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  • Question 1 - A 6-month-old boy has been febrile for 24 hours. His current temperature is...

    Incorrect

    • A 6-month-old boy has been febrile for 24 hours. His current temperature is 39C and there are no localising symptoms and signs. His skin is flushed but otherwise normal and he remains alert and is not dehydrated.
      Select the single most appropriate management option.

      Your Answer: Prescribe clarithromycin

      Correct Answer: Paracetamol, ibuprofen and review in 24 hours

      Explanation:

      Assessment of a Child with Feverish Illness

      According to the guideline ‘Feverish Illness in Children’ (NICE CG 47. May 2007), a child with feverish illness can be assessed using a traffic light system to determine the risk of serious illness. In this case, the child would be placed in the low-risk category, indicating that he most likely has a viral infection.

      Symptomatic treatment, along with safety-netting and review, is all that is required. However, it is recommended to send a urine sample for culture if possible. This assessment helps healthcare professionals to provide appropriate care and management for children with feverish illness.

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      • Infectious Disease And Travel Health
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  • Question 2 - A 25-year-old male patient complains of feeling unwell for the past three days...

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    • A 25-year-old male patient complains of feeling unwell for the past three days with a low-grade fever. He has developed painful ulcers in his mouth and gums. During examination, submandibular lymphadenopathy is observed. What is the probable diagnosis?

      Your Answer: Oral Candida

      Correct Answer: Herpes simplex virus infection

      Explanation:

      Primary herpes simplex virus infection is indicated by gingivostomatitis, which this man is experiencing.

      The herpes simplex virus (HSV) comes in two strains: HSV-1 and HSV-2. It was once believed that HSV-1 caused cold sores and HSV-2 caused genital herpes, but there is now significant overlap between the two. Symptoms of a primary infection may include severe gingivostomatitis, while cold sores and painful genital ulceration are also common. Treatment options include oral aciclovir and chlorhexidine mouthwash for gingivostomatitis, topical aciclovir for cold sores (although the evidence for its effectiveness is limited), and oral aciclovir for genital herpes. Pregnant women with herpes should be treated with suppressive therapy, and those who experience a primary attack during pregnancy after 28 weeks gestation should have an elective caesarean section. The risk of transmission to the baby is low for women with recurrent herpes. Pap smear images can show the cytopathic effect of HSV, including multinucleation, marginated chromatin, and molding of the nuclei.

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  • Question 3 - A man visits your clinic worried about contracting meningococcal meningitis from his wife...

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    • A man visits your clinic worried about contracting meningococcal meningitis from his wife who has been admitted to the hospital with the disease. He seeks advice on the most suitable prophylactic medication.
      What is the most appropriate drug for prophylaxis?

      Your Answer: Benzylpenicillin

      Correct Answer: Ciprofloxacin

      Explanation:

      Antibiotics for Prophylaxis and Treatment of Infectious Diseases

      Public Health England recommends ciprofloxacin as the preferred antibiotic for prophylaxis and treatment of meningococcal disease in all age groups, including pregnant women. Ciprofloxacin has advantages over rifampicin, such as being a single-dose medication, not interfering with oral contraceptives, and being more easily accessible in community pharmacies. However, it should not be used in patients with ciprofloxacin hypersensitivity. Although historically not recommended for children due to the risk of arthropathy, studies have shown that the risk is low and transient.

      Co-trimoxazole is the drug of choice for prophylaxis and treatment of Pneumocystis jirovecii pneumonia, as well as toxoplasmosis and nocardiasis. Vancomycin can be used orally to treat Clostridium difficile infection, with metronidazole as an alternative. Ceftriaxone can be used for prophylaxis of meningococcal and Haemophilus influenza type b disease, but its use is unlicensed and requires intramuscular administration. Benzylpenicillin is given intravenously or intramuscularly in the prehospital treatment of patients with suspected meningococcal disease.

      Antibiotics for Prophylaxis and Treatment of Infectious Diseases

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  • Question 4 - A 23-year-old nurse is undergoing communicable disease immunity screening before starting work. The...

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    • A 23-year-old nurse is undergoing communicable disease immunity screening before starting work. The test results are as follows:

      - Negative for HBsAg
      - Positive for anti-HBs
      - Positive for anti-HBc (IgG)

      What is the nurse's hepatitis B status based on these findings?

      Your Answer: Resolved infection - natural immunity

      Explanation:

      The patient has evidence of a past hepatitis B infection that has been resolved. This is indicated by the absence of hepatitis B surface antigen and the presence of positive anti-HBs and IgG anti-HBc. It is important to note that natural immunity is demonstrated by the presence of both anti-HBs and anti-HBc, while artificial immunity is only indicated by positive anti-HBs. The patient is not currently infected and is not a carrier.

      Understanding Hepatitis B Serology

      Interpreting hepatitis B serology can be a challenging task, but it is crucial for proper diagnosis and treatment. Here are some key points to keep in mind:

      The surface antigen (HBsAg) is the first marker to appear and triggers the production of anti-HBs. If HBsAg is present for more than six months, it indicates chronic disease, while its absence suggests acute disease.

      Anti-HBs indicates immunity, either from exposure or vaccination. It is negative in chronic disease.

      Anti-HBc suggests previous or current infection. IgM anti-HBc appears during acute or recent hepatitis B infection and lasts for about six months, while IgG anti-HBc persists.

      HbeAg is a marker of infectivity and HBV replication. It results from the breakdown of core antigen from infected liver cells.

      For example, if someone has previously been immunized against hepatitis B, their anti-HBs will be positive, while all other markers will be negative. If they had hepatitis B in the past but are not carriers, their anti-HBc will be positive, and HBsAg will be negative. However, if they are now carriers, both anti-HBc and HBsAg will be positive.

      In summary, understanding hepatitis B serology requires careful interpretation of various markers and their combinations. By doing so, healthcare professionals can accurately diagnose and manage this potentially serious condition.

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  • Question 5 - A 6-year-old girl is hospitalized with symptoms of fever, headache, and neck stiffness,...

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    • A 6-year-old girl is hospitalized with symptoms of fever, headache, and neck stiffness, and is diagnosed with pneumococcal meningitis. There have been no other cases of meningitis reported in the area in the past month. What is the recommended approach for managing the close contacts of this girl?

      Your Answer: Oral amoxicillin + pneumococcal vaccine booster

      Correct Answer: No action is needed

      Explanation:

      Antibiotic prophylaxis is usually unnecessary for the carriage of pneumococcus, as it is a prevalent occurrence. However, in the event of a cluster of cases, exceptions may apply. For further information, please refer to the HPA link.

      When suspected bacterial meningitis is being investigated and managed, it is important to prioritize timely antibiotic treatment to avoid negative consequences. Patients should be urgently transferred to the hospital, and if meningococcal disease is suspected in a prehospital setting, intramuscular benzylpenicillin may be given. An ABC approach should be taken initially, and senior review is necessary if any warning signs are present. A key decision is when to attempt a lumbar puncture, which should be delayed in certain circumstances. Management of patients without indication for delayed LP includes IV antibiotics, with cefotaxime or ceftriaxone recommended for patients aged 3 months to 50 years. Additional tests that may be helpful include blood gases and throat swab for meningococcal culture. Prophylaxis needs to be offered to households and close contacts of patients affected with meningococcal meningitis, and meningococcal vaccination should be offered to close contacts when serotype results are available.

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  • Question 6 - A 32-year-old woman complains of a yellowish-green frothy vaginal discharge with a foul...

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    • A 32-year-old woman complains of a yellowish-green frothy vaginal discharge with a foul odor that began 1 week ago. She experiences dysuria and dyspareunia. During examination, her vagina appears erythematous.
      What is the most probable diagnosis?

      Your Answer: Trichomoniasis

      Explanation:

      Understanding Vaginal Discharge: Causes and Symptoms

      Vaginal discharge is a common occurrence in women, but it can sometimes indicate an underlying health issue. The most common causes of vaginal discharge are physiological, bacterial vaginosis, and candidal infections. Bacterial vaginosis is caused by the anaerobe Gardnerella vaginalis, which disrupts the normal vaginal flora. It causes a thin, profuse, and fishy-smelling discharge without itch or soreness. Candidiasis results in a thick, white, non-offensive discharge, which is associated with vulval itch and soreness. It may cause mild dyspareunia and external dysuria.

      Sexually transmitted infections such as Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis can also cause purulent vaginal discharge. These infections may be asymptomatic, making it difficult to differentiate between them without laboratory testing. T. vaginalis is a protozoan parasite that causes an offensive yellow vaginal discharge, which is often profuse and frothy. It is associated with vulval itch and soreness, dysuria, abdominal pain, and superficial dyspareunia. A pelvic examination may reveal red blotches on the vaginal wall or cervix, and the labia may be swollen.

      It is important to understand the causes and symptoms of vaginal discharge to identify any potential health issues and seek appropriate treatment. Regular gynecological check-ups and practicing safe sex can help prevent and manage vaginal discharge.

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  • Question 7 - A 42-year-old woman comes to your clinic complaining of an insect bite on...

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    • A 42-year-old woman comes to your clinic complaining of an insect bite on her left ankle that has been getting increasingly itchy. Despite using over-the-counter creams, she has not seen any improvement. Her ankle is surrounded by a significant area of redness measuring approximately 12 cm in diameter. She reports no fever and has been in good health otherwise.

      What is the next course of action in managing her condition?

      Your Answer: Oral loratadine

      Explanation:

      Cream is a highly effective topical corticosteroid that can be utilized for the treatment of bite reactions. However, for milder cases, hydrocortisone 1 may be sufficient.

      Animal bites are a common occurrence in everyday practice, with dogs and cats being the most frequent culprits. These bites are usually caused by multiple types of bacteria, with Pasteurella multocida being the most commonly isolated organism. To manage these bites, it is important to cleanse the wound thoroughly. Puncture wounds should not be sutured unless there is a risk of cosmesis. The current recommendation is to use co-amoxiclav, but if the patient is allergic to penicillin, doxycycline and metronidazole are recommended.

      On the other hand, human bites can cause infections from a variety of bacteria, including both aerobic and anaerobic types. Common organisms include Streptococci spp., Staphylococcus aureus, Eikenella, Fusobacterium, and Prevotella. To manage these bites, co-amoxiclav is also recommended. It is important to consider the risk of viral infections such as HIV and hepatitis C when dealing with human bites.

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  • Question 8 - A 54-year-old man from Pakistan visits his GP complaining of numbness and tingling...

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    • A 54-year-old man from Pakistan visits his GP complaining of numbness and tingling in his feet that has been present for a week. He reports starting some new medications recently. Upon reviewing his medical history, it is revealed that he has been diagnosed with tuberculosis and hypertension.

      Which of the following medications is the most probable cause of his symptoms?

      Your Answer: Isoniazid

      Explanation:

      Peripheral neuropathy is a well-known adverse effect of isoniazid, while paraesthesia is a rare side effect of amlodipine according to the BNF. Therefore, it is more likely that isoniazid is the cause in this case.

      Common side effects of drugs:
      Rifampicin – orange bodily fluids, rash, hepatotoxicity, drug interactions
      Isoniazid – peripheral neuropathy, psychosis, hepatotoxicity

      Tuberculosis is a bacterial infection that can be treated with a combination of drugs. Each drug has a specific mechanism of action and can also cause side-effects. Rifampicin works by inhibiting bacterial DNA dependent RNA polymerase, which prevents the transcription of DNA into mRNA. However, it is a potent liver enzyme inducer and can cause hepatitis, orange secretions, and flu-like symptoms.

      Isoniazid, on the other hand, inhibits mycolic acid synthesis. It can cause peripheral neuropathy, which can be prevented with pyridoxine (Vitamin B6). It can also cause hepatitis and agranulocytosis, but it is a liver enzyme inhibitor.

      Pyrazinamide is converted by pyrazinamidase into pyrazinoic acid, which inhibits fatty acid synthase (FAS) I. However, it can cause hyperuricaemia, leading to gout, as well as arthralgia and myalgia. It can also cause hepatitis.

      Finally, Ethambutol inhibits the enzyme arabinosyl transferase, which polymerizes arabinose into arabinan. However, it can cause optic neuritis, so it is important to check visual acuity before and during treatment. The dose also needs adjusting in patients with renal impairment.

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  • Question 9 - A 54-year-old businessman returns from a recent trip to the Philippines and presents...

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    • A 54-year-old businessman returns from a recent trip to the Philippines and presents with symptoms of diarrhoea, flu-like illness, and a rash on his trunk. He also has cervical lymphadenopathy and a widespread maculopapular rash. On examination, his vital signs are stable. What investigation would be most helpful in determining the cause of his illness?

      Your Answer: Chest x-ray

      Correct Answer: HIV test

      Explanation:

      The symptoms and timing of this man’s illness suggest that he may be experiencing HIV seroconversion illness. Although he may have contracted a gastrointestinal infection while traveling, this is unlikely to account for his rash and swollen lymph nodes.

      Understanding HIV Seroconversion

      HIV seroconversion is a process that occurs in individuals who have been recently infected with the virus. It is characterized by symptoms that resemble those of glandular fever, such as sore throat, lymphadenopathy, malaise, myalgia, arthralgia, diarrhea, maculopapular rash, and mouth ulcers. In some rare cases, it can also lead to meningoencephalitis. The severity of the symptoms is associated with the long-term prognosis of the patient, with more severe symptoms indicating a poorer prognosis.

      Diagnosing HIV seroconversion can be challenging, as antibodies to the virus may not be present in the early stages of infection. However, HIV PCR and p24 antigen tests can confirm the diagnosis. Understanding the process of HIV seroconversion is crucial for early detection and treatment of the virus, as well as for preventing its spread to others. By recognizing the symptoms and seeking medical attention promptly, individuals can receive the care they need to manage the virus and improve their long-term outcomes.

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  • Question 10 - A 25-year-old man presents with a 4-day history of general malaise, conjunctivitis and...

    Incorrect

    • A 25-year-old man presents with a 4-day history of general malaise, conjunctivitis and a cough. He is starting to develop a maculopapular rash on his face and upper trunk and has a temperature of 39oC.
      Select the single most likely diagnosis.

      Your Answer: Parvovirus B19

      Correct Answer: Measles

      Explanation:

      Measles

      Measles is characterized by a 4-day prodrome with cough and conjunctivitis, which is not seen in any other condition. While rubella has a similar prodrome, it is milder and fever is not as high. Parvovirus B19’s rash appears in the convalescent phase, while infectious mononucleosis presents with sore throat, lymphadenopathy, and malaise. The rash in primary HIV is macular, erythematous, and truncal, and is accompanied by painful oral ulceration and lymphadenopathy. However, if a patient presents with cough and conjunctivitis, measles should be considered as a possible diagnosis.

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  • Question 11 - You see a 16-year-old boy with his father. They are planning on travelling...

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    • You see a 16-year-old boy with his father. They are planning on travelling to Africa to climb Mount Kenya in 3 months time. They would like you to prescribe some malaria prophylaxis as Kenya is a malaria endemic country. They were given some information from the nurse and they think they would like to take atovaquone/proguanil (brand name Malarone). They are aware that most regimens have side effects and would like to know a bit more about what to expect from this drug.

      What is a common side effect of atovaquone/proguanil that the 16-year-old boy and his father should be aware of before taking it as a malaria prophylaxis for their upcoming trip to Kenya?

      Your Answer: Discoloration of mucous membranes

      Correct Answer: Gastrointestinal upset

      Explanation:

      Malaria is a serious illness caused by Plasmodium parasites that infect red blood cells and is transmitted through mosquito bites. When traveling to areas where malaria is prevalent, it is recommended to take medication to prevent infection. There are several options available, including chloroquines, proguanil, mefloquine, and doxycycline. Each medication has its own set of potential side effects, with gastrointestinal upset being the most common. Other side effects may include headaches, rash, and neuropsychiatric reactions. It is important to discuss the risks and benefits of each medication with a healthcare provider before starting prophylaxis.

      Malaria is a serious disease caused by the Plasmodium falciparum protozoa, with around 1,500-2,000 cases reported each year in patients returning from endemic countries. The majority of these cases occur in patients who did not take prophylaxis. It is important to consult up-to-date charts for recommended regimens for malaria zones before prescribing. There are several drugs available for prophylaxis, including Atovaquone + proguanil (Malarone), Chloroquine, Doxycycline, Mefloquine (Lariam), and Proguanil (Paludrine). Pregnant women and children are at higher risk of serious complications and should avoid travel to malaria endemic regions if possible. However, if travel is essential, prophylaxis should be taken, and DEET can be used to repel mosquitoes. Doxycycline is only licensed for use in children over the age of 12 years.

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  • Question 12 - A new case of Chickenpox has been reported at the daycare yesterday. A...

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    • A new case of Chickenpox has been reported at the daycare yesterday. A mother attends with her 4-year-old son and is anxious because she is going away for a week’s holiday on the next day. She wonders how soon her son will develop symptoms.
      Select from the list the option within which the incubation period for Chickenpox lies.

      Your Answer: Greater than 6 weeks

      Correct Answer: Medium (7-21 days)

      Explanation:

      Understanding Incubation Periods and Latent Periods in Diseases

      Incubation period refers to the time between exposure to a pathogenic organism and the onset of symptoms. This period can range from minutes to even 30 years, depending on the disease. Latent period, on the other hand, is the time from infection to infectiousness. While the two terms may be synonymous, a distinction is sometimes made between them.

      Examples of diseases with short incubation periods include norovirus, influenza, and scarlet fever. Diseases with medium incubation periods include roseola, measles, and pertussis. Mumps, erythema infectiosum, and rubella have long incubation periods, while infectious mononucleosis and hepatitis A have extra-long incubation periods. Hepatitis B has an incubation period greater than six weeks.

      Clinical latency occurs in diseases like AIDS, where people infected with HIV may not show any symptoms or signs of AIDS despite having a large viral load. It is important to understand incubation and latent periods in diseases to prevent their spread and manage their symptoms effectively.

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  • Question 13 - A 42-year-old mother is curious about her child's immunisations.

    When is the meningococcal...

    Incorrect

    • A 42-year-old mother is curious about her child's immunisations.

      When is the meningococcal C vaccine given?

      Your Answer: 1 year and 14 years

      Correct Answer: 2 months and 3 months

      Explanation:

      UK Immunisation Schedule and Meningococcal Serogroup C Vaccine

      We have provided a reference to the current UK immunisation schedule at the end of this text. It is a two-page A4 summary that we suggest you save and print for future reference. According to the schedule, the meningococcal serogroup C (MenC) vaccine is given to infants at one year old and as part of the MenACWY vaccine at age fourteen. However, the infant dose of MenC conjugate vaccine is no longer administered at three months of age.

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  • Question 14 - A 35-year-old patient who is on methotrexate for psoriasis presents because her 6-year-old...

    Incorrect

    • A 35-year-old patient who is on methotrexate for psoriasis presents because her 6-year-old son has been suffering from Chickenpox and she is concerned about developing it. She has not previously had Chickenpox herself and is currently well, with no symptoms or rash.

      What advice should be given to this patient?

      Your Answer: Stop methotrexate

      Correct Answer: Test for varicella antibodies and give varicella-zoster immunoglobulin

      Explanation:

      Patients who are on long-term steroids or methotrexate and have weakened immune systems should be given VZIG if they come into contact with Chickenpox and have no antibodies to varicella. Although Chickenpox is usually a mild illness, it can be dangerous for those who are immunosuppressed or pregnant.

      If a patient has been exposed to varicella, they should be offered active post-exposure prophylaxis with varicella-zoster immunoglobulin. It is important to test people who have had significant exposure to Chickenpox and are immunocompromised for varicella-zoster antibody, regardless of their history of Chickenpox.

      It is inappropriate to wait for up to 21 days to see if symptoms appear or take no action because this patient is immunosuppressed and is at risk of severe varicella infection. Similarly, stopping her methotrexate would not be appropriate as the immunosuppressive effects would take time to wear off.

      Managing Chickenpox Exposure in At-Risk Groups

      Whilst Chickenpox is usually a mild condition in children with normal immune systems, it can cause serious systemic disease in at-risk groups. Pregnant women and their developing fetuses are particularly vulnerable. Therefore, it is crucial to know how to manage varicella exposure in these special groups.

      To determine who would benefit from active post-exposure prophylaxis, the following criteria should be met: significant exposure to Chickenpox or herpes zoster, a clinical condition that increases the risk of severe varicella (such as immunosuppression), and no antibodies to the varicella virus. Ideally, all at-risk exposed patients should have a blood test for varicella antibodies. However, post-exposure prophylaxis should not be delayed past 7 days after initial contact.

      Patients who meet the above criteria should be given varicella-zoster immunoglobulin (VZIG). The management of Chickenpox exposure in pregnancy is an important topic that is covered in more detail in a separate entry to the textbook.

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  • Question 15 - Sarah is a 35-year-old woman who presents to you with a 1 week...

