberculosis.
P450 Enzyme System and its Inducers and Inhibitors
The P450 enzyme system is responsible for metabolizing drugs in the body. Induction of this system usually requires prolonged exposure to the inducing drug, unlike P450 inhibitors, which have rapid effects. Some drugs that induce the P450 system include antiepileptics like phenytoin and carbamazepine, barbiturates such as phenobarbitone, rifampicin, St John’s Wort, chronic alcohol intake, griseofulvin, and smoking, which affects CYP1A2 and is the reason why smokers require more aminophylline.
On the other hand, some drugs inhibit the P450 system, including antibiotics like ciprofloxacin and erythromycin, isoniazid, cimetidine, omeprazole, amiodarone, allopurinol, imidazoles such as ketoconazole and fluconazole, SSRIs like fluoxetine and sertraline, ritonavir, sodium valproate, and acute alcohol intake. It is important to be aware of these inducers and inhibitors as they can affect the metabolism and efficacy of drugs in the body. Proper dosing and monitoring can help ensure safe and effective treatment.
-
This question is part of the following fields:
- Pharmacology/Therapeutics
-
-
Question 9
Correct
-
A 57-year-old woman, who is known to have rheumatoid arthritis, complains that she has had recurrent haemoptysis for over five years. She has never smoked and only takes a non-steroidal anti-inflammatory agent. According to her, she coughs up phlegm every day and at times this contains streaks of fresh blood. She has no known respiratory disease, but tends to get frequent chest infections that are relieved by a course of antibiotics.
Which of the following is the most likely diagnosis?Your Answer: Bronchiectasis
Explanation:Understanding Bronchiectasis: Causes, Symptoms, and Treatment
Bronchiectasis is a condition characterized by permanent and irreversible dilatations of the bronchial walls. It can be caused by various factors, including cystic fibrosis, immune system deficiencies, lung infections, foreign body aspiration, and smoking. Common symptoms of bronchiectasis include high sputum production, recurrent chest infections, and haemoptysis. A high-resolution computed tomography (HR-CT) scan of the lungs is usually used to diagnose bronchiectasis. Treatment involves a multidisciplinary approach, including chest physiotherapy, patient education, antibiotic treatment, and bronchodilators. While treatment of the underlying cause may be necessary, it does not provide reversal of the existing bronchiectasis. Other conditions, such as atypical pneumonia, lung cancer, tuberculosis, and pulmonary embolism, may have similar symptoms but require different diagnoses and treatments.
-
This question is part of the following fields:
- Respiratory Medicine
-
-
Question 10
Correct
-
An 80-year-old man with terminal lung cancer is evaluated by the palliative care team to determine his analgesic requirements. He is currently on a regimen of 30 mg slow-release morphine twice daily, which effectively manages his pain. However, he is experiencing difficulty swallowing both tablet and liquid forms of the medication. The palliative team suggests transitioning him to subcutaneous morphine. What is the appropriate daily dosage for him?
Your Answer: 30mg
Explanation:Palliative care prescribing for pain is guided by NICE and SIGN guidelines. NICE recommends starting treatment with regular oral modified-release or immediate-release morphine, with immediate-release morphine for breakthrough pain. Laxatives should be prescribed for all patients initiating strong opioids, and antiemetics should be offered if nausea persists. Drowsiness is usually transient, but if it persists, the dose should be adjusted. SIGN advises that the breakthrough dose of morphine is one-sixth the daily dose, and all patients receiving opioids should be prescribed a laxative. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred to morphine in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and all patients should be considered for referral to a clinical oncologist for further treatment. When increasing the dose of opioids, the next dose should be increased by 30-50%. Conversion factors between opioids are also provided. Opioid side-effects are usually transient, such as nausea and drowsiness, but constipation can persist. In addition to strong opioids, bisphosphonates, and radiotherapy, denosumab may be used to treat metastatic bone pain.
Overall, the guidelines recommend starting with regular oral morphine and adjusting the dose as needed. Laxatives should be prescribed to prevent constipation, and antiemetics may be needed for nausea. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and referral to a clinical oncologist should be considered. Conversion factors between opioids are provided, and the next dose should be increased by 30-50% when adjusting the dose. Opioid side-effects are usually transient, but constipation can persist. Denosumab may also be used to treat metastatic bone pain.
-
This question is part of the following fields:
- Respiratory Medicine
-
-
Question 11
Correct
-
A 26-year-old male patient complains of painful ulcers on his penis shaft and dysuria for the past three days. He has never experienced such symptoms before. The clinical diagnosis suggests primary genital herpes. What is the best course of action for managing this condition?
Your Answer: Oral aciclovir
Explanation:Even if the presentation is delayed for up to 5 days, primary genital herpes infections require oral antiviral therapy.
Understanding Herpes Simplex Virus
Herpes simplex virus (HSV) is a common viral infection that affects humans. There are two strains of the virus, HSV-1 and HSV-2, which were previously thought to cause oral and genital herpes, respectively. However, there is now considerable overlap between the two strains. The primary infection may present with severe gingivostomatitis, while cold sores and painful genital ulceration are common features.
Management of HSV includes oral aciclovir for gingivostomatitis and genital herpes, and topical aciclovir for cold sores, although the evidence base for the latter is modest. Patients with frequent exacerbations may benefit from longer-term aciclovir. In pregnant women, a primary attack of herpes during pregnancy at greater than 28 weeks gestation may require elective caesarean section at term. Women with recurrent herpes who are pregnant should be treated with suppressive therapy and advised that the risk of transmission to their baby is low.
The cytopathic effect of HSV can be seen in Pap smears, which show multinucleated giant cells representing infection by the virus. The 3 M’s – multinucleation, margination of the chromatin, and molding of the nuclei – are characteristic features of HSV infection. Understanding the features and management of HSV is important for effective treatment and prevention of transmission.
-
This question is part of the following fields:
- Infectious Diseases
-
-
Question 12
Correct
-
A 28-year-old man with ankylosing spondylitis (AS) comes in with photophobia and a painful red eye.
What is the most probable diagnosis?Your Answer: Uveitis
Explanation:Understanding Eye Conditions Associated with Ankylosing Spondylitis
Ankylosing spondylitis (AS) is a chronic inflammatory disorder that primarily affects the sacroiliac joints and axial skeleton. However, it can also lead to various eye conditions. Uveitis, also known as iritis or iridocyclitis, is the most common extra-articular manifestation of AS, occurring in 20-30% of patients. Acute anterior uveitis is often unilateral and presents with symptoms such as a painful red eye, photophobia, and blurred vision. Patients with uveitis may also have or develop other spondyloarthropathies, including reactive arthritis, undifferentiated spondyloarthropathy, and psoriatic arthritis.
Acute angle-closure glaucoma, on the other hand, is not associated with AS. It is a medical emergency that needs immediate treatment to prevent vision loss. Conjunctivitis, which is responsible for approximately 30% of all eye complaints, is usually benign and self-limited. Herpes zoster ophthalmicus and keratoconus are also not associated with AS.
It is important for patients with AS to be aware of these potential eye conditions and seek urgent ophthalmological assessment if they experience any symptoms. Early diagnosis and treatment can prevent vision loss and improve outcomes.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 13
Correct
-
A 35-year-old woman who was diagnosed with HIV-1 three years ago is being seen in clinic. She is currently in good health and has not reported any symptoms. She only takes paracetamol occasionally for headaches. Her recent blood tests show:
CD4 325 * 106/l
What is the recommended course of action for antiretroviral therapy?Your Answer: Start antiretroviral therapy now
Explanation:Antiretroviral therapy (ART) for HIV involves a combination of at least three drugs, typically two nucleoside reverse transcriptase inhibitors (NRTI) and either a protease inhibitor (PI) or a non-nucleoside reverse transcriptase inhibitor (NNRTI). Entry inhibitors, NRTIs, NNRTIs, PIs, and integrase inhibitors are all used to manage HIV. The 2015 BHIVA guidelines recommend starting ART as soon as a patient is diagnosed with HIV. Each drug has its own side effects, and some of the common ones include peripheral neuropathy, renal impairment, osteoporosis, diabetes, hyperlipidemia, and P450 enzyme interaction.
-
This question is part of the following fields:
- Infectious Diseases
-
-
Question 14
Incorrect
-
What is the most frequent cause of hypothyroidism in children in the United Kingdom?
Your Answer: Iodine deficiency
Correct Answer: Autoimmune thyroiditis
Explanation:Causes of Hypothyroidism in Children
Hypothyroidism in children, also known as juvenile hypothyroidism, is most commonly caused by autoimmune thyroiditis. This occurs when the body’s immune system attacks the thyroid gland, leading to decreased production of thyroid hormones. However, there are other causes of hypothyroidism in children as well. For example, children who have undergone total-body irradiation as part of treatment for acute lymphoblastic leukemia may develop hypothyroidism as a side effect. Additionally, iodine deficiency is a common cause of hypothyroidism in children in developing countries. It is important for parents and healthcare providers to be aware of these potential causes in order to properly diagnose and treat hypothyroidism in children.
