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  • Question 1 - A 7-year-old girl is diagnosed with Attention Deficit Hyperactivity Disorder and prescribed methylphenidate....

    Correct

    • A 7-year-old girl is diagnosed with Attention Deficit Hyperactivity Disorder and prescribed methylphenidate. What should be monitored during her treatment?

      Your Answer: Growth

      Explanation:

      In March 2018, NICE released new guidelines for identifying and managing Attention Deficit Hyperactivity Disorder (ADHD). This condition can have a significant impact on a child’s life and can continue into adulthood, making accurate diagnosis and treatment crucial. According to DSM-V, ADHD is characterized by persistent features of inattention and/or hyperactivity/impulsivity, with an element of developmental delay. Children up to the age of 16 must exhibit six of these features, while those aged 17 or over must exhibit five. ADHD has a UK prevalence of 2.4%, with a higher incidence in boys than girls, and there may be a genetic component.

      NICE recommends a holistic approach to treating ADHD that is not solely reliant on medication. After presentation, a ten-week observation period should be implemented to determine if symptoms change or resolve. If symptoms persist, referral to secondary care is necessary, typically to a paediatrician with a special interest in behavioural disorders or to the local Child and Adolescent Mental Health Service (CAMHS). A tailored plan of action should be developed, taking into account the patient’s needs and wants, as well as how their condition affects their lives.

      Drug therapy should be considered a last resort and is only available to those aged 5 years or older. Parents of children with mild/moderate symptoms can benefit from attending education and training programmes. For those who do not respond or have severe symptoms, pharmacotherapy may be considered. Methylphenidate is the first-line treatment for children and should be given on a six-week trial basis. It is a CNS stimulant that primarily acts as a dopamine/norepinephrine reuptake inhibitor. Side effects include abdominal pain, nausea, and dyspepsia. Weight and height should be monitored every six months in children. If there is an inadequate response, lisdexamfetamine should be considered, followed by dexamfetamine if necessary. In adults, methylphenidate or lisdexamfetamine are the first-line options, with switching between drugs if no benefit is seen after a trial of the other. All of these drugs are potentially cardiotoxic, so a baseline ECG should be performed before starting treatment, and referral to a cardiologist should be made if there is any significant past medical history or family history, or any doubt or ambiguity.

      As with most psychiatric conditions, a thorough history and clinical examination are essential, particularly given the overlap of ADHD with many other psychiatric and

    • This question is part of the following fields:

      • Paediatrics
      18.6
      Seconds
  • Question 2 - You review a 47-year-old man who is postoperative following a laparotomy. He complains...

    Incorrect

    • You review a 47-year-old man who is postoperative following a laparotomy. He complains of a lump in the middle of his abdomen. On examination, you note a mass arising from the site of surgical incision, which is reducible and reproducible when the patient coughs.
      Which of the following is a risk factor for the development of an incisional hernia?

      Your Answer: Sedentary lifestyle

      Correct Answer: Wound infection

      Explanation:

      Understanding Risk Factors for Incisional Hernia Development

      An infected wound can increase the risk of developing an incisional hernia due to poor wound healing and susceptibility to abdominal content herniation. Increasing age is also a risk factor, likely due to delayed wound healing and reduced collagen synthesis. However, being tall and thin does not increase the risk, while obesity can increase abdominal pressure and lead to herniation. A sedentary lifestyle does not appear to be associated with incisional hernias, but smoking and nutritional deficiencies can increase the risk. Post-operative vomiting, not nausea alone, can cause episodic increases in abdominal pressure and increase the risk of herniation. Understanding these risk factors can help prevent the development of incisional hernias.

    • This question is part of the following fields:

      • Surgery
      39.3
      Seconds
  • Question 3 - A 60-year-old man with a long history of diabetes arrives at the emergency...

    Correct

    • A 60-year-old man with a long history of diabetes arrives at the emergency department complaining of excruciating pain around his 'rear end', inability to defecate due to the pain, and spiking temperatures. During the examination, the patient is unable to tolerate an anal examination, but the anus appears red and inflamed. What is the most probable cause of this man's symptoms?

      Your Answer: Perianal abscess

      Explanation:

      Understanding Perianal Abscesses

      A perianal abscess is a type of anorectal abscess that occurs when pus collects within the subcutaneous tissue surrounding the anal sphincter. It is the most common form of anorectal abscess, accounting for around 60% of cases, and is more prevalent in men with an average age of 40 years. Symptoms include pain around the anus, hardened tissue in the anal region, and pus-like discharge from the anus. In some cases, patients may also experience systemic infection.

      Perianal abscesses are typically caused by gut flora such as E. coli, although those caused by Staph. aureus are more likely to be a skin infection. Diagnosis can be made through inspection of the anus and digital rectal examination, with further investigations such as colonoscopy and blood tests used to determine underlying causes. Imaging such as MRI and transperineal ultrasound may also be used in complicated cases.

      Treatment for perianal abscesses involves surgical incision and drainage under local anaesthetic, with the wound either packed or left open to heal over several weeks. Antibiotics may be used in cases of systemic infection, but are not typically used for wound healing. It is important to note that perianal abscesses are just one type of anorectal abscess, with others classified by the layers and planes they occupy, such as ischiorectal, supralevator, intersphincteric, and horseshoe abscesses.

      Overall, understanding perianal abscesses and their causes, symptoms, and treatment options is important for proper diagnosis and management of this common condition.

    • This question is part of the following fields:

      • Surgery
      59.7
      Seconds
  • Question 4 - A 23-year-old man comes to your clinic complaining of chronic back pain. He...

    Incorrect

    • A 23-year-old man comes to your clinic complaining of chronic back pain. He denies any history of trauma but reports experiencing anterior uveitis within the past year. You suspect that he may have ankylosing spondylitis (AS) and decide to perform Schober's test, which yields a positive result. What is a commonly utilized diagnostic test that could provide further evidence to support this diagnosis?

      Your Answer: Human leukocyte antigen B27

      Correct Answer: Pelvic radiograph

      Explanation:

      The most supportive diagnostic tool for ankylosing spondylitis is a pelvic X-ray that can reveal sacroiliitis. While a chest X-ray may show bamboo spine, it is a late sign and not likely to be present in the patient at this stage. A full-blood count is not useful for diagnosis. Although a CT scan can provide detailed imaging, it is not commonly used due to the high radiation exposure. HLA-B27 testing is not typically performed in clinical practice as it only indicates a predisposition to AS and is not specific to the condition, often being positive in healthy individuals.

      Investigating and Managing Ankylosing Spondylitis

      Ankylosing spondylitis is a type of spondyloarthropathy that is associated with HLA-B27. It is more commonly seen in males aged 20-30 years old. Inflammatory markers such as ESR and CRP are usually elevated, but normal levels do not necessarily rule out ankylosing spondylitis. HLA-B27 is not a reliable diagnostic tool as it can also be positive in normal individuals. The most effective way to diagnose ankylosing spondylitis is through a plain x-ray of the sacroiliac joints. However, if the x-ray is negative but suspicion for AS remains high, an MRI can be obtained to confirm the diagnosis.