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    • Sarah is a 35-year-old woman who presents to you with a 1 week history of fever, right sided abdominal pain and general malaise. She has no significant past medical history and has recently travelled to South America, returning 4 weeks ago. During examination, Sarah is found to be pyrexial. She complains of pain in the right upper quadrant of her abdomen and there is hepatomegaly.

      Upon further questioning, Sarah states that she is not sexually active and denies any history of intravenous drug use. Liver function tests reveal a significantly raised alanine aminotransferase (ALT) and alkaline phosphatase (ALP). A full liver screen confirms the diagnosis.

      Sarah is prescribed medication for symptomatic management and she makes a full recovery within 3 months.

      What is the most likely diagnosis?

      Your Answer: Hepatitis C

      Correct Answer: Hepatitis A

      Explanation:

      Acute hepatitis A is characterized by symptoms similar to those of other forms of acute viral hepatitis, including flu-like symptoms, RUQ pain, tender hepatomegaly, and abnormal liver function tests. It is difficult to differentiate hepatitis A from other forms of viral hepatitis based on medical history, physical examination, or routine laboratory tests. However, a history of exposure or risk factors, such as travel to regions with high prevalence, can increase suspicion. Unlike hepatitis C and D, which are transmitted through blood, hepatitis A is transmitted through the fecal-oral route.

      Understanding Hepatitis A: Symptoms, Transmission, and Prevention

      Hepatitis A is a viral infection that affects the liver. It is usually a mild illness that resolves on its own, with serious complications being rare. The virus is transmitted through the faecal-oral route, often in institutions. The incubation period is typically 2-4 weeks, and symptoms include a flu-like prodrome, abdominal pain (usually in the right upper quadrant), tender hepatomegaly, jaundice, and deranged liver function tests.

      While complications are rare, there is no increased risk of hepatocellular cancer. An effective vaccine is available, and it is recommended for people travelling to or residing in areas of high or intermediate prevalence, those with chronic liver disease, patients with haemophilia, men who have sex with men, injecting drug users, and individuals at occupational risk (such as laboratory workers, staff of large residential institutions, sewage workers, and people who work with primates).

      It is important to note that the vaccine requires a booster dose 6-12 months after the initial dose. By understanding the symptoms, transmission, and prevention of hepatitis A, individuals can take steps to protect themselves and others from this viral infection.

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  • Question 16 - Which of the following antibiotics is most likely to cause pseudomembranous colitis? ...

    Incorrect

    • Which of the following antibiotics is most likely to cause pseudomembranous colitis?

      Your Answer: Doxycycline

      Correct Answer: Cefaclor

      Explanation:

      C.difficile is strongly associated with cephalosporins, in addition to clindamycin.

      Clostridioides difficile is a type of bacteria that is commonly found in hospitals. It produces a toxin that can damage the intestines and cause a condition called pseudomembranous colitis. This bacteria usually develops when the normal gut flora is disrupted by broad-spectrum antibiotics, with second and third generation cephalosporins being the leading cause. Other risk factors include the use of proton pump inhibitors. Symptoms of C. difficile infection include diarrhea, abdominal pain, and a raised white blood cell count. The severity of the infection can be determined using the Public Health England severity scale.

      To diagnose C. difficile infection, a stool sample is tested for the presence of the C. difficile toxin. Treatment involves reviewing current antibiotic therapy and stopping antibiotics if possible. For a first episode of infection, oral vancomycin is the first-line therapy for 10 days, followed by oral fidaxomicin as second-line therapy and oral vancomycin with or without IV metronidazole as third-line therapy. Recurrent infections may require different treatment options, such as oral fidaxomicin within 12 weeks of symptom resolution or oral vancomycin or fidaxomicin after 12 weeks of symptom resolution. In life-threatening cases, oral vancomycin and IV metronidazole may be used, and surgery may be considered with specialist advice. Other therapies, such as bezlotoxumab and fecal microbiota transplant, may also be considered for preventing recurrences in certain cases.

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  • Question 17 - The school nurse is preparing for a visit from the health inspector tomorrow....

    Correct

    • The school nurse is preparing for a visit from the health inspector tomorrow. She seeks guidance on the appropriate temperature range (in Celsius) for storing vaccines in the fridge. What is the standard temperature range that vaccines should be stored at, unless otherwise stated by the manufacturer?

      Your Answer: +2C to +8C

      Explanation:

      Vaccinations: Types and Precautions

      Vaccinations are an important aspect of preventive healthcare. However, it is crucial to be aware of the different types of vaccines and their potential risks, especially for immunocompromised individuals. Live-attenuated vaccines, such as BCG, MMR, and oral polio, may pose a risk to these patients. In contrast, inactivated preparations, such as rabies and hepatitis A, and toxoid vaccines, such as tetanus and diphtheria, are safer options. Subunit and conjugate vaccines, which use only part of the pathogen or link bacterial polysaccharide outer coats to proteins, respectively, are also available for diseases like pneumococcus, haemophilus, meningococcus, hepatitis B, and human papillomavirus.

      It is important to note that different types of influenza vaccines are available, including whole inactivated virus, split virion, and sub-unit. Additionally, the cholera vaccine contains inactivated strains of Vibrio cholerae and the recombinant B-subunit of the cholera toxin. The hepatitis B vaccine is prepared from yeast cells using recombinant DNA technology and contains HBsAg adsorbed onto an aluminum hydroxide adjuvant.

      In summary, vaccinations are an essential tool in preventing the spread of infectious diseases. However, it is crucial to understand the different types of vaccines and their potential risks to make informed decisions about vaccination.

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  • Question 18 - A patient who is an intravenous drug user has contracted hepatitis C. What...

    Incorrect

    • A patient who is an intravenous drug user has contracted hepatitis C. What percentage of such patients in their age group will develop chronic hepatitis C infection?

      Your Answer: 5-10%

      Correct Answer: 55-85%

      Explanation:

      Develop a persistent infection.

      Hepatitis C is a virus that is expected to become a significant public health issue in the UK in the coming years, with around 200,000 people believed to be chronically infected. Those at risk include intravenous drug users and individuals who received a blood transfusion before 1991, such as haemophiliacs. The virus is an RNA flavivirus with an incubation period of 6-9 weeks. Transmission can occur through needle stick injuries, vertical transmission from mother to child, and sexual intercourse, although the risk is relatively low. There is currently no vaccine for hepatitis C.

      After exposure to the virus, only around 30% of patients will develop symptoms such as a transient rise in serum aminotransferases, jaundice, fatigue, and arthralgia. HCV RNA is the preferred diagnostic test for acute infection, although patients who spontaneously clear the virus will continue to have anti-HCV antibodies. Chronic hepatitis C is defined as the persistence of HCV RNA in the blood for 6 months and can lead to complications such as rheumatological problems, cirrhosis, hepatocellular cancer, and cryoglobulinaemia.

      The management of chronic hepatitis C depends on the viral genotype and aims to achieve sustained virological response (SVR), defined as undetectable serum HCV RNA six months after the end of therapy. Interferon-based treatments are no longer recommended, and a combination of protease inhibitors with or without ribavirin is currently used. However, these treatments can have side effects such as haemolytic anaemia, cough, flu-like symptoms, depression, fatigue, leukopenia, and thrombocytopenia. Women should not become pregnant within 6 months of stopping ribavirin as it is teratogenic.

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  • Question 19 - A 29-year-old man presents to the General Practitioner with complaints of anorexia, malaise...

    Incorrect

    • A 29-year-old man presents to the General Practitioner with complaints of anorexia, malaise and jaundice. Liver function tests reveal a hepatocellular pattern of liver damage, leading to suspicion of viral hepatitis.
      Which of the following choices would NOT aid in confirming the diagnosis?

      Your Answer: Hepatitis C virus-polymerase chain reaction (HCV-PCR)

      Correct Answer: Anti-hepatitis B surface antigen (HBs)

      Explanation:

      Understanding Hepatitis Tests

      Hepatitis is a viral infection that affects the liver. There are different types of hepatitis, including A, B, and C. To diagnose hepatitis, doctors use various tests. One of these tests is the Anti-HBs test, which indicates immunity to hepatitis B.

      Another test is the Hepatitis B surface antigen test, which can indicate an acute infection or a chronic carrier state. If a patient has acute hepatitis B virus infection, the presence of this antigen strongly suggests it. However, it doesn’t rule out chronic HBV with acute superinfection by another hepatitis virus.

      The most specific test for diagnosing acute HCV infection before antibodies have developed is the qualitative polymerase chain reaction (PCR) assay for viral particles. If all these tests are negative, doctors should consider other causes of hepatitis, such as another virus or alcohol.

      In conclusion, understanding hepatitis tests is crucial for diagnosing and treating this viral infection.

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  • Question 20 - A 3-year-old-boy has diarrhoea. Campylobacter is grown from a stool sample.
    Select from...

    Incorrect

    • A 3-year-old-boy has diarrhoea. Campylobacter is grown from a stool sample.
      Select from the list the commonest source of infection in the UK.

      Your Answer: Droplet transmission

      Correct Answer: Contaminated food

      Explanation:

      Campylobacter Enteritis: A Common Bacterial Infection of the Gut

      Campylobacter enteritis is a prevalent bacterial infection of the gut in industrialized countries, affecting people of all ages, especially young adults. In the United Kingdom alone, there are approximately 55,000 laboratory isolations reported annually, with an incidence rate of 100/100,000. However, the actual incidence rate is likely to be ten times higher than reported.

      The consumption of raw or barbecued meats, particularly poultry, carries a significant risk of infection. Broiler chickens are the most common source of Campylobacter spp, and almost all retailed chickens are contaminated. Therefore, self-infection or cross-contamination to other foods can occur if proper hygiene is not observed. Other sources of infection include unpasteurized milk, contaminated water, and pets with diarrhea. Person-to-person spread is also possible.

      Campylobacter is a notifiable disease in the UK. Although the condition is often self-limiting, antibiotic treatment may be necessary in severe cases, worsening disease, immunocompromised individuals, or symptoms lasting more than seven days. Erythromycin is the first-line antibiotic of choice, with a recommended dosage of 250-500mg for up to seven days.

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  • Question 21 - You are working in the urgent care centre, where John, a 44-year-old man...

    Incorrect

    • You are working in the urgent care centre, where John, a 44-year-old man comes to see you with a laceration to his right lower leg. He explains that 2 hours ago he was using a sharp tool to cut wood when it slipped and hit deep into his foot.

      On examination, there is a 6 cm laceration on the lateral aspect of John's right lower leg which is 4 cm deep. There is a lot of sawdust visible inside the wound.

      John is unsure about his tetanus immunisation history and there is no further information about this in his records.

      What is the most appropriate option to manage John's wound with regards to tetanus prophylaxis?

      Your Answer: A decision cannot be made until tetanus immunisation history is confirmed

      Correct Answer: Booster vaccine and tetanus immunoglobulin should be given

      Explanation:

      If a patient’s tetanus vaccination history is uncertain, they should receive a booster vaccine and immunoglobulin, unless the wound is minor and less than six hours old. In the case of Sarah, who has a tetanus-prone wound contaminated with soil, she requires treatment with human tetanus immunoglobulin. According to NICE guidelines, if a person’s immunisation status is unknown or uncertain, an immediate dose of vaccine should be given, followed by a full five-dose course if necessary to ensure future immunity. Therefore, the correct course of action is to administer both a booster vaccine and tetanus immunoglobulin. Waiting to confirm the tetanus immunisation history is not recommended, as tetanus prophylaxis needs to be given urgently. Advising that no tetanus prophylaxis is required is also incorrect, especially in the case of a tetanus-prone wound, which requires both a booster vaccine and tetanus immunoglobulin.

      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. This is considered to provide 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 non-penetrating with negligible tissue damage. Tetanus-prone wounds include puncture-type injuries acquired in a contaminated environment, wounds containing foreign bodies, and compound fractures. 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 that show 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.

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  • Question 22 - A recently graduated nurse at the nearby hospital receives hepatitis B vaccination. After...

    Incorrect

    • A recently graduated nurse at the nearby hospital receives hepatitis B vaccination. After three months of completing the primary course, the following outcomes are observed:

      Outcome Anti-HBs: 10 - 100 mIU/ml
      Reference A protective immunity is indicated by an antibody level of >100 mIU/ml.

      What is the best course of action to take?

      Your Answer: Repeat anti-HBs level in three months time

      Correct Answer: Give one further dose of hepatitis B vaccine

      Explanation:

      Understanding Hepatitis B: Causes, Symptoms, Complications, Prevention, and Management

      Hepatitis B is a virus that spreads through exposure to infected blood or body fluids, including from mother to child during birth. The incubation period is typically 6-20 weeks. Symptoms of hepatitis B include fever, jaundice, and elevated liver transaminases. Complications of the infection can include chronic hepatitis, fulminant liver failure, hepatocellular carcinoma, glomerulonephritis, polyarteritis nodosa, and cryoglobulinemia.

      Immunization against hepatitis B is recommended for at-risk groups, including healthcare workers, intravenous drug users, sex workers, close family contacts of an individual with hepatitis B, individuals receiving regular blood transfusions, chronic kidney disease patients, prisoners, and chronic liver disease patients. The vaccine is given in three doses and is typically effective, although around 10-15% of adults may not respond well to the vaccine.

      Management of hepatitis B typically involves antiviral medications such as tenofovir, entecavir, and telbivudine, which aim to suppress viral replication. Pegylated interferon-alpha was previously the only treatment available and can still be used as a first-line treatment, but other medications are increasingly being used. A better response to treatment is predicted by being female, under 50 years old, having low HBV DNA levels, being non-Asian, being HIV negative, and having a high degree of inflammation on liver biopsy.

      Overall, understanding the causes, symptoms, complications, prevention, and management of hepatitis B is important for both healthcare professionals and the general public. Vaccination and early detection and treatment can help prevent the spread of the virus and reduce the risk of complications.

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  • Question 23 - A 16-year-old male presents with a severe sore throat, fever and lethargy. On...

    Incorrect

    • A 16-year-old male presents with a severe sore throat, fever and lethargy. On examination he is noted to have cervical lymphadenopathy. He has now been unwell for 5 days. A blood test is taken the next day:

      Hb 15.0 g/L Male: (135-180)
      Female: (115 - 160)
      Platelets 280 * 109/L (150 - 400)
      WBC 8.5 * 109/L (4.0 - 11.0)
      Neuts 2.5 * 109/L (2.0 - 7.0)
      Lymphs 5.0 * 109/L (1.0 - 3.5)
      Mono 0.4 * 109/L (0.2 - 0.8)
      Eosin 0.2 * 109/L (0.0 - 0.4)
      Heterophil antibody test POSITIVE

      What is the most appropriate next step in management?

      Your Answer: Oseltamivir

      Correct Answer: Observation

      Explanation:

      Infectious mononucleosis typically resolves on its own and doesn’t require active treatment. However, it is important to advise patients to refrain from participating in contact sports for 8 weeks as there is a risk of splenic rupture.

      Understanding Infectious Mononucleosis

      Infectious mononucleosis, also known as glandular fever, is a viral infection caused by the Epstein-Barr virus (EBV) in 90% of cases. It is most commonly seen in adolescents and young adults. The classic symptoms of sore throat, pyrexia, and lymphadenopathy are present in around 98% of patients. Other symptoms include malaise, anorexia, headache, palatal petechiae, splenomegaly, hepatitis, lymphocytosis, haemolytic anaemia, and a rash. The symptoms typically resolve after 2-4 weeks.

      The diagnosis of infectious mononucleosis is confirmed through a heterophil antibody test (Monospot test) in the second week of the illness. Management is supportive and includes rest, drinking plenty of fluids, avoiding alcohol, and taking simple analgesia for any aches or pains. It is recommended to avoid playing contact sports for 4 weeks after having glandular fever to reduce the risk of splenic rupture.

      Interestingly, there is a correlation between EBV and socioeconomic groups. Lower socioeconomic groups have high rates of EBV seropositivity, having frequently acquired EBV in early childhood when the primary infection is often subclinical. However, higher socioeconomic groups show a higher incidence of infectious mononucleosis, as acquiring EBV in adolescence or early adulthood results in symptomatic disease.

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  • Question 24 - A 55-year-old man presents with pyrexia, urinary frequency, dysuria and pelvic discomfort. Examination...

    Incorrect

    • A 55-year-old man presents with pyrexia, urinary frequency, dysuria and pelvic discomfort. Examination reveals a tender prostate. A urine dipstick test shows white blood cells.
      What is the most appropriate first-line management for this patient?

      Your Answer: Ibuprofen

      Correct Answer: Ciprofloxacin

      Explanation:

      Treatment Options for Acute Prostatitis: Antibiotics and Pain Relief

      Acute prostatitis is a bacterial infection of the prostate gland that can cause pain, fever, and difficulty urinating. The National Institute for Health and Care Excellence recommends starting antibiotics immediately while waiting for urine culture results. Quinolones like ciprofloxacin or ofloxacin are preferred over trimethoprim because they are effective against a wider range of urinary pathogens. Treatment for at least four weeks is recommended to prevent chronic prostatitis. In severe cases, hospital admission or referral may be necessary. Pain relief with paracetamol and/or ibuprofen may also be necessary. Some authorities recommend α-blocker therapy like tamsulosin to improve outflow obstruction, but it is not first-line management. If quinolones cannot be taken, trimethoprim may be used as an off-label option.

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  • Question 25 - A 50-year-old woman presented 2 weeks ago with upper respiratory symptoms, cough with...

    Correct

    • A 50-year-old woman presented 2 weeks ago with upper respiratory symptoms, cough with scanty sputum, hoarseness and headache and a few left basal crepitations were heard on examination. She was treated with amoxicillin for 7 days but her cough persists and crepitations are still audible at the left base.
      What is the most appropriate management for this patient?

      Your Answer: Clarithromycin

      Explanation:

      Understanding Community-Acquired Pneumonia and Treatment Options

      Community-acquired pneumonia (CAP) is suggested by lower respiratory signs and symptoms, and amoxicillin is an appropriate choice of treatment. The most likely organisms causing CAP are S. pneumoniae, Staph. aureus, Mycoplasma pneumoniae, Haemophilus influenza, Chlamydophila pneumoniae, and respiratory viruses. Flucloxacillin is appropriate for suspected staphylococcal infection, but staphylococcal pneumonia is usually severe, which is not the case here. Atypical pneumonia due to Mycoplasma or Chlamydophila is more likely, with Chlamydophila causing symptoms that may drag on for weeks or months. A chest X-ray may show more severe changes than the symptoms and signs suggest. Treatment for atypical pneumonia is similar to other CAPs, with clarithromycin being the drug of choice. For moderately severe CAP, amoxicillin and clarithromycin or doxycycline alone are recommended. Severe cases will usually require hospitalization.

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  • Question 26 - A 24-year-old woman has plantar warts. Her mother has read that they are...

    Incorrect

    • A 24-year-old woman has plantar warts. Her mother has read that they are caused by human papillomavirus (HPV). She is aware of the link with cervical cancer and is concerned.
      Select from the list the type of HPV infection that is most commonly associated with the development of cervical cancer.

      Your Answer: Plane warts

      Correct Answer: Asymptomatic infection

      Explanation:

      Understanding Human Papillomavirus (HPV) and its Association with Cancer

      Human papillomavirus (HPV) is a virus that infects the skin and mucosae of the upper respiratory and anogenital tracts. With about 100 types of HPV, 40 of them infect the genital tract. HPV is classified as either ‘high-risk’ or ‘low-risk’ types, depending on their association with cancer. HPV16 is responsible for over 50% of all cervical cancers, while HPV18 is responsible for over 15%. Although most high-risk infections are transient and cause no clinical problems, persistent infection by a high-risk HPV type is the most important factor for the development of cancer. Types 6 and 11 are associated with anogenital warts and are included in one of the HPV vaccines (Gardasil®) along with types 16 and 18. It is recommended that individuals receive the HPV vaccine to prevent the development of cancer.

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  • Question 27 - A 32-year-old woman presents to her GP complaining of increasing fatigue and nausea...

    Incorrect

    • A 32-year-old woman presents to her GP complaining of increasing fatigue and nausea over the past two weeks. During the examination, the GP notices a yellowish tint to the whites of her eyes. The patient resides in a remote fishing village and consumes a diet high in seafood. She doesn't smoke or drink alcohol and reports no weight loss or other constitutional symptoms. The following are her liver function test results:

      - Bilirubin: 20 µmol/l
      - ALP: 160 u/l
      - ALT: 550 u/l
      - γGT: 30 u/l
      - Albumin: 35 g/l

      All other routine blood results are normal. What is the most likely cause of her symptoms?

      Your Answer: Hepatitis B

      Correct Answer: Hepatitis E

      Explanation:

      Understanding Hepatitis E

      Hepatitis E is a type of RNA hepevirus that is transmitted through the faecal-oral route. Its incubation period ranges from 3 to 8 weeks. This disease is common in Central and South-East Asia, North and West Africa, and in Mexico. It causes a similar illness to hepatitis A, but with a higher mortality rate of about 20% during pregnancy. Unlike other types of hepatitis, Hepatitis E doesn’t cause chronic disease or an increased risk of hepatocellular cancer. Although a vaccine is currently in development, it is not yet widely available.