-
This question is part of the following fields:
- Paediatrics
-
-
Question 15
Correct
-
A 75-year-old man visits his doctor with worries about a tiny spot on his inner, lower lip. The spot has been there for about a month and has not shown any changes during this time. He reports no pain. He used to smoke but quit a decade ago. During the examination, his oral hygiene appears to be good, and there is a small, white patch less than 1 cm in size on the inner surface of his lower lip.
What is the best course of action for this patient?Your Answer: Refer oral surgery under 2-week wait
Explanation:If a patient has had persistent oral ulceration for more than three weeks, it is recommended that they be referred to oral surgery under the two week wait. This is especially important for smokers, as it raises suspicion for malignancy. Referring the patient to oral surgery under the two week wait is more appropriate than routine referral, as it allows for a quicker diagnosis. Following up with a community dentist is not recommended, as it may cause delays in diagnosis if the patient does not attend. While chlorhexidine may provide symptom relief, it does not address the underlying diagnosis, and reassurance alone is also not sufficient. Medical practitioners should refer patients with this presentation to oral surgery.
When to Refer Patients with Mouth Lesions for Oral Surgery
Mouth lesions can be a cause for concern, especially if they persist for an extended period of time. In cases where there is unexplained oral ulceration or mass that lasts for more than three weeks, or red and white patches that are painful, swollen, or bleeding, a referral to oral surgery should be made within two weeks. Additionally, if a patient experiences one-sided pain in the head and neck area for more than four weeks, which is associated with earache but does not result in any abnormal findings on otoscopy, or has an unexplained recent neck lump or a previously undiagnosed lump that has changed over a period of three to six weeks, a referral should be made.
Patients who have persistent sore or painful throats or signs and symptoms in the oral cavity that last for more than six weeks and cannot be definitively diagnosed as a benign lesion should also be referred. It is important to note that the level of suspicion should be higher in patients who are over 40, smokers, heavy drinkers, and those who chew tobacco or betel nut (areca nut). By following these guidelines, healthcare professionals can ensure that patients with mouth lesions receive timely and appropriate care. For more information on this topic, please refer to the link provided.
-
This question is part of the following fields:
- ENT
-
-
Question 16
Correct
-
A 63-year-old woman with peripheral arterial disease is prescribed simvastatin. What blood test monitoring is most suitable?
Your Answer: LFTs at baseline, 3 months and 12 months
Explanation:To evaluate the effectiveness of treatment, a fasting lipid profile may be examined as part of the monitoring process.
Statins are drugs that inhibit the action of an enzyme called HMG-CoA reductase, which is responsible for producing cholesterol in the liver. However, they can cause some adverse effects such as myopathy, which includes muscle pain, weakness, and damage, and liver impairment. Myopathy is more common in lipophilic statins than in hydrophilic ones. Statins may also increase the risk of intracerebral hemorrhage in patients who have had a stroke before. Therefore, they should be avoided in these patients. Statins should not be taken during pregnancy and should be stopped if the patient is taking macrolides.
Statins are recommended for people with established cardiovascular disease, those with a 10-year cardiovascular risk of 10% or more, and patients with type 2 diabetes mellitus. Patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago, are over 40 years old, or have established nephropathy should also take statins. It is recommended to take statins at night as this is when cholesterol synthesis takes place. Atorvastatin 20mg is recommended for primary prevention, and the dose should be increased if non-HDL has not reduced for 40% or more. Atorvastatin 80 mg is recommended for secondary prevention. The graphic shows the different types of statins available.
-
This question is part of the following fields:
- Cardiovascular
-
-
Question 17
Correct
-
You are advising a 26-year-old woman who has recently discovered she is expecting a baby. She is a smoker and consumes 20 cigarettes per day. What is the primary risk factor linked to smoking while pregnant?
Your Answer: Increased risk of pre-term labour
Explanation:Risks of Smoking, Alcohol, and Illegal Drugs During Pregnancy
During pregnancy, drug use can have serious consequences for both the mother and the developing fetus. Smoking during pregnancy increases the risk of miscarriage, pre-term labor, stillbirth, and sudden unexpected death in infancy. Alcohol consumption can lead to fetal alcohol syndrome, which can cause learning difficulties, characteristic facial features, and growth restrictions. Binge drinking is a major risk factor for fetal alcohol syndrome. Cannabis use poses similar risks to smoking due to the tobacco content. Cocaine use can lead to hypertension in pregnancy, including pre-eclampsia, and placental abruption. Fetal risks include prematurity and neonatal abstinence syndrome. Heroin use can result in neonatal abstinence syndrome. It is important for pregnant women to avoid drug use to ensure the health and well-being of both themselves and their unborn child.
-
This question is part of the following fields:
- Reproductive Medicine
-
-
Question 18
Incorrect
-
A 65-year-old woman was diagnosed with angina after presenting to the Emergency Department with exertional chest pain. She had a positive exercise test at the Cardiology Clinic and was started on aspirin, metoprolol, rosuvastatin and a glyceryl trinitrate (GTN) spray.
Eight months later, she presented to her General Practitioner with an increasing frequency of anginal episodes. These responded to GTN spray and did not occur at rest.
Which of the following is the most appropriate additional medication?Your Answer: Ivabradine
Correct Answer: Amlodipine
Explanation:The treatment of stable angina involves lifestyle changes, medication, percutaneous coronary intervention, and surgery. The first-line treatment recommended by NICE is either a beta-blocker or a calcium-channel blocker (CCB), depending on the patient’s comorbidities, contraindications, and preferences. If a beta-blocker at the maximum tolerated dose is not controlling angina, a long-acting dihydropyridine CCB, such as amlodipine, modified-release nifedipine, or modified-release felodipine, should be added. Aspirin and a statin should also be given, along with sublingual GTN to abort angina attacks.
However, if a patient is taking a beta-blocker, a non-rate-limiting long-acting dihydropyridine CCB should be used instead of diltiazem, as the combination of diltiazem and a beta-blocker can lead to life-threatening bradycardia and heart failure. If a patient cannot tolerate a beta-blocker or CCB, ivabradine, nicorandil, or ranolazine can be considered. Ivabradine should only be used on specialist advice and cannot be initiated if the resting heart rate is less than 70 bpm. Nicorandil induces vasodilation of arterioles and large coronary arteries by activating potassium channels. Verapamil should also be avoided in combination with a beta-blocker, as it can result in life-threatening bradycardia and heart failure.
-
This question is part of the following fields:
- Cardiovascular
-
-
Question 19
Incorrect
-
A 72-year-old man undergoing evaluation in the Medical Outpatient Department for complaints of joint pain is found to have weakly positive serum antinuclear antibodies (ANAs). All his other blood tests are within normal limits.
What is the most probable cause of this patient's ANA positivity?Your Answer: Ankylosing spondylitis (AS)
Correct Answer: Age related
Explanation:Understanding the Relationship Between ANAs and Various Medical Conditions
As individuals age, the level of anti-nuclear antibodies (ANAs) in their blood tends to increase, particularly in those over 65 years old. Therefore, a weakly positive ANA sample in an older patient with normal blood results is likely due to age-related factors.
Chronic fatigue syndrome (CFS) is not associated with ANA positivity. This diagnosis is made only after ruling out all other possibilities and finding no biochemical evidence to support it.
Ankylosing spondylitis (AS) is not linked to any known antibodies. While patients with AS may have elevated levels of non-specific inflammatory markers, such as C-reactive protein and erythrocyte sedimentation rate, genetic testing for human leukocyte antigen (HLA)-B27 may aid in diagnosis.
Primary antiphospholipid (APL) antibody syndrome does not typically involve ANA positivity. If ANAs are present in a patient with APL syndrome, it suggests a secondary form of the condition associated with a connective tissue disorder. APL syndrome is usually characterized by anti-cardiolipin antibodies and abnormal clotting studies.
Myasthenia gravis, a condition characterized by fatiguability and weakness induced by repeated actions, is not related to ANAs. Instead, it is caused by antibodies targeting the nicotinic acetylcholine receptor.
-
This question is part of the following fields:
- Immunology/Allergy
-
-
Question 20
Correct
-
A 42-year-old woman presents to the Ear, Nose and Throat Clinic with a 4-month history of right-sided hearing loss. She reports occasional buzzing in her right ear and feeling unsteady. She has no significant medical history and denies any recent infections. On examination, Rinne's test is positive in both ears, with Weber's test lateralizing to her left ear. There is no evidence of nystagmus, and her coordination remains intact. Apart from an absent right-sided corneal reflex, the rest of her cranial-nerve examination is unremarkable. What is the most appropriate investigation to confirm the diagnosis?
Your Answer: Magnetic resonance imaging (MRI) of the cerebellopontine angle with contrast
Explanation:Diagnostic Tests for Acoustic Tumours: Importance of MRI with Contrast
Acoustic tumours require accurate diagnosis for effective treatment. The most definitive diagnostic test is gadolinium-enhanced magnetic resonance imaging (MRI) of the cerebellopontine angle. This test can detect tumours as small as 1-2 mm in diameter, while fine-cut computed tomography (CT) scanning may miss tumours as large as 1.5 cm even with intravenous contrast enhancement.