      Management of ankylosing spondylitis involves regular exercise, such as swimming, and the use of NSAIDs as the first-line treatment. Physiotherapy can also be helpful. Disease-modifying drugs used for rheumatoid arthritis, such as sulphasalazine, are only useful if there is peripheral joint involvement. Anti-TNF therapy, such as etanercept and adalimumab, should be given to patients with persistently high disease activity despite conventional treatments, according to the 2010 EULAR guidelines. Ongoing research is being conducted to determine whether anti-TNF therapies should be used earlier in the course of the disease. Spirometry may show a restrictive defect due to a combination of pulmonary fibrosis, kyphosis, and ankylosis of the costovertebral joints.

    • This question is part of the following fields:

      • Musculoskeletal
      34.8
      Seconds
  • Question 5 - As an F2 in psychiatry, you come across the notes of a 27-year-old...

    Incorrect

    • As an F2 in psychiatry, you come across the notes of a 27-year-old man who is noted to prefer solitude, has never been in a romantic relationship, and has no desire for one. He also displays minimal interest in engaging in sexual activities with others. Despite performing well at work, he places little importance on feedback from his colleagues. Based on this information, which personality disorder is most likely present in this individual?

      Your Answer: Antisocial

      Correct Answer: Schizoid

      Explanation:

      Schizoid personality disorder is characterized by a preference for solitude, a lack of interest in close relationships, and a low libido. It is important to note that while asexuality is recognized as part of the LGBTQ+ spectrum, it is not included in the diagnostic criteria for this disorder. The DSM-5 and ICD-10 both list a lack of desire for close relationships, a preference for solitary activities, and a limited capacity for expressing emotions as key features of schizoid personality disorder. Individuals with this disorder may also appear indifferent to praise or criticism, lack close friends or confidants, and exhibit emotional detachment or flattened affectivity. In contrast, borderline personality disorder is characterized by emotional instability in relationships, including sudden mood swings, rages, self-harming behaviors, and intense jealousy. Dependent personality disorder involves a reliance on others for reassurance and decision-making.

      Personality disorders are a set of personality traits that are maladaptive and interfere with normal functioning in life. It is estimated that around 1 in 20 people have a personality disorder, which are typically categorized into three clusters: Cluster A, which includes Odd or Eccentric disorders such as Paranoid, Schizoid, and Schizotypal; Cluster B, which includes Dramatic, Emotional, or Erratic disorders such as Antisocial, Borderline (Emotionally Unstable), Histrionic, and Narcissistic; and Cluster C, which includes Anxious and Fearful disorders such as Obsessive-Compulsive, Avoidant, and Dependent.

      Paranoid individuals exhibit hypersensitivity and an unforgiving attitude when insulted, a reluctance to confide in others, and a preoccupation with conspiratorial beliefs and hidden meanings. Schizoid individuals show indifference to praise and criticism, a preference for solitary activities, and emotional coldness. Schizotypal individuals exhibit odd beliefs and magical thinking, unusual perceptual disturbances, and inappropriate affect. Antisocial individuals fail to conform to social norms, deceive others, and exhibit impulsiveness, irritability, and aggressiveness. Borderline individuals exhibit unstable interpersonal relationships, impulsivity, and affective instability. Histrionic individuals exhibit inappropriate sexual seductiveness, a need to be the center of attention, and self-dramatization. Narcissistic individuals exhibit a grandiose sense of self-importance, lack of empathy, and excessive need for admiration. Obsessive-compulsive individuals are occupied with details, rules, and organization to the point of hampering completion of tasks. Avoidant individuals avoid interpersonal contact due to fears of criticism or rejection, while dependent individuals have difficulty making decisions without excessive reassurance from others.

      Personality disorders are difficult to treat, but a number of approaches have been shown to help patients, including psychological therapies such as dialectical behavior therapy and treatment of any coexisting psychiatric conditions.

    • This question is part of the following fields:

      • Psychiatry
      34.7
      Seconds
  • Question 6 - A 19-year-old man is suffering from acne vulgaris, with inflamed, open comedones on...

    Correct

    • A 19-year-old man is suffering from acne vulgaris, with inflamed, open comedones on his face, chest and neck. What micro-organism degrades sebum to produce inflammatory fatty acids in such cases?

      Your Answer: Propionibacterium acnes

      Explanation:

      Common Skin Infections and their Causes

      Acne vulgaris is a prevalent skin condition among adolescents and young adults, particularly men. Hormonal changes stimulate the sebaceous glands to produce more sebum, leading to the formation of open comedones, which are inflamed follicles with a central dark plug of keratin. Propionibacterium acnes is responsible for breaking down complex lipids in sebum into free fatty acids, which cause inflammation of hair follicles. Treatment with antibiotics and 13-cis-retinoic acid can alleviate the symptoms of acne vulgaris.

      Molluscum contagiosum is caused by the poxvirus, which leads to epidermal hyperplasia and ellipsoid molluscum bodies in the stratum corneum.

      Impetigo is a bacterial infection of the skin caused by Staphylococcus aureus. It is highly contagious and often affects healthy children. The infection starts as a reddened macule and progresses to multiple serum-filled pustules that rupture and form a yellowish crust.

      Papillomavirus causes warts or verrucae, which are common on the hands. They appear as several papules with a rough, irregular surface.

      Tinea versicolor is caused by Malassezia furfur, a fungus that causes superficial fungal infections in the skin. Other forms of tinea are also caused by fungal infections.

    • This question is part of the following fields:

      • Dermatology
      7.6
      Seconds
  • Question 7 - A 21-year-old man experiences sudden right-sided chest pain while exercising. The pain persists...

    Incorrect

    • A 21-year-old man experiences sudden right-sided chest pain while exercising. The pain persists in the Emergency Department, but he is not short of breath. There is no past medical history of note. Observations are recorded:
      temperature 36.6 °C
      heart rate (HR) 90 bpm
      blood pressure (BP) 115/80 mmHg
      respiratory rate (RR) 18 breaths/minute
      oxygen saturation (SaO2) 99%.
      A chest X-ray reveals a 1.5 cm sliver of air in the pleural space of the right lung.
      Which of the following is the most appropriate course of action?

      Your Answer: Aspirate the air with a needle and syringe

      Correct Answer: Consider prescribing analgesia and discharge home with information and advice

      Explanation:

      Management Options for Primary Pneumothorax

      Primary pneumothorax is a condition where air accumulates in the pleural space, causing the lung to collapse. The management of primary pneumothorax depends on the severity of the condition and the presence of symptoms. Here are some management options for primary pneumothorax:

      Prescribe analgesia and discharge home with information and advice: This option can be considered if the patient is not breathless and has only a small defect. The patient can be discharged with pain relief medication and given information and advice on how to manage the condition at home.

      Admit for a trial of nebulised salbutamol and observation: This option is not indicated for a patient with primary pneumothorax, as a trial of salbutamol is not effective in treating this condition.

      Aspirate the air with a needle and syringe: This option should only be attempted if the patient has a rim of air of >2 cm on the chest X-ray or is breathless. Aspiration can be attempted twice at a maximum, after which a chest drain should be inserted.

      Insert a chest drain: This option should be done if the second attempt of aspiration is unsuccessful. Once air has stopped leaking, the drain should be left in for a further 24 hours prior to removal and discharge.