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  • Question 28 - A 28-year-old worker in a care home returns from a camping trip with...

    Correct

    • A 28-year-old worker in a care home returns from a camping trip with diarrhoea. A stool specimen is sent which is positive for Campylobacter.
      Select the single correct statement regarding management.

      Your Answer: She should stay off work until 48 hours after the diarrhoea has settled

      Explanation:

      Campylobacter: Causes, Management, and Prevention

      Campylobacter is the most commonly reported bacterial cause of infectious intestinal disease in England and Wales. The disease is usually contracted from animals farmed for meat and poultry, but person-to-person transmission can also occur due to poor personal hygiene. The primary management approach is rehydration. Infected healthcare workers or food handlers should not work, and antibiotics may be prescribed to reduce the duration of excretion and manage severe or prolonged illness, especially in pregnant women and immunocompromised individuals. Erythromycin and azithromycin are the most effective antibiotics for treating Campylobacter. Anti-motility drugs should not be used routinely, but may be considered for adults in special circumstances. The disease is typically self-limiting, and cultures are rarely positive after two weeks. For work or school, individuals should be excluded for 48 hours from the last episode of diarrhea.

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  • Question 29 - You are contacted by the father of a 6-year-old boy who is in...

    Incorrect

    • You are contacted by the father of a 6-year-old boy who is in first grade. He is worried because a classmate has been absent for a week due to whooping cough, but the classmate's twin brother is still attending school while taking antibiotics. The father wants to know if his son could catch the illness from the twin brother and if he needs to take antibiotics as well.

      His son has received all the recommended vaccinations up to this point.

      What is your response?

      Your Answer: Explain that asymptomatic contacts of a case do not need exclusion

      Correct Answer: Recommend the boy is excluded until he has finished his antibiotics

      Explanation:

      Pertussis Guidelines for Asymptomatic Contacts

      Asymptomatic contacts of suspected or confirmed pertussis do not need exclusion from school or nursery, even if they are being treated with antibiotics. It is important to follow current guidelines and advise parents accordingly. Prophylactic antibiotics are only recommended for close contacts, which include household contacts and those sharing a room overnight with a case. Antibiotics are only recommended if there is a vulnerable contact and the onset of illness in the case is within 21 days.

      If more cases of pertussis were to be diagnosed at the nursery, this would constitute an outbreak, and advice may then change at the discretion of the outbreak control team. Vulnerable contacts include newborn infants born to symptomatic mothers, infants under 1-year-old who have received less than three doses of DTaP/IPV/Hib, unimmunised or partially immunised infants or children up to ten years, women in the last month of pregnancy, adults who work in a healthcare, social care or childcare facility, immunocompromised individuals, and those with the presence of other chronic illnesses.

      It is important for GPs to understand and implement key national guidelines that influence healthcare provision for respiratory problems, as outlined in the RCGP Curriculum Statement 15.8. By following these guidelines, we can ensure the best possible care for our patients and prevent the spread of pertussis.

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  • Question 30 - A 24-year-old male presents with a purulent urethral discharge. A sample of the...

    Incorrect

    • A 24-year-old male presents with a purulent urethral discharge. A sample of the discharge reveals a Gram-negative diplococcus, but sensitivities are not yet available. What is the most suitable initial antimicrobial therapy?

      Your Answer: Oral azithromycin stat dose

      Correct Answer: Intramuscular ceftriaxone stat dose

      Explanation:

      Gonorrhoea is best treated with intramuscular ceftriaxone, while ciprofloxacin should only be considered if the organism is confirmed to be susceptible, as resistance is becoming more common. Penicillin, which was previously the preferred treatment, is now seldom used due to widespread resistance.

      Understanding Gonorrhoea: Causes, Symptoms, and Treatment

      Gonorrhoea is a sexually transmitted infection caused by the Gram-negative diplococcus Neisseria gonorrhoeae. It can occur on any mucous membrane surface, including the genitourinary tract, rectum, and pharynx. Symptoms in males include urethral discharge and dysuria, while females may experience cervicitis leading to vaginal discharge. However, rectal and pharyngeal infections are usually asymptomatic. Unfortunately, immunisation is not possible, and reinfection is common due to antigen variation of type IV pili and Opa proteins.

      If left untreated, gonorrhoea can lead to local complications such as urethral strictures, epididymitis, and salpingitis, which may result in infertility. Disseminated infection may also occur, with gonococcal infection being the most common cause of septic arthritis in young adults. The pathophysiology of disseminated gonococcal infection is not fully understood but is thought to be due to haematogenous spread from mucosal infection.

      Management of gonorrhoea involves the use of antibiotics. Ciprofloxacin used to be the treatment of choice, but there is now increased resistance to it. Cephalosporins are now more widely used, with a single dose of IM ceftriaxone 1g being the new first-line treatment. If sensitivities are known, a single dose of oral ciprofloxacin 500mg may be given. Disseminated gonococcal infection and gonococcal arthritis may also occur, with symptoms including tenosynovitis, migratory polyarthritis, and dermatitis.

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  • Question 31 - A 7-year-old boy, the son of farmers, is brought to the clinic appearing...

    Correct

    • A 7-year-old boy, the son of farmers, is brought to the clinic appearing quite ill. He has been experiencing fever, vomiting, diarrhea, leg pain, and headache overnight. He appears pale, has cold extremities, neck stiffness, and a few spots that blanch on pressure.
      What is the most crucial management option to consider?

      Your Answer: Intramuscular penicillin and admit to hospital

      Explanation:

      Early Treatment for Suspected Meningococcal Meningitis

      Suspected meningococcal meningitis should be treated as an emergency, even in the absence of a non-blanching rash. The rash may be nonspecific or absent early on in the disease. Any patient with suspected bacterial meningitis or suspected meningococcal septicaemia should be admitted to the hospital immediately. In cases where there may be a delay in admission, Benzylpenicillin should be given. The recommended dose of benzylpenicillin is 1200 mg for adults, 600 mg for those aged 1-9 years, and 300 mg for those aged < 1 year. Cefotaxime may be used as an alternative in cases of penicillin allergy. Antibiotics should be injected intravenously or intramuscularly (IM) in adults and IM in children, with the recommended site of IM injection being the quadriceps muscle. GPs should carry these drugs (up-to-date) in their bags.

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  • Question 32 - A 27-year-old male presents with painful genital ulcers a few weeks after a...

    Incorrect

    • A 27-year-old male presents with painful genital ulcers a few weeks after a trip to Kenya.

      On examination, he has multiple eroded genital ulcers, as well as a tender, enlarged lymph node present in the right inguinal region. He is systemically well.

      Swabs of a genital ulcer are taken and a sexually-transmitted infection screen is performed. The results are shown below.

      NAAT test: negative
      Swab culture: Haemophilus ducreyi grown

      What is the most likely diagnosis?

      Your Answer: Lymphogranuloma venereum

      Correct Answer: Chancroid

      Explanation:

      Chancroid is a sexually transmitted infection that causes genital ulcers in tropical regions. The ulcers are multiple, have ragged edges, and a granular base. Painful, unilateral inguinal lymphadenopathy may also be present. The bacterium Haemophilus ducreyi is responsible for this condition.

      Syphilis, on the other hand, is caused by the bacterium Treponema pallidum. Chancres, which are similar to chancroid ulcers, are painless, singular lesions with bilateral lymphadenopathy. They can heal without treatment.

      Herpes simplex virus types 1 and 2 are common causes of sexually transmitted ulceration in the UK.

      Lymphogranuloma venereum (LGV) is caused by the bacterium Chlamydia trachomatis. It presents with a singular, painless ulcer that resolves spontaneously.

      Klebsiella granulomatis is responsible for granuloma inguinale, which presents with painless genital ulceration and inguinal node abscesses.

      Understanding Chancroid

      Chancroid is a disease that is commonly found in tropical regions and is caused by a bacterium called Haemophilus ducreyi. This disease is characterized by the development of painful ulcers in the genital area, which are often accompanied by painful swelling of the lymph nodes in the groin area on one side of the body. The ulcers are typically defined by a sharp, ragged border that appears to be undermined.

      Chancroid is a sexually transmitted disease that can be easily spread through sexual contact with an infected person. Treatment typically involves a course of antibiotics, which can help to clear up the infection and prevent further spread of the disease.

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  • Question 33 - A 35-year-old teacher presents to your clinic. She experienced upper respiratory symptoms during...

    Correct

    • A 35-year-old teacher presents to your clinic. She experienced upper respiratory symptoms during the COVID-19 pandemic in March 2020 and subsequently tested positive for the virus. Her dyspnea gradually worsened, and she was hospitalized ten days into her illness. She received oxygen therapy and was discharged one week later. She has been off work for three months since the onset of her symptoms and has interacted with several colleagues during this time. She now comes to you nine months after the onset of her symptoms, complaining of persistent fatigue. On physical examination, everything appears normal. Her chest X-ray, lung function tests, electrocardiogram, full blood count, and thyroid function tests are all normal, and she has been discharged from the care of respiratory physicians. How would you manage this patient?

      Your Answer: Consider that she could be suffering with psychological effects following her illness

      Explanation:

      Dealing with Uncertainty in Long Covid Management

      Dealing with uncertainty can be challenging for both patients and clinicians, especially in a rapidly evolving field like long covid management. It is unlikely that candidates will be tested on precise details that may change between question setting and the exam. Instead, questions may focus on the management of conditions that are poorly understood or the more reliable do not dos.

      One important point to note is that there is no reliable evidence to support prescribing steroids or antivirals for suspected long covid, especially by a generalist. At least 10% of people with acute covid-19 may experience symptoms that persist for months, and recovery timescales can vary. There is no set date by which patients should have settled, and there is no evidence that patients are infectious at this stage of the disease.

      It is also important to consider psychological illness as a potential factor in long covid management. Clinicians should keep an open mind about this when evaluating patients, while also being alert to alternative diagnoses and investigating where appropriate. By staying informed and adaptable, clinicians can better navigate the uncertainties of long covid management.

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  • Question 34 - A 32-year-old man with a history of glucose-6-phosphate dehydrogenase deficiency visits his doctor...

    Correct

    • A 32-year-old man with a history of glucose-6-phosphate dehydrogenase deficiency visits his doctor complaining of symptoms suggestive of a urinary tract infection. The physician prescribes an antibiotic. After a few days, the man's partner notices that he appears pale and jaundiced and is feeling unwell. Which medication is the most probable cause of his symptoms?

      Your Answer: Ciprofloxacin

      Explanation:

      Haemolysis in G6PD is caused by the sulfamethoxazole component of co-trimoxazole, not by the trimethoprim component.

      Understanding G6PD Deficiency

      G6PD deficiency is a common red blood cell enzyme defect that is inherited in an X-linked recessive fashion and is more prevalent in people from the Mediterranean and Africa. The deficiency can be triggered by many drugs, infections, and broad (fava) beans, leading to a crisis. G6PD is the first step in the pentose phosphate pathway, which converts glucose-6-phosphate to 6-phosphogluconolactone and results in the production of nicotinamide adenine dinucleotide phosphate (NADPH). NADPH is essential for converting oxidized glutathione back to its reduced form, which protects red blood cells from oxidative damage by oxidants such as superoxide anion (O2-) and hydrogen peroxide. Reduced G6PD activity leads to decreased reduced glutathione and increased red cell susceptibility to oxidative stress, resulting in neonatal jaundice, intravascular hemolysis, gallstones, splenomegaly, and the presence of Heinz bodies on blood films. Diagnosis is made by using a G6PD enzyme assay, and some drugs are known to cause hemolysis, while others are considered safe.

      Compared to hereditary spherocytosis, G6PD deficiency is more common in males of African and Mediterranean descent and is characterized by neonatal jaundice, infection/drug-induced hemolysis, and gallstones. On the other hand, hereditary spherocytosis affects both males and females of Northern European descent and is associated with chronic symptoms, spherocytes on blood films, and the presence of erythrocyte membrane protein band 4.2 (EMA) binding.

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  • Question 35 - An 80-year-old woman lives in a residential home in which some residents have...

    Incorrect

    • An 80-year-old woman lives in a residential home in which some residents have influenza-like symptoms at the start of the influenza season. She has no chronic disease and no symptoms of influenza. The residents have not yet received seasonal influenza immunisation.
      What is the single most suitable immediate prophylactic measure?

      Your Answer: influenza vaccine

      Correct Answer: Oseltamivir

      Explanation:

      Treatment and Prevention of influenza: A Summary of NICE Recommendations

      influenza is best prevented through vaccination, but in cases where the protective response is not quick enough, antiviral medications such as oseltamivir and zanamivir can be effective. These medications work by inhibiting viral neuraminidase and reducing the replication of influenza A and B viruses. They are most effective when started within a few hours of symptom onset and can reduce the duration of symptoms by about 1-1.5 days in otherwise healthy individuals.

      Oseltamivir and zanamivir are also recommended for at-risk patients, including the elderly and those with chronic disease, to reduce the risk of complications from influenza. In addition, they can be used for post-exposure prophylaxis when influenza is circulating in the community or in exceptional circumstances when vaccination doesn’t cover the infecting strain.

      It is important to note that amantadine is not recommended for the treatment or prevention of influenza. Overall, vaccination remains the most effective way to prevent illness from influenza, but antiviral medications can be a useful tool in certain situations.

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  • Question 36 - A 20-year-old female scheduled an appointment with her GP. She was 28-weeks pregnant...

    Incorrect

    • A 20-year-old female scheduled an appointment with her GP. She was 28-weeks pregnant and reported a rash.

      She mentioned being outside in the warm weather and feeling a bite on her left lower leg. The area became extremely itchy and she spent most of the night scratching it. The next morning, she woke up with a hot, swollen, and tender spot where she had been bitten. Throughout the day, she began to feel ill and developed a fever.

      Upon examination, the patient appeared fatigued. Her temperature was 38ºC, oxygen saturation was 97% on air, heart rate was 100 beats per minute, respiratory rate was 20 breaths per minute, and blood pressure was 122/81 mmHg. The examination revealed a red, hot, swollen area of tender skin on her left lower leg, measuring approximately 4 cm in diameter. The diagnosis was cellulitis.

      The patient had no significant medical history, but did have a documented allergy to penicillin.

      Which of the following treatment options is the most appropriate?

      Your Answer: Co-amoxiclav

      Correct Answer: Erythromycin

      Explanation:

      If a pregnant patient has a penicillin allergy and is diagnosed with cellulitis, the recommended antibiotic is erythromycin as per the NICE antimicrobial guidance. Flucloxacillin and co-amoxiclav should not be prescribed in this case. It is important to note that doxycycline, a tetracycline antibiotic, is contraindicated in pregnancy and should not be prescribed.

      Understanding Cellulitis: Symptoms, Diagnosis, and Treatment

      Cellulitis is a common skin infection caused by Streptococcus pyogenes or Staphylococcus aureus. It is characterized by inflammation of the skin and subcutaneous tissues, usually on the shins, accompanied by erythema, pain, swelling, and sometimes fever. The diagnosis of cellulitis is based on clinical features, and no further investigations are required in primary care. However, bloods and blood cultures may be requested if the patient is admitted and septicaemia is suspected.

      To guide the management of patients with cellulitis, NICE Clinical Knowledge Summaries recommend using the Eron classification. Patients with Eron Class III or Class IV cellulitis, severe or rapidly deteriorating cellulitis, very young or frail patients, immunocompromised patients, patients with significant lymphoedema, or facial or periorbital cellulitis (unless very mild) should be admitted for intravenous antibiotics. Patients with Eron Class II cellulitis may not require admission if the facilities and expertise are available in the community to give intravenous antibiotics and monitor the patient.

      The first-line treatment for mild/moderate cellulitis is flucloxacillin, while clarithromycin, erythromycin (in pregnancy), or doxycycline is recommended for patients allergic to penicillin. Patients with severe cellulitis should be offered co-amoxiclav, cefuroxime, clindamycin, or ceftriaxone. Understanding the symptoms, diagnosis, and treatment of cellulitis is crucial for effective management and prevention of complications.

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  • Question 37 - A 50-year-old man visits his doctor with complaints of fever, dry cough, chest...

    Incorrect

    • A 50-year-old man visits his doctor with complaints of fever, dry cough, chest pain and worsening shortness of breath. He experienced a mild headache, myalgia and malaise the day before. He has been healthy in recent weeks and works as an air conditioning system installer and repairer. There are no known underlying medical conditions. What is the most probable causative organism for this infection?

      Your Answer: Chlamydia psittaci

      Correct Answer: Legionella species

      Explanation:

      Differentiating Causes of Pneumonia: A Case Study

      Pneumonia is a common respiratory infection that can be caused by various pathogens. In this case study, the patient presents with symptoms of high fever, chills, rigours, and a cough. To determine the cause of the pneumonia, different pathogens are considered.

      Legionella species is a possible cause, as it is commonly found in recirculating water systems and can be transmitted through inhalation of contaminated water droplets. However, the patient doesn’t have any known exposure to such systems.

      Staphylococcus aureus is another potential cause, but the patient doesn’t have any risk factors for staphylococcal pneumonia, which typically occurs in immunosuppressed individuals or intravenous drug users.

      Chlamydia psittaci is unlikely, as the patient has not been exposed to birds, which is a common source of infection.

      Mycoplasma spp. is a common cause of community-acquired pneumonia, but the patient’s symptoms came on acutely, whereas mycoplasma pneumonia typically has a gradual onset.

      Pneumocystis jirovecii is also unlikely, as it is typically seen in immunosuppressed patients with a history of HIV.

      In conclusion, based on the patient’s symptoms and risk factors, Legionella species is a possible cause of pneumonia, but further testing is needed to confirm the diagnosis.

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  • Question 38 - A 30-year-old man observed a painless papule on the glans of his penis...

    Incorrect

    • A 30-year-old man observed a painless papule on the glans of his penis that turned into an ulcer within a few days. Upon examination, a solitary, circular, hardened ulcer is visible.
      What is the MOST PROBABLE diagnosis? Choose only ONE option.

      Your Answer: Human immunodeficiency virus (HIV) infection

      Correct Answer: Syphilis

      Explanation:

      Primary Syphilis: The First Sign and Symptoms

      Primary syphilis is characterized by the appearance of a small, painless papule that quickly turns into an ulcer known as a chancre. This ulcer is typically solitary, round or oval, painless, and surrounded by a bright-red margin. Unlike other open syphilitic lesions, it is not usually infected with secondary bacteria. Treponema pallidum, the bacteria responsible for syphilis, can be detected in the serum from the sore, which can be easily obtained by slightly abrading the base. If left untreated, primary syphilis can progress to more severe stages of the disease. Therefore, it is important to seek medical attention if you suspect you may have syphilis.

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  • Question 39 - A 72-year-old woman presents with complaints of dysuria and frequency. She has a...

    Incorrect

    • A 72-year-old woman presents with complaints of dysuria and frequency. She has a medical history of hypertension, ischaemic heart disease, previous Clostridium difficile infection, and chronic kidney disease stage 4. Her regular medications include ramipril, amlodipine, furosemide, and aspirin. She has reported allergies to statins and co-trimoxazole. Upon urine dipstick examination, nitrites and leucocytes are detected, leading to a diagnosis of urinary tract infection. What would be the most appropriate antibiotic to initiate treatment?

      Your Answer: Nitrofurantoin

      Correct Answer: Amoxicillin

      Explanation:

      The most suitable antibiotic for this patient’s urinary tract infection is amoxicillin. According to the BNF, trimethoprim or nitrofurantoin are recommended as first-line treatments, while amoxicillin or a cephalosporin are considered alternatives. However, in this case, the patient is allergic to co-trimoxazole, which contains trimethoprim and sulphamethoxazole, making it unsuitable. Additionally, the patient has CKD 4, which contraindicates nitrofurantoin, and cefaclor is not recommended due to its association with Clostridium difficile. Doxycycline is not a recommended treatment for UTI. Therefore, amoxicillin is the most appropriate antibiotic for this patient.

      Antibiotic Guidelines for Common Infections

      Respiratory infections such as chronic bronchitis and community-acquired pneumonia are typically treated with amoxicillin, tetracycline, or clarithromycin. In cases where atypical pathogens may be the cause of pneumonia, clarithromycin is recommended. Hospital-acquired pneumonia within five days of admission is treated with co-amoxiclav or cefuroxime, while infections occurring more than five days after admission are treated with piperacillin with tazobactam, a broad-spectrum cephalosporin, or a quinolone.

      For urinary tract infections, lower UTIs are treated with trimethoprim or nitrofurantoin, while acute pyelonephritis is treated with a broad-spectrum cephalosporin or quinolone. Acute prostatitis is treated with a quinolone or trimethoprim.

      Skin infections such as impetigo, cellulitis, and erysipelas are treated with topical hydrogen peroxide, oral flucloxacillin, or erythromycin if the infection is widespread. Animal or human bites are treated with co-amoxiclav, while mastitis during breastfeeding is treated with flucloxacillin.