Audiometry is also important, but only 5% of patients with acoustic tumours will have a normal audiogram. If MRI is contraindicated, air-contrast cisternography can detect relatively small intracanalicular tumours with high sensitivity.
Fine-cut CT scanning of the internal auditory canal with contrast can rule out medium to large tumours, but cannot reliably detect tumours smaller than 1-1.5 cm. CT scanning without contrast can rule out medium-sized tumours, but is not reliable for detecting smaller tumours.
It is critical to use gadolinium contrast in MRI of the cerebellopontine angle, as non-enhanced MRI may miss small tumours. Therefore, MRI with contrast is the most important diagnostic test for acoustic tumours.
-
This question is part of the following fields:
- Neurology
-
-
Question 21
Correct
-
A 35-year-old man complains of pain in his left ear. He was using cotton buds to clean his ears earlier today and experienced a sharp pain during the process. He now has slightly reduced hearing in his left ear. The patient reports no discharge and is in good health otherwise.
All of the patient's vital signs are normal. Upon examination of the left ear, a small perforation in the tympanic membrane is observed. There is no discharge or redness in the ear, and the ear canal is dry. The cranial nerve examination is unremarkable.
What is the next best course of action for managing this patient's condition?Your Answer: Reassure patient and review in 4 weeks
Explanation:If a patient has an uncomplicated tympanic membrane perforation that is dry, they can be managed with watchful waiting for a month without needing to see an ENT specialist. These perforations can occur due to various reasons such as blunt trauma, penetrating injuries, or barotrauma. Typically, the perforation will heal on its own within 4-8 weeks. However, patients should schedule a follow-up appointment after 4 weeks to ensure that the perforation is healing properly. If the patient experiences increasing ear pain, discharge, or worsening hearing loss, they should see their GP. During the examination, the patient should undergo a full examination, including otoscopy, cranial nerve examination, and Rinne/Weber tests. If there are any cranial nerve deficits, the patient should discuss them with an ENT specialist. Patients should keep their ears clean and dry, and topical antibiotics are not recommended for clean, dry perforations. If there are any signs of infection or contamination, topical antibiotics may be given. In cases where the patient has more complex issues such as temporal bone fractures or slowly healing perforations, they may need to be reviewed by an ENT specialist in an emergency clinic. If the perforation does not heal, surgical intervention may be necessary.
Perforated Tympanic Membrane: Causes and Management
A perforated tympanic membrane, also known as a ruptured eardrum, is a condition where there is a tear or hole in the thin tissue that separates the ear canal from the middle ear. The most common cause of this condition is an infection, but it can also be caused by barotrauma or direct trauma. When left untreated, a perforated tympanic membrane can lead to hearing loss and increase the risk of otitis media.
In most cases, no treatment is needed as the tympanic membrane will usually heal on its own within 6-8 weeks. During this time, it is important to avoid getting water in the ear. However, if the perforation occurs following an episode of acute otitis media, antibiotics may be prescribed. This approach is supported by the 2008 Respiratory tract infection guidelines from the National Institute for Health and Care Excellence (NICE).
If the tympanic membrane does not heal by itself, myringoplasty may be performed. This is a surgical procedure where a graft is used to repair the hole in the eardrum.
-
This question is part of the following fields:
- ENT
-
-
Question 22
Incorrect
-
A 62-year-old man presents to the clinic with a history of ischaemic heart disease and a recent diagnosis of type 2 diabetes mellitus. His HbA1c at the time of diagnosis was 7.6% (60 mmol/mol) and he was started on metformin, which was titrated up to a dose of 1g bd. His most recent blood work shows a HbA1c of 6.8% (51 mmol/mol). He has recently retired from the IT industry and has a BMI of 28 kg/m². He is currently taking atorvastatin 80 mg, aspirin 75mg, bisoprolol 2.5 mg, and ramipril 5mg. What would be the most appropriate next step?
Your Answer: Make no changes to his medication
Correct Answer: Add empagliflozin
Explanation:In addition to metformin, an SGLT-2 inhibitor (such as empagliflozin) should be prescribed for this patient who has a history of cardiovascular disease.
NICE updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022, reflecting advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. The first-line drug of choice remains metformin, which should be titrated up slowly to minimize gastrointestinal upset. HbA1c targets should be agreed upon with patients and checked every 3-6 months until stable, with consideration for relaxing targets on a case-by-case basis. Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates and controlling intake of foods containing saturated fats and trans fatty acids. Blood pressure targets are the same as for patients without type 2 diabetes, and antiplatelets should not be offered unless a patient has existing cardiovascular disease. Only patients with a 10-year cardiovascular risk > 10% should be offered a statin, with atorvastatin 20mg as the first-line choice.
-
This question is part of the following fields:
- Endocrinology/Metabolic Disease
-
-
Question 23
Correct
-
A 45-year-old man presents to the General Practitioner complaining of leg weakness. Other than a recent cold 1 month ago, he has been feeling well and has no significant medical history. On examination, it is noted that he has reduced power in his legs as well as reduced knee and ankle reflexes. His lower peripheral sensation was intact. What investigation can be done to confirm the likely diagnosis?
Your Answer: Lumbar puncture
Explanation:Diagnostic Tests for Guillain-Barré Syndrome
Guillain–Barré syndrome (GBS) is a rare autoimmune disorder that affects the peripheral nervous system. To confirm a diagnosis of GBS, several diagnostic tests may be performed.
Lumbar puncture (LP) is often done to confirm GBS and rule out an infection in the meninges. An LP in GBS would show a rise in protein with a normal white-blood-cell count, found in 66% of patients with GBS.
Magnetic resonance imaging (MRI) of the whole spine is unlikely to show GBS-specific abnormalities in the early stages of the disease, as it starts in the peripheral nervous system.
Blood cultures are not diagnostic of GBS, as the presence of Campylobacter jejuni (often the trigger for GBS) is unlikely to be detected four weeks after the infection.
Computed tomography (CT) of the head is not useful in diagnosing GBS, as the pathology is in the peripheral nervous system, and an abnormality in the brain would not be seen on imaging.
Electromyography (EMG) is not typically performed in GBS diagnosis. Instead, nerve conduction studies may be performed, which could show decreased motor nerve-conduction velocity (due to demyelination), prolonged distal motor latency, and increased F-wave latency.
In conclusion, a combination of clinical presentation, lumbar puncture, and nerve conduction studies can help diagnose Guillain-Barré syndrome.
-
This question is part of the following fields:
- Neurology
-
-
Question 24
Correct
-
A 68-year-old man comes to the Emergency Department complaining of left-sided chest pain that has been ongoing for 2 hours. He mentions experiencing similar pains that occur during exercise and subside when he rests. The patient appears to be in distress, sweating, and having difficulty breathing. An ECG is conducted, revealing new T-wave inversion in V3-V6. His troponin and d-dimer levels are as follows:
Troponin 223 ng/L (<5)
D-Dimer 932 ng/mL (< 400)
What is the most probable diagnosis?Your Answer: Non-ST-elevation myocardial infarction (NSTEMI)
Explanation:Acute coronary syndrome (ACS) is a term that covers various acute presentations of ischaemic heart disease, including ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina. ACS develops in patients with ischaemic heart disease, which is the gradual build-up of fatty plaques in the coronary arteries. ACS can cause chest pain, dyspnoea, sweating, and nausea and vomiting. The two most important investigations for ACS are an ECG and cardiac markers. Treatment for ACS includes preventing worsening of presentation, revascularising the vessel is occluded, and treating pain. Patients who have had an ACS require lifelong drug therapy to reduce the risk of a further event.
-
This question is part of the following fields:
- Cardiovascular
-
-
Question 25
Incorrect
-
A 25-year-old hiker comes to you with complaints of fever, joint pain, and a red rash after being bitten by a tick during a recent hike. Upon examination, you find that his neurological and cardiovascular functions are normal. You suspect that he may have contracted Lyme disease and have ordered serology for Borrelia burgdorferi. What would be the most suitable course of action for managing this condition?
Your Answer: 7 day course of doxycycline
Correct Answer: 14 day course of doxycycline
Explanation:The recommended initial treatment for early Lyme disease is a 14-21 day regimen of oral doxycycline. For non-disseminated Lyme disease, the first line treatment is a 14-day course of oral doxycycline, making option 2 the correct answer. Amoxicillin may be used if doxycycline is contraindicated, such as during pregnancy. Ceftriaxone is reserved for disseminated disease. Treatment should be initiated based on clinical suspicion, as serology may take several weeks to become positive.
Understanding Lyme Disease
Lyme disease is a bacterial infection caused by Borrelia burgdorferi and is transmitted through tick bites. The early symptoms of Lyme disease include erythema migrans, a characteristic bulls-eye rash that appears at the site of the tick bite. This rash is painless, slowly increases in size, and can be more than 5 cm in diameter. Other early symptoms include headache, lethargy, fever, and joint pain.
