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Question 1
Correct
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An 85-year-old woman with hypercholesterolaemia, ischaemic heart disease and hypertension complains to her General Practitioner of tingling and numbness in both feet that has been worsening over a period of six months.
Examination reveals that she has an altered pinprick sensation over both feet and absent ankle reflexes. Her urea and electrolyte levels are normal. Her blood glucose is normal and there is no history of alcohol ingestion. She is, however, taking a number of medications for the secondary presentation of her vascular problems.
Which of the following medications is most likely to have caused her symptoms?
Select the SINGLE most appropriate medication from the list below.Your Answer: Simvastatin
Explanation:Medication Analysis for Peripheral Neuropathy: Simvastatin, Bendroflumethiazide, Clopidogrel, Ramipril, and Spironolactone
Peripheral neuropathy is a condition characterized by numbness and tingling in the extremities, often accompanied by a loss of ankle reflexes. Statins, such as simvastatin, are a known risk factor for peripheral neuropathy, with onset ranging from the first dose to years of use. Bendroflumethiazide, on the other hand, is not associated with neuropathy but can cause electrolyte imbalances leading to central neurological disturbances. Clopidogrel, an anti-platelet medication, is unlikely to contribute to peripheral neuropathy. Ramipril, a blood-pressure-lowering medication, can cause cough and dizziness but would not lead to peripheral neuropathy. Spironolactone, a diuretic, can cause hyperkalemia but would not lead to peripheral neuropathy. It is important to consider medication use when evaluating patients with peripheral neuropathy symptoms.
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This question is part of the following fields:
- Neurology
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Question 2
Correct
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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.
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This question is part of the following fields:
- Cardiovascular
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Question 3
Incorrect
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A 45-year-old man presents to the Vascular Clinic. He has been found to have a left internal carotid dissection incidentally while having cross-sectional neck imaging. He is asymptomatic, there are no intracranial or extracranial haematomas and he has not had a stroke or transient ischaemic attack in the past.
Which of the following is the most appropriate next step for this patient?Your Answer: Yearly surveillance with computed tomography (CT) angiography
Correct Answer: Conservative management with antiplatelet or anticoagulation agents
Explanation:Treatment and Surveillance Options for Carotid Artery Dissection
Carotid artery dissection is a condition that requires careful management and surveillance to prevent stroke and other complications. The treatment approach depends on various factors, including the cause of the dissection, the location, and the presence of bleeding. Conservative management with antiplatelet or anticoagulation agents is often used to minimize the risk of stroke. Endovascular stenting may be an option for some patients, particularly those who cannot tolerate anticoagulation or have failed medical management.
Surveillance is also crucial for patients with carotid artery dissection, particularly those who are asymptomatic. Yearly surveillance with carotid ultrasound Doppler is a non-invasive and cost-effective option that can be used for follow-up monitoring. However, it has some limitations, including difficulty scanning the distal-internal carotid artery and detecting emboli. Computed tomography (CT) angiography has high sensitivity in diagnosis and follow-up reviews of carotid-artery dissections, but it has no role in treatment. Magnetic resonance (MR) angiography and MR imaging can also be used for follow-up monitoring and diagnostic purposes, but they are not appropriate for treatment. Overall, a comprehensive approach that considers the individual patient’s needs and circumstances is essential for managing carotid artery dissection effectively.
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This question is part of the following fields:
- Neurology
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Question 4
Incorrect
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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: Audiometry
Correct 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.
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This question is part of the following fields:
- Neurology
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Question 5
Incorrect
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A 7-year-old boy who has recently arrived from India complains of fever. During examination, extensive cervical lymphadenopathy is observed and a grey coating is seen surrounding the tonsils. What is the probable diagnosis?
Your Answer: Paratyphoid
Correct Answer: Diphtheria
Explanation:Understanding Diphtheria: Causes, Symptoms, and Treatment
Diphtheria is a bacterial infection caused by the Gram positive bacterium Corynebacterium diphtheriae. The pathophysiology of this disease involves the release of an exotoxin encoded by a β-prophage, which inhibits protein synthesis by catalyzing ADP-ribosylation of elongation factor EF-2. This toxin commonly causes a ‘diphtheric membrane’ on tonsils, resulting in a grey, pseudomembrane on the posterior pharyngeal wall. Systemic distribution may produce necrosis of myocardial, neural, and renal tissue.
Possible presentations of diphtheria include sore throat with a ‘diphtheric membrane’, bulky cervical lymphadenopathy, and neuritis of cranial nerves. It may also result in a ‘bull neck’ appearance and heart block. People who have recently visited Eastern Europe, Russia, or Asia are at a higher risk of contracting this disease.
To diagnose diphtheria, a culture of throat swab is taken using tellurite agar or Loeffler’s media. The treatment for diphtheria involves intramuscular penicillin and diphtheria antitoxin.
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This question is part of the following fields:
- Infectious Diseases
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Question 6
Incorrect
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An increase in alkaline phosphatase can be attributed to any of the following conditions except?
Your Answer: Healing bone fractures
Correct Answer: Hypoparathyroidism
Explanation:Understanding Alkaline Phosphatase and Its Causes
Alkaline phosphatase (ALP) is an enzyme found in various tissues throughout the body, including the liver, bones, and intestines. When the levels of ALP in the blood are elevated, it can indicate a potential health issue. The causes of raised ALP can be divided into two categories based on the calcium level in the blood.
If both ALP and calcium levels are high, it may indicate bone metastases, hyperparathyroidism, osteomalacia, or renal failure. On the other hand, if ALP is high but calcium is low, it may be due to cholestasis, hepatitis, fatty liver, neoplasia, Paget’s disease, or physiological factors such as pregnancy, growing children, or healing fractures.
It is important to note that elevated ALP levels do not necessarily indicate a specific condition, but rather serve as a signal for further investigation.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 7
Correct
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A 67-year-old male visits his primary care clinic complaining of progressive dyspnea on exertion and a dry cough. He has a smoking history of 35 pack-years. He denies chest pain, weight loss, or hemoptysis. In the past, he was prescribed bronchodilators for COPD, but they did not alleviate his symptoms.
During the examination, the physician detects fine crackles at the lung bases bilaterally, and the patient has significant finger clubbing. The physician orders a chest X-ray, pulmonary function tests, and refers him urgently to a respiratory clinic.