      Ear, nose, and throat infections such as throat infections, sinusitis, and otitis media are treated with phenoxymethylpenicillin or amoxicillin. Otitis externa is treated with flucloxacillin or erythromycin, while periapical or periodontal abscesses are treated with amoxicillin.

      Genital infections such as gonorrhoea, chlamydia, and bacterial vaginosis are treated with intramuscular ceftriaxone, doxycycline or azithromycin, and oral or topical metronidazole or topical clindamycin, respectively. Pelvic inflammatory disease is treated with oral ofloxacin and oral metronidazole or intramuscular ceftriaxone, oral doxycycline, and oral metronidazole.

      Gastrointestinal infections such as Clostridioides difficile, Campylobacter enteritis, Salmonella (non-typhoid), and Shigellosis are treated with oral vancomycin, clarithromycin, ciprofloxacin, and ciprofloxacin, respectively.

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  • Question 40 - A 28-year-old woman returns from a holiday to Spain with diarrhoea. This began...

    Incorrect

    • A 28-year-old woman returns from a holiday to Spain with diarrhoea. This began on the third night of a long weekend trip to Madrid. She has been opening her bowels more than eight times per day over the past 24 hours. There had been associated nausea which was stopping her from maintaining an adequate fluid intake, but she is now tolerating fluids by mouth.

      On examination her BP is 130/78 lying, and 126/76 standing with a corresponding increase in her pulse rate. Her mouth looks dry and she has poor skin turgor. Her abdomen is soft and minimally tender and there are very active bowel sounds.

      Which one of the following represents the most appropriate management for her?

      Your Answer: Imodium

      Correct Answer: Metronidazole

      Explanation:

      Treatment and Management of Travellers’ Diarrhoea

      Travellers’ diarrhoea is commonly caused by E. coli and typically lasts for 72 hours. In healthy individuals, oral rehydration salts and paracetamol can effectively manage the symptoms. However, if the patient is unable to tolerate oral fluids and is significantly dehydrated, hospital admission may be necessary.

      In severe cases of campylobacter or salmonella, where the patient is already weakened by chronic illness, ciprofloxacin may be prescribed. Meanwhile, metronidazole may be used as an option for giardiasis.

      It is important to note that travellers’ diarrhoea can be prevented by practicing good hygiene, such as washing hands frequently and avoiding contaminated food and water sources.

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  • Question 41 - A 32-year-old female patient comes to the clinic 2 weeks after returning from...

    Incorrect

    • A 32-year-old female patient comes to the clinic 2 weeks after returning from a family vacation involving kayaking. She complains of feeling extremely tired due to persistent fatty diarrhea, abdominal pain, bloating, and flatulence that began during her trip. She notes that her symptoms worsen whenever she consumes dairy products. What is the probable reason for her symptoms?

      Your Answer: Salmonella

      Correct Answer: Giardiasis

      Explanation:

      The patient’s ongoing diarrhoea, lethargy, bloating, flatulence, steatorrhoea, weight loss, and recent travel suggest giardiasis as the likely cause. Giardiasis is often associated with foreign travel and exposure to contaminated water sources. Treatment with metronidazole may be beneficial. Cholera and hepatitis D are unlikely causes as their symptoms and characteristics differ from those of giardiasis.

      Understanding Giardiasis

      Giardiasis is a disease caused by a type of protozoan called Giardia lamblia. It is transmitted through the faeco-oral route and can be contracted through various means such as foreign travel, drinking water from rivers or lakes, and even male-male sexual contact. While some people may not experience any symptoms, others may suffer from non-bloody diarrhea, bloating, abdominal pain, lethargy, flatulence, and weight loss. In some cases, malabsorption and lactose intolerance may also occur. To diagnose giardiasis, stool microscopy for trophozoite and cysts is usually done, although stool antigen detection assay and PCR assays are also being developed. Treatment for giardiasis involves the use of metronidazole.

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  • Question 42 - One of your younger colleagues confides in you that she has just been...

    Incorrect

    • One of your younger colleagues confides in you that she has just been diagnosed with hepatitis B. She has not told anyone else as she is worried she may lose her job. She is currently working as a nurse in the local hospital. You try to persuade her to inform occupational health but she refuses. What is the most appropriate action?

      Your Answer: Keep confidentiality but ask him to stop taking blood

      Correct Answer: Inform your colleagues employing body

      Explanation:

      Patient safety is the top priority, as stated in the updated GMC guidelines.

      GMC Guidance on Confidentiality

      Confidentiality is a crucial aspect of medical practice that must be upheld at all times. The General Medical Council (GMC) provides extensive guidance on confidentiality, which can be accessed through a link provided. As such, we will not attempt to replicate the detailed information provided by the GMC here. It is important for healthcare professionals to familiarize themselves with the GMC’s guidance on confidentiality to ensure that they are meeting the necessary standards and protecting patient privacy.

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  • Question 43 - A 36-year-old male who has recently immigrated from sub-Saharan Africa is undergoing tuberculosis...

    Incorrect

    • A 36-year-old male who has recently immigrated from sub-Saharan Africa is undergoing tuberculosis screening. He reports no prior medical history and has never received a BCG vaccination. Although his chest x-ray appears normal, his Mantoux test and interferon gamma test are both positive. An HIV test is negative, leading to a suspected diagnosis of latent tuberculosis. What treatment option is most likely to be offered to him?

      Your Answer: Observe

      Correct Answer: Isoniazid for 6 months

      Explanation:

      Managing Tuberculosis: Treatment and Complications

      Tuberculosis is a serious infectious disease that requires prompt and effective treatment. The standard therapy for active tuberculosis involves an initial phase of two months with a combination of four drugs: rifampicin, isoniazid, pyrazinamide, and ethambutol. The continuation phase lasts for four months and involves rifampicin and isoniazid. For latent tuberculosis, treatment involves three months of isoniazid and rifampicin or six months of isoniazid with pyridoxine. Patients with meningeal tuberculosis require prolonged treatment of at least 12 months with the addition of steroids.

      Directly observed therapy may be necessary for certain groups, such as homeless individuals, prisoners, and patients with poor concordance. However, treatment can also lead to complications. Immune reconstitution disease can occur 3-6 weeks after starting treatment and often presents with enlarging lymph nodes. Drug adverse effects can also occur, such as hepatitis, orange secretions, flu-like symptoms, peripheral neuropathy, agranulocytosis, hyperuricaemia causing gout, arthralgia, myalgia, and optic neuritis. It is important to monitor patients for these complications and adjust treatment as necessary.

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  • Question 44 - A 58-year-old woman presents with symptoms of a lower respiratory tract infection and...

    Incorrect

    • A 58-year-old woman presents with symptoms of a lower respiratory tract infection and is prescribed a course of amoxicillin. She comes back after 2 weeks with complaints of dysuria, pruritus vulvae, and a white vaginal discharge.
      What is the most probable diagnosis?

      Your Answer: Atrophic vaginitis

      Correct Answer: Vulvovaginal candidiasis

      Explanation:

      Understanding and Treating Vulvovaginal Candidiasis

      Vulvovaginal candidiasis is a common condition that affects approximately 75% of women in their reproductive years. It is caused by an overgrowth of yeast in the vaginal area and can be triggered by various factors such as pregnancy, diabetes, and the use of broad-spectrum antibiotics. While routine culture is not necessary for diagnosis, it is important to rule out underlying conditions such as type 2 diabetes in older women.

      Treatment for vulvovaginal candidiasis typically involves the use of topical or oral antifungal medications such as azoles or triazoles. In cases where an azole has failed, nystatin may be more effective, especially if the infection is caused by Candida glabrata rather than Candida albicans. It is also important to note that approximately 10% of women with vulvovaginal candidiasis have a mixed infection with bacteria, which may require additional testing and treatment.

      Overall, understanding the causes and treatment options for vulvovaginal candidiasis can help women effectively manage this common condition.

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  • Question 45 - A 25-year-old farm labourer presents with a lesion on his finger. The lesion...

    Correct

    • A 25-year-old farm labourer presents with a lesion on his finger. The lesion began as a small red papule and has now grown to form a blood-tinged pustule-like lesion measuring 2 cm in diameter over the course of a week. He reports some lymphadenopathy but is otherwise asymptomatic.
      What is the most probable diagnosis?

      Your Answer: Orf

      Explanation:

      Common Skin Infections: Orf, Cat Scratch Disease, Ringworm, Pompholyx, and Lyme Disease

      Orf, also known as contagious pustular dermatitis, is a skin infection caused by a poxvirus that is typically acquired from sheep or goats. The infection begins with a small, firm, red or reddish-blue lump that develops into a flat-topped, blood-tinged pustule or blister after an incubation period of 5-6 days. The lesion is usually 2-3 cm in diameter but can be as large as 5 cm. Although it may appear to contain pus, incising the lesion will reveal firm, red tissue underneath. Orf can also cause erythema multiforme and typically resolves within 6 weeks.

      Cat scratch disease is a mild infectious disease that primarily affects children and is caused by the intracellular bacterium Bartonella henselae. Symptoms may include fever and a papule at the site of the scratch, as well as regional lymphadenopathy.

      Ringworm, also known as tinea corporis, is a fungal infection that causes a slowly enlarging scaly lesion with central clearing. Pompholyx, on the other hand, is a type of eczema that presents with multiple vesicles on the palms and soles.

      Finally, Lyme disease is a bacterial infection that is transmitted through tick bites. It causes a slowly spreading erythematous rash at the site of the bite, accompanied by flu-like symptoms.

      In summary, these common skin infections can present with a variety of symptoms and should be diagnosed and treated by a healthcare professional.

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  • Question 46 - A patient of yours with COPD who is in his 60s wants to...

    Incorrect

    • A patient of yours with COPD who is in his 60s wants to travel to Spain on holiday. He plans to fly, but is prepared to drive and take the ferry if you tell him that he is not fit to do so.

      You currently manage his COPD with a high dose seretide inhaler and PRN salbutamol. On examination at the surgery he looks relatively well. He has good bilateral air entry on auscultation of his chest and sparse bilateral wheeze.

      What level of O2 saturation constitutes the threshold above which he should be able to fly?

      Your Answer: 98%

      Correct Answer: 90%

      Explanation:

      Fitness to Fly: Guidelines and Recommendations

      Maintaining good health is crucial when it comes to air travel. Before boarding a plane, it is important to ensure that you are fit to fly. One way to determine this is by assessing your ability to walk 50 meters on level ground or climb a flight of stairs without experiencing shortness of breath. If you can do this, it is usually indicative that you are fit to fly.

      Another way to assess fitness to fly is through a hypoxic challenge test. This test mimics the conditions on a plane, and if your PaO2 (partial pressure of oxygen) is less than 55 mmHg, it is not recommended to fly.

      During an exam, you may be asked about your fitness to fly after an illness. It is important to consider any recent health issues and consult with a healthcare professional before making a decision to fly.

      If you have experienced a pneumothorax (collapsed lung), it is recommended to wait at least two weeks after conservative management before considering flying. Additionally, evidence of resolution of the pneumothorax should be confirmed before flying.

      In summary, it is important to prioritize your health and assess your fitness to fly before boarding a plane. By following these guidelines and recommendations, you can ensure a safe and comfortable flight.

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  • Question 47 - A 65-year-old man has come to see you to discuss whether he requires...

    Incorrect

    • A 65-year-old man has come to see you to discuss whether he requires antibiotics prior to undergoing a root canal procedure. His dentist has suggested that he consult with his GP due to his history of infective endocarditis. Upon reviewing his electronic medical record, you discover that he has hypertension and type 2 diabetes. Additionally, he has native valvular heart disease and his previous infection was caused by staphylococcus. Presently, he appears to be in good health and is not experiencing any acute medical problems.

      As per NICE guidelines, what treatment is recommended in this case?

      Your Answer: Flucloxacillin

      Correct Answer: No specific treatment

      Explanation:

      In the UK, it is not standard practice to use antibiotic prophylaxis as a preventive measure against infective endocarditis during dental or other procedures.

      Changes in Antibiotic Prophylaxis for Infective Endocarditis

      In 2008, the National Institute for Health and Care Excellence (NICE) released new guidelines regarding antibiotic prophylaxis for infective endocarditis. These guidelines significantly altered the list of procedures for which prophylaxis is recommended. According to NICE, dental procedures, gastrointestinal and genitourinary tract procedures, and respiratory tract procedures no longer require prophylaxis. However, NICE does recommend that any infections in individuals at risk of infective endocarditis be promptly investigated and treated to reduce the risk of developing endocarditis. Additionally, if an individual at risk of infective endocarditis is receiving antimicrobial therapy due to a suspected infection at the site of a gastrointestinal or genitourinary procedure, they should be given an antibiotic that covers organisms that cause infective endocarditis.

      It is important to note that these recommendations differ from those of the American Heart Association and European Society of Cardiology, which still advocate for antibiotic prophylaxis for high-risk patients undergoing dental procedures.

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  • Question 48 - At what age should a patient be vaccinated against pneumococcus? ...

    Correct

    • At what age should a patient be vaccinated against pneumococcus?

      Your Answer: A 67-year-old man who has no significant medical history of note other than gout

      Explanation:

      The pneumococcal vaccine is only necessary for asthmatics who use oral steroids at a level that significantly weakens their immune system. Having multiple sclerosis doesn’t warrant the pneumococcal vaccine. The 67-year-old man is eligible for the vaccine based on his age, not his medical background.

      The pneumococcal vaccine comes in two types: the pneumococcal conjugate vaccine (PCV) and the pneumococcal polysaccharide vaccine (PPV). The PCV is given to children as part of their routine immunizations at 3 and 12-13 months. On the other hand, the PPV is offered to adults over 65 years old, patients with chronic conditions such as COPD, and those who have had a splenectomy.

      The vaccine is recommended for individuals with asplenia or splenic dysfunction, chronic respiratory disease, chronic heart disease, chronic kidney disease, chronic liver disease, diabetes mellitus, immunosuppression, cochlear implants, and patients with cerebrospinal fluid leaks. However, controlled hypertension is not an indication for vaccination. Patients with any stage of HIV infection are also included in the list of those who should be vaccinated.

      Adults usually require only one dose of the vaccine, but those with asplenia, splenic dysfunction, or chronic kidney disease need a booster every five years. It is important to note that asthma is only included if it requires the use of oral steroids at a dose sufficient to act as a significant immunosuppressant.

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  • Question 49 - Which infection is most strongly linked to the development of Guillain-Barre syndrome? ...

    Incorrect

    • Which infection is most strongly linked to the development of Guillain-Barre syndrome?

      Your Answer: E. coli H7:0157

      Correct Answer: Campylobacter jejuni

      Explanation:

      Understanding Guillain-Barre Syndrome and Miller Fisher Syndrome

      Guillain-Barre syndrome is a condition that affects the peripheral nervous system and is often triggered by an infection, particularly Campylobacter jejuni. The immune system attacks the myelin sheath that surrounds nerve fibers, leading to demyelination. This results in symptoms such as muscle weakness, tingling sensations, and paralysis.

      The pathogenesis of Guillain-Barre syndrome involves the cross-reaction of antibodies with gangliosides in the peripheral nervous system. Studies have shown a correlation between the presence of anti-ganglioside antibodies, particularly anti-GM1 antibodies, and the clinical features of the syndrome. In fact, anti-GM1 antibodies are present in 25% of patients with Guillain-Barre syndrome.

      Miller Fisher syndrome is a variant of Guillain-Barre syndrome that is characterized by ophthalmoplegia, areflexia, and ataxia. This syndrome typically presents as a descending paralysis, unlike other forms of Guillain-Barre syndrome that present as an ascending paralysis. The eye muscles are usually affected first in Miller Fisher syndrome. Studies have shown that anti-GQ1b antibodies are present in 90% of cases of Miller Fisher syndrome.

      In summary, Guillain-Barre syndrome and Miller Fisher syndrome are conditions that affect the peripheral nervous system and are often triggered by infections. The pathogenesis of these syndromes involves the cross-reaction of antibodies with gangliosides in the peripheral nervous system. While Guillain-Barre syndrome is characterized by muscle weakness and paralysis, Miller Fisher syndrome is characterized by ophthalmoplegia, areflexia, and ataxia.

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  • Question 50 - A 36-year-old woman complains of persistent fatigue.

    She has no other symptoms and physical...

    Incorrect

    • A 36-year-old woman complains of persistent fatigue.

      She has no other symptoms and physical examination is normal. She works as a teacher.

      You send blood samples for tests. Her full blood count, urea, electrolytes, and thyroid function tests are normal but her liver functions tests are abnormal. Because of this you send some blood to the laboratory to test for hepatitis. You explain first to your patient what the tests are for.

      The results are:

      Anti-HAV IgG Negative

      HBsAg Negative

      Anti-HBs Positive

      Anti-HBc Negative

      HBeAg Negative

      Anti-HBe Negative

      Anti-HCV Positive

      What is the patient's most likely diagnosis?

      Your Answer: Evidence of previous immunisation against hepatitis B and C

      Correct Answer: Hepatitis C infection

      Explanation:

      Hepatitis C Infection and Vaccination Recommendations

      Abnormal liver function tests and anti-hepatitis C virus antibodies suggest that a patient has hepatitis C infection. If a patient has been vaccinated against hepatitis B, it may indicate that they work in a healthcare setting. The risk of seroconversion to hepatitis C after a needlestick injury from a patient positive for hepatitis C virus is low, but still present. Patients may not experience symptoms during seroconversion, and many with hepatitis C have normal liver function tests.

      It is important to vaccinate patients against hepatitis B if they have not already been vaccinated, as co-existent hepatitis B infection can worsen liver injury. Patients with hepatitis C who do not have detectable immunoglobulin G (IgG) anti-hepatitis A virus (HAV) antibodies are at risk of acquiring hepatitis A infection, which can be severe and associated with increased mortality. Therefore, hepatitis A vaccination is recommended.

      In summary, patients with abnormal liver function tests and anti-hepatitis C virus antibodies should be checked for hepatitis C infection, even if their liver function tests are normal. Healthcare workers may have been vaccinated against hepatitis B. Vaccination against hepatitis B and A is recommended for patients with hepatitis C infection.

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  • Question 51 - What advice should be given regarding rubella vaccination and attempting to conceive after...

    Incorrect

    • What advice should be given regarding rubella vaccination and attempting to conceive after a patient is found to be non-immune to rubella during investigation for infertility?

      Your Answer: She can continue trying to conceive from the day she has had the vaccination

      Correct Answer: She should not try to get pregnant for at least 1 month following vaccination

      Explanation:

      Rubella Vaccination and Pregnancy

      Women who have received the rubella vaccination are advised to wait for at least one month before attempting to become pregnant. This recommendation is in accordance with guidelines from both the National Institute for Health and Care Excellence (NICE) and the Centers for Disease Control and Prevention (CDC). It is important to follow this advice to ensure the safety of both the mother and the developing fetus. By waiting for a month after vaccination, women can reduce the risk of any potential complications that may arise during pregnancy. Therefore, it is crucial for women to consult with their healthcare provider and discuss their vaccination history before planning to conceive.

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  • Question 52 - How is the BCG vaccine administered for infants? ...

    Incorrect

    • How is the BCG vaccine administered for infants?

      Your Answer: Subcutaneously

      Correct Answer: Intradermally

      Explanation:

      The BCG vaccine is a form of immunization that provides limited protection against tuberculosis (TB). In the UK, it is typically given to high-risk infants and was previously administered to children at the age of 13 years until 2005. The Greenbook recommends that the vaccine be given to infants living in areas with an annual incidence of TB of 40/100,000 or greater, as well as infants with a parent or grandparent born in a country with a similar incidence rate. Other groups that should receive the vaccine include previously unvaccinated contacts of respiratory TB cases, healthcare workers, prison staff, and those who work with homeless people.

      The vaccine contains live attenuated Mycobacterium bovis and also offers limited protection against leprosy. Before receiving the BCG vaccine, individuals must undergo a tuberculin skin test, with the exception of children under six years old who have had no contact with tuberculosis. The vaccine is administered intradermally to the lateral aspect of the left upper arm and can be given at the same time as other live vaccines, with a four-week interval if not administered simultaneously.

      There are several contraindications for the BCG vaccine, including previous vaccination, a history of tuberculosis, HIV, pregnancy, and a positive tuberculin test. It is not recommended for individuals over the age of 35, as there is no evidence that it is effective for this age group.

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  • Question 53 - A 55-year-old sewage worker complains of feeling unwell and having a fever for...

    Correct

    • A 55-year-old sewage worker complains of feeling unwell and having a fever for the past week. What symptom would be the least indicative of a diagnosis of leptospirosis?

      Your Answer: Productive cough

      Explanation:

      Leptospirosis can lead to pulmonary complications, particularly in cases of severe and advanced disease. These complications may include acute respiratory distress syndrome or pulmonary haemorrhage. The RCGP Curriculum for 2019 includes zoonotic diseases such as brucellosis and leptospirosis in its Knowledge and Skills guide.