If erythema migrans is present, Lyme disease can be diagnosed clinically, and antibiotics should be started immediately. The first-line test for Lyme disease is an enzyme-linked immunosorbent assay (ELISA) to detect antibodies to Borrelia burgdorferi. If the ELISA is negative but Lyme disease is still suspected, it should be repeated 4-6 weeks later. If Lyme disease is suspected in patients who have had symptoms for 12 weeks or more, an immunoblot test should be done.
Tick bites can cause significant anxiety, but routine antibiotic treatment is not recommended by NICE. If the tick is still present, it should be removed using fine-tipped tweezers, and the area should be washed. In cases of suspected or confirmed Lyme disease, doxycycline is the preferred treatment for early disease, while ceftriaxone is used for disseminated disease. A Jarisch-Herxheimer reaction may occur after initiating therapy, which can cause fever, rash, and tachycardia.
In summary, Lyme disease is a bacterial infection transmitted through tick bites. Early symptoms include erythema migrans, headache, lethargy, fever, and joint pain. Diagnosis is made through clinical presentation and ELISA testing, and treatment involves antibiotics. Tick bites do not require routine antibiotic treatment, and ticks should be removed using fine-tipped tweezers.
-
This question is part of the following fields:
- Infectious Diseases
-
-
Question 26
Correct
-
A 72-year-old male presents with weight loss and heat intolerance. He is taking multiple medications for atrial fibrillation, ischaemic heart disease and rheumatoid arthritis. Thyroid function tests are requested and the results are shown in the table below:
Thyroid stimulating hormone (TSH) 0.2 mU/L
Free T4 35 pmol/L
What is the most likely cause of these findings?Your Answer: Amiodarone
Explanation:Amiodarone and Thyroid Dysfunction
Amiodarone is a medication used to treat heart rhythm disorders. However, around 1 in 6 patients taking amiodarone develop thyroid dysfunction. This can manifest as either amiodarone-induced hypothyroidism (AIH) or amiodarone-induced thyrotoxicosis (AIT).
The pathophysiology of AIH is thought to be due to the high iodine content of amiodarone causing a Wolff-Chaikoff effect. This is an autoregulatory phenomenon where thyroxine formation is inhibited due to high levels of circulating iodide. Despite this, amiodarone may be continued if desirable.
On the other hand, AIT may be divided into two types: type 1 and type 2. Type 1 is caused by excess iodine-induced thyroid hormone synthesis, while type 2 is caused by amiodarone-related destructive thyroiditis. In patients with AIT, amiodarone should be stopped if possible.
It is important for healthcare professionals to monitor patients taking amiodarone for any signs of thyroid dysfunction and adjust treatment accordingly.
-
This question is part of the following fields:
- Pharmacology/Therapeutics
-
-
Question 27
Correct
-
A 50-year-old right-handed male gardener presents with elbow pain. He reports a gradual onset of pain in his left elbow over a period of four weeks with only mild relief from over-the-counter pain medication. The patient enjoys playing tennis and does yard work regularly. He does recall a fall at home four weeks ago where he landed on his right elbow. The patient denies any fever and feels generally well. During the examination, the patient experiences tenderness over the left elbow with resisted wrist extension/supination and the elbow held in extension. There is no significant swelling over the olecranon. What is the most probable cause of this man's elbow pain?
Your Answer: Lateral epicondylitis
Explanation:The most probable diagnosis for this patient is lateral epicondylitis, which is characterized by pain around the lateral epicondyle of the humerus that radiates to the forearm. The pain is exacerbated by repetitive movements with the dominant hand, which is common in the patient’s job as a cleaner. The pain is worsened by resisted wrist extension and supination while the elbow is extended. Medial epicondylitis, olecranon bursitis, radial head fractures, and septic arthritis are less likely differentials as they do not match the examination findings in this scenario.
Understanding Lateral Epicondylitis
Lateral epicondylitis, commonly known as tennis elbow, is a condition that often occurs after engaging in activities that the body is not accustomed to, such as painting or playing tennis. It is most prevalent in individuals aged 45-55 years and typically affects the dominant arm. The primary symptom of this condition is pain and tenderness localized to the lateral epicondyle. The pain is often exacerbated by wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended. Episodes of lateral epicondylitis can last between 6 months and 2 years, with patients experiencing acute pain for 6-12 weeks.
To manage lateral epicondylitis, it is essential to avoid muscle overload and engage in simple analgesia. Steroid injections and physiotherapy are also viable options for managing the condition. By understanding the symptoms and management options for lateral epicondylitis, individuals can take the necessary steps to alleviate pain and discomfort associated with this condition.
-
This question is part of the following fields:
- Musculoskeletal
-
-
Question 28
Correct
-
A 67-year-old man with COPD comes to the emergency department complaining of right-sided chest pain and shortness of breath that has been present for the past 4 days. A chest x-ray reveals a 2cm right-sided apical pneumothorax, which the on-call emergency physician promptly aspirates. The man has a smooth recovery but is curious about how he can avoid any future recurrences.
What recommendations should be given to the patient?Your Answer: Avoid deep sea diving for life
Explanation:The patient should be advised to avoid deep-sea diving for life due to the risk of pneumothorax. However, they can fly one week after having a chest x-ray showing complete resolution of the pneumothorax. There is no increased risk of catamenial pneumothoraces. Pleurodesis is not necessary for a single pneumothorax, whether primary or secondary.
Management of Pneumothorax: BTS Guidelines
Pneumothorax is a condition where air accumulates in the pleural space, causing the lung to collapse. The British Thoracic Society (BTS) has published updated guidelines for the management of spontaneous pneumothorax, which can be primary or secondary. Primary pneumothorax occurs without any underlying lung disease, while secondary pneumothorax is associated with lung disease.
The BTS guidelines recommend that patients with a rim of air less than 2cm and no shortness of breath may be discharged, while those with a larger rim of air or shortness of breath should undergo aspiration or chest drain insertion. For secondary pneumothorax, patients over 50 years old with a rim of air greater than 2cm or shortness of breath should undergo chest drain insertion. Aspiration may be attempted for those with a rim of air between 1-2cm, but chest drain insertion is necessary if aspiration fails.
For iatrogenic pneumothorax, observation is usually sufficient, but chest drain insertion may be necessary in some cases. Ventilated patients and those with chronic obstructive pulmonary disease (COPD) may require chest drain insertion. If a patient has persistent or recurrent pneumothorax, video-assisted thoracoscopic surgery (VATS) may be necessary.
Patients should be advised to avoid smoking to reduce the risk of further episodes. Fitness to fly is an absolute contraindication, but patients may travel 1 week after successful drainage if there is no residual air. Scuba diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.
Overall, the BTS guidelines provide a comprehensive approach to the management of pneumothorax, taking into account the type of pneumothorax, patient characteristics, and potential complications.
-
This question is part of the following fields:
- Respiratory Medicine
-
-
Question 29
Incorrect
-
A 50-year-old female patient visits the clinic complaining of an itchy rash. During the examination, the doctor observes several purple papular rashes on the flexural surface of her wrists. Additionally, a similar rash is present at the edges of a laceration wound she suffered a week ago. What is the recommended initial treatment for this condition?
Your Answer: Calcitriol ointment
Correct Answer: Hydrocortisone cream
Explanation:Lichen planus is present in this woman, but it appears to be limited in scope. The initial treatment for lichen planus is potent topical steroids. Oral azathioprine or prednisolone is only prescribed if the condition is widespread. Coal tar cream and calcitriol ointment are not effective treatments for lichen planus.
Understanding Lichen Planus
Lichen planus is a skin condition that is believed to be caused by an immune response, although the exact cause is unknown. It is characterized by an itchy, papular rash that typically appears on the palms, soles, genitalia, and flexor surfaces of the arms. The rash often has a polygonal shape and a distinctive white-lines pattern on the surface, known as Wickham’s striae. In some cases, new skin lesions may appear at the site of trauma, a phenomenon known as the Koebner phenomenon.
Oral involvement is common in around 50% of patients, with a white-lace pattern often appearing on the buccal mucosa. Nail changes may also occur, including thinning of the nail plate and longitudinal ridging. Lichenoid drug eruptions can be caused by certain medications, such as gold, quinine, and thiazides.
The main treatment for lichen planus is potent topical steroids. For oral lichen planus, benzydamine mouthwash or spray is recommended. In more extensive cases, oral steroids or immunosuppression may be necessary.
-
This question is part of the following fields:
- Dermatology
-
-
Question 30
Correct
-
A 6-year-old girl with known sickle cell disease presents with pallor, back pain and a 6-cm tender, enlarged spleen. She is anaemic with a raised reticulocyte count, and is moderately jaundiced.
Which one of the following is the most likely diagnosis?