      Insert a 16G cannula into the second intercostal space: This option is used for tension pneumothoraces and is not indicated for primary pneumothorax.

      In conclusion, the management of primary pneumothorax depends on the severity of the condition and the presence of symptoms. It is important to choose the appropriate management option to ensure the best outcome for the patient.

    • This question is part of the following fields:

      • Respiratory
      51.8
      Seconds
  • Question 8 - A 2-year-old girl presents with bilious vomiting, abdominal distension and has been constipated...

    Incorrect

    • A 2-year-old girl presents with bilious vomiting, abdominal distension and has been constipated since birth and did not pass meconium until she was 3 days old. Height and weight are at the fifth percentile. On examination, the abdomen is distended and a PR examination causes stool ejection. What is the probable diagnosis?

      Your Answer: Pyloric stenosis

      Correct Answer: Hirschsprung disease

      Explanation:

      Hirschsprung disease is a bowel disease that is present at birth and is more common in boys than girls, occurring five times more frequently. The typical symptoms include vomiting of bile, swelling of the abdomen, difficulty passing stool, and failure to pass meconium within the first two days of life. However, in some cases, the disease may not become apparent until later in childhood or adolescence. A colon biopsy is used to diagnose the condition, which reveals a segment of bowel that lacks nerve cells.

      Understanding Hirschsprung’s Disease

      Hirschsprung’s disease is a rare condition that affects 1 in 5,000 births. It is caused by a developmental failure of the parasympathetic Auerbach and Meissner plexuses, resulting in an aganglionic segment of bowel. This leads to uncoordinated peristalsis and functional obstruction, which can present as constipation and abdominal distension in older children or failure to pass meconium in the neonatal period.

      Hirschsprung’s disease is three times more common in males and is associated with Down’s syndrome. Diagnosis is made through a rectal biopsy, which is considered the gold standard. Treatment involves initial rectal washouts or bowel irrigation, followed by surgery to remove the affected segment of the colon.

      In summary, Hirschsprung’s disease is a rare condition that can cause significant gastrointestinal symptoms. It is important to consider this condition as a differential diagnosis in childhood constipation, especially in male patients or those with Down’s syndrome. Early diagnosis and treatment can improve outcomes and prevent complications.

    • This question is part of the following fields:

      • Paediatrics
      75.4
      Seconds
  • Question 9 - A 24-year-old man, who is a known intravenous drug user, presented with progressive...

    Incorrect

    • A 24-year-old man, who is a known intravenous drug user, presented with progressive dyspnoea. On examination, his respiratory rate was 31 breaths per minute and his chest X-ray showed diffuse infiltrates in a bat-wing pattern. However, chest auscultation was normal. While staying in hospital, he developed sudden severe dyspnoea, and an emergency chest X-ray showed right-sided pneumothorax.
      What is the underlying disease of this patient?

      Your Answer: Pulmonary histoplasmosis

      Correct Answer: Pneumocystis jirovecii infection

      Explanation:

      Differential Diagnosis for a Young Injection Drug User with Dyspnea and Chest X-ray Findings

      A young injection drug user presenting with gradually progressive dyspnea and a typical chest X-ray finding is likely to have Pneumocystis jirovecii infection, an opportunistic fungal infection that predominantly affects the lungs. This infection is often seen in individuals with underlying human immunodeficiency virus (HIV) infection-related immunosuppression. Other opportunistic infections should also be ruled out. Pneumocystis typically resides in the alveoli of the lungs, resulting in extensive exudation and formation of hyaline membrane. Lung biopsy shows foamy vacuolated exudates. Extrapulmonary sites involved include the thyroid, lymph nodes, liver, and bone marrow.

      Other potential diagnoses, such as chronic obstructive pulmonary disease (COPD), cystic fibrosis, pneumoconiosis, and pulmonary histoplasmosis, are less likely. COPD and pneumoconiosis are typically seen in individuals with a history of smoking or occupational exposure to dust, respectively. Cystic fibrosis would present with a productive cough and possible hemoptysis, while pulmonary histoplasmosis is not commonly found in Europe.

    • This question is part of the following fields:

      • Respiratory
      29.9
      Seconds
  • Question 10 - A 35-year-old woman comes to the obstetric clinic during her 28th week of...

    Incorrect

    • A 35-year-old woman comes to the obstetric clinic during her 28th week of pregnancy. She has been diagnosed with gestational diabetes and has been taking metformin for the past two weeks. However, her blood glucose levels are still elevated despite following a strict diet and taking the maximum dose of metformin. What is the next best course of action to manage her blood glucose levels?

      Your Answer: Add on an sodium-glucose co-transporter-2 (SGLT-2) antagonist and review in one week

      Correct Answer: Add on insulin therapy

      Explanation:

      When a woman has gestational diabetes, it is important to control her blood glucose levels to prevent complications such as premature birth, stillbirth, and macrosomia. If diet and exercise changes along with metformin do not meet blood glucose targets, insulin therapy should be added, according to NICE guidelines. Sulfonylureas are not recommended for gestational diabetes as they are less effective than the metformin and insulin combination and have been shown to be teratogenic in animals. Metformin should not be stopped as it increases insulin sensitivity, which is lacking during pregnancy. SGLT-2 antagonists are also not recommended due to their teratogenic effects in animals. Continuing metformin alone for two weeks despite high blood glucose levels increases the risk of complications, so insulin therapy should be added at this stage.

      Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.

    • This question is part of the following fields:

      • Obstetrics
      67.2
      Seconds
  • Question 11 - A 28-year-old woman presents to the Emergency Department with sharp, left lower abdominal...

    Correct

    • A 28-year-old woman presents to the Emergency Department with sharp, left lower abdominal pain, which has been intermittently present for several days. It does not radiate anywhere. It is not associated with any gastrointestinal upset. Her last menstrual period was 10 weeks ago. She is sexually active although admits to not using contraception all the time. Her past medical history includes multiple chlamydial infections. On examination, the abdomen is tender. An internal examination is also performed; adnexal tenderness is demonstrated. A urine pregnancy test is positive.
      What investigation is recommended as the first choice for the likely diagnosis?

      Your Answer: Transvaginal ultrasound

      Explanation:

      The most appropriate investigation for a suspected ectopic pregnancy is a transvaginal ultrasound. In this case, the patient’s symptoms and examination findings suggest an ectopic pregnancy, making transvaginal ultrasound the investigation of choice. Transabdominal ultrasound is less sensitive and therefore not ideal. NAAT, which is used to detect chlamydia, is not relevant in this case as the patient’s history suggests a higher likelihood of ectopic pregnancy rather than infection. Laparoscopy, which is used to diagnose endometriosis, is not indicated based on the clinical presentation.

      Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.

      There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingostomy, depending on the patient’s risk factors for infertility.

      Salpingectomy is the first-line treatment for women without other risk factors for infertility, while salpingostomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingostomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.

    • This question is part of the following fields:

      • Gynaecology
      34.6
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  • Question 12 - You are a healthcare professional working in the emergency department during the winter...