What pulmonary function test pattern would you expect to see based on the most likely underlying diagnosis?Your Answer: FEV1:FVC normal or increased, TLCO reduced
Explanation:In cases of IPF, the TLCO (gas transfer test) is reduced, indicating a restrictive lung disease that results in a reduced FEV1 and reduced FVC. This leads to a normal or increased FEV1:FVC ratio, which is a distinguishing factor from obstructive lung diseases like COPD or asthma. Therefore, the correct statement is that in IPF, the FEV1:FVC ratio is normal or increased, while the TLCO is reduced.
Understanding Idiopathic Pulmonary Fibrosis
Idiopathic pulmonary fibrosis (IPF) is a chronic lung condition that causes progressive fibrosis of the interstitium of the lungs. Unlike other causes of lung fibrosis, IPF has no underlying cause. It is typically seen in patients aged 50-70 years and is more common in men.
The symptoms of IPF include progressive exertional dyspnoea, dry cough, clubbing, and bibasal fine end-inspiratory crepitations on auscultation. Diagnosis is made through spirometry, impaired gas exchange tests, and imaging such as chest x-rays and high-resolution CT scans.
Management of IPF includes pulmonary rehabilitation, but very few medications have been shown to be effective. Some evidence suggests that pirfenidone, an antifibrotic agent, may be useful in selected patients. Many patients will eventually require supplementary oxygen and a lung transplant.
The prognosis for IPF is poor, with an average life expectancy of around 3-4 years. CT scans can show advanced pulmonary fibrosis, including honeycombing. While there is no cure for IPF, early diagnosis and management can help improve quality of life and potentially prolong survival.
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This question is part of the following fields:
- Respiratory Medicine
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Question 8
Correct
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A 35-year-old woman presents to the emergency department with sudden right iliac fossa pain. She reports the pain as sharp and radiating to her right shoulder. She has a medical history of endometriosis and type 2 diabetes mellitus and smokes 10 cigarettes per day. Her last menstrual period was 35 days ago, and she is concerned about being pregnant. She has a 4-year-old daughter, and her previous pregnancy was complicated by pre-eclampsia. Based on her history, what is a potential risk factor for her current presentation?
Your Answer: Endometriosis
Explanation:Having endometriosis increases the risk of experiencing an ectopic pregnancy. This patient’s symptoms and positive pregnancy test suggest a likely diagnosis of an ectopic pregnancy. Other risk factors for ectopic pregnancy include previous ectopic pregnancy, fallopian tube damage, and IVF. However, multiparity, previous pre-eclampsia, twin pregnancy, and type 2 diabetes mellitus are not associated with an increased risk of ectopic pregnancy.
Understanding Ectopic Pregnancy: Incidence and Risk Factors
Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, usually in the fallopian tubes. This condition is a serious medical emergency that requires immediate attention. According to epidemiological studies, ectopic pregnancy occurs in approximately 0.5% of all pregnancies.
Several risk factors can increase the likelihood of ectopic pregnancy. These include damage to the fallopian tubes due to pelvic inflammatory disease or surgery, a history of previous ectopic pregnancy, endometriosis, the use of intrauterine contraceptive devices (IUCDs), and the progesterone-only pill. In vitro fertilization (IVF) also increases the risk of ectopic pregnancy, with approximately 3% of IVF pregnancies resulting in ectopic implantation.
It is important to note that any factor that slows down the passage of the fertilized egg to the uterus can increase the risk of ectopic pregnancy. Early detection and prompt treatment are crucial in managing this condition and preventing serious complications.
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This question is part of the following fields:
- Reproductive Medicine
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Question 9
Correct
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A 24-year-old man with a history of recurrent otitis media, two bouts of pneumonia, and a recent Giardia infection suffered a severe allergic reaction to a blood transfusion after a road traffic accident. His investigations showed slightly decreased immunoglobulins, a mild obstructive pattern on spirometry, and normal values for haemoglobin, white cell count, and platelets. What is the most likely diagnosis for this patient?
Your Answer: Immunoglobulin A (IgA) deficiency
Explanation:Understanding Immunoglobulin Deficiencies and Their Symptoms
Immunoglobulin deficiencies are a group of disorders that affect the body’s ability to produce specific types of antibodies, leading to an increased risk of infections and autoimmune diseases. Here, we will discuss the different types of immunoglobulin deficiencies and their associated symptoms.
IgA Deficiency:
This deficiency is characterized by a decrease in immunoglobulin A, which can lead to an increased incidence of mucosal infections, particularly gastrointestinal infections with Giardia. Patients may also experience recurrent ear infections, sinusitis, bronchitis, pneumonia, and urinary tract infections. Additionally, IgA deficiency increases the risk of autoimmune diseases, such as rheumatoid arthritis and systemic lupus erythematosus.IgE Deficiency:
IgE is responsible for fighting parasitic and helminthic infections, so patients with IgE deficiency are more likely to develop these types of infections. They are also at an increased risk of autoimmune disease and non-allergic reactive airways disease.IgG Deficiency:
Patients with IgG deficiency are prone to developing infections from encapsulated bacteria, such as Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis. This deficiency can lead to upper and lower respiratory tract infections and meningitis.IgM Deficiency:
Primary selective IgM deficiency results in increased infections by bacteria, fungi, and viruses, as well as increased autoimmune diseases. However, this deficiency does not have the selectivity for mucosal membrane infections seen in IgA deficiency.Severe Combined Immunoglobulin Deficiency (SCID):
SCID is a rare disorder that results from abnormal T- and B-cell development due to inherited genetic mutations. Patients with SCID are affected early in life with multiple severe bacterial, viral, and fungal infections, as well as failure to thrive, interstitial lung disease, and chronic diarrhea.In conclusion, understanding the different types of immunoglobulin deficiencies and their associated symptoms is crucial for prompt recognition and treatment of opportunistic bacterial infections and autoimmune diseases.
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This question is part of the following fields:
- Immunology/Allergy
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Question 10
Correct
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A 6-year-old boy is brought to the Emergency Department by his mother with complaints of right iliac fossa pain for the past two days. He has no previous medical history except for a cough and sore throat in the last week. He has had a high fever for the past two days and has lost his appetite but denies any other symptoms.
On examination, his temperature is 38.9 °C, and his pulse is 130 beats per minute. Bilateral enlarged submandibular and cervical lymph nodes are palpable and slightly tender. Chest examination is clear, with transmitted sounds from the upper airways. Abdominal examination reveals marked tenderness in the right iliac fossa with no guarding.