Your Answer: Splenic sequestration crisis
Explanation:Differentiating Sickle Cell Disease Complications: A Guide
Sickle cell disease is a genetic disorder that affects the shape of red blood cells, leading to a range of complications. Here is a guide to differentiating between some of the most common complications:
Splenic Sequestration Crisis: This occurs when sickled red blood cells become trapped in the spleen, leading to abdominal pain, splenomegaly, and signs of anemia. It is most common in children aged 5 months to 2 years and may be associated with infection. Treatment involves fluid resuscitation and transfusion, with splenectomy advised for recurrent cases.
Haemolytic Crisis: Chronic haemolysis is a feature of sickle cell disease, but worsening haemolysis may accompany acute deteriorations. This leads to a reduction in haemoglobin and an increase in unconjugated bilirubin. However, isolated haemolysis would not lead to abdominal pain and splenomegaly.
Aplastic Crisis: This is a temporary cessation of red blood cell production, often associated with parvovirus B19 infection. Patients present with fatigue, pallor, shortness of breath, and low reticulocyte counts.
Girdle Syndrome: This rare complication is characterised by an established ileus, with vomiting, distended abdomen, and absent bowel sounds. It is often associated with bilateral basal lung consolidation, but this patient does not exhibit these features.
Painful Crisis: This is the most common reason for hospital admission in sickle cell disease patients. It is characterised by recurrent attacks of acute severe pain, triggered by sickling and vaso-occlusion. Splenomegaly is not a feature of painful crisis.
-
This question is part of the following fields:
- Paediatrics
-
-
Question 31
Correct
-
You are the paediatric SHO on call. You receive a call to attend the emergency department to assess a 3-year-old with stridor. Upon arrival, you find the patient sitting on their mother's lap, leaning forward and drooling. Audible stridor can be heard from the end of the bed. The patient's medical history reveals that they have not received any vaccinations.
What is the most suitable course of action in this scenario?Your Answer: Call the anaesthetist on call
Explanation:Do not perform oral or throat examination on a child with suspected acute epiglottitis as it may lead to further airway obstruction and distress. Basic observations can be done but call the senior paediatric team and an anaesthetist.
Stridor in Children: Causes and Symptoms
Stridor is a high-pitched, wheezing sound that occurs during breathing and is commonly seen in children. There are several causes of stridor in children, including croup, acute epiglottitis, inhaled foreign body, and laryngomalacia. Croup is a viral infection that affects the upper respiratory tract and is characterized by stridor, barking cough, fever, and coryzal symptoms. Acute epiglottitis is a rare but serious infection caused by Haemophilus influenzae type B, which can lead to airway obstruction. Inhaled foreign body can cause sudden onset of coughing, choking, vomiting, and stridor, depending on the site of impaction. Laryngomalacia is a congenital abnormality of the larynx that typically presents at 4 weeks of age with stridor.
It is important to recognize the symptoms of stridor in children and seek prompt medical attention, especially if the child appears unwell or toxic. Treatment may include medications, such as corticosteroids or nebulized epinephrine, or in severe cases, intubation or tracheostomy. Prevention measures, such as vaccination against Haemophilus influenzae type B, can also help reduce the incidence of acute epiglottitis. Overall, early recognition and management of stridor in children can help prevent complications and improve outcomes.
-
This question is part of the following fields:
- Paediatrics
-
-
Question 32
Incorrect
-
A 65-year-old female is referred for management of a chronic ulcer above the left medial malleolus. The ankle-brachial pressure index readings are as follows:
Right 0.95
Left 0.95
The ulcer has been treated with standard dressings by the District Nurse. What is the best course of action to increase the chances of healing the ulcer?Your Answer: Intermittent pneumatic compression
Correct Answer:
Explanation:Compression bandaging is recommended for the management of venous ulceration, as the ankle-brachial pressure index readings suggest that the ulcers are caused by venous insufficiency rather than arterial issues.
Venous Ulceration and its Management
Venous ulceration is a type of ulcer that is commonly seen above the medial malleolus. To assess for poor arterial flow that could impair healing, an ankle-brachial pressure index (ABPI) is important in non-healing ulcers. A normal ABPI is usually between 0.9 – 1.2, while values below 0.9 indicate arterial disease. Interestingly, values above 1.3 may also indicate arterial disease, particularly in diabetics, due to false-negative results caused by arterial calcification.
The only treatment that has been shown to be of real benefit for venous ulceration is compression bandaging, usually four-layer. Oral pentoxifylline, a peripheral vasodilator, can also improve the healing rate. There is some small evidence supporting the use of flavonoids, but little evidence to suggest benefit from hydrocolloid dressings, topical growth factors, ultrasound therapy, and intermittent pneumatic compression. Proper management of venous ulceration is crucial to promote healing and prevent complications.
-
This question is part of the following fields:
- Dermatology
-
-
Question 33
Correct
-
A 16-year-old complains of left knee pain that has been present for the last 4 weeks. No injury history is reported. The pain is located in the front of the joint and is aggravated when ascending or descending stairs. Physical examination reveals no significant findings. What is the probable diagnosis?
Your Answer: Chondromalacia patellae
Explanation:Common Knee Problems in Children and Young Adults
Knee problems are common in children and young adults, especially those who are active in sports.
Chondromalacia patellae is a condition that is more common in teenage girls. It is characterized by the softening of the cartilage of the patella, which can cause anterior knee pain when walking up and down stairs or rising from prolonged sitting. This condition usually responds well to physiotherapy.Osgood-Schlatter disease, also known as tibial apophysitis, is often seen in sporty teenagers. It causes pain, tenderness, and swelling over the tibial tubercle.
Osteochondritis dissecans can cause pain after exercise, as well as intermittent swelling and locking of the knee.
Patellar subluxation can cause medial knee pain due to lateral subluxation of the patella. The knee may also give way.
Patellar tendonitis is more common in athletic teenage boys. It causes chronic anterior knee pain that worsens after running. On examination, the area below the patella is tender. It is important to note that referred pain may come from hip problems such as slipped upper femoral epiphysis.
-
This question is part of the following fields:
- Paediatrics
-
-
Question 34
Correct
-
A 30-year-old woman visits her doctor with worries about a genetic disorder. Her granddaughter, who is three years old, has been diagnosed with sickle cell anemia. She reports that no one else in the family has the condition.
What is the likelihood of her being a carrier of the sickle cell allele?Your Answer: 1 in 2
Explanation:Understanding the Probability of Cystic Fibrosis Inheritance
Cystic fibrosis is a genetic condition that is inherited in an autosomal recessive pattern. This means that for a child to be affected, they must inherit two mutated alleles – one from each parent. If one grandparent is a carrier, there is a 1 in 2 chance that they passed the gene on to their offspring, who is the parent of the affected child.
When both parents are carriers, there is a 1 in 4 chance that their child will be affected by cystic fibrosis. However, the chance of inheriting the condition is always 1 in 2 for boys and girls.
Diagnosis of cystic fibrosis often occurs before the age of two, with up to 75% of patients being diagnosed at this age. It is important to note that carriers of cystic fibrosis are relatively common, with an estimated 1 in 25 people in the UK being carriers.
Understanding the probability of cystic fibrosis inheritance is crucial for families with a history of the condition, as it can help them make informed decisions about family planning and genetic testing.
-
This question is part of the following fields:
- Genetics
-
-
Question 35
Incorrect
-
A 45-year-old woman with type II diabetes mellitus and a history of hypertension, on maximum-dose metformin, was started on gliclazide three weeks ago. Since then she has had recurrent hypoglycaemic events requiring Accident and Emergency (A&E) attendance.
Investigation Result Normal values
HbA1c 72 mmol/mol (8.7%) 20-42 mmol/mol (4.2-6.2%)
Which of the following is the best action to take?
Select the SINGLE action from the list below.Your Answer: Stop gliclazide and start pioglitazone
Correct Answer: Stop gliclazide and start sitagliptin
Explanation:Choosing the Right Treatment for Hypoglycaemic Episodes in Type 2 Diabetes
When metformin alone is not enough to control HbA1c in type 2 diabetes, NICE recommends adding a sulfonylurea, pioglitazone, or a DPP-4 inhibitor. However, if the patient experiences hypoglycaemic episodes, it is important to reassess the treatment plan.
Stopping gliclazide, a sulfonylurea, is necessary as it is likely causing the hypoglycaemic episodes. Pioglitazone is contraindicated in patients with heart failure, so a DPP-4 inhibitor like sitagliptin is the appropriate next step.
Initiating insulin is not recommended as it can be dangerous, and should only be considered after other options have failed. Reducing metformin is unlikely to prevent hypoglycaemic episodes as it does not typically cause them on its own.
In summary, choosing the right treatment for hypoglycaemic episodes in type 2 diabetes involves careful consideration of the patient’s medical history and NICE guidelines.