      Leptospirosis: A Tropical Disease with Early and Late Phases

      Leptospirosis is a disease caused by the bacterium Leptospira interrogans, which is commonly spread through contact with infected rat urine. While it is often associated with certain occupations such as sewage workers, farmers, and vets, it is more prevalent in tropical regions and should be considered in returning travelers. The disease has two phases: an early phase characterized by flu-like symptoms and fever, and a later immune phase that can lead to more severe symptoms such as acute kidney injury, hepatitis, and aseptic meningitis. Diagnosis can be made through serology, PCR, or culture, but treatment typically involves high-dose benzylpenicillin or doxycycline.

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  • Question 54 - At what point in the NHS vaccination schedule would you provide routine immunisation...

    Incorrect

    • At what point in the NHS vaccination schedule would you provide routine immunisation for Hepatitis B?

      Your Answer: At 2, 3 and 4 weeks

      Correct Answer: At 15 months of age

      Explanation:

      The Importance of Understanding Immunisation Schedules

      Immunisation schedules are crucial to understand, especially with recent changes to UK guidance in January 2020. One significant change relates to the timing of pneumococcal immunisation. Additionally, hepatitis B vaccination is routinely available as part of the NHS vaccination schedule. It is offered to all babies at 8, 12, and 16 weeks of age, as well as those at increased risk of hepatitis B or its complications.

      It is essential to memorise the latest schedule, as it may feature in your exam. We have included a reference to a summary guide below for your convenience. Understanding immunisation schedules is crucial for healthcare professionals to ensure that patients receive the appropriate vaccinations at the correct time.

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  • Question 55 - A 27-year-old man with a history of epilepsy seeks guidance on malaria prophylaxis...

    Correct

    • A 27-year-old man with a history of epilepsy seeks guidance on malaria prophylaxis for his upcoming trip to Vietnam. He will be visiting coastal tourist spots as well as traveling inland. What is the most suitable medication to prevent malaria?

      Your Answer: Atovaquone + proguanil

      Explanation:

      Malaria is a serious disease caused by the Plasmodium falciparum protozoa, with around 1,500-2,000 cases reported each year in patients returning from endemic countries. The majority of these cases occur in patients who did not take prophylaxis. It is important to consult up-to-date charts for recommended regimens for malaria zones before prescribing. There are several drugs available for prophylaxis, including Atovaquone + proguanil (Malarone), Chloroquine, Doxycycline, Mefloquine (Lariam), and Proguanil (Paludrine). Pregnant women and children are at higher risk of serious complications and should avoid travel to malaria endemic regions if possible. However, if travel is essential, prophylaxis should be taken, and DEET can be used to repel mosquitoes. Doxycycline is only licensed for use in children over the age of 12 years.

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  • Question 56 - You are on rotation at a sexual health clinic. A 26-year-old male comes...

    Incorrect

    • You are on rotation at a sexual health clinic. A 26-year-old male comes in with symptoms of mucopurulent urethral discharge and dysuria. He provides samples for testing. You suspect a possible diagnosis of Chlamydia.

      What laboratory methods are typically utilized to confirm this diagnosis?

      Your Answer: Lancefield grouping

      Correct Answer: Nucleic acid amplification testing

      Explanation:

      When Chlamydia is suspected in a patient, the preferred method of investigation is nucleic acid amplification tests (NAATs). Samples can be collected through swabs or first-catch urine. Direct culture is no longer commonly utilized for diagnosing Chlamydia.

      Chlamydia is the most common sexually transmitted infection in the UK caused by Chlamydia trachomatis. It is often asymptomatic but can cause cervicitis and dysuria in women and urethral discharge and dysuria in men. Complications include epididymitis, pelvic inflammatory disease, and infertility. Testing is done through nuclear acid amplification tests (NAATs) on urine or swab samples. Screening is recommended for sexually active individuals aged 15-24 years. Doxycycline is the first-line treatment, but azithromycin may be used if contraindicated. Partners should be notified and treated.

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  • Question 57 - A 42-year-old male accountant presents to the clinic with complaints of rectal pain,...

    Incorrect

    • A 42-year-old male accountant presents to the clinic with complaints of rectal pain, tenesmus, and cramping during bowel movements. Four years ago, he traveled to Thailand for a vacation and had unprotected sex with a sex worker. A few weeks later, he noticed a sore on his penis and tenderness in his left groin, which eventually resolved.

      What is the most probable diagnosis?

      Your Answer: African trypanosomiasis

      Correct Answer: Lymphogranuloma venereum

      Explanation:

      Lymphogranuloma venereum (LGV) is a sexually transmitted infection caused by Chlamydia trachomatis. It is commonly found in tropical regions and typically presents with a painless genital papule or pustule that later ulcerates. Within 2 to 6 weeks, unilateral painful lymphadenopathy develops. If left untreated, LGV can progress to proctocolitis or even systemic illness.

      African trypanosomiasis, also known as sleeping sickness, is caused by the protist Trypanosoma brucei. It is spread by the tsetse fly and is not sexually transmitted. It presents with posterior cervical lymphadenopathy and severe neurological complications.

      Genital herpes typically results in multiple painful genital ulcers, which is different from the solitary painless genital sores associated with LGV.

      Chancroid is an STI caused by Haemophilus ducreyi. It also results in genital ulceration and painful inguinal lymphadenopathy, but the ulcers are painful (unlike LGV) and are more likely to be multiple. Chancroid is also unlikely to progress to proctocolitis.

      Understanding STI Ulcers

      Genital ulcers are a common symptom of several sexually transmitted infections (STIs). One of the most well-known causes is the herpes simplex virus (HSV) type 2, which can cause severe primary attacks with fever and subsequent attacks with multiple painful ulcers. Syphilis, caused by the spirochaete Treponema pallidum, has primary, secondary, and tertiary stages, with a painless ulcer (chancre) appearing in the primary stage. Chancroid, a tropical disease caused by Haemophilus ducreyi, causes painful genital ulcers with a sharply defined, ragged, undermined border and unilateral, painful inguinal lymph node enlargement. Lymphogranuloma venereum (LGV), caused by Chlamydia trachomatis, has three stages, with the first stage showing a small painless pustule that later forms an ulcer, followed by painful inguinal lymphadenopathy in the second stage and proctocolitis in the third stage. LGV is treated with doxycycline. Other causes of genital ulcers include Behcet’s disease, carcinoma, and granuloma inguinale (previously called Calymmatobacterium granulomatis). Understanding the different causes of STI ulcers is crucial in diagnosing and treating these infections.

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  • Question 58 - A 35-year-old man comes in with a swollen red finger and tenderness in...

    Incorrect

    • A 35-year-old man comes in with a swollen red finger and tenderness in his left armpit, one day after being bitten by his pet dog. What is the most effective treatment?

      Your Answer: Fluconazole

      Correct Answer: Co-amoxiclav

      Explanation:

      Treatment of Infected Dog Bites

      Dog bites have a 10% chance of becoming infected, with the most common organisms being anaerobic mouth flora and Pasteurella multocida. Capnocytophaga spp. and Streptococcus pyogenes are also possible. The recommended treatment is co-amoxiclav, which is effective against all likely organisms. Herpes simplex infection is rare in dog bites, but monkey bites can transmit the virus. Fungal infections in dogs do not typically infect bites, so fluconazole is not necessary. Flucloxacillin is ineffective against anaerobic bacteria, and metronidazole doesn’t cover aerobic Gram-negative organisms.

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  • Question 59 - Sarah is a 35-year-old woman who previously visited you with symptoms of vaginal...

    Incorrect

    • Sarah is a 35-year-old woman who previously visited you with symptoms of vaginal discharge. A swab was taken and has confirmed a diagnosis of gonorrhoea. What recommendations would you make?

      Your Answer: Doxycycline 100 mg twice a day for 7 days

      Correct Answer: Attend GUM clinic

      Explanation:

      To manage gonorrhoea, it is now recommended to use a combination of IM ceftriaxone 500 mg and oral azithromycin 1g due to the rising resistance. It is important to ensure strict partner notification and therefore, patients are advised to attend the GUM clinic.

      Understanding Gonorrhoea: Causes, Symptoms, and Treatment

      Gonorrhoea is a sexually transmitted infection caused by the Gram-negative diplococcus Neisseria gonorrhoeae. It can occur on any mucous membrane surface, including the genitourinary tract, rectum, and pharynx. Symptoms in males include urethral discharge and dysuria, while females may experience cervicitis leading to vaginal discharge. However, rectal and pharyngeal infections are usually asymptomatic. Unfortunately, immunisation is not possible, and reinfection is common due to antigen variation of type IV pili and Opa proteins.

      If left untreated, gonorrhoea can lead to local complications such as urethral strictures, epididymitis, and salpingitis, which may result in infertility. Disseminated infection may also occur, with gonococcal infection being the most common cause of septic arthritis in young adults. The pathophysiology of disseminated gonococcal infection is not fully understood but is thought to be due to haematogenous spread from mucosal infection.

      Management of gonorrhoea involves the use of antibiotics. Ciprofloxacin used to be the treatment of choice, but there is now increased resistance to it. Cephalosporins are now more widely used, with a single dose of IM ceftriaxone 1g being the new first-line treatment. If sensitivities are known, a single dose of oral ciprofloxacin 500mg may be given. Disseminated gonococcal infection and gonococcal arthritis may also occur, with symptoms including tenosynovitis, migratory polyarthritis, and dermatitis.

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  • Question 60 - A 10-year-old boy presents with an episode of diarrhoea followed by jaundice.
    Select the...

    Incorrect

    • A 10-year-old boy presents with an episode of diarrhoea followed by jaundice.
      Select the single most likely pathogen.

      Your Answer: E. coli

      Correct Answer: Hepatitis A virus

      Explanation:

      Hepatitis A: A Self-Limiting Liver Infection

      Hepatitis A is a viral infection that causes acute and self-limiting hepatitis. It is often preceded by flu-like symptoms and a brief diarrheal illness, especially in children. Unlike other forms of hepatitis, there is no chronic viral carriage or long-term liver damage associated with hepatitis A. The virus is transmitted orally and has an incubation period of 2 to 6 weeks. The most common mode of transmission is through the ingestion of contaminated food or water that has been contaminated with fecal matter from an infected person.

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  • Question 61 - A 45-year-old patient has a 3-day history of general malaise associated with nausea,...

    Incorrect

    • A 45-year-old patient has a 3-day history of general malaise associated with nausea, diarrhoea and headache. On examination the patient looks unwell and has red/bluish petechiae on the extensor surfaces of both legs that do not blanch on pressure.
      Select the single most important immediate management option.

      Your Answer: Treatment not indicated

      Correct Answer: Benzylpenicillin

      Explanation:

      Prehospital Antibiotic Treatment for Suspected Meningococcal Infection

      Health authorities in many countries recommend that general practitioners initiate prehospital antibiotic treatment, such as benzylpenicillin, in suspected cases of meningococcal infection. The primary objective of this strategy is to halt the rapid growth of meningococci in the bloodstream before intravascular inflammation becomes irreversible or causes severe complications. Patients who live far from the hospital and experience rapidly progressing symptoms, resulting in compromised circulation and extensive haemorrhagic skin lesions, are most likely to benefit from this approach if implemented early enough. Retrospective studies conducted in England and Wales indicate that prehospital penicillin treatment can reduce case fatality. In cases of penicillin allergy, cefotaxime is a viable alternative.

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  • Question 62 - A 50-year-old man has inquired with the nurse at the clinic about getting...

    Incorrect

    • A 50-year-old man has inquired with the nurse at the clinic about getting vaccinated before his upcoming trip overseas. He has a medical history of asthma and has been on a 20 mg daily dose of prednisolone for the past 2 months, which was recently upped to 40 mg during a flare-up. Identify the one vaccine that would not be recommended for this individual.

      Your Answer: Meningococcus

      Correct Answer: Yellow fever

      Explanation:

      Understanding Yellow Fever Vaccination and Other Vaccines

      Yellow fever vaccination is a type of live vaccine that is made from the 17-d strain of the virus grown in hen’s eggs. However, it is not recommended for individuals with a history of impaired immune responsiveness or anaphylactic reaction to egg. Moreover, those who are currently undergoing corticosteroid therapy should not receive live vaccination. On the other hand, the other vaccines are not live vaccines. Hepatitis B and meningococcal vaccinations are surface antigen based, while the other two are toxoids and do not contain any active components. Understanding the differences between these vaccines is important in ensuring proper vaccination and protection against diseases.

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  • Question 63 - A 7-year-old boy has pruritus ani. His mother has noticed what look like...

    Incorrect

    • A 7-year-old boy has pruritus ani. His mother has noticed what look like tiny pieces of cotton moving on his stool and around his anus.
      Select from the list the single most suitable management option.

      Your Answer: Senna

      Correct Answer: Mebendazole

      Explanation:

      Understanding Threadworm: Symptoms, Diagnosis, and Treatment

      Threadworm, also known as pinworm or enterobiasis, is a common nematode infection caused by Enterobius vermicularis. This infection is exclusive to humans and doesn’t affect family pets. Female worms lay eggs outside the anus, causing irritation and discomfort. The eggs can easily spread through contaminated hands, food, clothing, and bedding, leading to re-infection.

      Diagnosing threadworm involves examining adhesive tape applied to the anal area under a microscope, as stool examination is only positive in 5% of cases. Asymptomatic infection is common, so it is recommended that the entire family be treated together. Mebendazole is the preferred drug for treating threadworm in adults and children over 2 years old. It is given as a single oral dose and repeated after 2-3 weeks in case of re-infection. Piperazine, licensed for use in children as young as 3 months, paralyzes the worms but doesn’t kill them. It is often combined with senna as a powder (Pripsen) to expel the worms and is given as a single dose, repeated after 14 days.

      In conclusion, understanding the symptoms, diagnosis, and treatment of threadworm is crucial in preventing the spread of this common infection.

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  • Question 64 - A 33-year-old man visits his GP complaining of difficulty concentrating, muscle aches, and...

    Incorrect

    • A 33-year-old man visits his GP complaining of difficulty concentrating, muscle aches, and fatigue that have persisted for three months. He works as a gamekeeper in rural Scotland and spends most of his day walking through long grass. He mentions removing ticks from his legs on a daily basis.

      During the examination, the GP observes a circular rash measuring 16cm on the lower leg, which is indicative of erythema migrans.

      What is the appropriate course of action for this patient?

      Your Answer: Refer the patient to a specialist

      Correct Answer: Start antibiotics immediately without further tests

      Explanation:

      According to the NICE Clinical Knowledge Summary, if a patient presents with erythema migrans, a characteristic rash associated with Lyme disease, no further laboratory testing is necessary for diagnosis. Prompt treatment with antibiotics is recommended to prevent the development of additional symptoms. However, if a patient presents with specific focal symptoms such as uveitis, facial nerve palsy, or arthritis, referral to a specialist or consultation with a specialist should be considered without delaying antibiotic treatment.

      Understanding Lyme Disease

      Lyme disease is an illness caused by a type of bacteria called Borrelia burgdorferi, which is transmitted to humans through the bite of infected ticks. The disease can cause a range of symptoms, which can be divided into early and later features.

      Early features of Lyme disease typically occur within 30 days of being bitten by an infected tick. These can include a distinctive rash known as erythema migrans, which often appears as a bulls-eye pattern around the site of the tick bite. Other early symptoms may include headache, lethargy, fever, and joint pain.

      Later features of Lyme disease can occur after 30 days and may affect different parts of the body. These can include heart block or myocarditis, which affect the cardiovascular system, and facial nerve palsy or meningitis, which affect the nervous system.

      To diagnose Lyme disease, doctors may look for the presence of erythema migrans or use blood tests to detect antibodies to Borrelia burgdorferi. Treatment typically involves antibiotics, such as doxycycline or amoxicillin, depending on the stage of the disease.

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  • Question 65 - A 27-year-old woman calls for guidance. She is 10 weeks pregnant and works...

    Incorrect

    • A 27-year-old woman calls for guidance. She is 10 weeks pregnant and works in a daycare with young children. She is seeking advice on which infections to avoid during early pregnancy. What viral illness is most likely to cause birth defects in the baby if the mother contracts it during the first trimester?

      Your Answer: Parvovirus

      Correct Answer: Rubella

      Explanation:

      Maternal Rubella and Fetal Damage

      Maternal rubella infection during the first 8-10 weeks of pregnancy can result in fetal damage in as many as 90% of infants, with multiple defects being common. However, the risk of fetal damage decreases to 10-20% by 16 weeks gestation. After 16 weeks, fetal damage due to maternal rubella infection is rare. It is important for pregnant women to ensure they are vaccinated against rubella to prevent potential harm to their developing fetus.

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  • Question 66 - A 49-year-old man with a severe cough and fever has blood taken for...

    Incorrect

    • A 49-year-old man with a severe cough and fever has blood taken for antibody titres when he fails to respond to amoxicillin. The results are shown below (CFT = complement fixation test).
      Chlamydia psittaci Ab (CFT) 1/10
      Coxiella burnetii (Q fever) phase 2 1/10
      influenza A antibody (CFT) 1/40
      influenza B antibody (CFT) 1/10
      Legionella antibody (CFT) 1/10
      Mycoplasma pneumoniae antibody (CFT) 1/640
      Select from the list the single most likely diagnosis.

      Your Answer: Recent infection with influenza A

      Correct Answer: Recent infection with Mycoplasma pneumoniae

      Explanation:

      Understanding Serology Tests for Mycoplasma Pneumonia Infection

      Serology tests are used to detect antibodies in the blood that indicate the presence of an infection. In the case of Mycoplasma pneumonia, a positive result suggests an infection, but a second test is needed several weeks later to confirm this with a falling titre. The result is expressed as a dilution, with a larger denominator indicating a stronger antibody reaction. It’s important to note that antibody levels can remain raised for some time after the acute infection, which may explain the raised result for influenza A. Repeat serology is necessary to detect changing levels.

      To support the diagnosis of Mycoplasma pneumonia, serology tests that demonstrate a 4-fold or greater increase or decrease in paired sera titres or a single titre greater than or equal to 1:32 are used. These tests include complement fixation, enzyme-linked immunoassay, and indirect hemagglutination. However, a sputum Gram stain is usually not helpful because M pneumonia lacks a cell wall and cannot be stained. Additionally, the bacteria is difficult to culture, requiring special culture media and up to 21 days to grow.

      In summary, serology tests are an important tool for detecting Mycoplasma pneumonia infection, but a second test and careful interpretation of results are necessary for accurate diagnosis.

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  • Question 67 - A rather embarrassed 27-year-old man is seen at the out-of-hours centre complaining of...

    Incorrect

    • A rather embarrassed 27-year-old man is seen at the out-of-hours centre complaining of dysuria and discharge from his penis. This started about a week earlier and is increasingly uncomfortable. He is normally fit and well. You send a urethral swab for microscopy and culture and urine sample for NAAT & microscopy & culture. The results come back showing a few pus cells in his urine but no growth on either culture & negative NAAT.
      What is the single most likely diagnosis?

      Your Answer: Gonorrhoea

      Correct Answer: nonspecific urethritis

      Explanation:

      Common Genitourinary Conditions and Diagnostic Methods

      Chronic prostatitis is a condition that often results in pain in the perineal area. Gonorrhoea, on the other hand, can be diagnosed through a nucleic acid amplification test (NAAT) using urine samples in men or through a positive culture of urethral discharge. Urinary tract infections (UTIs) can be detected through a midstream urine culture. Meanwhile, balanitis xerotica et obliterans is a chronic condition characterized by atrophic white patches on the foreskin and glans penis. These conditions can be diagnosed through various diagnostic methods, which are essential in determining the appropriate treatment plan.

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  • Question 68 - A 38-year-old woman comes to the clinic complaining of a dry cough and...

    Incorrect

    • A 38-year-old woman comes to the clinic complaining of a dry cough and difficulty breathing for the past three days. She reports having flu-like symptoms prior to this. During the physical examination, a symmetrical rash with 'target' lesions is observed all over her body. What is the probable causative agent responsible for these symptoms?

      Your Answer: Legionella pneumophilia

      Correct Answer: Mycoplasma pneumoniae

      Explanation:

      Erythema multiforme can be caused by Mycoplasma and pneumococcus.

      Comparison of Legionella and Mycoplasma pneumonia

      Legionella and Mycoplasma pneumonia are both causes of atypical pneumonia, but they have some differences. Legionella is associated with outbreaks in buildings with contaminated water systems, while Mycoplasma pneumonia is more common in younger patients and is associated with epidemics every 4 years. Both diseases have flu-like symptoms, but Mycoplasma pneumonia has a more gradual onset and a dry cough. On x-ray, both diseases show bilateral consolidation. However, it is important to recognize Mycoplasma pneumonia as it may not respond to penicillins or cephalosporins due to it lacking a peptidoglycan cell wall.

      Complications of Mycoplasma pneumonia include cold autoimmune haemolytic anaemia, erythema multiforme, meningoencephalitis, and other immune-mediated neurological diseases. In contrast, Legionella can cause Legionnaires’ disease, which is a severe form of pneumonia that can lead to respiratory failure and death.