Urine dipstick reveals 2+ of ketones and 1+ of protein.
Blood test results for his full blood count (FBC) are as follows:
Investigation Result Normal value
Haemoglobin (Hb) 145 g/l 135–175 g/l
White cell count (WCC) 14.3 × 109/ 4.0–11.0 × 109/l
Platelets (PLT) 425 × 109/l 150–400 × 109/l
What is the most likely clinical diagnosis for this 6-year-old boy?Your Answer: Mesenteric adenitis
Explanation:Possible Diagnoses for a Child with Right Iliac Fossa Pain and High Temperature
When a child presents with right iliac fossa pain and high temperature, several possible diagnoses should be considered. One of them is mesenteric adenitis, which is characterized by abdominal pain resulting from mesenteric lymphadenopathy and often accompanied by enlarged neck nodes and a recent history of viral upper respiratory tract infection. Appendicitis is another possibility, but it tends to present with a low-grade fever and peritoneal irritation that causes involuntary muscle spasm in the abdominal wall. Meckel’s diverticulitis, which is clinically indistinguishable from appendicitis, is an intra-operative or radiological diagnosis and can cause gastrointestinal bleeding, obstruction, inflammation, or umbilical discharge. Retroperitoneal appendix abscess is an uncommon type of infection that presents with fever, back pain, and abdominal pain, but it can also cause other symptoms such as gastrointestinal bleeding, poor wound healing, chest pain, general discomfort, urinary frequency, and haematuria. Finally, urinary tract infection (UTI) is unlikely if there are no nitrites or leukocytes on urine dipstick, but it can cause non-specific symptoms such as vomiting/diarrhoea, mild abdominal pain, dysuria, frequency, and enuresis, especially in infants.
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This question is part of the following fields:
- Paediatrics
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Question 11
Incorrect
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A 7-year-old girl is seen in clinic for nocturnal enuresis. Despite her mother's attempts at using a reward system, there has been no improvement. What is the best initial approach to management?
Your Answer: Trial of oral desmopressin
Correct Answer: Enuresis alarm
Explanation:If general advice has not been effective, an enuresis alarm is typically the initial treatment for nocturnal enuresis. It is not advisable to limit fluid intake. According to Clinical Knowledge Summaries, children should consume approximately eight drinks per day, evenly distributed throughout the day, with the last one consumed approximately one hour before bedtime.
Nocturnal enuresis, or bedwetting, is when a child involuntarily urinates during the night. Most children achieve continence by the age of 3 or 4, so enuresis is defined as the involuntary discharge of urine in a child aged 5 or older without any underlying medical conditions. Enuresis can be primary, meaning the child has never achieved continence, or secondary, meaning the child has been dry for at least 6 months before.
When managing bedwetting, it’s important to look for any underlying causes or triggers, such as constipation, diabetes mellitus, or recent onset UTIs. General advice includes monitoring fluid intake and encouraging regular toileting patterns, such as emptying the bladder before sleep. Reward systems, like star charts, can also be helpful, but should be given for agreed behavior rather than dry nights.
The first-line treatment for bedwetting is an enuresis alarm, which has a high success rate. These alarms have sensor pads that detect wetness and wake the child up to use the toilet. If short-term control is needed, such as for sleepovers, or if the alarm is ineffective or not acceptable to the family, desmopressin may be prescribed. Overall, managing bedwetting involves identifying any underlying causes and implementing strategies to promote continence.
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This question is part of the following fields:
- Paediatrics
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Question 12
Incorrect
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A 25-year-old man with known type I diabetes mellitus presents to the Emergency Department with abdominal pain and vomiting.
On examination, he appears dehydrated. He is started on an insulin infusion. His blood tests are shown below:
Investigation Result Normal value
pH (venous) 7.23 7.35–7.45
Partial pressure of carbon dioxide (pCO2) 2.1 kPa 4.5–6.0 kPa
Partial pressure of oxygen (pO2) 11.2 kPa 10–14 kPa
Sodium (Na+) 135 mmol/l 135–145 mmol/l
Potassium (K+) 3.1 mmol/l 3.5–5.0 mmol/l
Bicarbonate 13 mmol/l 22–28 mmol/l
Glucose 22.4 mmol/l < 11.1 mmol/l
Ketones 3.6 mmol/l < 0.6 mmol/l
What should happen to his regular insulin while he is treated?
Select the SINGLE best treatment from the list below.
Your Answer: Continue short-acting insulin and stop long-acting insulin
Correct Answer: Continue long-acting insulin and stop short-acting insulin
Explanation:Treatment of Diabetic Ketoacidosis: Continuing Long-Acting Insulin and Stopping Short-Acting Insulin
When a patient presents with diabetic ketoacidosis (DKA), it is important to provide prompt treatment. This involves fluid replacement with isotonic saline and an intravenous insulin infusion at 0.1 unit/kg per hour. While this takes place, the patient’s normal long-acting insulin should be continued, but their short-acting insulin should be stopped to avoid hypoglycemia.
In addition to insulin and fluid replacement, correction of electrolyte disturbance is essential. Serum potassium levels may be high on admission, but often fall quickly following treatment with insulin, resulting in hypokalemia. Potassium may need to be added to the replacement fluids, guided by the potassium levels. If the rate of potassium infusion is greater than 20 mmol/hour, cardiac monitoring is required.
Overall, the key to successful treatment of DKA is a careful balance of insulin, fluids, and electrolyte replacement. By continuing long-acting insulin and stopping short-acting insulin, healthcare providers can help ensure the best possible outcome for their patients.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 13
Incorrect
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A 25-year-old student presents to the Emergency Department with confusion and recurring fevers. He describes a flu-like illness in recent days, with myalgia and rigours every two days. He has previously been well, other than an episode of suspected malaria on a gap year in Brazil three years ago, which was felt to be successfully treated. He has not been abroad since.
On examination, he has splenomegaly, scleral icterus and a temperature of 39.1°C.