-
This question is part of the following fields:
- Endocrinology/Metabolic Disease
-
-
Question 36
Correct
-
A 35-year-old pregnant woman and her husband are informed at the 20-week antenatal scan of the presence of echogenic bowel in the male fetus. They had been trying to conceive unsuccessfully for three years until investigations revealed oligospermia and this pregnancy was a result of intrauterine insemination. Both parents are aged 35 years old. The father has had several episodes of upper respiratory tract infections that have required antibiotics and he has been admitted to hospital in the past with acute gastritis. The mother is fit and well without any significant past medical history.
Which of the following would be the most appropriate next investigation?
Your Answer: Testing for the CFTR gene mutation in both parents
Explanation:Cystic fibrosis (CF) is a genetic condition that requires two copies of a faulty CFTR gene, one from each parent. If symptoms are present, it is important to confirm the diagnosis in the father and determine if the mother is a carrier of the faulty gene before pursuing further testing. While a sweat test can diagnose CF in the father, it cannot determine carrier status in the mother. Invasive procedures such as amniocentesis and chorionic villous sampling should only be performed if there is strong suspicion of a chromosomal or genetic abnormality, and less invasive genetic testing of both parents should be considered first. Karyotyping is not a useful diagnostic tool for CF, as it only detects chromosomal abnormalities and not genetic ones.
-
This question is part of the following fields:
- Genetics
-
-
Question 37
Correct
-
A 58-year-old man has been experiencing recurrent epigastric pain for several years. His symptoms improved with a proton pump inhibitor (PPI) but returned after discontinuing the medication. He tested positive for Helicobacter pylori, but his symptoms returned after receiving eradication therapy. He now has unexplained iron deficiency anemia. What is the most appropriate next step in management?
Your Answer: Refer for endoscopy under the 2-week wait pathway
Explanation:Management of a Patient with ‘Red Flag’ Symptoms: Urgent Referral for Endoscopy
When managing a patient aged over 55 years with ‘red flag’ symptoms such as gastrointestinal bleeding, anorexia, weight loss, dysphagia, or the presence of an epigastric mass, it is crucial to refer them for an urgent endoscopy to exclude serious pathology such as malignancy. In such cases, it would be inappropriate to manage the patient with medication alone, even if a previous trial of proton pump inhibitors (PPIs) provided effective symptom relief. While dietary and lifestyle advice could be provided, it would not be an appropriate management strategy as a single intervention. Additionally, retesting for H. pylori would not be necessary as adequate triple therapy for H. pylori eradication has reported high cure rates. The priority in managing such patients is to refer them for urgent endoscopy to ensure timely diagnosis and appropriate treatment.
-
This question is part of the following fields:
- Gastroenterology/Nutrition
-
-
Question 38
Correct
-
A mother brings her 8-year-old daughter into the clinic with worries about her eyes. She believes her daughter's left eye is 'turned outwards'. The child reports no changes in her vision. Upon examination, a left exotropia is observed. The child is instructed to cover her right eye while looking at a fixed point, and the left eye moves inward to maintain focus. What is the best course of action for this patient?
Your Answer: Referral to ophthalmology
Explanation:Children with a squint should be referred to ophthalmology for assessment. Exotropia, or an outwardly turned eye, requires evaluation of the type and severity of the squint by a paediatric eye service. Advising the use of a plaster over the good eye before follow-up is not appropriate as the underlying causes of the squint need to be addressed first, such as a space-occupying lesion or refractive error. Optometrists are not medical doctors and a full assessment by an ophthalmologist is necessary to identify and treat any medical or surgical causes, such as retinoblastoma. Reassurance is not appropriate as squints can worsen and lead to amblyopia, which can be prevented with early treatment. Follow-up in 6 months would also be inappropriate.
Squint, also known as strabismus, is a condition where the visual axes are misaligned. There are two types of squints: concomitant and paralytic. Concomitant squints are more common and are caused by an imbalance in the extraocular muscles. On the other hand, paralytic squints are rare and are caused by the paralysis of extraocular muscles. It is important to detect squints early on as they can lead to amblyopia, where the brain fails to process inputs from one eye and favours the other eye over time.
To detect a squint, a corneal light reflection test can be performed by holding a light source 30cm from the child’s face to see if the light reflects symmetrically on the pupils. The cover test is also used to identify the nature of the squint. This involves asking the child to focus on an object, covering one eye, and observing the movement of the uncovered eye. The test is then repeated with the other eye covered.
If a squint is detected, it is important to refer the child to secondary care. Eye patches may also be used to help prevent amblyopia.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 39
Incorrect
-
A 65-year-old overweight man presents with worsening shortness of breath and leg swelling due to advanced heart failure. His kidney function is normal and his potassium level is 4.2 mmol/l. Which combination of medications would provide the greatest mortality benefit for him?
Your Answer: Ramipril, amiloride, bendroflumethiazide and atenolol
Correct Answer: Ramipril and bisoprolol
Explanation:There are several medications used to treat heart failure, including ACE inhibitors and beta-blockers, which have been shown to provide a mortality benefit. However, ACE inhibitors can cause hyperkalaemia, so potassium levels should be monitored closely when starting. If ACE inhibitors are not tolerated, angiotensin II receptor antagonists can be used instead. Atenolol is not recommended for use in heart failure, and agents typically used are bisoprolol, carvedilol, or metoprolol. Diuretics like furosemide and bendroflumethiazide provide symptom relief but do not improve mortality. When used together, they have a potent diuretic effect that may be required when patients accumulate fluid despite an adequate furosemide dose. However, this combination provides no long-term mortality benefit. It is important to note that decisions regarding medication management should be made by a specialist.
-
This question is part of the following fields:
- Cardiovascular
-
-
Question 40
Correct
-
A 50-year-old female patient arrives at the emergency department via ambulance after experiencing a sudden onset of facial droop and speech impairment. Upon examination, she is conscious but displays both expressive and receptive aphasia. The patient's GP summary record indicates that she is only taking tamoxifen. Based on this information, what is the most probable medical condition in her past medical history?
Your Answer: Oestrogen receptor-positive breast cancer
Explanation:Pre-menopausal women with oestrogen receptor-positive breast cancer are managed using Tamoxifen.
Tamoxifen is ineffective in treating oestrogen receptor-negative breast cancer or ovarian cancer.
However, Tamoxifen may increase the risk of endometrial cancer.
Colorectal cancer is not treated with Tamoxifen.Anti-oestrogen drugs are used in the management of oestrogen receptor-positive breast cancer. Selective oEstrogen Receptor Modulators (SERM) such as Tamoxifen act as an oestrogen receptor antagonist and partial agonist. However, Tamoxifen can cause adverse effects such as menstrual disturbance, hot flushes, venous thromboembolism, and endometrial cancer. On the other hand, aromatase inhibitors like Anastrozole and Letrozole reduce peripheral oestrogen synthesis, which is important in postmenopausal women. Anastrozole is used for ER +ve breast cancer in this group. However, aromatase inhibitors can cause adverse effects such as osteoporosis, hot flushes, arthralgia, myalgia, and insomnia. NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer.
-
This question is part of the following fields:
- Neurology
-
-
Question 41
Correct
-
A 72-year-old man with atrial fibrillation (AF) experiences colicky abdominal pain after eating a large meal; this has been happening consistently for the past 3 weeks, causing him to develop a fear of eating.
What is the most probable diagnosis?
Your Answer: Chronic mesenteric ischaemia (CMI)
Explanation:Differential Diagnosis for Abdominal Pain: Chronic Mesenteric Ischaemia, Chronic Pancreatitis, Diverticulitis, Gastric Cancer, and Acute Mesenteric Ischaemic Embolism
Abdominal pain is a common presenting symptom in clinical practice, and it can be caused by a variety of conditions. In this article, we will discuss the differential diagnosis for abdominal pain, including chronic mesenteric ischaemia (CMI), chronic pancreatitis, diverticulitis, gastric cancer, and acute mesenteric ischaemic embolism.
CMI usually results from atherosclerotic disease of two or more mesenteric vessels, while chronic pancreatitis is characterised by a continuing, chronic, inflammatory process of the pancreas. Diverticulitis is an inflammation of one or more diverticula, while gastric cancer is the third most common cause of cancer-related death in the world. Acute mesenteric ischaemic embolism is characterised by pain that is disproportionate to physical examination findings.
Each condition has its own unique set of symptoms and clinical presentation. By understanding the differential diagnosis for abdominal pain, clinicians can make an accurate diagnosis and provide appropriate treatment for their patients.
-
This question is part of the following fields:
- Gastroenterology/Nutrition
-
-
Question 42
Incorrect
-
A 23-year-old woman contacts her doctor to request a referral for antenatal care. She has been attempting to conceive for the past year and has recently received a positive pregnancy test result. Her LMP was 5 weeks ago, which prompted her to take the test. The patient is in good health with no underlying medical conditions, does not smoke, and abstains from alcohol. Her BMI is 34 kg/m².