    Correct

    • You are a healthcare professional working in the emergency department during the winter season. A patient, who is in his 50s, is brought in by air ambulance after being involved in a car accident. The trauma team assesses him and conducts the necessary tests. The patient is found to have a fracture in his right radius and small frontal contusions on his CT scan. Both injuries are treated conservatively, and he is admitted to the observation ward. However, after a few days of observation, the patient remains confused, and his family reports that he has not spoken a coherent sentence since his arrival. What investigation is the most appropriate given the possibility of diffuse axonal injury?

      Your Answer: MRI brain

      Explanation:

      Diffuse axonal injury can be diagnosed most accurately through MRI scans, which are highly sensitive. To monitor the progression of contusions, repeat CT scans can be helpful. Electro-encephalograms are recommended for patients with epilepsy, while CT angiograms are useful in identifying the cause of subarachnoid hemorrhage. For detecting tumors or potential abscesses, CT scans with contrast are a valuable tool.

      Types of Traumatic Brain Injury

      Traumatic brain injury can result in primary and secondary brain injury. Primary brain injury can be focal or diffuse. Diffuse axonal injury occurs due to mechanical shearing, which causes disruption and tearing of axons. intracranial haematomas can be extradural, subdural, or intracerebral, while contusions may occur adjacent to or contralateral to the side of impact. Secondary brain injury occurs when cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury. The normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia. The Cushings reflex often occurs late and is usually a pre-terminal event.

      Extradural haematoma is bleeding into the space between the dura mater and the skull. It often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of epidural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Subdural haematoma is bleeding into the outermost meningeal layer. It most commonly occurs around the frontal and parietal lobes. Risk factors include old age, alcoholism, and anticoagulation. Subarachnoid haemorrhage classically causes a sudden occipital headache. It usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury. Intracerebral haematoma is a collection of blood within the substance of the brain. Causes/risk factors include hypertension, vascular lesion, cerebral amyloid angiopathy, trauma, brain tumour, or infarct. Patients will present similarly to an ischaemic stroke or with a decrease in consciousness. CT imaging will show a hyperdensity within the substance of the brain. Treatment is often conservative under the care of stroke physicians, but large clots in patients with impaired consciousness may warrant surgical evacuation.

    • This question is part of the following fields:

      • Surgery
      42.3
      Seconds
  • Question 13 - At what site does rheumatoid arthritis typically initiate inflammation? ...

    Correct

    • At what site does rheumatoid arthritis typically initiate inflammation?

      Your Answer: Synovium

      Explanation:

      Rheumatoid Arthritis

      Rheumatoid arthritis (RA) is a long-term inflammatory condition that affects the joints and surrounding tissues. The exact cause of RA is unknown, but it is believed to be an autoimmune disorder where the body’s immune system mistakenly attacks its own tissues. The disease typically affects multiple joints, causing pain, stiffness, and swelling. Over time, the condition can progress and lead to joint deformity and limited mobility. This chronic condition can significantly impact a person’s quality of life, making it important to seek early diagnosis and treatment.

    • This question is part of the following fields:

      • Clinical Sciences
      128.2
      Seconds
  • Question 14 - A 27-year-old Afro-Caribbean female patient complains of fatigue, fever, and a rash that...

    Correct

    • A 27-year-old Afro-Caribbean female patient complains of fatigue, fever, and a rash that has persisted for 3 months. During the examination, the doctor observes a rash that does not affect the nasolabial folds and cold extremities. What is the most precise diagnostic test for this patient's probable condition?

      Your Answer: Anti-double stranded DNA

      Explanation:

      A certain percentage of individuals diagnosed with SLE exhibit positivity for rheumatoid factor.

      Systemic lupus erythematosus (SLE) can be investigated through various tests, including antibody tests. ANA testing is highly sensitive, making it useful for ruling out SLE, but it has low specificity. About 99% of SLE patients are ANA positive. Rheumatoid factor testing is positive in 20% of SLE patients. Anti-dsDNA testing is highly specific (>99%), but less sensitive (70%). Anti-Smith testing is also highly specific (>99%), but only 30% of SLE patients test positive. Other antibody tests include anti-U1 RNP, SS-A (anti-Ro), and SS-B (anti-La).

      Monitoring of SLE can be done through various markers, including inflammatory markers such as ESR. During active disease, CRP levels may be normal, but a raised CRP may indicate an underlying infection. Complement levels (C3, C4) are low during active disease due to the formation of complexes that lead to the consumption of complement. Anti-dsDNA titres can also be used for disease monitoring, but it is important to note that they are not present in all SLE patients. Proper monitoring of SLE is crucial for effective management of the disease.

    • This question is part of the following fields:

      • Musculoskeletal
      22.2
      Seconds
  • Question 15 - A 6-year-old boy is brought to the Emergency department by his mother who...

    Correct

    • A 6-year-old boy is brought to the Emergency department by his mother who reports that he has put a small bead into his ear. Upon examination, you confirm the presence of a plastic bead lodged deep in the external canal of his left ear.

      What is the best course of action in this situation?

      Your Answer: Refer the patient for review in ENT clinic

      Explanation:

      Ear foreign bodies are common and can be removed by skilled ENT staff using appropriate equipment. If unsuccessful, a general anaesthetic may be required. In cases of infection or trauma, referral as an emergency is necessary. Antibiotics are only needed if there is evidence of infection. Foreign bodies should not be left in the ear to prevent infection and ensure no associated injuries.

    • This question is part of the following fields:

      • Emergency Medicine
      22.7
      Seconds
  • Question 16 - A 42-year-old female with a lengthy history of schizophrenia has been admitted to...

    Correct

    • A 42-year-old female with a lengthy history of schizophrenia has been admitted to a psychiatric inpatient facility due to a worsening of her psychosis caused by non-adherence to medication. During an interview with the patient, the psychiatrist observes that while the patient's speech is mostly comprehensible, she occasionally employs words like flibbertigibbet and snollygoster that appear to hold significance only for the patient.

      What is the most appropriate term to describe the patient's speech abnormality?

      Your Answer: Neologism

      Explanation:

      Language Disturbances in Mental Health

      Neologism is the term used to describe the creation of new words. This phenomenon can occur in individuals with schizophrenia or brain injury. Clanging, on the other hand, is the use of rhyming words in speech. Pressured speech is characterized by rapid speech that is difficult to interrupt and is often seen in individuals experiencing mania or hypomania. Circumstantiality refers to speech that may wander from the topic for periods of time before finally returning to answer the question that was asked. Lastly, word salad is a type of speech that is completely disorganized and not understandable, which may occur in individuals who have suffered a stroke affecting Wernicke’s area.

      In summary, language disturbances are common in individuals with mental health conditions. These disturbances can range from the creation of new words to completely disorganized speech. these language disturbances can aid in the diagnosis and treatment of mental health conditions.

    • This question is part of the following fields:

      • Psychiatry
      31.9
      Seconds
  • Question 17 - A new medication is being tested on healthy participants. It is only distributed...

    Correct

    • A new medication is being tested on healthy participants. It is only distributed in the vascular space and has limited hepatic metabolism. At 10:00 am, an intramuscular injection of the medication is administered, and a peak plasma concentration is achieved by 11:00 am. The drug concentrations in the blood plasma at different time points are provided below:

      Time Drug concentration
      11:00 70 mg/L
      13:00 50 mg/L
      15:00 30 mg/L
      17:00 10 mg/L
      19:00 0.1 mg/L

      What conclusion can be drawn about the clearance of this medication?