Investigations reveal the following:
Investigation Result Normal value
Haemoglobin (Hb) 95 g/l 135–175 g/l
White Cell Count (WCC) 14 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 100 × 109 150–450× 109/l
Blood film Awaited
Which of the following is the most likely causative organism?Your Answer: Dengue virus
Correct Answer: Plasmodium vivax
Explanation:Differential Diagnosis for a Patient with Fluctuating Pyrexia: Malaria vs. Other Causes
The patient in question is experiencing fluctuating rigours of malaria, despite not having been in a malaria-affected zone for two years. This suggests a recurrence of pre-existing malaria, with the most likely subtype being P. vivax due to its ability to lie dormant in the liver for extended periods. While dengue fever is a possibility, the history of fluctuating pyrexia is more indicative of malaria, which also causes anaemia and thrombocytopenia. P. falciparum is a reasonable differential, but less likely given the patient’s travel history. P. malariae is rare and typically presents with fevers recurring every three days, making it less likely. Yellow fever is also unlikely due to the patient’s travel timeline and lack of jaundice. Overall, malaria is the most likely cause of the patient’s symptoms.
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This question is part of the following fields:
- Infectious Diseases
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Question 14
Correct
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A 35-year-old woman presents to the hospital with diarrhea and abdominal pain. She has a history of depression and takes citalopram, smokes 20 cigarettes per day, and drinks 20 units of alcohol per week. During ileocolonoscopy, Crohn's disease is diagnosed, and she is treated with glucocorticoid therapy. What is the most crucial step to decrease the likelihood of future episodes?
Your Answer: Stop smoking
Explanation:Managing Crohn’s Disease: Guidelines and Treatment Options
Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract. To manage this condition, the National Institute for Health and Care Excellence (NICE) has published guidelines that provide recommendations for inducing and maintaining remission, as well as treating complications. One of the most important steps in managing Crohn’s disease is to advise patients to quit smoking, as this can worsen the condition. Additionally, some medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and the combined oral contraceptive pill, may increase the risk of relapse, although the evidence is not conclusive.
To induce remission, glucocorticoids are often used, either orally, topically, or intravenously. Budesonide is an alternative for some patients. Enteral feeding with an elemental diet may also be used, especially in young children or when there are concerns about the side effects of steroids. Second-line treatments for inducing remission include 5-ASA drugs like mesalazine, as well as azathioprine or mercaptopurine, which may be used in combination with other medications. Methotrexate is another option. Infliximab is useful for refractory disease and fistulating Crohn’s, and patients may continue on azathioprine or methotrexate.
To maintain remission, stopping smoking is a priority, and azathioprine or mercaptopurine is used first-line. TPMT activity should be assessed before starting these medications. Methotrexate is used second-line. Surgery may be necessary for around 80% of patients with Crohn’s disease, depending on the location and severity of the disease. Complications of Crohn’s disease include small bowel cancer, colorectal cancer, and osteoporosis. Perianal fistulae and abscesses require specific treatments, such as oral metronidazole, anti-TNF agents like infliximab, or a draining seton. By following these guidelines and treatment options, patients with Crohn’s disease can better manage their condition and improve their quality of life.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 15
Incorrect
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During your assessment of a 55-year-old patient admitted to the medical ward, you observe a rash on her legs. The rash has a lace-like pattern in a purple color and does not disappear when touched. It is located on the lower legs. The patient has a medical history of systemic lupus erythematosus and reports experiencing this rash on and off in the past, often triggered by cold weather. What is the most probable diagnosis for this rash?
Your Answer: Erythema ab igne
Correct Answer: Livedo reticularis
Explanation:Understanding Livedo Reticularis
Livedo reticularis is a skin condition characterized by a purplish, non-blanching, reticulated rash. This occurs when the capillaries become obstructed, leading to swollen venules. The most common cause of this condition is idiopathic, meaning that the cause is unknown. However, it can also be caused by various underlying medical conditions such as polyarteritis nodosa, systemic lupus erythematosus, cryoglobulinaemia, antiphospholipid syndrome, Ehlers-Danlos Syndrome, and homocystinuria.
It is important to note that livedo reticularis is not a disease in itself, but rather a symptom of an underlying condition.
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This question is part of the following fields:
- Dermatology
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Question 16
Incorrect
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A 25-year-old female student attends the blood transfusion service wishing to donate blood. She is currently well, has never had a serious illness and weighs 60 kg. About three months ago she spent the summer doing voluntary work in Nigeria. She also had her ears pierced three years ago and had a tattoo put on her left arm one year ago. She is not acceptable as a donor.
Which of the following is the reason for her rejection to donate blood in the UK?Your Answer: Tattoo
Correct Answer: Recent travel to an endemic area
Explanation:Blood Donation Eligibility Criteria: Factors to Consider
When it comes to donating blood, there are several factors to consider to ensure the safety of both the donor and the recipient. Here are some examples:
Recent travel to an endemic area: If a person has recently traveled to a country with a high risk of infectious diseases, they may have to wait a certain period before donating blood. For instance, if someone has returned from Nigeria, they must wait at least six months before donating blood in the UK.
Underweight: A person must weigh at least 50 kg to donate blood. If they weigh less than that, they may not have enough blood volume to spare.
Body piercing: If someone has had a body piercing within the last 12 months, they should inform the staff before donating blood. They may have to wait for at least four months before donating.
Tattoo: Similarly, if someone has had a tattoo within the last 12 months, they should inform the staff before donating blood. They may have to wait for at least four months before donating.
Age: To donate blood, a person must be between 17 and 66 years old (or 70 if they have donated blood before). If they are over 70, they can still donate if they have donated blood in the last two years.
By considering these factors, blood donation centers can ensure that the blood they collect is safe and suitable for transfusion.
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This question is part of the following fields:
- Haematology/Oncology
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Question 17
Incorrect
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A 50-year-old woman with a history of severe disabling arthritis presents to the Emergency Department with a 3-week history of dyspnoea. She reports a dry cough of similar duration. She has never smoked and has never been employed. On cardiovascular examination, no abnormalities are detected. Respiratory examination reveals reduced air entry at the left base, which is stony dull to percussion. A chest X-ray shows blunting of the left costophrenic angle.
What is the most likely diagnosis associated with her current respiratory problem?Your Answer: Psoriatic arthritis
Correct Answer: Rheumatoid arthritis (RA)
Explanation:Respiratory Manifestations of Rheumatoid Arthritis
Rheumatoid arthritis (RA) is an inflammatory arthritis that can affect various parts of the body, including the respiratory tract. One common manifestation of RA in the respiratory system is pleural involvement, which can present as pleural effusion, pleural nodules, or pleurisy. Other respiratory complications associated with RA include pulmonary fibrosis and bronchiolitis obliterans.