What is the advised folic acid consumption for this patient?Your Answer: Folic acid 400mcg daily, continue until end of pregnancy
Correct Answer: Folic acid 5mg daily, continue until end of 1st trimester
Explanation:Pregnant women who have a BMI of 30 kg/m² or higher should be given a daily dose of 5mg folic acid until the 13th week of their pregnancy. Folic acid is crucial during the first trimester as it helps prevent neural tube defects (NTD). Typically, a daily dose of 400mcg is sufficient for most pregnant women during the first 12 weeks of pregnancy. However, those with a BMI of over 30 kg/m², as well as those with diabetes, sickle cell disease (SCD), thalassaemia trait, coeliac disease, on anti-epileptic medication, personal or family history of NTD, or who have previously given birth to a baby with an NTD, should be prescribed a daily dose of 5mg folic acid. It is recommended that folic acid be taken while trying to conceive to further reduce the risk of NTD. Additionally, NICE advises all pregnant women to take a daily dose of 10mcg (400 units) of vitamin D throughout their entire pregnancy.
Pregnancy and Obesity: Risks and Management
Obesity during pregnancy can lead to various complications for both the mother and the unborn child. A BMI of 30 kg/m² or higher at the first antenatal visit is considered obese. Maternal risks include miscarriage, venous thromboembolism, gestational diabetes, pre-eclampsia, dysfunctional and induced labour, postpartum haemorrhage, wound infections, and a higher rate of caesarean section. Fetal risks include congenital anomaly, prematurity, macrosomia, stillbirth, increased risk of developing obesity and metabolic disorders in childhood, and neonatal death.
It is important to inform women with a BMI of 30 or more at the booking appointment about the risks associated with obesity during pregnancy. They should not attempt to reduce the risk by dieting while pregnant, and healthcare professionals will manage the risk during their pregnancy.
Management of obesity during pregnancy includes taking 5mg of folic acid instead of 400mcg, screening for gestational diabetes with an oral glucose tolerance test (OGTT) at 24-28 weeks, giving birth in a consultant-led obstetric unit if the BMI is 35 kg/m² or higher, and having an antenatal consultation with an obstetric anaesthetist and a plan made if the BMI is 40 kg/m² or higher. It is important to manage obesity during pregnancy to reduce the risks and ensure the health of both the mother and the unborn child.
-
This question is part of the following fields:
- Reproductive Medicine
-
-
Question 43
Incorrect
-
A 29-year-old woman comes to see her GP due to feeling down and lonely. She reports being a naturally shy person and experiencing intense anxiety about being judged or rejected by others for her perceived inadequacies. This has led her to avoid forming close relationships and she has even stopped seeing the few friends she had. Her social anxiety affects all aspects of her life, including her choice of a solitary job, solo hobbies, and never having been in a romantic relationship. She finds it challenging to deviate from her limited daily routine, although she feels unfulfilled by it. What is the probable diagnosis?
Your Answer: Generalised anxiety disorder
Correct Answer: Avoidant personality disorder
Explanation:The patient’s description of feeling lonely and avoiding social situations due to fear of negative evaluation and criticism suggests a diagnosis of avoidant personality disorder. This disorder is characterized by chronic patterns of interpersonal inhibition, fear of rejection, and social inhibition. The patient’s symptoms are pervasive and have been present since childhood or adolescence, indicating a personality disorder rather than a transient condition. While other disorders such as autism spectrum disorder, generalized anxiety disorder, and schizoid personality disorder may also involve social difficulties, they do not have the same fear of rejection and feelings of inadequacy that are characteristic of avoidant personality disorder.
Personality disorders are a set of personality traits that are maladaptive and interfere with normal functioning in life. It is estimated that around 1 in 20 people have a personality disorder, which are typically categorized into three clusters: Cluster A, which includes Odd or Eccentric disorders such as Paranoid, Schizoid, and Schizotypal; Cluster B, which includes Dramatic, Emotional, or Erratic disorders such as Antisocial, Borderline (Emotionally Unstable), Histrionic, and Narcissistic; and Cluster C, which includes Anxious and Fearful disorders such as Obsessive-Compulsive, Avoidant, and Dependent.
Paranoid individuals exhibit hypersensitivity and an unforgiving attitude when insulted, a reluctance to confide in others, and a preoccupation with conspirational beliefs and hidden meanings. Schizoid individuals show indifference to praise and criticism, a preference for solitary activities, and emotional coldness. Schizotypal individuals exhibit odd beliefs and magical thinking, unusual perceptual disturbances, and inappropriate affect. Antisocial individuals fail to conform to social norms, deceive others, and exhibit impulsiveness, irritability, and aggressiveness. Borderline individuals exhibit unstable interpersonal relationships, impulsivity, and affective instability. Histrionic individuals exhibit inappropriate sexual seductiveness, a need to be the center of attention, and self-dramatization. Narcissistic individuals exhibit a grandiose sense of self-importance, lack of empathy, and excessive need for admiration. Obsessive-compulsive individuals are occupied with details, rules, and organization to the point of hampering completion of tasks. Avoidant individuals avoid interpersonal contact due to fears of criticism or rejection, while dependent individuals have difficulty making decisions without excessive reassurance from others.
Personality disorders are difficult to treat, but a number of approaches have been shown to help patients, including psychological therapies such as dialectical behavior therapy and treatment of any coexisting psychiatric conditions.
-
This question is part of the following fields:
- Psychiatry
-
-
Question 44
Correct
-
A 62-year-old non-smoker with no significant medical history presents to their GP with a cough producing green sputum, fatigue, and shortness of breath that has lasted for several days. During chest examination, coarse crackles are heard in the lower right zone. The patient's observations are as follows: respiratory rate of 20 breaths per minute, oxygen saturation of 97% on air, heart rate of 80 beats per minute, blood pressure of 110/75 mmHg, temperature of 38.1ºC, and an abbreviated mental test score of 10/10. The patient is not on any regular medication and has no allergies. What is the most appropriate treatment?
Your Answer: Discharge with oral amoxicillin
Explanation:The recommended first-line antibiotic for patients with low severity community-acquired pneumonia (CAP) is oral amoxicillin. Therefore, it is appropriate to discharge this patient with oral amoxicillin as they present with symptoms of CAP, including a new cough, temperature, purulent sputum, and focal chest signs. While a chest x-ray could confirm the diagnosis, it is not usually necessary for suspected CAP managed in primary care. The patient’s CRB-65 score is 0, indicating that they can be managed in the community. Hospitalization may be required for patients with higher scores or clinical factors that increase the risk of complications, but this is not the case for this patient. Discharge with oral clarithromycin or doxycycline is not appropriate as there is no indication that amoxicillin is unsuitable as the first-line antibiotic.
Pneumonia is a serious respiratory infection that requires prompt assessment and management. In the primary care setting, the CRB65 criteria are used to stratify patients based on their risk of mortality. Patients with a score of 0 are considered low risk and may be treated at home, while those with a score of 3 or 4 are high risk and require urgent admission to hospital. The use of a point-of-care CRP test can help guide antibiotic therapy. In the secondary care setting, the CURB65 criteria are used, which includes an additional criterion of urea > 7 mmol/L. Chest x-rays and blood and sputum cultures are recommended for intermediate or high-risk patients. Treatment for low-severity community acquired pneumonia typically involves a 5-day course of amoxicillin, while moderate and high-severity cases may require dual antibiotic therapy for 7-10 days. Discharge criteria and advice post-discharge are also provided, including information on expected symptom resolution timeframes and the need for a repeat chest x-ray at 6 weeks.
-
This question is part of the following fields:
- Respiratory Medicine
-
-
Question 45
Correct
-
An infant develops bile-stained vomiting; an abdominal X-ray shows a ‘double bubble’ appearance. The infant is also hypotonic with brachycephaly.
Which of the following is the most likely diagnosis?
Your Answer: Trisomy 21
Explanation:Genetic Disorders and Associated Phenotypic Features
Trisomy 21: Down Syndrome and Duodenal Atresia
Neonates with Down syndrome have an increased risk of duodenal atresia, accounting for around a third of cases. Prenatal imaging can detect this condition, which presents with bilious vomiting within hours of birth. Down syndrome is also characterized by distinct physical features such as brachiocephaly, upward slanting palpebral fissures, and joint hyperflexibility.45,XO: Turner Syndrome and Cardiac Defects
Turner syndrome affects females with a genetic complement of 45XO. It is characterized by short stature, webbed neck, and lymphoedema. Cardiac defects, including coarctation of the aorta, may also be present.Fragile X: Learning Disability and Autism
Fragile X is a common X-linked form of learning disability and autism. Physical features are difficult to detect in infancy, but delayed motor milestones and speech and language delay may be present. Macro-orchidism is almost universal post-puberty, and cardiac defects, including mitral valve prolapse, may occur.Trisomy 18: Edwards’ Syndrome and Neonatal Hypotonia
Trisomy 18, or Edwards’ syndrome, is characterized by neonatal hypotonia, apnoea, and seizures. There is severe psychomotor and growth retardation, microcephaly, and microphthalmia. Over 90% have cardiac defects, commonly VSD, as well as anomalies in most organ systems.47,XXY: Klinefelter’s Syndrome and Infertility
Klinefelter’s syndrome affects males with a genetic complement of either 47,XXY or 48,XXXY. It is a random mutation, not inherited, and is characterized by tall stature, poorly developed testes or cryptorchidism, and gynaecomastia. Infertility is common. Physical features are not obvious in infancy. -
This question is part of the following fields:
- Paediatrics
-
-
Question 46
Incorrect
-
An 85-year-old man complains of increasing back pain and overall weakness. An X-ray of his back reveals multiple vertebral collapses and lytic lesions.