      Your Answer: The drug is eliminated by zero order kinetics

      Explanation:

      Metabolism, Excretion, and Clearance of Drugs

      Metabolism and excretion play a crucial role in removing active drugs from the body. Metabolism converts drugs into inactive metabolites, while excretion eliminates drugs or their metabolites from the body. Renal excretion is the most common method of drug elimination, but some drugs may also be excreted through bile or feces.

      Clearance refers to the rate at which active drugs are removed from the circulation. It involves both renal excretion and hepatic metabolism, although the latter is often difficult to measure. Therefore, clearance is typically used to measure the renal excretion of a drug.

      Most drugs follow first order kinetics during clearance, meaning they are cleared at a constant rate regardless of their concentration in the blood. However, some drugs may be eliminated through zero order kinetics, where the drug is cleared at a constant rate regardless of its concentration. In this case, a true half-life cannot be calculated, and the decrease in drug concentration is primarily due to renal excretion. the metabolism, excretion, and clearance of drugs is essential for determining the appropriate dosages and avoiding potential adverse effects.

    • This question is part of the following fields:

      • Pharmacology
      63.2
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  • Question 18 - A 25-year-old female presents to her GP after testing positive on a urine...

    Correct

    • A 25-year-old female presents to her GP after testing positive on a urine pregnancy test, suspecting she is 4-5 weeks pregnant. She expresses concern about the possibility of having an ectopic pregnancy, having recently heard about a friend's experience. Her medical records indicate that she had an IUS removed 8 months ago and was treated for Chlamydia infection 5 years ago. During a gynaecology appointment 2 months ago, a cervical ectropion was identified after a 3 cm simple ovarian cyst was detected on ultrasound. The patient also admits to excessive drinking at a party two nights ago, having previously consumed a bottle of wine per week. Which aspect of this patient's medical history could increase her risk?

      Your Answer: Previous Chlamydia infection

      Explanation:

      Pelvic inflammatory disease can raise the likelihood of an ectopic pregnancy occurring.

      If a patient has a history of Chlamydia, it may have caused pelvic inflammatory disease before being diagnosed. Chlamydia can cause scarring of the fallopian tubes, subfertility, and an increased risk of ectopic pregnancy. Any condition that slows the egg’s movement to the uterus can lead to a higher risk of ectopic pregnancy.

      While drinking excessively during pregnancy is not recommended due to the risk of neural tube defects and foetal alcohol syndrome, it is not linked to ectopic pregnancy. However, smoking is believed to increase the risk of ectopic pregnancy, highlighting the importance of asking about social history when advising patients who want to conceive.

      A history of cervical ectropion is not a risk factor for ectopic pregnancy, but it can make a patient more prone to bleeding during pregnancy.

      The previous use of an IUS will not increase the risk of an ectopic pregnancy. However, conceiving while an IUS is in place will raise the risk of this happening. This is due to the effect of slowing the ovum’s transit to the uterus.

      A simple ovarian cyst will not increase the risk of an ectopic pregnancy. Large ovarian cysts can cause ovarian torsion, but a 3 cm cyst is not a cause for concern, and the patient does not have any signs or symptoms of ovarian torsion or ectopic pregnancy.

      Understanding Ectopic Pregnancy: Incidence and Risk Factors

      Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, usually in the fallopian tubes. This condition is a serious medical emergency that requires immediate attention. According to epidemiological studies, ectopic pregnancy occurs in approximately 0.5% of all pregnancies.

      Several risk factors can increase the likelihood of ectopic pregnancy. These include damage to the fallopian tubes due to pelvic inflammatory disease or surgery, a history of previous ectopic pregnancy, endometriosis, the use of intrauterine contraceptive devices (IUCDs), and the progesterone-only pill. In vitro fertilization (IVF) also increases the risk of ectopic pregnancy, with approximately 3% of IVF pregnancies resulting in ectopic implantation.

      It is important to note that any factor that slows down the passage of the fertilized egg to the uterus can increase the risk of ectopic pregnancy. Early detection and prompt treatment are crucial in managing this condition and preventing serious complications.

    • This question is part of the following fields:

      • Gynaecology
      51
      Seconds
  • Question 19 - A 25-year-old female arrives at the emergency department after overdosing on a substance....

    Incorrect

    • A 25-year-old female arrives at the emergency department after overdosing on a substance. She reports experiencing tinnitus and displays signs of anxiety and sweating. Your task is to conduct an arterial blood gas (ABG) test. What are the probable ABG findings?

      Your Answer: Metabolic acidosis

      Correct Answer: Respiratory alkalosis followed by metabolic acidosis

      Explanation:

      Based on the symptoms of tinnitus, anxiety, and diaphoresis, it is probable that the patient has overdosed on salicylates. Salicylate overdoses usually manifest with respiratory alkalosis at first, caused by hyperventilation, and then metabolic acidosis due to the buildup of lactic acid. Therefore, although options 1 and 3 are feasible, option 4 is the most probable.

      Salicylate overdose can result in a combination of respiratory alkalosis and metabolic acidosis. The initial effect of salicylates is to stimulate the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the overdose progresses, the direct acid effects of salicylates, combined with acute renal failure, can cause metabolic acidosis. In children, metabolic acidosis tends to be more prominent. Other symptoms of salicylate overdose include tinnitus, lethargy, sweating, pyrexia, nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.

      The treatment for salicylate overdose involves general measures such as airway, breathing, and circulation support, as well as administering activated charcoal. Urinary alkalinization with intravenous sodium bicarbonate can help eliminate aspirin in the urine. In severe cases, hemodialysis may be necessary. Indications for hemodialysis include a serum concentration of salicylates greater than 700 mg/L, metabolic acidosis that is resistant to treatment, acute renal failure, pulmonary edema, seizures, and coma.

      It is important to note that salicylates can cause the uncoupling of oxidative phosphorylation, which leads to decreased adenosine triphosphate production, increased oxygen consumption, and increased carbon dioxide and heat production. Therefore, prompt and appropriate treatment is crucial in managing salicylate overdose.

    • This question is part of the following fields:

      • Pharmacology
      51.1
      Seconds
  • Question 20 - A 40-year-old woman presents to your clinic with complaints of difficulty reading, which...

    Correct

    • A 40-year-old woman presents to your clinic with complaints of difficulty reading, which she has noticed over the past two weeks. She has never worn glasses and is not taking any medications.

      Upon examination, her pupils are of normal size but react sluggishly to light. Both optic discs appear sharp, without signs of haemorrhages or exudates. However, her visual acuity is significantly impaired and remains so even when using a pinhole card. Additionally, she exhibits five-beat nystagmus and double vision when looking to the left.

      What is the most likely diagnosis for this patient?

      Your Answer: Multiple sclerosis

      Explanation:

      Possible Diagnosis of Multiple Sclerosis in a Young Woman

      This young woman shows signs of retrobulbar neuritis, which is characterized by inflammation of the optic nerve behind the eye. Additionally, she exhibits some cerebellar features such as nystagmus, which is an involuntary eye movement. These symptoms suggest a possible diagnosis of Multiple sclerosis (MS), a chronic autoimmune disease that affects the central nervous system.