It is important to note that other types of arthritis, such as ankylosing spondylitis, Behçet’s disease, gout, and psoriatic arthritis, do not typically present with respiratory complications like pleural effusion. Ankylosing spondylitis is associated with apical fibrosis, while Behçet’s disease is known for neurological complications. Gout is caused by purine metabolism abnormality and affects the joints and renal tract, while psoriatic arthritis is strongly associated with psoriasis and can lead to ocular and cardiovascular complications.
Overall, if a patient with RA presents with respiratory symptoms, it is important to consider the possibility of pleural involvement and other respiratory complications associated with the disease.
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This question is part of the following fields:
- Respiratory Medicine
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Question 18
Correct
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A 72-year-old man is admitted after a fall and a period of time on the floor. He has a long history of chronic illness and immobility, with medications for hypertension, cardiac failure and chronic chest disease.
On examination, he is obese, with a blood pressure of 110/75 mmHg, a pulse of 100 beats per minute and a temperature of 38.5°C. Respiratory examination reveals evidence of right lower lobe consolidation. He has no signs of traumatic bone injury.
Investigations reveal the following:
Investigation Result Normal value
Chest X-ray Right lower lobe pneumonia
Haemoglobin (Hb) 131 g/l 135–175 g/l
White cell count (WCC) 15.4 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 312 × 109/l 150–400 × 109/l
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 6.7 mmol/l 3.5–5.0 mmol/l
Urea 15.1 mmol/l 2.5–6.5 mmol/l
Creatinine (Cr) 312 μmol/l 50–120 µmol/l
Creatine kinase (CK) 1524 IU/l 23–175 IU/l
Catheter specimen of urine: Red/brown in colour.
+++ for blood.
No red cells on microscopy
Which of the following diagnoses fits best with this clinical picture?Your Answer: Rhabdomyolysis
Explanation:The patient’s elevated CK levels and urine test indicating blood without cells strongly suggest rhabdomyolysis as the cause of their kidney failure, likely due to their fall and prolonged time on the floor. Treatment should focus on managing hyperkalemia and ensuring proper hydration. While acute myocardial infarction cannot be ruled out entirely, the absence of discolored urine and other symptoms make rhabdomyolysis a more likely diagnosis. Acute tubular necrosis is also unlikely, as there are no epithelial cells present on urinalysis. While sepsis should be considered, the presence of red-colored urine and a history of a fall make rhabdomyolysis the most probable cause. Polymyositis, a type of inflammatory myopathy, typically presents with proximal myopathy and is more commonly seen in middle-aged women.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 19
Correct
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A 25-year-old woman visits the GP clinic seeking emergency contraception after having unprotected sex last night, 14 days after giving birth. What is the most appropriate course of action?
Your Answer: Advice the patient that she does not require emergency contraception
Explanation:After giving birth, women need to use contraception only after 21 days.
As the woman in the question is only 14 days post-partum, she does not need emergency contraception. Therefore, the advice to her would be that emergency contraception is not necessary.
After giving birth, women need to use contraception after 21 days. The progestogen-only pill (POP) can be started at any time postpartum, according to the FSRH. Additional contraception should be used for the first two days after day 21. A small amount of progestogen enters breast milk, but it is not harmful to the infant. On the other hand, the combined oral contraceptive pill (COCP) is absolutely contraindicated (UKMEC 4) if breastfeeding is less than six weeks post-partum. If breastfeeding is between six weeks and six months postpartum, it is a UKMEC 2. The COCP may reduce breast milk production in lactating mothers. It should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum. After day 21, additional contraception should be used for the first seven days. The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after four weeks.
The lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breastfeeding (no supplementary feeds), amenorrhoeic, and less than six months post-partum. It is important to note that an inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight, and small for gestational age babies.
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This question is part of the following fields:
- Reproductive Medicine
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Question 20
Correct
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A 25-year-old female presents with a history of weight loss and diarrhoea. To investigate her symptoms, she undergoes a colonoscopy and a biopsy is taken. The biopsy report indicates the presence of pigment-laden macrophages suggestive of melanosis coli. What is the probable diagnosis?
Your Answer: Laxative abuse
Explanation:Understanding Melanosis Coli
Melanosis coli is a condition that affects the pigmentation of the bowel wall. This disorder is characterized by the presence of pigment-laden macrophages, which can be observed through histology. The primary cause of melanosis coli is laxative abuse, particularly the use of anthraquinone compounds like senna.
In simpler terms, melanosis coli is a condition that causes changes in the color of the bowel wall due to the accumulation of pigments. This condition is often associated with the excessive use of laxatives, which can lead to the accumulation of pigment-laden macrophages in the bowel wall. These macrophages are responsible for the discoloration of the bowel wall, which can be observed through histology. It is important to note that melanosis coli is not a life-threatening condition, but it can be a sign of underlying health issues that need to be addressed.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 21
Correct
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A 45-year-old man with type 2 diabetes mellitus presents with fatigue. He is currently taking metformin and gliclazide, but may need to discontinue the latter due to his obesity. After conducting several blood tests, the following results were obtained:
- HbA1c: 66 mmol/mol (< 48)
- Ferritin: 204 ng/mL (25 - 350)
- Bilirubin: 23 µmol/L (3 - 17)
- ALP: 162 u/L (30 - 100)
- ALT: 120 u/L (3 - 40)
- AST: 109 u/L (3 - 40)
Upon further discussion, the patient denies consuming alcohol. What is the most likely explanation for these abnormal findings?Your Answer: Non-alcoholic fatty liver disease
Explanation:When a patient with type 2 diabetes and obesity presents with abnormal liver function tests, the most probable diagnosis is non-alcoholic fatty liver disease. To confirm this diagnosis, the patient will need to undergo a liver screen, ultrasound, and liver biopsy. While haemochromatosis should be considered in patients with both abnormal LFTs and diabetes, a normal ferritin level makes this diagnosis less likely.
Non-Alcoholic Fatty Liver Disease: Causes, Features, and Management
Non-alcoholic fatty liver disease (NAFLD) is a prevalent liver disease in developed countries, primarily caused by obesity. It encompasses a range of conditions, from simple steatosis (fat accumulation in the liver) to steatohepatitis (fat with inflammation) and may progress to fibrosis and liver cirrhosis. Insulin resistance is believed to be the primary mechanism leading to steatosis, making NAFLD a hepatic manifestation of metabolic syndrome. Non-alcoholic steatohepatitis (NASH) is a type of liver damage similar to alcoholic hepatitis but occurs in the absence of alcohol abuse. It affects around 3-4% of the general population and may be responsible for some cases of cryptogenic cirrhosis.