What is the most probable diagnosis?Your Answer: Bone metastases
Correct Answer: Multiple myeloma
Explanation:Understanding Multiple Myeloma: A Malignant Disease of Plasma Cells
Multiple myeloma is a malignant disease of plasma cells that commonly affects adults aged over 60 years. It is characterized by the production of paraproteinaemia in the blood, which can affect multiple organs including the blood, bone, kidneys, and immune system. The most common symptoms of multiple myeloma include unexplained bone pain, hypercalcaemia, weight loss, hyperviscosity symptoms, spinal cord compression, and fever.
On the other hand, osteoporosis is a condition characterized by low bone mass and deterioration of the structure of the bone tissue, resulting in bone fragility and susceptibility to fracture. Multiple vertebral collapses and lytic lesions are more sinister in nature and are commonly associated with multiple myeloma.
Osteosarcoma, bone metastases, and chronic myeloblastic leukaemia (CML) are not related to multiple myeloma. Osteosarcoma is characterized by cortical destruction and the presence of a soft-tissue mass, while bone metastases usually lead to destruction of the cortex on plain radiographs. Symptoms of CML include fatigue, night sweats, weight loss, abdominal fullness, and left upper quadrant pain.
In summary, understanding the symptoms and characteristics of multiple myeloma is crucial in diagnosing and treating this malignant disease of plasma cells.
-
This question is part of the following fields:
- Haematology/Oncology
-
-
Question 47
Incorrect
-
A 62-year-old woman complains of blood in her stool and unintentional weight loss. During rectal examination, you notice a suspicious lesion below the pectinate line, which raises concern for cancer. You proceed to check for any signs of lymphadenopathy.
Where would you anticipate discovering enlarged lymph nodes?Your Answer: Internal iliac
Correct Answer: Inguinal
Explanation:Lymph Node Drainage in the Pelvic Region
The lymphatic drainage in the pelvic region is an important aspect of the body’s immune system. There are several lymph nodes in this area that drain different parts of the body. Here is a breakdown of the lymph node drainage in the pelvic region:
1. Inguinal: The inguinal lymph nodes drain the anal canal inferior to the pectinate line. These nodes then drain into the lateral pelvic nodes.
2. External iliac: The external iliac nodes drain the adductor region of the upper thigh, glans, clitoris, cervix, and upper bladder.
3. Inferior mesenteric: The inferior mesenteric nodes drain the sigmoid, upper rectum, and descending colon.
4. Internal iliac: The internal iliac nodes drain the rectum and the part of the anal canal superior to the pectinate line.
5. Superior mesenteric: The superior mesenteric nodes drain parts of the upper gastrointestinal tract, specifically the duodenum and jejunum.
Understanding the lymph node drainage in the pelvic region is important for diagnosing and treating certain conditions. By knowing which lymph nodes drain which parts of the body, healthcare professionals can better identify the source of an infection or cancer and provide appropriate treatment.
-
This question is part of the following fields:
- Immunology/Allergy
-
-
Question 48
Correct
-
A 50-year-old woman presents with a two-month history of neck and right arm pain, which is exacerbated by neck flexion. She has a medical history of knee osteoarthritis, obesity, and depression. Upon examination, there is no apparent muscle weakness or atrophy in the right arm, but there is some sensory loss in the middle finger and palm of the hand. Which nerve root is most likely to be affected by the impingement?
Your Answer: C7
Explanation:Understanding Dermatomes: Major Landmarks and Mnemonics
Dermatomes are areas of skin that are innervated by a single spinal nerve. Understanding dermatomes is important in diagnosing and treating various neurological conditions. The major dermatome landmarks are listed, along with helpful mnemonics to remember them.
Starting from the top of the body, the C2 dermatome covers the posterior half of the skull, resembling a cap. Moving down to C3, it covers the area of a high turtleneck shirt. C4 covers the area of a low-collar shirt. The C5 dermatome runs along the ventral axial line of the upper limb, while C6 covers the thumb and index finger. To remember this, make a 6 with your left hand by touching the tip of the thumb and index finger together.
Moving down to C7, it covers the middle finger and palm of the hand. C8 covers the ring and little finger. The T4 dermatome covers the area of the nipples, while T5 covers the inframammary fold. T6 covers the xiphoid process, and T10 covers the umbilicus. To remember this, think of BellybuT-TEN.
The L1 dermatome covers the inguinal ligament, which can be remembered by thinking of L for ligament, 1 for 1nguinal. L4 covers the knee caps, and to remember this, think of being down on all fours. L5 covers the big toe and dorsum of the foot (except the lateral aspect), and can be remembered by thinking of it as the largest of the five toes. Finally, the S1 dermatome covers the lateral foot and small toe, while S2 and S3 cover the genitalia.
Understanding dermatomes and their landmarks can aid in diagnosing and treating various neurological conditions. The mnemonics provided can help in remembering these important landmarks.
-
This question is part of the following fields:
- Neurology
-
-
Question 49
Correct
-
A 52-year-old woman with a body mass index (BMI) of 32 was diagnosed with type 2 diabetes mellitus during a routine check-up six months ago. Despite being advised about a low-energy, weight-reducing diet and exercise, she has not followed through with these recommendations and her postprandial blood glucose concentration is 13.8 mmol/l (reference range <11.1 mmol/l). What would be the drug of choice in this case?
Your Answer: Metformin
Explanation:Medications for Type 2 Diabetes
Metformin: The Initial Drug Treatment of Choice
For adults with type 2 diabetes, standard-release metformin is the recommended initial drug treatment. The dose should be gradually increased to avoid gastrointestinal side effects. If significant GI side effects occur, modified-release metformin can be tried. Metformin reduces hepatic gluconeogenesis and increases insulin sensitivity, leading to an increase in peripheral glucose uptake. However, caution should be exercised when using metformin in patients with renal failure, and it should be stopped if the estimated glomerular filtration rate is less than 30 ml/min per 1.73m2.Tolbutamide and Chlorpropamide: First-Generation Sulfonylureas
Tolbutamide and chlorpropamide are first-generation sulfonylureas that are no longer routinely used in the treatment of type 2 diabetes due to a higher incidence of side effects compared to newer, second-generation sulfonylureas. Chlorpropamide is not available in the UK.Insulin: Considered for Dual Therapy
Insulin-based treatment should be considered in type 2 diabetes patients who have not achieved optimal glycated haemoglobin control with dual therapy using metformin and another oral drug. Metformin should continue to be offered to patients without contraindications or intolerance.Pioglitazone: An Alternative Second-Line Agent
Pioglitazone can be considered as an alternative second-line agent for patients with type 2 diabetes who cannot take metformin or have not tolerated it well. It can also be used in dual therapy for first intensification of treatment. -
This question is part of the following fields:
- Endocrinology/Metabolic Disease
-
-
Question 50
Correct
-
A 35-year-old woman complains of rectal bleeding and discomfort during bowel movements for the past two weeks. She has a history of poor dietary habits and chronic constipation. Upon wiping, she notices fresh blood on the toilet paper. During examination, her abdomen is soft and nontender, and rectal examination is painful but reveals no masses.
What is the most probable diagnosis?Your Answer: Anal fissure
Explanation:Differential Diagnosis of Anal Pain: Understanding the Causes
Anal pain can be a distressing symptom that can have various underlying causes. One of the most common causes is an anal fissure, which is a painful tear in the anal canal. This condition is often caused by trauma from hard or painful bowel movements and is associated with low-fiber diets.
Patients with anal fissures typically experience severe pain during bowel movements, which can lead to constipation and worsening symptoms. However, medical therapy with stool-bulking agents and fiber supplementation can help resolve acute anal fissures in most cases.
Other potential causes of anal pain include distal colonic polyps, anal warts, hemorrhoids, and rectal carcinoma. Distal colonic polyps are slow-growing overgrowths of the colonic mucosa that carry a small risk of becoming malignant. Anal warts are caused by the human papillomavirus (HPV) and can present as painless bumps or eruptions in the anogenital area.
Hemorrhoids are swollen blood vessels in the lower rectum that can cause rectal bleeding, pain, pruritus, or prolapse. Rectal carcinoma is a rare but serious condition that can cause bleeding, change in bowel habits, abdominal pain, and malaise.
In summary, understanding the differential diagnosis of anal pain is crucial for accurate diagnosis and appropriate treatment. A thorough physical examination and medical history can help identify the underlying cause and guide management.
-
This question is part of the following fields:
- Gastroenterology/Nutrition
-
00
Correct
00
Incorrect
00
:
00
:
00
Session Time
00
:
00
Average Question Time (
Secs)