      Further diagnostic tests can support this diagnosis. Visual evoked responses can measure the electrical activity in the brain in response to visual stimuli, which can be abnormal in MS. Magnetic resonance imaging (MRI) can reveal demyelinating plaques, or areas of damage to the protective covering of nerve fibers in the brain and spinal cord. Finally, oligoclonal bands can be detected in the cerebrospinal fluid (CSF) of MS patients, indicating an immune response in the central nervous system.

      In summary, this young woman’s symptoms and diagnostic tests suggest a possible diagnosis of MS. Further evaluation and treatment by a healthcare professional are necessary to confirm this diagnosis and manage her symptoms.

    • This question is part of the following fields:

      • Neurology
      90.8
      Seconds
  • Question 21 - A three-year-old child is admitted to the hospital with a high fever of...

    Correct

    • A three-year-old child is admitted to the hospital with a high fever of 39ºC that has persisted for the past five days. The parents are worried as they have noticed redness in the child's eyes, swelling in the neck, and a new rash.

      During the examination, the child is found to have a widespread maculopapular rash and bilateral conjunctivitis. Additionally, there is unilateral cervical lymphadenopathy, cracked and erythematosus lips, and a strawberry tongue.

      What is the initial treatment that should be given to this three-year-old child?

      Your Answer: Aspirin

      Explanation:

      Kawasaki disease is a systemic vasculitis that typically affects children under the age of 5. Symptoms include a fever lasting over 5 days, bilateral non-purulent conjunctivitis, a rash, mucosal erythema with a strawberry tongue, and unilateral cervical lymphadenopathy. In some cases, swelling of the hands and feet can occur, followed by desquamation in the second week. If left untreated, up to one-quarter of patients can develop coronary aneurysms. The main goal of treatment is to reduce the risk of cardiac complications. In the UK, the standard treatment is intravenous immunoglobulin and high dose aspirin, despite the fact that aspirin is usually contraindicated in children. Benzylpenicillin is not indicated in the treatment of Kawasaki disease. Conservative management is also not appropriate, as specific treatment is required to reduce inflammation and prevent the risk of coronary complications. Corticosteroids may be used as a second-line treatment if the patient does not respond to intravenous immunoglobulins.

      Understanding Kawasaki Disease

      Kawasaki disease is a rare type of vasculitis that primarily affects children. It is important to identify this disease early on as it can lead to serious complications, such as coronary artery aneurysms. The disease is characterized by a high-grade fever that lasts for more than five days and is resistant to antipyretics. Other symptoms include conjunctival injection, bright red, cracked lips, strawberry tongue, cervical lymphadenopathy, and red palms and soles that later peel.

      Diagnosis of Kawasaki disease is based on clinical presentation as there is no specific diagnostic test available. Management of the disease involves high-dose aspirin, which is one of the few indications for aspirin use in children. Intravenous immunoglobulin is also used as a treatment option. Echocardiogram is the initial screening test for coronary artery aneurysms, rather than angiography.

      Complications of Kawasaki disease can be serious, with coronary artery aneurysm being the most common. It is important to recognize the symptoms of Kawasaki disease early on and seek medical attention promptly to prevent potential complications.

    • This question is part of the following fields:

      • Paediatrics
      847.7
      Seconds
  • Question 22 - A 29-year-old primiparous woman presented to Labour Ward triage at 34+1/40 with upper...

    Correct

    • A 29-year-old primiparous woman presented to Labour Ward triage at 34+1/40 with upper back/chest pain and a headache. The pregnancy had been uncomplicated up to this point, with only some lower back pain over the past 2 weeks.
      Obs: blood pressure 151/102, respiratory rate 18, sats 100% room air, heart rate 60 bpm, afebrile. On examination, she appeared well – PERL. Heart sounds were normal, chest was clear, and there was no shortness of breath (SOB). Her abdomen and uterus were soft and non-tender (SNT), and her calves were also SNT. Reflexes were normal. A urine dip showed nitrate +, leukocytes +, protein 1+. Electrocardiography (ECG) and cardiotocography (CTG) were both normal. Blood tests were taken, and results were pending.
      Considering the likely diagnosis, what would be your first step in management?

      Your Answer: Start po labetalol and admit for monitoring

      Explanation:

      Management of Pre-eclampsia with Hypertension in Pregnancy

      Pre-eclampsia is a common condition affecting pregnant women, with hypertension and proteinuria being the main clinical features. The first line of management for hypertension is oral labetalol, with close monitoring of blood pressure. In cases of mild hypertension, induction of labor is not necessary. However, admission for monitoring and commencement of labetalol is recommended. IV magnesium sulfate may be needed later on, but not initially. Discharge home is not appropriate for women with pre-eclampsia. Early recognition and management of pre-eclampsia is crucial for the well-being of both the mother and the baby.

    • This question is part of the following fields:

      • Obstetrics
      119
      Seconds
  • Question 23 - Which patient has abnormal blood results that suggest they may have myeloma?

    Patient...

    Incorrect

    • Which patient has abnormal blood results that suggest they may have myeloma?

      Patient A:
      Adjusted calcium - 2.3 mmol/L
      Phosphate - 0.9 mmol/L
      PTH - 8.09 pmol/L
      Urea - 7.8 mmol/L
      Creatinine - 132 μmol/L
      Albumin - 36 g/L
      Total protein - 77 g/L

      Patient B:
      Adjusted calcium - 2.9 mmol/L
      Phosphate - 0.5 mmol/L
      PTH - 7.2 pmol/L
      Urea - 5 mmol/L
      Creatinine - 140 μmol/L
      Albumin - 38 g/L
      Total protein - 68 g/L

      Patient C:
      Adjusted calcium - 2.8 mmol/L
      Phosphate - 1.2 mmol/L
      PTH - 0.45 pmol/L
      Urea - 7.2 mmol/L
      Creatinine - 150 μmol/L
      Albumin - 28 g/L
      Total protein - 88 g/L

      Patient D:
      Adjusted calcium - 2.5 mmol/L
      Phosphate - 1.6 mmol/L
      PTH - 2.05 pmol/L
      Urea - 32.8 mmol/L
      Creatinine - 190 μmol/L
      Albumin - 40 g/L
      Total protein - 82 g/L

      Patient E:
      Adjusted calcium - 2.2 mmol/L
      Phosphate - 0.7 mmol/L
      PTH - 5.88 pmol/L
      Urea - 4.6 mmol/L
      Creatinine - 81 μmol/L
      Albumin - 18 g/L
      Total protein - 55 g/L

      Your Answer: Patient A

      Correct Answer: Patient C

      Explanation:

      Myeloma Diagnosis in Patient C

      Patient C has been diagnosed with myeloma, a type of cancer that affects the plasma cells in the bone marrow. This diagnosis is supported by several indicators, including elevated total protein levels with low albumin and abnormally high globulins. Additionally, the patient has high serum calcium levels and suppressed parathyroid hormone, which are consistent with hypercalcaemia of malignancy. High phosphate levels are also present, which is a common occurrence in haematological malignancies where there is a large amount of cell turnover.