NAFLD is usually asymptomatic, but hepatomegaly, increased echogenicity on ultrasound, and elevated ALT levels are common features. The enhanced liver fibrosis (ELF) blood test is recommended by NICE to check for advanced fibrosis in patients with incidental NAFLD. If the ELF blood test is not available, non-invasive tests such as the FIB4 score or NAFLD fibrosis score, in combination with a FibroScan, may be used to assess the severity of fibrosis. Patients with advanced fibrosis should be referred to a liver specialist for further evaluation, which may include a liver biopsy to stage the disease more accurately.
The mainstay of NAFLD treatment is lifestyle changes, particularly weight loss, and monitoring. Research is ongoing into the role of gastric banding and insulin-sensitizing drugs such as metformin and pioglitazone. While there is no evidence to support screening for NAFLD in adults, NICE guidelines recommend the management of incidental NAFLD findings.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 22
Correct
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A pair in their early 30s visit their GP seeking advice on their inability to conceive despite engaging in regular sexual activity for 6 months. What would be the most suitable course of action for you to recommend?
Your Answer: Wait until they have been having regular intercourse for 12 months
Explanation:Couples are advised to engage in regular sexual intercourse every 2-3 days for a period of 12 months before seeking referral to a specialist. After this time, fertility testing should be conducted, including semen analysis for the male and mid-luteal progesterone level for the female to confirm ovulation. The use of basal body temperature kits is not recommended as they can increase anxiety and have not been proven effective. However, early referral should be considered for females over 35 years of age, those with a history of amenorrhea or pelvic surgery, and those with abnormal genital examinations. Males with a history of genital surgery, STIs, varicocele, or significant systemic illness should also be referred early.
Infertility is a common issue that affects approximately 1 in 7 couples. It is important to note that around 84% of couples who have regular sexual intercourse will conceive within the first year, and 92% within the first two years. The causes of infertility can vary, with male factor accounting for 30%, unexplained causes accounting for 20%, ovulation failure accounting for 20%, tubal damage accounting for 15%, and other causes accounting for the remaining 15%.
When investigating infertility, there are some basic tests that can be done. These include a semen analysis and a serum progesterone test. The serum progesterone test is done 7 days prior to the expected next period, typically on day 21 for a 28-day cycle. The interpretation of the serum progesterone level is as follows: if it is less than 16 nmol/l, it should be repeated and if it remains consistently low, referral to a specialist is necessary. If the level is between 16-30 nmol/l, it should be repeated, and if it is greater than 30 nmol/l, it indicates ovulation.
It is important to counsel patients on lifestyle factors that can impact fertility. This includes taking folic acid, maintaining a healthy BMI between 20-25, and advising regular sexual intercourse every 2 to 3 days. Additionally, patients should be advised to quit smoking and limit alcohol consumption to increase their chances of conceiving.
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This question is part of the following fields:
- Reproductive Medicine
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Question 23
Correct
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A 27 year old pregnant woman is currently experiencing a prolonged second stage of labour due to cephalopelvic disproportion. The midwife is aware of the potential risks to both the mother and foetus and calls for an obstetrician. The obstetrician performs a perineal incision in a mediolateral direction. What is the name of this procedure?
Your Answer: Episiotomy
Explanation:The procedure being performed is called an episiotomy, which can be done using various techniques. In this case, the medio-lateral approach is being used, which involves making a cut at either the 7 o’clock or 5 o’clock positions. The main reasons for performing this procedure are twofold. Firstly, it helps to prevent the vagina from tearing during childbirth, particularly in cases where the baby’s head is too large for the mother’s pelvis. By making a controlled incision, the risk of the tear extending towards the anus and surrounding muscles is reduced, which could lead to long-term problems such as fecal incontinence. Secondly, the episiotomy creates more space for the baby to pass through, making delivery easier and safer for both the mother and child.
Understanding Episiotomy
Episiotomy is a surgical procedure that involves making an incision in the posterior wall of the vagina and perineum during the second stage of labor. This procedure is done to make it easier for the baby to pass through the birth canal. The incision is made in the area between the vagina and anus, and it can be either midline or mediolateral.
Episiotomy is usually performed when the baby is in distress, and there is a need to speed up the delivery process. It can also be done to prevent tearing of the perineum, which can be more difficult to repair than an episiotomy. However, the procedure is not without risks, and it can lead to complications such as pain, infection, and bleeding.
In recent years, there has been a decline in the use of episiotomy, as studies have shown that it does not necessarily reduce the risk of tearing or improve healing time. Many healthcare providers now only perform episiotomy when it is medically necessary. It is important for expectant mothers to discuss the use of episiotomy with their healthcare provider and understand the risks and benefits before making a decision.
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This question is part of the following fields:
- Reproductive Medicine
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Question 24
Incorrect
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A 20-year-old man is brought to the emergency department after experiencing a possible allergic reaction to seafood he ate at a restaurant. He administered his adrenaline autoinjector and received an additional dose of intramuscular adrenaline from the paramedics.
Upon examination, his temperature is 37.8ºC, heart rate is 130 beats/min, and blood pressure is 88/50 mmHg. He has a respiratory rate of 30 breaths/min and oxygen saturation of 93% on room air.
What is the next course of action in managing this patient?Your Answer: Intravenous hydrocortisone
Correct Answer: Intravenous adrenaline infusion
Explanation:For patients with refractory anaphylaxis, which is characterized by persistent respiratory and/or cardiovascular problems despite receiving 2 doses of intramuscular adrenaline, the recommended next step is to start an intravenous adrenaline infusion. Administering further intramuscular adrenaline is not recommended. Intravenous chlorphenamine and hydrocortisone are also no longer recommended in the updated guidelines for anaphylaxis management.
Anaphylaxis is a severe and potentially life-threatening allergic reaction that affects the entire body. It can be caused by various triggers, including food, drugs, and insect venom. The symptoms of anaphylaxis typically occur suddenly and progress rapidly, affecting the airway, breathing, and circulation. Common signs include swelling of the throat and tongue, hoarse voice, respiratory wheeze, dyspnea, hypotension, and tachycardia. In addition, around 80-90% of patients experience skin and mucosal changes, such as generalized pruritus, erythematous rash, or urticaria.