      Diagnosis of Legionella is generally by urinary antigen testing, while diagnosis of Mycoplasma pneumonia is generally by serology. Treatment for Legionella includes fluoroquinolones or macrolides, while treatment for Mycoplasma pneumonia includes doxycycline or a macrolide. Overall, while both diseases are causes of atypical pneumonia, they have some distinct differences in their epidemiology, symptoms, and complications.

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  • Question 69 - An 18-year-old, non-pregnant, asymptomatic woman with no past medical history is discovered to...

    Incorrect

    • An 18-year-old, non-pregnant, asymptomatic woman with no past medical history is discovered to have >100,000 colony-forming units of Escherichia coli/ml urine during a routine health examination.
      What is the most suitable course of action?

      Your Answer: Prescribe long-term prophylactic antibiotics according to sensitivity

      Correct Answer: No antibiotics are indicated

      Explanation:

      Asymptomatic Bacteriuria and Treatment Considerations

      Asymptomatic bacteriuria is a common occurrence in non-pregnant women, affecting approximately 3% of the population. While it doesn’t require treatment as it poses no risk of morbidity or mortality, treatment may increase the frequency of symptomatic infections. However, treatment is necessary if there are comorbid factors such as diabetes, renal transplantation, invasive GU investigations, or a renal stone.

      Pregnancy is an absolute indication for treatment as asymptomatic bacteriuria increases the risk of pyelonephritis, pre-eclampsia, prematurity, and perinatal death. However, a single finding of asymptomatic bacteriuria is not an indication for renal tract investigation.

      For individuals with long-term urinary catheters in place, administering antibiotics may cause additional problems. These patients invariably have bacteriuria, and the bacteria may be more difficult to treat, leading to the development of a yeast infection. Therefore, treatment considerations should be carefully evaluated in such cases.

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  • Question 70 - Samantha is a 62-year-old woman who has just been diagnosed with heart failure....

    Incorrect

    • Samantha is a 62-year-old woman who has just been diagnosed with heart failure. She has been researching her condition online and wants to know which vaccinations she needs due to her diagnosis. Samantha also has hypertension and type 2 diabetes.

      What vaccinations would you suggest for her?

      Your Answer: Single pneumococcal vaccination, single meningococcal vaccination

      Correct Answer: Annual influenza vaccination, single pneumococcal vaccination

      Explanation:

      Patients with heart failure should receive annual influenza vaccination as part of their overall lifestyle approach. Additionally, those with chronic respiratory and heart conditions, such as severe asthma, chronic pulmonary disease, and heart failure, should receive both annual influenza and single pneumococcal vaccinations. Meningococcal vaccination is not typically administered to heart failure patients, but is recommended for those with asplenia or splenic dysfunction, including those with sickle cell and coeliac disease, as well as those with complement disorder. For patients with splenic dysfunction and chronic kidney disease, a pneumococcal booster should be given every 5 years after the initial dose.

      Chronic heart failure can be managed through drug therapy, as outlined in the updated guidelines issued by NICE in 2018. While loop diuretics are useful in managing fluid overload, they do not reduce mortality in the long term. The first-line treatment for all patients is an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Aldosterone antagonists are the standard second-line treatment, but both ACE inhibitors and aldosterone antagonists can cause hyperkalaemia, so potassium levels should be monitored. SGLT-2 inhibitors are increasingly being used to manage heart failure with a reduced ejection fraction, as they reduce glucose reabsorption and increase urinary glucose excretion. Third-line treatment options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, and cardiac resynchronisation therapy. Other treatments include annual influenza and one-off pneumococcal vaccines.

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  • Question 71 - A 44-year-old woman is seen in an emergency appointment complaining that her cold...

    Incorrect

    • A 44-year-old woman is seen in an emergency appointment complaining that her cold has gone onto her chest, giving her a productive cough and occasional retrosternal chest pain. On examination she has a slight wheeze in her chest but no signs of respiratory distress. She is otherwise fit and well.
      Select the single correct statement about her management.

      Your Answer: This condition is usually caused by pneumococci and she should be treated with amoxicillin unless contraindicated

      Correct Answer: She should be advised that she has a viral infection and to take analgesics and antipyretics, with instructions to return if her symptoms worsen

      Explanation:

      Treatment Options for Acute Bronchitis

      Acute bronchitis is often caused by a virus, and in individuals with mild symptoms who are otherwise healthy, bacterial infections typically resolve on their own. Treatment options for acute bronchitis include deferred prescriptions with advice sheets or simple reassurance.

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  • Question 72 - A 21-year-old man presents 5 days after returning from a backpacking trip across...

    Correct

    • A 21-year-old man presents 5 days after returning from a backpacking trip across Peru. He complains of sudden onset fever, headache, joint pains, and rash all over his body. He has no pre-existing medical conditions and is not taking any medication.

      During examination, he has a petechial rash on his limbs. There are no signs of meningism or focal neurology.

      Hemoglobin: 100 g/l
      Platelets: 80 * 109/l
      White blood cells: 4.0 * 109/l
      Eosinophils: 0.4 * 109/l

      What is the most likely diagnosis?

      Your Answer: Dengue fever

      Explanation:

      A returning traveler experiencing retro-orbital headache, fever, facial flushing, rash, and thrombocytopenia is likely suffering from dengue fever. This disease is commonly found in South America and Southeast Asia and is characterized by sudden onset fever and joint pain, as well as low platelet counts and bleeding in severe cases. Chagas disease, which is also found in this region, typically presents with mild symptoms and elevated eosinophil levels. Viral hepatitis and malaria are less probable causes of a petechial rash.

      Understanding Dengue Fever

      Dengue fever is a viral infection that can lead to viral haemorrhagic fever, which includes diseases like yellow fever, Lassa fever, and Ebola. The dengue virus is an RNA virus that belongs to the Flavivirus genus and is transmitted by the Aedes aegypti mosquito. The incubation period for dengue fever is seven days.

      Patients with dengue fever can be classified into three categories: those without warning signs, those with warning signs, and those with severe dengue (dengue haemorrhagic fever). Symptoms of dengue fever include fever, headache (often retro-orbital), myalgia, bone pain, arthralgia (also known as ‘break-bone fever’), pleuritic pain, facial flushing, maculopapular rash, and haemorrhagic manifestations such as a positive tourniquet test, petechiae, purpura/ecchymosis, and epistaxis. Warning signs include abdominal pain, hepatomegaly, persistent vomiting, and clinical fluid accumulation (ascites, pleural effusion). Severe dengue (dengue haemorrhagic fever) is a form of disseminated intravascular coagulation (DIC) that results in thrombocytopenia and spontaneous bleeding. Around 20-30% of these patients go on to develop dengue shock syndrome (DSS).

      Typically, blood tests are used to diagnose dengue fever, which may show leukopenia, thrombocytopenia, and raised aminotransferases. Diagnostic tests such as serology, nucleic acid amplification tests for viral RNA, and NS1 antigen tests may also be used. Treatment for dengue fever is entirely symptomatic, including fluid resuscitation and blood transfusions. Currently, there are no antivirals available for the treatment of dengue fever.

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  • Question 73 - You come across an 8-year-old patient in your clinic who presents with a...

    Correct

    • You come across an 8-year-old patient in your clinic who presents with a fever, rash, and strawberry tongue, and you diagnose them with scarlet fever. According to Public Health England, what is the timeframe within which you must submit a Notifiable Diseases form?

      Your Answer: 72 hours

      Explanation:

      In England and Wales, clinicians are required by law to report cases of scarlet fever as it is a notifiable disease. They do not need to wait for laboratory confirmation before notifying their local health protection team. Public Health England advises that the necessary forms should be filled out immediately upon suspicion of a notifiable disease and submitted within 72 hours. In case of an emergency, verbal notification should be made within 24 hours.

      Notifiable Diseases in the UK

      In the UK, certain diseases are considered notifiable, meaning that the Local Health Protection Team must be notified if a case is suspected or confirmed. These diseases are then reported to the Health Protection Agency on a weekly basis. Notifiable diseases include acute encephalitis, acute infectious hepatitis, acute meningitis, acute poliomyelitis, anthrax, botulism, brucellosis, cholera, COVID-19, diphtheria, enteric fever, food poisoning, haemolytic uraemic syndrome, infectious bloody diarrhoea, invasive group A streptococcal disease, Legionnaires Disease, leprosy, malaria, measles, meningococcal septicaemia, mumps, plague, rabies, rubella, severe acute respiratory syndrome, scarlet fever, smallpox, tetanus, tuberculosis, typhus, viral haemorrhagic fever, whooping cough, and yellow fever.

      It is important to note that HIV is not a notifiable disease in the UK. Additionally, in April 2010, dysentery, ophthalmia neonatorum, leptospirosis, and relapsing fever were removed from the list of notifiable diseases.

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  • Question 74 - Sarah is a 28-year-old woman who comes to the emergency department after being...

    Incorrect

    • Sarah is a 28-year-old woman who comes to the emergency department after being bitten on the hand by a dog while walking in the park. She has a laceration on her left index finger which is bleeding. There is no visible foreign object and the wound appears clean. She is stable and has no other medical issues. Her last tetanus shot was 2 years ago.

      What is the most probable treatment that Sarah will receive?

      Your Answer: Post exposure prophylaxis

      Correct Answer: Broad spectrum antibiotics

      Explanation:

      It is not advisable to administer post-exposure prophylaxis for HIV after being bitten by a human. Since the wound is free from contamination and the individual received a tetanus shot 4 years ago, there is no need for a tetanus booster.

      Post-Exposure Prophylaxis for Viral Infections

      Post-exposure prophylaxis (PEP) is a preventive treatment given to individuals who have been exposed to a viral infection. The type of PEP given depends on the virus and the clinical situation. For hepatitis A, either human normal immunoglobulin or the hepatitis A vaccine may be used. For hepatitis B, the PEP given depends on whether the source is known to be positive for HBsAg or not. If the person exposed is a known responder to the HBV vaccine, then a booster dose should be given. If they are a non-responder, they need to have hepatitis B immune globulin and a booster vaccine. For hepatitis C, monthly PCR is recommended, and if seroconversion occurs, interferon +/- ribavirin may be given. For HIV, a combination of oral antiretrovirals should be given as soon as possible for four weeks. The risk of HIV transmission depends on the incident and the current viral load of the patient. For varicella zoster, VZIG is recommended for IgG negative pregnant women or immunosuppressed individuals. The risk of transmission for single needlestick injuries varies depending on the virus, with hepatitis B having a higher risk than hepatitis C and HIV.

      Overall, PEP is an important preventive measure for individuals who have been exposed to viral infections. It is crucial to determine the appropriate PEP based on the virus and the clinical situation to ensure the best possible outcome.

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  • Question 75 - A 35-year-old man has experienced severe diarrhoea with occasional flecks of blood and...

    Incorrect

    • A 35-year-old man has experienced severe diarrhoea with occasional flecks of blood and unpleasant griping abdominal pain. The symptoms appeared 6-7 hours after he ate a rice-based dish from a local Chinese takeaway. His flatmate had similar symptoms after visiting the same takeaway a few days earlier, which resolved within a day. What is the most probable causative organism?

      Your Answer: Campylobacter

      Correct Answer: Bacillus cereus

      Explanation:

      Understanding Bacillus cereus Infection

      Bacillus cereus is a type of bacteria that can cause food poisoning. Its incubation period is between 6 to 24 hours, and symptoms usually appear within 1 to 2 days. The bacteria produce a toxin that can cause either severe diarrhea or profuse vomiting, depending on the type of toxin produced.

      In Europe, Bacillus cereus infection is commonly associated with diarrhea. The bacteria are often found in reheated fried rice, which is a common cause of the infection. However, the infection is self-limiting, and appropriate oral rehydration advice is usually enough to manage the symptoms.

      Overall, it is important to understand the symptoms and causes of Bacillus cereus infection to prevent its spread and manage its effects.

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  • Question 76 - A 25-year-old Romanian patient presents to the clinic with a two-day history of...

    Incorrect

    • A 25-year-old Romanian patient presents to the clinic with a two-day history of upper left gumline pain, accompanied by a loss of appetite and a temperature of 38.2ºC. On examination, there is tenderness over the gum, and a dental abscess is suspected. Urgent referral to a dentist is recommended, along with antibiotic therapy. What is the most appropriate antibiotic to prescribe?

      Your Answer: Doxycycline

      Correct Answer: Amoxicillin

      Explanation:

      Antibiotics may be necessary in cases of fever or delayed presentation to a dentist. The BNF recommends amoxicillin as the first-line treatment for dental abscesses, followed by metronidazole for more invasive dental conditions.

      Since GPs have limited knowledge of dental issues, it is best for the patient to be treated by their dentist. The most effective treatment for an abscess is prompt drainage. Antibiotics are generally not recommended for healthy individuals unless there are signs of spreading infection or if the person is systemically unwell. According to NICE CKS guidelines, antibiotics should only be prescribed for severe infections (e.g. fever, lymphadenopathy, cellulitis, diffuse swelling) or for high-risk individuals (e.g. those who are immunocompromised, diabetic, or have valvular heart disease) to reduce the risk of complications.

      Antibiotic Guidelines for Common Infections

      Respiratory infections such as chronic bronchitis and community-acquired pneumonia are typically treated with amoxicillin, tetracycline, or clarithromycin. In cases where atypical pathogens may be the cause of pneumonia, clarithromycin is recommended. Hospital-acquired pneumonia within five days of admission is treated with co-amoxiclav or cefuroxime, while infections occurring more than five days after admission are treated with piperacillin with tazobactam, a broad-spectrum cephalosporin, or a quinolone.

      For urinary tract infections, lower UTIs are treated with trimethoprim or nitrofurantoin, while acute pyelonephritis is treated with a broad-spectrum cephalosporin or quinolone. Acute prostatitis is treated with a quinolone or trimethoprim.

      Skin infections such as impetigo, cellulitis, and erysipelas are treated with topical hydrogen peroxide, oral flucloxacillin, or erythromycin if the infection is widespread. Animal or human bites are treated with co-amoxiclav, while mastitis during breastfeeding is treated with flucloxacillin.

      Ear, nose, and throat infections such as throat infections, sinusitis, and otitis media are treated with phenoxymethylpenicillin or amoxicillin. Otitis externa is treated with flucloxacillin or erythromycin, while periapical or periodontal abscesses are treated with amoxicillin.

      Genital infections such as gonorrhoea, chlamydia, and bacterial vaginosis are treated with intramuscular ceftriaxone, doxycycline or azithromycin, and oral or topical metronidazole or topical clindamycin, respectively. Pelvic inflammatory disease is treated with oral ofloxacin and oral metronidazole or intramuscular ceftriaxone, oral doxycycline, and oral metronidazole.

      Gastrointestinal infections such as Clostridioides difficile, Campylobacter enteritis, Salmonella (non-typhoid), and Shigellosis are treated with oral vancomycin, clarithromycin, ciprofloxacin, and ciprofloxacin, respectively.

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  • Question 77 - A 20-year-old otherwise healthy young man presents with a problem with recurrent boils.
    Which...

    Incorrect

    • A 20-year-old otherwise healthy young man presents with a problem with recurrent boils.
      Which of the following is the most likely cause?

      Your Answer: Diabetes mellitus

      Correct Answer: Nasal carriage of staphylococci

      Explanation:

      Understanding Boils: Causes, Risk Factors, and Treatment Options

      Boils, also known as furuncles, are a common skin infection caused by Staphylococcus aureus. They typically occur in adolescents and young adults, particularly in males. Recurrent infections may be caused by persistent nasal carriage of the bacteria. While the link between diabetes and multiple boils is unclear, individuals with diabetes may experience more extensive boils. Other risk factors include obesity, immunosuppression, skin diseases, poor hygiene, and exposure to chemicals or oils.

      To prevent recurrent infections, swabs should be taken from various sites to identify the source of the bacteria. If Panton-Valentine leukocidin Staphylococcus aureus (PVL-SA) or methicillin-resistant Staphylococcus aureus (MRSA) is suspected, specialist advice should be sought. Nasal carriage of staphylococci can be treated with a chlorhexidine and neomycin cream, although re-colonization is common. Antiseptics can also be used to reduce bacteria on the skin.

      Overall, maintaining good hygiene practices, such as daily washing and bathing in antiseptic solutions, can help prevent and treat boils.

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  • Question 78 - A 32-year-old construction worker presents to the clinic after being bitten by a...

    Incorrect

    • A 32-year-old construction worker presents to the clinic after being bitten by a dog on his left hand. What would be the most suitable antibiotic treatment?

      Your Answer: Flucloxacillin + penicillin

      Correct Answer: Co-amoxiclav

      Explanation:

      Animal bites are a common occurrence in everyday practice, with dogs and cats being the most frequent culprits. These bites are usually caused by multiple types of bacteria, with Pasteurella multocida being the most commonly isolated organism. To manage these bites, it is important to cleanse the wound thoroughly. Puncture wounds should not be sutured unless there is a risk of cosmesis. The current recommendation is to use co-amoxiclav, but if the patient is allergic to penicillin, doxycycline and metronidazole are recommended.

      On the other hand, human bites can cause infections from a variety of bacteria, including both aerobic and anaerobic types. Common organisms include Streptococci spp., Staphylococcus aureus, Eikenella, Fusobacterium, and Prevotella. To manage these bites, co-amoxiclav is also recommended. It is important to consider the risk of viral infections such as HIV and hepatitis C when dealing with human bites.

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  • Question 79 - A 68-year-old man presents for follow-up after being hospitalized for erysipelas of his...

    Correct

    • A 68-year-old man presents for follow-up after being hospitalized for erysipelas of his leg. He was feeling ill and needed intravenous antibiotics. He is now finishing his course of oral antibiotics. He has no reported allergies to medications.

      What medication is expected to be prescribed?

      Your Answer: Flucloxacillin

      Explanation:

      For individuals with cellulitis or erysipelas, an antibiotic is necessary. These conditions are characterized by acute inflammation and swelling, with erysipelas having more superficial lesions with a distinct raised margin.

      When selecting an antibiotic, consider the severity of symptoms, the location of the infection, the risk of complications, and previous antibiotic use. If the individual was admitted to the hospital due to systemic illness, oral flucloxacillin is the preferred treatment for erysipelas. However, co-amoxiclav should be used for cellulitis near the eyes or nose.

      Ciprofloxacin should only be used for specific indications due to its association with Clostridium difficile infection. Doxycycline is not the first choice, and if there is a penicillin allergy, clarithromycin or erythromycin should be used instead of flucloxacillin for erysipelas or cellulitis.

      Erythromycin is not the first-line choice, but it may be appropriate if there is a history of penicillin allergy.

      Antibiotic Guidelines for Common Infections

      Respiratory infections such as chronic bronchitis and community-acquired pneumonia are typically treated with amoxicillin, tetracycline, or clarithromycin. In cases where atypical pathogens may be the cause of pneumonia, clarithromycin is recommended. Hospital-acquired pneumonia within five days of admission is treated with co-amoxiclav or cefuroxime, while infections occurring more than five days after admission are treated with piperacillin with tazobactam, a broad-spectrum cephalosporin, or a quinolone.

      For urinary tract infections, lower UTIs are treated with trimethoprim or nitrofurantoin, while acute pyelonephritis is treated with a broad-spectrum cephalosporin or quinolone. Acute prostatitis is treated with a quinolone or trimethoprim.

      Skin infections such as impetigo, cellulitis, and erysipelas are treated with topical hydrogen peroxide, oral flucloxacillin, or erythromycin if the infection is widespread. Animal or human bites are treated with co-amoxiclav, while mastitis during breastfeeding is treated with flucloxacillin.

      Ear, nose, and throat infections such as throat infections, sinusitis, and otitis media are treated with phenoxymethylpenicillin or amoxicillin. Otitis externa is treated with flucloxacillin or erythromycin, while periapical or periodontal abscesses are treated with amoxicillin.

      Genital infections such as gonorrhoea, chlamydia, and bacterial vaginosis are treated with intramuscular ceftriaxone, doxycycline or azithromycin, and oral or topical metronidazole or topical clindamycin, respectively. Pelvic inflammatory disease is treated with oral ofloxacin and oral metronidazole or intramuscular ceftriaxone, oral doxycycline, and oral metronidazole.

      Gastrointestinal infections such as Clostridioides difficile, Campylobacter enteritis, Salmonella (non-typhoid), and Shigellosis are treated with oral vancomycin, clarithromycin, ciprofloxacin, and ciprofloxacin, respectively.

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  • Question 80 - A 42-year-old man comes back from a two week business trip to Kenya....

    Incorrect

    • A 42-year-old man comes back from a two week business trip to Kenya. Six weeks after his return, he visits his GP with complaints of malaise, headaches, and night sweats. During the examination, the doctor observes a symmetrical erythematous macular rash on his trunk and limbs along with cervical and inguinal lymphadenopathy. What is the probable diagnosis?