      Furthermore, the patient is experiencing renal impairment, which is typically caused by chronic kidney deterioration due to the deposition of myeloma casts in the nephrons. However, the hypercalcaemia can also cause dehydration, exacerbating the renal impairment. Overall, these indicators point towards a diagnosis of myeloma in Patient C.

    • This question is part of the following fields:

      • Nephrology
      83.1
      Seconds
  • Question 24 - A 61-year-old man has been admitted to a General Surgical Ward, following an...

    Correct

    • A 61-year-old man has been admitted to a General Surgical Ward, following an endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis. The procedure took place approximately two hours ago and went well, without complications. The patient is now complaining of central abdominal pain, radiating to the back.
      His observations are normal. Examination is significant for central abdominal pain. His blood tests are significant for an amylase level of 814 u/l. His pre-ERCP amylase level was 89 u/l.
      What is the most likely diagnosis?

      Your Answer: Acute pancreatitis

      Explanation:

      Complications of ERCP: Post-ERCP Pancreatitis, Papillary Stenosis, Anaphylaxis, Duodenal Pneumostasis, and Oesophageal Perforation

      Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic and therapeutic procedure used to examine the bile ducts and pancreatic ducts. However, like any medical procedure, ERCP is not without risks. Here are some of the possible complications of ERCP:

      Post-ERCP Pancreatitis: This is a common complication of ERCP, with an incidence of approximately 2-3%. It is characterized by abdominal pain that radiates to the back and a significant elevation in amylase levels. Treatment involves analgesia, hydration, and bowel rest.

      Papillary Stenosis: This is a late complication of ERCP that occurs in approximately 2-4% of patients. It is treated with endoscopic management, such as stenting or balloon dilation.

      Anaphylaxis: Although rare, anaphylactic reactions to contrast agents used during ERCP can occur. Symptoms include respiratory compromise and hypotension, and treatment involves adrenaline and airway support.

      Duodenal Pneumostasis: This complication refers to a collection of air in the duodenal wall and is typically recognized during the procedure. The procedure should be stopped to avoid bowel perforation.

      Oesophageal Perforation: This is a rare complication of ERCP that typically presents with chest pain, mediastinitis, and cardiovascular instability.

      In conclusion, while ERCP is a useful diagnostic and therapeutic tool, it is important to be aware of the potential complications and to take appropriate measures to prevent and manage them.

    • This question is part of the following fields:

      • Gastroenterology
      125
      Seconds
  • Question 25 - A 60-year-old man presents with shortness of breath and dizziness. On examination, he...

    Incorrect

    • A 60-year-old man presents with shortness of breath and dizziness. On examination, he has an irregularly irregular pulse.
      Which of the following conditions in his past medical history might be the cause of his presentation?

      Your Answer: Hypothyroidism

      Correct Answer: Hyperthyroidism

      Explanation:

      Common Endocrine Disorders and their Cardiac Manifestations

      Endocrine disorders can have significant effects on the cardiovascular system, including the development of arrhythmias. Atrial fibrillation is a common arrhythmia that can be caused by hyperthyroidism, which should be tested for in patients presenting with this condition. Other signs of thyrotoxicosis include sinus tachycardia, physiological tremor, lid lag, and lid retraction. Graves’ disease, a common cause of hyperthyroidism, can also present with pretibial myxoedema, proptosis, chemosis, and thyroid complex ophthalmoplegia. Mnemonics such as SHIMMERS and ABCD can be used to remember the causes and management of atrial fibrillation.

      Cushing syndrome, hyperparathyroidism, and hypothyroidism can also have cardiac manifestations, although they are not typically associated with arrhythmias. Cushing syndrome is not commonly associated with arrhythmias, while hyperparathyroidism can cause hypercalcemia, leading to non-specific symptoms such as aches and pains, dehydration, fatigue, mood disturbance, constipation, and renal stones. Hypothyroidism, on the other hand, may cause bradycardia and can be caused by various factors such as Hashimoto’s thyroiditis, subacute thyroiditis, iodine deficiency, and iatrogenic factors such as post-carbimazole treatment, radio-iodine, thyroidectomy, and certain medications like lithium and amiodarone.

      In summary, endocrine disorders can have significant effects on the cardiovascular system, and it is important to be aware of their potential cardiac manifestations, including arrhythmias. Early detection and management of these conditions can help prevent serious complications and improve patient outcomes.

    • This question is part of the following fields:

      • Cardiology
      55.1
      Seconds
  • Question 26 - A 52-year-old woman comes in for her routine cervical smear. She reports discomfort...

    Correct

    • A 52-year-old woman comes in for her routine cervical smear. She reports discomfort during the insertion of the speculum and reveals that she has been experiencing dyspareunia and a burning sensation when using tampons for the past few months. The pain can persist for several hours after sexual intercourse. She denies having any vaginal discharge, and her skin appears normal. What is the most probable cause of her symptoms?

      Your Answer: Provoked vulvodynia

      Explanation:

      Understanding Vulvodynia: Types, Causes, and Associated Conditions

      Vulvodynia is a chronic pain condition that affects the vulvovaginal region and lasts for at least three months without any identifiable cause. There are two types of vulvodynia: provoked and unprovoked. Provoked vulvodynia is triggered by sexual intercourse or tampon insertion, while unprovoked vulvodynia is a spontaneous chronic pain that is present most of the time.

      Vulvodynia can be localised or generalised and can be primary or secondary. It can affect women of any age and is associated with various factors such as neurological conditions, chronic pain syndromes, genetic predisposition, pelvic muscle overactivity, anxiety, and depression. The exact mechanism of vulvodynia is not yet understood, but it is believed to be multifactorial and complex.

      Other conditions that can cause pain in the vulvovaginal region include sexually transmitted infections, lichen sclerosus, and lichen planus. Sexually transmitted infections usually present with dyspareunia, abnormal bleeding, and a vaginal discharge. Lichen sclerosus presents with itching and burning, while lichen planus presents with purple-red lesions and overlying lacy markings.

      Vulvodynia is a dysfunctional pain syndrome that can significantly impact a woman’s quality of life. It is essential to seek medical attention if you experience any pain or discomfort in the vulvovaginal region to determine the underlying cause and receive appropriate treatment.

    • This question is part of the following fields:

      • Gynaecology
      33.2
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  • Question 27 - A 38-year-old man is referred by his general practitioner due to experiencing epigastric...

    Correct

    • A 38-year-old man is referred by his general practitioner due to experiencing epigastric pain. The pain occurs approximately 3 hours after eating a meal. Despite using both histamine 2 receptor blockers and proton pump inhibitors (PPIs), he has only experienced moderate relief and tests negative on a urease breath test. An endoscopy is performed, revealing multiple duodenal ulcers. The patient's gastrin level is tested and found to be above normal. A computed tomography (CT) scan is ordered, and the patient is diagnosed with Zollinger-Ellison syndrome. Which hormone typically inhibits gastrin secretion?

      Your Answer: Somatostatin

      Explanation:

      Hormones and Enzymes: Their Effects on Gastrin Secretion

      Gastrin secretion is regulated by various hormones and enzymes in the body. One such hormone is somatostatin, which inhibits the release of gastrin. In the treatment of gastrinomas, somatostatin analogues like octreotide can be used instead of proton pump inhibitors (PPIs).