The management of anaphylaxis requires prompt and decisive action, as it is a medical emergency. The Resuscitation Council guidelines recommend intramuscular adrenaline as the most important drug for treating anaphylaxis. The recommended doses of adrenaline vary depending on the patient’s age, ranging from 100-150 micrograms for infants under 6 months to 500 micrograms for adults and children over 12 years. Adrenaline can be repeated every 5 minutes if necessary, and the best site for injection is the anterolateral aspect of the middle third of the thigh. In cases of refractory anaphylaxis, IV fluids and expert help should be sought.
Following stabilisation, patients may be given non-sedating oral antihistamines to manage persisting skin symptoms. It is important to refer all patients with a new diagnosis of anaphylaxis to a specialist allergy clinic and provide them with an adrenaline injector as an interim measure before the specialist assessment. Patients should also be prescribed two adrenaline auto-injectors and trained on how to use them. A risk-stratified approach to discharge should be taken, as biphasic reactions can occur in up to 20% of patients. The Resus Council UK recommends a fast-track discharge for patients who have had a good response to a single dose of adrenaline and complete resolution of symptoms, while those who require two doses of IM adrenaline or have a history of biphasic reaction should be observed for at least 12 hours following symptom resolution.
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This question is part of the following fields:
- Immunology/Allergy
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Question 25
Correct
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You are evaluating a 23-year-old man who reports experiencing auditory hallucinations that have been occurring more frequently, now happening every day. Based on his history, which of the following factors is the most significant risk factor for psychotic disorders?
Your Answer: Having a parent with schizophrenia
Explanation:The most significant risk factor for psychotic disorders is a person’s family history.
Understanding the Epidemiology of Schizophrenia
Schizophrenia is a psychotic disorder that affects a significant portion of the population. The strongest risk factor for developing this condition is having a family history of the disorder. Individuals with a parent who has schizophrenia have a relative risk of 7.5. Additionally, monozygotic twins have a 50% chance of developing schizophrenia, while siblings have a 10% chance. In contrast, individuals with no relatives with schizophrenia have a 1% chance of developing the disorder.
Aside from family history, other factors can increase the risk of developing schizophrenia. Black Caribbean ethnicity has a relative risk of 5.4, while migration and living in an urban environment have relative risks of 2.9 and 2.4, respectively. Cannabis use also increases the risk of developing schizophrenia, with a relative risk of 1.4.
Understanding the epidemiology of schizophrenia is crucial in identifying individuals who may be at risk of developing the disorder. By recognizing these risk factors, healthcare professionals can provide early interventions and support to prevent or manage the onset of schizophrenia.
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This question is part of the following fields:
- Psychiatry
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Question 26
Incorrect
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A 55-year-old man presents to the respiratory clinic for a follow-up on his chronic obstructive pulmonary disease. He has a history of chronic CO2 retention and his oxygen saturation goals are between 88-92%. Upon examination, his chest sounds are quiet throughout, with equal air expansion, and a hyper-expanded chest. His oxygen saturation levels are at 91% on air. The clinic performs an arterial blood gas test.
What would be the most likely blood gas results for this patient?Your Answer: pH = 7.25, pO2 = 10.6 kPa, pCO2 = 6.2 kPa, HCO3- = 18 mmol/l
Correct Answer: pH = 7.37, pO2 = 9.1 kPa, pCO2 = 6.1 kPa, HCO3- = 30 mmol/l
Explanation:Arterial Blood Gas Interpretation Made Easy
Arterial blood gas interpretation can be a daunting task for healthcare professionals. However, the Resuscitation Council (UK) has provided a simple 5-step approach to make it easier. The first step is to assess the patient’s overall condition. The second step is to determine if the patient is hypoxaemic, which is indicated by a PaO2 level of less than 10 kPa on air. The third step is to check if the patient is acidaemic or alkalaemic, which is determined by the pH level. A pH level of less than 7.35 indicates acidaemia, while a pH level of more than 7.45 indicates alkalaemia.
The fourth step is to assess the respiratory component by checking the PaCO2 level. A PaCO2 level of more than 6.0 kPa suggests respiratory acidosis, while a PaCO2 level of less than 4.7 kPa suggests respiratory alkalosis. The fifth and final step is to evaluate the metabolic component by checking the bicarbonate level or base excess. A bicarbonate level of less than 22 mmol/l or a base excess of less than -2mmol/l indicates metabolic acidosis, while a bicarbonate level of more than 26 mmol/l or a base excess of more than +2mmol/l indicates metabolic alkalosis.
To make it easier to remember, healthcare professionals can use the ROME acronym. Respiratory is opposite, which means that low pH and high PaCO2 indicate acidosis, while high pH and low PaCO2 indicate alkalosis. Metabolic is equal, which means that low pH and low bicarbonate indicate acidosis, while high pH and high bicarbonate indicate alkalosis. By following this simple approach, healthcare professionals can easily interpret arterial blood gas results and provide appropriate treatment for their patients.
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This question is part of the following fields:
- Respiratory Medicine
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Question 27
Correct
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When visiting a 60-year-old patient at home to do a wound dressing, the District Nurse wants to confirm if the patient has received complete tetanus vaccination. What is the number of tetanus vaccine doses required for life-long protection?
Your Answer: 5
Explanation:Tetanus Vaccination and Management of Wounds
The tetanus vaccine is a purified toxin that is given as part of a combined vaccine. In the UK, it is given as part of the routine immunisation schedule at 2, 3, and 4 months, 3-5 years, and 13-18 years, providing a total of 5 doses for long-term protection against tetanus.
When managing wounds, the first step is to classify them as clean, tetanus-prone, or high-risk tetanus-prone. Clean wounds are less than 6 hours old and have negligible tissue damage, while tetanus-prone wounds include puncture-type injuries acquired in a contaminated environment or wounds containing foreign bodies. High-risk tetanus-prone wounds include wounds or burns with systemic sepsis, certain animal bites and scratches, heavy contamination with material likely to contain tetanus spores, wounds or burns with extensive devitalised tissue, and wounds or burns that require surgical intervention.
If the patient has had a full course of tetanus vaccines with the last dose less than 10 years ago, no vaccine or tetanus immunoglobulin is required regardless of the wound severity. If the patient has had a full course of tetanus vaccines with the last dose more than 10 years ago, a reinforcing dose of vaccine is required for tetanus-prone wounds, and a reinforcing dose of vaccine plus tetanus immunoglobulin is required for high-risk wounds. If the vaccination history is incomplete or unknown, a reinforcing dose of vaccine is required regardless of the wound severity, and a reinforcing dose of vaccine plus tetanus immunoglobulin is required for tetanus-prone and high-risk wounds.