      Your Answer: Tuberculosis

      Correct Answer: Acute HIV infection

      Explanation:

      Understanding HIV Seroconversion

      HIV seroconversion is a process that occurs in individuals who have been recently infected with the virus. It is characterized by symptoms that resemble those of glandular fever, such as sore throat, lymphadenopathy, malaise, myalgia, arthralgia, diarrhea, maculopapular rash, and mouth ulcers. In some rare cases, it can also lead to meningoencephalitis. The severity of the symptoms is associated with the long-term prognosis of the patient, with more severe symptoms indicating a poorer prognosis.

      Diagnosing HIV seroconversion can be challenging, as antibodies to the virus may not be present in the early stages of infection. However, HIV PCR and p24 antigen tests can confirm the diagnosis. Understanding the process of HIV seroconversion is crucial for early detection and treatment of the virus, as well as for preventing its spread to others. By recognizing the symptoms and seeking medical attention promptly, individuals can receive the care they need to manage the virus and improve their long-term outcomes.

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  • Question 81 - A 55-year-old man is diagnosed with human immunodeficiency virus (HIV) infection at a...

    Incorrect

    • A 55-year-old man is diagnosed with human immunodeficiency virus (HIV) infection at a relatively late stage when he is already starting to get opportunistic infections. Select from the list the single correct statement about the complications of HIV/AIDS.

      Your Answer: Mycobacterium avium infection occurs with CD4 counts as high as <300/mm3

      Correct Answer:

      Explanation:

      Complications of HIV/AIDS and the Role of Antiretroviral Therapy

      HIV/AIDS is a disease that suppresses T-cell mediated immunity, leading to various complications. However, antiretroviral therapy (ART) has been effective in inhibiting the replication of the virus, restoring the immune system, and reducing the risk of opportunistic infections. Combinations of three or more drugs are used to prevent resistance.

      One of the hallmark complications of late-stage HIV disease is pneumocystis pneumonia, which is now less common due to ART and primary prophylaxis. Symptoms include shortness of breath, dry cough, fever, malaise, fatigue, weight loss, and chest pain. Diagnosis can be difficult, with few signs in the chest and unhelpful radiology.

      Mycobacterium avium infection is another complication that often occurs at a CD4 count < 200/mm3, and is seen in 40% of patients with late-stage HIV in industrialized countries. Symptoms include fever, night sweats, weight loss, diarrhea, abdominal pain, anemia, or hepatic dysfunction. Dementia is usually caused by HIV encephalopathy, but can also be caused by cytomegalovirus encephalitis or cerebral toxoplasmosis. The incidence of Kaposi’s sarcoma and non-Hodgkin’s lymphoma has been reduced by ART, but the incidence of other cancers in HIV patients has not changed.

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  • Question 82 - A 25-year-old woman had unprotected sex after an office party 4 days ago....

    Correct

    • A 25-year-old woman had unprotected sex after an office party 4 days ago. She is currently taking antibiotics for a respiratory tract infection. She has intense difficulty passing urine, accompanied by burning, itching and pain over her labia. On examination there is a crop of vesicles and erosions on her vulva.
      Select the single most likely diagnosis.

      Your Answer: Herpes simplex infection (HSV-2)

      Explanation:

      Understanding Herpes Simplex Infection: Types, Symptoms, and Treatment

      Herpes simplex infection is caused by two viral subtypes, HSV-1 and HSV-2. HSV-1 is commonly associated with oral or facial infections, while HSV-2 is mainly responsible for genital infections. After primary infection, the virus enters nerve endings in the skin and remains latent until reactivated. Symptoms usually appear 3-7 days after contact and may include a low-grade fever and general malaise. At the site of infection, symptoms include pain, burning, itching, and tingling, with the presence of groups of vesicles surrounded by erythema. These lesions usually ulcerate and crust over within 48 hours, lasting between 2 and 6 weeks without scarring. Women may experience urinary retention due to associated pain. Recurrent infection may occur due to fatigue, stress, local skin trauma, exposure to sunlight, or the menstrual cycle. Treatment involves the use of antiviral agents such as aciclovir, and prophylactic use of oral antiviral therapy may reduce the frequency and severity of recurrent infection.

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  • Question 83 - A 32-year-old male presents to your clinic with an 8-hour history of a...

    Incorrect

    • A 32-year-old male presents to your clinic with an 8-hour history of a red and painful leg. He sustained a cut while jogging in the park. Upon examination, his left leg is warm and tender. You diagnose him with cellulitis and inquire about any allergies. He reports having a widespread rash to amoxicillin in the past. What antibiotic would you recommend?

      Your Answer: Co-amoxiclav

      Correct Answer: Clarithromycin

      Explanation:

      Patients who are allergic to penicillin and have cellulitis can receive clarithromycin, erythromycin (during pregnancy), or doxycycline. Penicillins are known to cause allergies, and current guidelines recommend clarithromycin for patients with cellulitis who are allergic to penicillin. Clindamycin is an alternative, but it has more adverse effects than clarithromycin. Flucloxacillin and co-amoxiclav contain penicillin, and ceftriaxone is not used for cellulitis. Although ciprofloxacin can be given to children with varicella who have cellulitis and are allergic to penicillin, it is not appropriate for this patient.

      Understanding Cellulitis: Symptoms, Diagnosis, and Treatment

      Cellulitis is a common skin infection caused by Streptococcus pyogenes or Staphylococcus aureus. It is characterized by inflammation of the skin and subcutaneous tissues, usually on the shins, accompanied by erythema, pain, swelling, and sometimes fever. The diagnosis of cellulitis is based on clinical features, and no further investigations are required in primary care. However, bloods and blood cultures may be requested if the patient is admitted and septicaemia is suspected.

      To guide the management of patients with cellulitis, NICE Clinical Knowledge Summaries recommend using the Eron classification. Patients with Eron Class III or Class IV cellulitis, severe or rapidly deteriorating cellulitis, very young or frail patients, immunocompromised patients, patients with significant lymphoedema, or facial or periorbital cellulitis (unless very mild) should be admitted for intravenous antibiotics. Patients with Eron Class II cellulitis may not require admission if the facilities and expertise are available in the community to give intravenous antibiotics and monitor the patient.

      The first-line treatment for mild/moderate cellulitis is flucloxacillin, while clarithromycin, erythromycin (in pregnancy), or doxycycline is recommended for patients allergic to penicillin. Patients with severe cellulitis should be offered co-amoxiclav, cefuroxime, clindamycin, or ceftriaxone. Understanding the symptoms, diagnosis, and treatment of cellulitis is crucial for effective management and prevention of complications.

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  • Question 84 - A 27-year-old woman who is 12 weeks pregnant presents with a concern after...

    Incorrect

    • A 27-year-old woman who is 12 weeks pregnant presents with a concern after being exposed to her mother who has been diagnosed with facial shingles one day ago.

      She was unaware of what the rash was and had examined the rash closely two days ago before her mother was diagnosed. She informs you that she is unaware of ever having Chickenpox.

      What is the most appropriate action that should be taken for this patient?

      Your Answer: She should be treated with Varicella zoster immunoglobulin

      Correct Answer: She should be tested immediately for IgG antibodies to Varicella zoster

      Explanation:

      Management of VZV Exposure in a Non-Immune Patient

      The patient has a significant history of exposure to Varicella zoster virus (VZV), which puts her at risk of acquiring Chickenpox if she is non-immune. However, it is possible that she may have had VZV infection as a child. Therefore, the first step in managing this situation is to measure IgG antibodies to VZV. If the antibodies are present, no further action is required, and the patient can be relatively reassured.

      On the other hand, if the patient is non-immune, she will likely need to be treated with VZ immunoglobulin. This treatment has been shown to reduce the severity of the infection and prevent fetal infection. It is important to note that prompt management of VZV exposure in non-immune patients is crucial to prevent complications and ensure the best possible outcome.

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  • Question 85 - You have been seeing a 52-year-old man who has been frequently attending with...

    Correct

    • You have been seeing a 52-year-old man who has been frequently attending with lower respiratory tract infections. He has lost weight and appears pale and gaunt. During your consultation, you inquire about his travel history and any potential exposure to sexually transmitted infections. The patient confesses to having unprotected sexual intercourse with a sex worker while on a business trip to Thailand a few years ago when his marriage was going through a rough patch. Since then, he has reconciled with his wife and she has been his only sexual partner. With the patient's consent, you conduct a blood test to screen for Human Immunodeficiency Virus (HIV), which comes back positive. You discuss the implications of the result with the patient, but he insists that he cannot disclose this information to his wife, who is also a patient at your practice. What is your course of action?

      Your Answer: Give the patient an opportunity to tell his wife and if he doesn't then inform him that it is your duty to inform her

      Explanation:

      The question pertains to patient confidentiality and when it is acceptable to breach it. Specifically, if a patient has been diagnosed with a serious communicable disease, there is a risk of transmission to another patient. According to GMC guidelines, it is permissible to disclose information to a sexual partner of a patient with a sexually transmitted serious communicable disease if the patient has not informed them and cannot be convinced to do so. However, the patient should be informed before the disclosure is made, if possible and safe to do so. Any decision to disclose personal information without consent must be justified. Therefore, in this scenario, if the patient refuses to inform their spouse, it is appropriate to inform the spouse after informing the patient of the decision. It is important to follow professional guidelines in such situations, and other options would not be appropriate.

      GMC Guidance on Confidentiality

      Confidentiality is a crucial aspect of medical practice that must be upheld at all times. The General Medical Council (GMC) provides extensive guidance on confidentiality, which can be accessed through a link provided. As such, we will not attempt to replicate the detailed information provided by the GMC here. It is important for healthcare professionals to familiarize themselves with the GMC’s guidance on confidentiality to ensure that they are meeting the necessary standards and protecting patient privacy.

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  • Question 86 - Four middle-aged patients returned from a trip to Spain with symptoms of cough,...

    Correct

    • Four middle-aged patients returned from a trip to Spain with symptoms of cough, fever, and general malaise. They had traveled with a group of 60 people and participated in activities such as hiking in the mountains and swimming in rivers. The group stayed in various hotels, but the four patients who fell ill all stayed in the same hotel. Based on this information, what is the most probable organism responsible for their illness?

      Your Answer: Mycoplasma pneumoniae

      Explanation:

      Legionnaires’ Disease: A Deadly Outbreak

      Legionnaires’ disease is a severe form of pneumonia caused by Legionella pneumophila. The condition was first described in a veterans’ legion conference, where a group of attendees became ill with similar symptoms. The disease is often linked to contaminated air conditioning units, which can spread the bacteria through the air.

      Symptoms of Legionnaires’ disease include fever, cough, shortness of breath, muscle aches, and headaches. In severe cases, the disease can lead to respiratory failure, septic shock, and even death. It is important to seek medical attention immediately if you experience any of these symptoms, especially if you have been exposed to a potential source of Legionella bacteria.

      It is important to note that Weil’s disease and Lyme disease are unlikely to be the cause of the symptoms described in this scenario. Weil’s disease is caused by a different type of bacteria, while Lyme disease is transmitted by ticks.

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  • Question 87 - A 25-year-old otherwise healthy man comes to his General Practitioner with a 4-day...

    Incorrect

    • A 25-year-old otherwise healthy man comes to his General Practitioner with a 4-day history of a sore throat. It is painful to swallow but he is able to maintain his fluid intake. He is afebrile and has a mild cough. On examination, his tonsils are severely inflamed bilaterally but there is no exudate. There is tender cervical lymphadenopathy present.
      Which of the following is the most appropriate management?

      Your Answer: He should be admitted to hospital for fluids

      Correct Answer: An antibiotic is not indicated

      Explanation:

      Antibiotic Decision Making in a Case of Tonsillitis

      Explanation:

      When it comes to treating tonsillitis, the decision to prescribe antibiotics should be based on the severity of the infection and the presence of certain criteria. The Centor criteria, which include tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever, and absence of cough, can help determine if streptococcal infection is present. A FeverPAIN score can also be used to assess the severity of tonsillitis.

      In the case of an otherwise healthy, afebrile patient with a Centor score of one for lymphadenopathy and a FeverPAIN score of one for severe tonsil inflammation, antibiotics are not indicated. However, if the condition doesn’t improve or worsens, a reassessment should be offered.

      Admission to the hospital for fluids is not necessary if the patient is able to maintain fluid intake despite painful swallowing and shows no other signs of systemic illness.

      If antibiotics are deemed necessary, a delayed prescription for phenoxymethylpenicillin may be given if the FeverPAIN score is two or three. Clarithromycin may be prescribed as a second-line option if there is a true penicillin allergy and group A streptococcus is suspected as the cause, based on a FeverPAIN score of four or five or Centor score of three or four. Phenoxymethylpenicillin would be the first-line option in such cases.

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  • Question 88 - Of the following scenarios, which one would indicate it was inappropriate for the...

    Incorrect

    • Of the following scenarios, which one would indicate it was inappropriate for the child to take an airline flight?

      Your Answer: A 54-year-old woman who had a laparoscopic cholecystectomy 5 days ago

      Correct Answer: A 17-year-old flying back to the UK who broke his leg whilst skiing in Canada. Had a plaster cast applied 24 hours ago

      Explanation:

      Patients should wait for 24 hours before taking short flights (< 2 hours) and 48 hours before taking longer flights after applying a plaster cast. This is necessary to avoid the possibility of air getting trapped beneath the cast. The CAA has issued guidelines on air travel for people with medical conditions. Patients with certain cardiovascular diseases, uncomplicated myocardial infarction, coronary artery bypass graft, and percutaneous coronary intervention may fly after a certain period of time. Patients with respiratory diseases should be clinically improved with no residual infection before flying. Pregnant women may not be allowed to travel after a certain number of weeks and may require a certificate confirming the pregnancy is progressing normally. Patients who have had surgery should avoid flying for a certain period of time depending on the type of surgery. Patients with haematological disorders may travel without problems if their haemoglobin is greater than 8 g/dl and there are no coexisting conditions.

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  • Question 89 - A 14-year-old girl has measles.
    Select from the list the single most likely complication....

    Correct

    • A 14-year-old girl has measles.
      Select from the list the single most likely complication.

      Your Answer: Bronchopneumonia

      Explanation:

      Complications and Risks Associated with Measles Infection

      Measles infection can lead to various complications and risks, including bronchopneumonia, lobar pneumonia, encephalitis, and hepatitis. Bronchopneumonia is the most common cause of death, usually caused by Staphylococcus aureus or secondary viral infections. Lobar pneumonia, on the other hand, is caused by Streptococcus pneumoniae. Other bacterial infections such as cervical adenitis and otitis media can also occur. Close follow-up is necessary for patients with measles.

      Borderline vitamin A deficiency increases the risk of death and blindness from measles. The World Health Organization recommends high-dose vitamin A for all children with measles in countries where the case fatality rate is greater than 1%. Encephalitis and hepatitis are rare complications.

      Lymphopenia, a condition characterized by low levels of lymphocytes, is a common effect of measles infection. Infants and adults may experience delayed recovery from this condition, and immunodeficiency can persist for several weeks even after lymphocyte counts have returned to normal. This is believed to be a significant contributor to the high all-cause mortality rate following acute measles worldwide.

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  • Question 90 - A 30-year-old aid worker returns from a 6-month placement in the former Soviet...

    Incorrect

    • A 30-year-old aid worker returns from a 6-month placement in the former Soviet Union with a severe sore throat. He has a fever and generalised weakness and is restless. Examination reveals a swollen neck, tender lymph nodes and a white membrane over his throat. When you take a swab from the throat there is contact bleeding.
      Select from the list the single most likely diagnosis.

      Your Answer: Acute HIV infection

      Correct Answer: Diphtheria

      Explanation:

      Diphtheria: A Rare but Serious Disease

      Diphtheria is a rare disease in Western Europe, but it still exists in the former USSR. The disease has an incubation period of 2-6 days and causes severe sore throat, malaise, and a pseudomembrane over the throat. Removing the pseudomembrane can cause bleeding. The toxin produced by Corynebacterium diphtheriae can lead to myocarditis and bulbar palsy. Diagnosis is done through a throat swab, and treatment involves macrolide antibiotics and antitoxin in severe cases. People traveling to areas where diphtheria is endemic should get vaccinated against the disease.

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  • Question 91 - A 35-year-old man presents with an acute onset of pain and blurred vision...

    Correct

    • A 35-year-old man presents with an acute onset of pain and blurred vision of his right eye. On examination there is conjunctival injection and dendritic ulceration is seen on his cornea.
      Select from the list the single most appropriate topical agent for the treatment of this patient.

      Your Answer: Aciclovir

      Explanation:

      Herpes Simplex Infection of the Eye: Diagnosis and Treatment

      Patients suspected of having a herpes simplex infection of the eye should be referred to the local ophthalmology team on the same day. Steroid eye preparations should not be initiated in the primary care setting. If there is evidence of epithelial keratitis, topical antiviral treatment is recommended, such as aciclovir five times a day until at least 3 days after complete healing. Antibacterial ointment may prevent secondary infection of the lesions. To diagnose the dendritic ulcer, fluorescein is a topical stain used.

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  • Question 92 - A 6-year-old is brought to the emergency department by his parents due to...

    Incorrect

    • A 6-year-old is brought to the emergency department by his parents due to a fever and headache. Upon examination, the child appears ill, with a central capillary refill of 4 seconds, a heart rate of 150 beats/min, a respiratory rate of 45 breaths/min, a temperature of 38ºC, and a non-blanching rash on his right leg and torso.

      What is the recommended course of action for the parents?

      Your Answer: Oral amoxicillin

      Correct Answer: Oral ciprofloxacin

      Explanation:

      When suspected bacterial meningitis is being investigated and managed, it is important to prioritize timely antibiotic treatment to avoid negative consequences. Patients should be urgently transferred to the hospital, and if meningococcal disease is suspected in a prehospital setting, intramuscular benzylpenicillin may be given. An ABC approach should be taken initially, and senior review is necessary if any warning signs are present. A key decision is when to attempt a lumbar puncture, which should be delayed in certain circumstances. Management of patients without indication for delayed LP includes IV antibiotics, with cefotaxime or ceftriaxone recommended for patients aged 3 months to 50 years. Additional tests that may be helpful include blood gases and throat swab for meningococcal culture. Prophylaxis needs to be offered to households and close contacts of patients affected with meningococcal meningitis, and meningococcal vaccination should be offered to close contacts when serotype results are available.

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  • Question 93 - A 25-year-old man has just arrived from Bangladesh and presents with sudden onset...

    Incorrect

    • A 25-year-old man has just arrived from Bangladesh and presents with sudden onset of nausea and vomiting associated with watery diarrhoea. The diarrhoea intensified and is now 'rice watery' character.
      Select from the list the single most likely diagnosis.

      Your Answer: Ulcerative colitis

      Correct Answer: Cholera

      Explanation:

      Cholera: Symptoms, Transmission, and Prevention

      Cholera is a bacterial infection caused by the bacterium Vibrio cholerae. The incubation period for cholera is typically 2-5 days. The initial signs of cholera include vomiting and watery diarrhea. At first, the diarrhea may be modest and consist of faecal matter and watery stool. However, in some patients, the diarrhea becomes profound and can exceed 200 ml/kg body weight per day. The stool in these cases becomes ‘rice-watery’ in character, resembling the opaque white water discarded after rice has been washed. The diarrhea is painless, and patients are often incontinent of stool. Without antimicrobial treatment, the total stool volume during the illness can exceed total body weight.

      Cholera is rarely imported from abroad, with an average of only 10 cases of cholera in the UK annually. The most common serotype is V. cholerae El Tor, and most infections are acquired on the Indian subcontinent. The risk of cholera for most travelers to endemic areas is very low, particularly in short-term travelers. However, the risk increases for those staying in areas of outbreaks. An oral cholera vaccine is now available in the UK and may be suitable for those who are unable to take adequate precautions in highly endemic or epidemic areas, such as disaster relief workers and adventurous backpackers.

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  • Question 94 - A father comes to see you for some advice regarding immunisation of his...

    Incorrect

    • A father comes to see you for some advice regarding immunisation of his toddler son who is HIV positive. He is not sure if his son is able to have the usual routine childhood immunisations.

      You review his clinical record and discuss things further. The child is well at present with no clinical or biochemical evidence of immunosuppression.

      What do you advise?

      Your Answer: She should not have any immunisations as the risk of her developing problems following both 'inactivated' and 'live' vaccinations is too great

      Correct Answer: She should only receive 'inactivated' vaccines and 'live' vaccines are absolutely contraindicated

      Explanation:

      Immunisation for HIV-positive patients

      Immunisation is a crucial aspect of managing HIV-positive patients. Inactivated vaccines are safe to administer as they pose no risk of infection. However, the response to the vaccine may not be as effective as in immunocompetent individuals. Live vaccines carry a risk of infection, and therefore, certain restrictions apply. For instance, the MMR vaccine is a live vaccine that requires an assessment of immune status before administration. The Department of Health recommends that HIV-positive individuals receive the MMR vaccine according to national guidelines, provided they do not have severe immunosuppression. However, for children under 12, CD4 counts may not be an accurate assessment of immune status, and expert assessment is advised. In conclusion, routine immunisations can be safely given to HIV-positive individuals without evidence of immunosuppression, but specialist advice should be sought to clarify this.