      Aldosterone, on the other hand, is a steroid hormone that is not related to gastrin and has no effect on its secretion. Similarly, glycogen synthase and hexokinase, which play regulatory roles in carbohydrate metabolism, do not affect gastrin secretion.

      Another steroid hormone, progesterone, also does not play a role in the regulation of gastrin secretion. Understanding the effects of hormones and enzymes on gastrin secretion can help in the development of targeted treatments for gastrointestinal disorders.

    • This question is part of the following fields:

      • Gastroenterology
      20.8
      Seconds
  • Question 28 - The ward doctor is requested to assess a 24-hour-old neonate, born at 35...

    Correct

    • The ward doctor is requested to assess a 24-hour-old neonate, born at 35 weeks gestation to a healthy mother via an uncomplicated vaginal delivery. Upon examination, the neonate appears comfortable. Auscultation of the heart reveals a continuous 'machinery-like' murmur and a left-sided thrill. The apex beat is palpable and appears to be heaving. A widened pulse pressure is observed, but there is no visible cyanosis. An echocardiogram is performed and confirms the diagnosis while ruling out other cardiac issues.
      What is the most appropriate course of action for management at this stage, given the likely diagnosis?

      Your Answer: Indomethacin given to the neonate

      Explanation:

      The most likely diagnosis based on the findings is patent ductus arteriosus (PDA). To prompt duct closure in the majority of cases, the appropriate action is to administer indomethacin to the neonate in the postnatal period, not to the mother during the antenatal period. If another defect was present, prostaglandin E1 may be preferred to keep the duct open until after surgical repair. Referral for surgery is not necessary at this time. While percutaneous closure may be an option for older children, it is not suitable for neonates.

      Patent ductus arteriosus is a type of congenital heart defect that is typically classified as ‘acyanotic’. However, if left untreated, it can eventually lead to late cyanosis in the lower extremities, which is known as differential cyanosis. This condition is caused by a connection between the pulmonary trunk and descending aorta that fails to close with the first breaths due to increased pulmonary flow that enhances prostaglandins clearance. Patent ductus arteriosus is more common in premature babies, those born at high altitude, or those whose mothers had rubella infection during the first trimester of pregnancy.

      The features of patent ductus arteriosus include a left subclavicular thrill, a continuous ‘machinery’ murmur, a large volume, bounding, collapsing pulse, a wide pulse pressure, and a heaving apex beat. To manage this condition, indomethacin or ibuprofen is given to the neonate, which inhibits prostaglandin synthesis and closes the connection in the majority of cases. If patent ductus arteriosus is associated with another congenital heart defect that is amenable to surgery, then prostaglandin E1 is useful to keep the duct open until after surgical repair.

    • This question is part of the following fields:

      • Paediatrics
      37.1
      Seconds
  • Question 29 - A 56-year-old man without medical history is beginning treatment with tranylcypromine for his...

    Correct

    • A 56-year-old man without medical history is beginning treatment with tranylcypromine for his depression. What foods should he be cautioned against consuming?

      Your Answer: Cheese

      Explanation:

      To prevent a hypertensive crisis, individuals taking monoamine oxidase inhibitors (MAOIs) should steer clear of tyramine-containing foods, such as cheese. Other foods have not been found to have an interaction with MAOIs.

      Monoamine Oxidase Inhibitors and their Adverse Effects

      Monoamine oxidase inhibitors are drugs that inhibit the enzyme monoamine oxidase, which is responsible for the breakdown of neurotransmitters such as serotonin and noradrenaline in the presynaptic cell. Non-selective monoamine oxidase inhibitors, such as tranylcypromine and phenelzine, are used in the treatment of atypical depression and other psychiatric disorders. However, they are not commonly used due to their adverse effects.

      One of the main adverse effects of non-selective monoamine oxidase inhibitors is hypertensive reactions when consuming tyramine-containing foods such as cheese, pickled herring, Bovril, Oxo, Marmite, and broad beans. This is because monoamine oxidase normally breaks down tyramine, but when inhibited by the drug, tyramine can accumulate and cause a sudden increase in blood pressure. Therefore, patients taking non-selective monoamine oxidase inhibitors must adhere to a strict diet that avoids these foods.

      Another adverse effect of non-selective monoamine oxidase inhibitors is anticholinergic effects, which can cause dry mouth, blurred vision, constipation, and urinary retention. These effects are due to the inhibition of the enzyme acetylcholinesterase, which breaks down the neurotransmitter acetylcholine. As a result, acetylcholine levels increase and can lead to these side effects.

      In conclusion, while non-selective monoamine oxidase inhibitors can be effective in treating certain psychiatric disorders, they are not commonly used due to their adverse effects. Patients taking these drugs must adhere to a strict diet and be monitored for potential side effects.

    • This question is part of the following fields:

      • Psychiatry
      8.1
      Seconds
  • Question 30 - A 50-year-old man presents to the Emergency Department with a painful and swollen...

    Correct

    • A 50-year-old man presents to the Emergency Department with a painful and swollen left knee that has been bothering him for the past 2 days. He is running a fever. The patient has a history of rheumatoid arthritis, which was recently diagnosed and is being treated with NSAIDs and low-dose oral corticosteroids. He reports that he visited his general practitioner 5 days ago for a painful right ear, and was prescribed antibiotics for an ear infection. Upon examination, the left knee is swollen, red, tender, and slightly flexed, leading to a diagnosis of septic arthritis. What is the most likely causative organism in this case?

      Your Answer: Staphylococcus aureus

      Explanation:

      Common Bacterial Causes of Septic Arthritis

      Septic arthritis can be caused by a variety of bacterial organisms. Among them, Staphylococcus aureus is the most common aetiological agent in Europe and the United States. Streptococcus pyogenes is the next most commonly isolated bacteria, often associated with autoimmune diseases, chronic skin infections, and trauma. Gram-negative bacilli, such as Escherichia coli, account for approximately 10-20% of cases, with a higher prevalence in patients with a history of intravenous drug abuse, extremes of age, or immunocompromised status. Historically, Haemophilus influenzae, S. aureus, and group A streptococci were the most common causes of infectious arthritis in children younger than 2 years, but the overall incidence of H. influenzae is decreasing due to vaccination. Pseudomonas aeruginosa, a less common cause, may affect children, the elderly, intravenous drug users, and immunocompromised patients.

    • This question is part of the following fields:

      • Rheumatology
      71.5
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SESSION STATS - PERFORMANCE PER SPECIALTY

Paediatrics (3/4) 75%
Surgery (2/3) 67%
Musculoskeletal (1/2) 50%
Psychiatry (2/3) 67%
Dermatology (1/1) 100%
Respiratory (0/2) 0%
Obstetrics (1/2) 50%
Gynaecology (3/3) 100%
Clinical Sciences (1/1) 100%
Emergency Medicine (1/1) 100%
Pharmacology (1/2) 50%
Neurology (1/1) 100%
Nephrology (0/1) 0%
Gastroenterology (2/2) 100%
Cardiology (0/1) 0%
Rheumatology (1/1) 100%
Passmed