Overall, proper vaccination and wound management are crucial in preventing tetanus infection.
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This question is part of the following fields:
- Infectious Diseases
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Question 28
Correct
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A 25-year-old woman arrives at the Emergency Department accompanied by a colleague from work. She complains of experiencing a 'fluttering' sensation in her chest for the past 30 minutes. Although she admits to feeling 'a bit faint,' she denies any chest pain or difficulty breathing. Upon conducting an ECG, the results show a regular tachycardia of 166 bpm with a QRS duration of 110 ms. Her blood pressure is 102/68 mmHg, and her oxygen saturation levels are at 99% on room air. What is the most appropriate course of action?
Your Answer: Carotid sinus massage
Explanation:Vagal manoeuvres, such as carotid sinus massage or the Valsalva manoeuvre, are the initial treatment for supraventricular tachycardia. Adenosine should only be administered if these manoeuvres are ineffective. According to the ALS guidelines, direct current cardioversion is not recommended for this condition.
Understanding Supraventricular Tachycardia
Supraventricular tachycardia (SVT) is a type of tachycardia that originates above the ventricles. It is commonly associated with paroxysmal SVT, which is characterized by sudden onset of a narrow complex tachycardia, usually an atrioventricular nodal re-entry tachycardia (AVNRT). Other causes include atrioventricular re-entry tachycardias (AVRT) and junctional tachycardias.
When it comes to acute management, vagal maneuvers such as the Valsalva maneuver or carotid sinus massage can be used. Intravenous adenosine is also an option, with a rapid IV bolus of 6mg given initially, followed by 12mg and then 18mg if necessary. However, adenosine is contraindicated in asthmatics, and verapamil may be a better option for them. Electrical cardioversion is another option.
To prevent episodes of SVT, beta-blockers can be used. Radio-frequency ablation is also an option. It is important to work with a healthcare provider to determine the best course of treatment for each individual case.
Overall, understanding SVT and its management options can help individuals with this condition better manage their symptoms and improve their quality of life.
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This question is part of the following fields:
- Cardiovascular
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Question 29
Correct
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A 32-year-old man is diagnosed with a phaeochromocytoma.
The urine levels of which of the following is most likely to be elevated in this patient?Your Answer: Metanephrines
Explanation:Urinary Metabolites as Diagnostic Markers for Adrenal Tumors and Disorders
The urinary excretion of certain metabolites can serve as diagnostic markers for various adrenal tumors and disorders. For instance, metanephrines, vanillylmandelic acid (VMA), and homovanillic acid (HVA) are the principal metabolic products of adrenaline and noradrenaline. Normal individuals excrete only minimal amounts of these substances in the urine. However, in phaeochromocytoma and neuroblastoma, urinary excretion of adrenaline and noradrenaline, and their metabolic products, increases intermittently.
Similarly, increased urinary excretion of the serotonin metabolite 5-hydroxyindoleacetic acid is seen in functioning carcinoids. Free urinary cortisol levels are elevated in Cushing syndrome, which is characterized by weight gain, fatty tissue deposits, moon face, buffalo hump, striae, thin skin, and acne. Urinary dehydroepiandrosterone excretion is often increased in congenital adrenal hyperplasia, while urinary pregnanetriol excretion is often increased in congenital adrenal hyperplasia caused by 21-hydroxylase deficiency.
It is important to note that elevated excretion of these compounds may also occur in other conditions such as coma, dehydration, extreme stress states, medication use, and ingestion of certain foods. Therefore, careful interpretation of urinary metabolite levels is necessary for accurate diagnosis of adrenal tumors and disorders.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 30
Incorrect
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A 68-year-old woman is referred with fatigue. Her primary care physician observes that she has jaundice and suspects liver disease. She also presents with angular cheilitis. She has a history of taking steroid inhalers for asthma, but no other significant medical history. A blood smear shows signs of megaloblastic anemia, and her serum bilirubin level is elevated, but her other laboratory results are normal. There are no indications of gastrointestinal (GI) issues.
What is the most appropriate diagnosis for this clinical presentation?Your Answer: Autoimmune hepatitis
Correct Answer: Pernicious anaemia
Explanation:Differential Diagnosis of Anaemia: Understanding the Causes
Anaemia is a common condition that can be caused by a variety of factors. Here, we will discuss some of the possible causes of anaemia and their corresponding laboratory findings.
Pernicious Anaemia: This type of anaemia is caused by a deficiency in vitamin B12 due to impaired intrinsic factor (IF) production. It is usually seen in adults aged 40-70 years and is characterized by megaloblastic changes in rapidly dividing cells. Anti-parietal cell antibodies are present in 90% of patients with pernicious anaemia. The Schilling test is useful in confirming the absence of IF. Treatment involves parenteral administration of cyanocobalamin or hydroxycobalamin.
Chronic Myeloid Leukaemia: CML is a myeloproliferative disorder that results in increased proliferation of granulocytic cells. Symptoms include fatigue, anorexia, weight loss, and hepatosplenomegaly. Mild to moderate anaemia is usually normochromic and normocytic. Diagnosis is based on histopathological findings in the peripheral blood and Philadelphia chromosome in bone marrow cells.
Iron Deficiency Anaemia: This type of anaemia is primarily a laboratory diagnosis and is characterized by microcytic and hypochromic erythropoiesis. It is caused by chronic iron deficiency and can be due to multiple causes, including chronic inflammation, iron malabsorption, chronic blood loss, and malabsorption of vitamin B12 or folate.
Crohn’s Disease: This chronic inflammatory process can affect any part of the GI tract and can cause anaemia due to chronic inflammation, iron malabsorption, chronic blood loss, and malabsorption of vitamin B12 or folate. However, the lack of GI symptoms in the clinical scenario provided is not consistent with a history of inflammatory bowel disease.
Autoimmune Hepatitis: This chronic disease is characterized by continuing hepatocellular inflammation and necrosis, with a tendency to progress to cirrhosis. Elevated serum aminotransferase levels are present in 100% of patients at initial presentation. Anaemia, if present, is usually normochromic. However, this clinical picture and laboratory findings are not consistent with the scenario given.
In conclusion, understanding the different causes of anaemia and their corresponding laboratory findings is crucial in making an accurate diagnosis and providing appropriate treatment.
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This question is part of the following fields:
- Haematology/Oncology
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