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  • Question 95 - A 50-year-old man has had a painful right ear for 5 days. Moving...

    Incorrect

    • A 50-year-old man has had a painful right ear for 5 days. Moving the ear is painful. The external auditory canal is swollen and tender.
      Select the single most likely infecting organism.

      Your Answer: Streptococcus pneumonia

      Correct Answer: Pseudomonas aeruginosa

      Explanation:

      Understanding Acute Otitis Externa: Causes and Complications

      Acute otitis externa is a condition characterized by inflammation of the outer ear canal. While infection is the most likely cause, skin diseases and irritants may also contribute to the condition. In the acute phase, there may be little discharge. Pseudomonas aeruginosa is the most common cause, followed by other Gram-positive and Gram-negative species. Fungal pathogens like Candida albicans and Aspergillus species may also be responsible, especially after prolonged treatment with antibiotics. Malignant otitis externa, a rare but life-threatening complication, occurs when the infection spreads to the mastoid and temporal bones. It is usually caused by P. aeruginosa or S. aureus and affects elderly people with diabetes or those who are immunocompromised. Symptoms include intense pain and headache.

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  • Question 96 - A 35-year-old man presents with a past medical history of abdominal pain and...

    Incorrect

    • A 35-year-old man presents with a past medical history of abdominal pain and febrile illness. His liver function tests reveal an alanine aminotransferase level of 80 IU/l and a bilirubin level of 18 µmol/l. Serological tests for hepatitis viruses indicate that he is positive for hepatitis B (HepB) surface antigen (Ag), but negative for anti-HepB core or immunoglobulin M. What do these results suggest?

      Your Answer: Acute hepatitis B

      Correct Answer: Carrier of hepatitis B

      Explanation:

      Understanding Hepatitis B Infection and Vaccination Status

      Hepatitis B infection can be identified through the presence of specific antigens and antibodies in the blood. In acute cases, the surface antigen appears first, followed by a highly infectious antigen. Transaminase levels may also increase. If the surface antigen persists after the acute illness, it indicates a carrier status, which occurs in 10% of cases.

      Vaccination against hepatitis B can be confirmed by the presence of antibodies to the surface antigen. However, if these antibodies are not present, it suggests that the patient has not been vaccinated.

      High levels of immunoglobulin M antibodies to the core antigen indicate an acute infection, while positive immunoglobulin G antibodies to anti-Hep B core indicate a past infection.

      Recovery from past hepatitis B infection is indicated by the clearance of the surface antigen and the development of anti-HBs antibodies.

      If a patient has hepatitis B surface antigen and core antibodies, it suggests that they have been infected with hepatitis B and do not require vaccination.

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  • Question 97 - A woman you are treating for tuberculosis mentions that she has observed her...

    Incorrect

    • A woman you are treating for tuberculosis mentions that she has observed her urine turning orange since commencing treatment. Which medication is causing this change?

      Your Answer: Isoniazid

      Correct Answer: Rifampicin

      Explanation:

      One of the peculiar side effects of rifampicin, a medication used in TB treatment, is the discoloration of bodily secretions to orange. However, the other medications used in TB treatment do not cause such a side effect. The notes below provide information on the side effects of these medications.

      Tuberculosis is a bacterial infection that can be treated with a combination of drugs. Each drug has a specific mechanism of action and can also cause side-effects. Rifampicin works by inhibiting bacterial DNA dependent RNA polymerase, which prevents the transcription of DNA into mRNA. However, it is a potent liver enzyme inducer and can cause hepatitis, orange secretions, and flu-like symptoms.

      Isoniazid, on the other hand, inhibits mycolic acid synthesis. It can cause peripheral neuropathy, which can be prevented with pyridoxine (Vitamin B6). It can also cause hepatitis and agranulocytosis, but it is a liver enzyme inhibitor.

      Pyrazinamide is converted by pyrazinamidase into pyrazinoic acid, which inhibits fatty acid synthase (FAS) I. However, it can cause hyperuricaemia, leading to gout, as well as arthralgia and myalgia. It can also cause hepatitis.

      Finally, Ethambutol inhibits the enzyme arabinosyl transferase, which polymerizes arabinose into arabinan. However, it can cause optic neuritis, so it is important to check visual acuity before and during treatment. The dose also needs adjusting in patients with renal impairment.

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  • Question 98 - Which statement regarding methicillin-resistant Staphylococcus aureus (MRSA) is correct? ...

    Incorrect

    • Which statement regarding methicillin-resistant Staphylococcus aureus (MRSA) is correct?

      Your Answer: Fusidic acid can be used as monotherapy in suspected MRSA infection

      Correct Answer: MRSA is often sensitive to trimethoprim

      Explanation:

      Understanding MRSA: Causes, Transmission, and Treatment

      MRSA, or Methicillin-resistant Staphylococcus aureus, is a type of bacteria that can be acquired in both hospital and community settings. While it is carried by many people without causing harm, it can also cause serious infections. MRSA can be spread through direct contact or airborne infection. When treatment is necessary, a combination of doxycycline, fusidic acid, or trimethoprim with rifampicin is typically effective. However, it is important to note that fusidic acid and rifampicin should not be used alone due to the risk of resistance developing. Understanding the causes, transmission, and treatment of MRSA is crucial in preventing its spread and managing infections.

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  • Question 99 - A 25-year-old nurse has a needlestick injury after taking blood from a patient...

    Incorrect

    • A 25-year-old nurse has a needlestick injury after taking blood from a patient known to be HIV positive.
      Select the single most appropriate immediate management after hand-washing for 10 minutes.

      Your Answer: Hepatitis B immunisation

      Correct Answer: Antiretroviral therapy

      Explanation:

      Reducing the Risk of HIV and Hepatitis B Transmission in Healthcare Workers

      Healthcare workers are at risk of occupational exposure to HIV and hepatitis B through needlestick injuries or other percutaneous and mucous membrane exposures. The average risk of HIV infection after such exposure is 0.3%, while the risk of hepatitis B transmission is higher. The risk is greatest for deep injuries, visible blood on the device, direct cannulation of blood vessels, or advanced HIV disease in the source patient.

      To reduce the risk of HIV transmission, healthcare workers should receive post-exposure prophylaxis (PEP) as soon as possible after exposure. A small study showed an 80% reduction in seroconversion with zidovudine, and current recommendations include two nucleoside inhibitors and a protease inhibitor for 1 month. Nevirapine is not recommended due to adverse reactions.

      In addition to PEP, healthcare workers should receive hepatitis B immunoglobulin within 72 hours if the source is HBeAg positive or unknown, and they have negative serology. All healthcare workers should also be offered hepatitis B immunisation if they have not been immunised or are non-immune, following baseline serology testing.

      A careful risk assessment and information provision are crucial in the management of occupational exposure to HIV and hepatitis B in healthcare workers.

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  • Question 100 - A 28-year-old man presents to his GP with complaints of joint pain and...

    Incorrect

    • A 28-year-old man presents to his GP with complaints of joint pain and swelling, feeling generally unwell. He recently returned from a hiking trip in Thailand, and one day after his return, he experienced severe watery diarrhoea and abdominal cramps that lasted for a week.

      During the examination, the patient appears unwell and fatigued. He has large effusions of the left knee and right ankle, along with tender plantar fascia bilaterally. Additionally, he has tender metatarsophalangeal joints on both feet, and a papular rash on the soles of his feet.

      Despite taking regular paracetamol and ibuprofen for the past week, the patient's symptoms have only minimally improved. What is the most appropriate next step in managing this patient, given the most likely diagnosis?

      Your Answer: Celecoxib

      Correct Answer: Oral prednisolone

      Explanation:

      Reactive arthritis doesn’t usually have an acute onset and can develop up to four weeks after the initial infection. It may have a relapsing-remitting course over several months.

      The correct treatment for this patient’s severe polyarthritis would be oral prednisolone, a systemic corticosteroid. The dosing should be based on the severity of the arthritis, with tapering to the lowest effective dose. Typical starting doses are 20-40 mg/day.

      TNF inhibitor therapy would not be appropriate in this case. However, it may be effective and safe for patients with reactive arthritis who are unresponsive to NSAID or non-biologic DMARD therapy.

      Celecoxib is not the correct choice for this patient. Since regular ibuprofen did not provide relief for a week, the next step would be oral corticosteroids. Although patients may require high doses of NSAIDs with a long half-life, such as Naproxen 500mg BD, systemic corticosteroids are more appropriate for this patient with multiple joints involved and systemic illness.

      Intra-articular injections are useful for large joint effusions, but in this case, systemic corticosteroids are more appropriate due to the patient’s multiple joint involvement and systemic illness.

      Understanding Reactive Arthritis: Symptoms and Features

      Reactive arthritis is a type of seronegative spondyloarthropathy that is associated with HLA-B27. It was previously known as Reiter’s syndrome, which was characterized by a triad of urethritis, conjunctivitis, and arthritis following a dysenteric illness during World War II. However, later studies revealed that patients could develop symptoms after a sexually transmitted infection, now referred to as sexually acquired reactive arthritis (SARA).

      This condition is defined as an arthritis that develops after an infection where the organism cannot be recovered from the joint. The symptoms typically develop within four weeks of the initial infection and last for around 4-6 months. Approximately 25% of patients experience recurrent episodes, while 10% develop chronic disease.

      The arthritis associated with reactive arthritis is usually an asymmetrical oligoarthritis of the lower limbs, and patients may also experience dactylitis. Other symptoms include urethritis, conjunctivitis (seen in 10-30% of patients), and anterior uveitis. Skin symptoms may also occur, such as circinate balanitis (painless vesicles on the coronal margin of the prepuce) and keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles).

      To remember the symptoms associated with reactive arthritis, the phrase can’t see, pee, or climb a tree is often used. It is important to note that the term Reiter’s syndrome is no longer used due to the fact that the eponym was named after a member of the Nazi party. Understanding the symptoms and features of reactive arthritis can aid in prompt diagnosis and treatment.

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  • Question 101 - A 30-year-old woman presents to your clinic after cutting her hand while preparing...

    Incorrect

    • A 30-year-old woman presents to your clinic after cutting her hand while preparing dinner. Upon examination, you note a three inch laceration on her left hand which is cleaned and sutured. She recalls receiving a tetanus booster shot approximately 10 years ago and has received a total of five tetanus vaccines throughout her life. What is the appropriate recommendation for tetanus prophylaxis?

      Your Answer: She doesn't require any further intervention

      Correct Answer: She should be given tetanus immunoglobulin

      Explanation:

      Tetanus Vaccination Not Required for Low-Risk Wound

      This woman’s wound is clean and low-risk, with a very low chance of being contaminated with tetanus bacteria. Fortunately, she has already received five doses of the tetanus vaccine in the past, which means she should not require any further vaccination. It is important to note that tetanus vaccination is crucial for individuals who have not received the vaccine or have not completed the recommended doses. However, in this case, the woman can rest assured that she is protected against tetanus and can focus on proper wound care to promote healing.

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  • Question 102 - A 39-year-old woman presents with jaundice. Her liver screen reveals the following results:

    Negative...

    Incorrect

    • A 39-year-old woman presents with jaundice. Her liver screen reveals the following results:

      Negative for Anti-HBs
      Positive for Anti-HBc
      Positive for HBs antigen
      Negative for IgM anti-HBc

      What is the hepatitis B status of this patient?

      Your Answer: Previous immunisation to hepatitis B

      Correct Answer: Chronic hepatitis B

      Explanation:

      If a person has a positive result for anti-HBc IgG, negative result for anti-HBc IgM, and negative result for anti-HBc while HBsAg is present, it indicates that the person has a chronic HBV infection. The absence of IgM anti-HBc suggests that the infection is not acute but rather long-term.

      Understanding Hepatitis B Serology

      Interpreting hepatitis B serology can be a challenging task, but it is crucial for proper diagnosis and treatment. Here are some key points to keep in mind:

      The surface antigen (HBsAg) is the first marker to appear and triggers the production of anti-HBs. If HBsAg is present for more than six months, it indicates chronic disease, while its absence suggests acute disease.

      Anti-HBs indicates immunity, either from exposure or vaccination. It is negative in chronic disease.

      Anti-HBc suggests previous or current infection. IgM anti-HBc appears during acute or recent hepatitis B infection and lasts for about six months, while IgG anti-HBc persists.

      HbeAg is a marker of infectivity and HBV replication. It results from the breakdown of core antigen from infected liver cells.

      For example, if someone has previously been immunized against hepatitis B, their anti-HBs will be positive, while all other markers will be negative. If they had hepatitis B in the past but are not carriers, their anti-HBc will be positive, and HBsAg will be negative. However, if they are now carriers, both anti-HBc and HBsAg will be positive.

      In summary, understanding hepatitis B serology requires careful interpretation of various markers and their combinations. By doing so, healthcare professionals can accurately diagnose and manage this potentially serious condition.

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  • Question 103 - A 42-year-old Bangladeshi man with a history of mitral stenosis and atrial fibrillation...

    Correct

    • A 42-year-old Bangladeshi man with a history of mitral stenosis and atrial fibrillation has been diagnosed with tuberculosis and started on anti-tuberculosis therapy. However, three weeks into the treatment, his INR has increased to 5.6. Which medication is the most likely cause of this increase?

      Your Answer: Isoniazid

      Explanation:

      When answering questions about liver enzymes, it is crucial to determine whether the question pertains to induction or inhibition. Candidates should avoid hastily providing drugs that cause induction as the answer. Inhibited liver enzymes can result in an elevated INR. Additionally, isoniazid is known to inhibit the P450 system.

      P450 Enzyme System and its Inducers and Inhibitors

      The P450 enzyme system is responsible for metabolizing many drugs in the body. Induction of this system occurs when a drug or substance causes an increase in the activity of the P450 enzymes. This process usually requires prolonged exposure to the inducing drug. On the other hand, P450 inhibitors decrease the activity of the enzymes and their effects are often seen rapidly.

      Some common inducers of the P450 system include antiepileptics like phenytoin and carbamazepine, barbiturates such as phenobarbitone, rifampicin, St John’s Wort, chronic alcohol intake, griseofulvin, and smoking. Smoking affects CYP1A2, which is the reason why smokers require more aminophylline.

      In contrast, some common inhibitors of the P450 system include antibiotics like ciprofloxacin and erythromycin, isoniazid, cimetidine, omeprazole, amiodarone, allopurinol, imidazoles such as ketoconazole and fluconazole, SSRIs like fluoxetine and sertraline, ritonavir, sodium valproate, acute alcohol intake, and quinupristin.

      It is important to be aware of the potential for drug interactions when taking medications that affect the P450 enzyme system. Patients should always inform their healthcare provider of all medications and supplements they are taking to avoid any adverse effects.

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  • Question 104 - A 55-year-old man complains of back pain, fever, and chills persisting for the...

    Incorrect

    • A 55-year-old man complains of back pain, fever, and chills persisting for the last four weeks. He recently visited a sheep farm in Cyprus two months ago. His chest x-ray and urine culture are normal. The doctor suspects Brucellosis. What test is most likely to confirm the diagnosis?

      Your Answer: Liver biopsy

      Correct Answer: Brucella serology

      Explanation:

      The Knowledge and skills guide of the 2019 RCGP Curriculum includes zoonotic diseases such as leptospirosis and brucellosis.

      Understanding Brucellosis

      Brucellosis is a disease that can be transmitted from animals to humans, and is more commonly found in the Middle East and among individuals who work with animals such as farmers, vets, and abattoir workers. The disease is caused by four major species of bacteria: B. melitensis (sheep), B. abortus (cattle), B. canis and B. suis (pigs). The incubation period for brucellosis is typically 2-6 weeks.

      Symptoms of brucellosis are nonspecific and may include fever and malaise, as well as hepatosplenomegaly and spinal tenderness. Complications of the disease can include osteomyelitis, infective endocarditis, meningoencephalitis, and orchitis. Leukopenia is also commonly seen in patients with brucellosis.

      Diagnosis of brucellosis can be done through the Rose Bengal plate test for screening, but other tests are required to confirm the diagnosis. Brucella serology is the best test for diagnosis, and blood and bone marrow cultures may be suitable in certain patients, although these tests are often negative.

      Management of brucellosis typically involves the use of doxycycline and streptomycin. It is important for individuals who work with animals to take precautions to prevent the transmission of brucellosis, such as wearing protective clothing and practicing good hygiene.

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  • Question 105 - Which pathogen is annual immunisation proven to reduce mortality and hospital admissions against...

    Incorrect

    • Which pathogen is annual immunisation proven to reduce mortality and hospital admissions against in patients aged 65 or above who are more susceptible to community acquired infections?

      Your Answer: Pneumococcus

      Correct Answer: influenza virus

      Explanation:

      The Importance of influenza Vaccination in the Elderly Population

      influenza vaccination is crucial for promoting health and preventing disease in the elderly population, especially those with underlying chronic conditions. While recommended for all individuals over 65, those with cardiorespiratory, metabolic, or neoplastic diseases are at the highest risk. Despite being cost-effective, protection rates against influenza-associated respiratory illness are lower in the elderly population. In England, the uptake for patients over 65 was 73% in 2010/2011. While vaccination doesn’t change the incidence of upper respiratory tract symptoms, it significantly reduces hospital admission and mortality rates by 72% and 87%, respectively, in community-dwelling elderly individuals. However, nursing-home residents may not experience the same efficacy due to a greater burden of chronic disease.

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  • Question 106 - Conjunctivitis has only one correct statement. What is it? ...

    Incorrect

    • Conjunctivitis has only one correct statement. What is it?

      Your Answer: It should be treated with antibiotic eye drops

      Correct Answer: Simple bacterial conjunctivitis commonly resolves without treatment

      Explanation:

      Managing Conjunctivitis in Children: Antibiotics Not Always Necessary

      As of April 2010, ophthalmia neonatorum is no longer a notifiable disease. A randomized controlled trial published in the Lancet in 2005 compared placebo with chloramphenicol drops in children with conjunctivitis and concluded that prescribing antibiotic drops for conjunctivitis in children should be stopped. Instead, children should be advised to keep the eye clean and return for review if no better after one week. The Health Professionals Alliance’s guidance on infection control in schools and other childcare settings doesn’t recommend any time away for children with conjunctivitis. Simple bacterial conjunctivitis usually lasts 10-14 days and is self-limiting. A review if no better at one week to exclude corneal involvement or other complications is recommended. Adenoviral conjunctivitis is highly contagious and often rapidly becomes bilateral.

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  • Question 107 - A 27-year-old man has been hospitalized due to multiple injuries sustained during a...

    Incorrect

    • A 27-year-old man has been hospitalized due to multiple injuries sustained during a mugging on his way back from the bar last night. The assailant bit him during the altercation, leaving deep bite marks on his hand, which appears red and swollen. You decide to administer tetanus and hepatitis B prophylaxis.

      What antibiotic do you recommend for his treatment?

      Your Answer: Doxycycline and metronidazole

      Correct Answer: Co-amoxiclav

      Explanation:

      Co-amoxiclav is the appropriate treatment for human bites, similar to animal bites. In case the patient is allergic to penicillin, doxycycline and metronidazole can be used. However, since there is no mention of any allergies, we assume that the patient has none. Waiting for the swab results is not the correct approach. Antibiotic prophylaxis is recommended for various conditions, including hand/foot/facial injuries, deep puncture wounds, wounds requiring surgical debridement, wounds involving joints/tendons/ligaments, suspected fractures, and patients who are immunosuppressed, diabetic, cirrhotic, asplenic, or elderly. Antibiotic treatment is necessary for infected bites, which is the case here as the bite appears red, swollen, and is on the hand. Cellulitis, on the other hand, is treated with flucloxacillin.

      Animal bites are a common occurrence in everyday practice, with dogs and cats being the most frequent culprits. These bites are usually caused by multiple types of bacteria, with Pasteurella multocida being the most commonly isolated organism. To manage these bites, it is important to cleanse the wound thoroughly. Puncture wounds should not be sutured unless there is a risk of cosmesis. The current recommendation is to use co-amoxiclav, but if the patient is allergic to penicillin, doxycycline and metronidazole are recommended.

      On the other hand, human bites can cause infections from a variety of bacteria, including both aerobic and anaerobic types. Common organisms include Streptococci spp., Staphylococcus aureus, Eikenella, Fusobacterium, and Prevotella. To manage these bites, co-amoxiclav is also recommended. It is important to consider the risk of viral infections such as HIV and hepatitis C when dealing with human bites.

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  • Question 108 - Which one of the following is a notifiable disease in the UK? ...

    Incorrect

    • Which one of the following is a notifiable disease in the UK?

      Your Answer: Mycoplasma pneumonia

      Correct Answer: Tuberculosis

      Explanation:

      Notifiable Diseases in the UK

      In the UK, certain diseases are considered notifiable, meaning that the Local Health Protection Team must be notified if a case is suspected or confirmed. These diseases are then reported to the Health Protection Agency on a weekly basis. Notifiable diseases include acute encephalitis, a