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  • Question 1 - An 72-year-old woman contacts her doctor suspecting shingles. The rash started about 48...

    Correct

    • An 72-year-old woman contacts her doctor suspecting shingles. The rash started about 48 hours ago and is localized to the T4 dermatome on her right trunk. It is accompanied by pain and blistering. The patient has a medical history of type 2 diabetes and is currently on metformin, canagliflozin, and atorvastatin. After confirming the diagnosis of shingles through photo review, the doctor prescribes aciclovir. What measures can be taken to prevent post-herpetic neuralgia in this patient?

      Your Answer: Antiviral treatment

      Explanation:

      Antiviral therapy, such as aciclovir, can effectively reduce the severity and duration of shingles. It can also lower the incidence of post-herpetic neuralgia, especially in older patients. However, for antivirals to be effective, they must be administered within 72 hours of rash onset.

      Individuals with chronic diseases such as diabetes mellitus, chronic kidney disease, inflammatory bowel disease, asthma, chronic obstructive pulmonary disease, rheumatoid arthritis, autoimmune diseases, and immunosuppressive conditions like HIV are at a higher risk of developing post-herpetic neuralgia.

      Older patients, particularly those over 50 years old, are also at an increased risk of developing post-herpetic neuralgia. However, the relationship between gender and post-herpetic neuralgia is still unclear, with some studies suggesting that females are at a higher risk, while others indicate the opposite or no association.

      Unfortunately, having a shingles rash on either the trunk or face is associated with an increased risk of post-herpetic neuralgia, not a reduced risk.

      Shingles is a painful blistering rash caused by reactivation of the varicella-zoster virus. It is more common in older individuals and those with immunosuppressive conditions. The diagnosis is usually clinical and management includes analgesia, antivirals, and reminding patients they are potentially infectious. Complications include post-herpetic neuralgia, herpes zoster ophthalmicus, and herpes zoster oticus. Antivirals should be used within 72 hours to reduce the incidence of post-herpetic neuralgia.

    • This question is part of the following fields:

      • Dermatology
      38.5
      Seconds
  • Question 2 - During a localised outbreak of measles your practice is inundated with requests for...

    Correct

    • During a localised outbreak of measles your practice is inundated with requests for MMR vaccine from worried parents of young children.

      In which of the following age groups is MMR vaccine contraindicated?

      Your Answer: Pregnant women

      Explanation:

      Who Should Not Receive the MMR Vaccine?

      There are only a few circumstances where the MMR vaccine cannot be given. Firstly, pregnant women should not receive the vaccine. Secondly, those with a confirmed anaphylactic reaction to gelatin or neomycin should not receive the vaccine. Thirdly, those who are immunocompromised should not receive the vaccine. Lastly, those who have had a confirmed anaphylactic reaction to a previous dose of measles, mumps or rubella-containing vaccine should not receive the vaccine.

      Breastfeeding is not a contraindication to MMR immunisation, and MMR can be given to breastfeeding mothers without any risk to the baby. While two MMR vaccinations are needed for 99% protection, there is no limit to the number of MMR vaccinations an individual can receive. The risk of adverse reactions becomes less with increasing doses of MMR. Additionally, there is no upper age limit to receiving the MMR vaccine, and a 1-year-old child could theoretically receive the vaccine.

    • This question is part of the following fields:

      • Children And Young People
      23.9
      Seconds
  • Question 3 - A 55-year-old woman has terminal breast cancer. She has liver metastases but her...

    Incorrect

    • A 55-year-old woman has terminal breast cancer. She has liver metastases but her pain is well controlled.

      Her main symptom, however, is anxiety. She feels nervous all the time and has a tremor. She says she feels tense about almost anything. She has read that beta blockers can help people like her and asks whether they would be worthwhile.

      What symptoms are beta blockers most likely to alleviate in a 55-year-old woman with terminal breast cancer and anxiety?

      Your Answer: Tremor

      Correct Answer: Psychological tension

      Explanation:

      Beta-blockers and Anxiety Symptoms

      Beta-blockers are effective in managing the autonomic symptoms of anxiety, such as tremors and palpitations. However, they are not likely to alleviate the psychological symptoms of anxiety. While beta-blockers may help with physical symptoms, other approaches may be necessary to address the emotional and cognitive aspects of anxiety. Therefore, it is important to consider a comprehensive treatment plan that includes therapy, medication, and lifestyle changes to manage anxiety effectively.

    • This question is part of the following fields:

      • End Of Life
      22.4
      Seconds
  • Question 4 - A 79-year-old man presents for a chest review after being discharged from the...

    Correct

    • A 79-year-old man presents for a chest review after being discharged from the hospital a month ago due to an exacerbation of COPD. He reports feeling well with no cough or breathing issues. Over the past year, he has experienced four exacerbations that required steroid treatment, including his recent hospitalization. The patient inquires about any potential interventions to decrease the frequency of his exacerbations.

      Currently, the patient is taking a combination inhaler of fluticasone furoate/umeclidinium/vilanterol and salbutamol.

      What is the most appropriate course of action for managing this patient's condition?

      Your Answer: Referral to secondary care for consideration of prophylactic antibiotic treatment

      Explanation:

      Referral to secondary care for consideration of prophylactic antibiotic treatment is the recommended option for COPD patients who meet certain criteria and continue to have exacerbations. NICE suggests considering prophylactic oral macrolide therapy, such as azithromycin, for individuals who have had more than three exacerbations requiring steroid therapy and at least one exacerbation requiring hospital admission in the previous year.

      Referral to secondary care for consideration of nebulisers is not appropriate for this patient as they are not experiencing distressing or disabling breathlessness despite maximal therapy using inhalers.

      Referral to secondary care for consideration of phosphodiesterase-4 inhibitors is not applicable for this patient as they do not have severe disease with persistent symptoms and exacerbations despite optimal inhaled and pharmacological therapy.

      Starting the patient on long term corticosteroids is not recommended in primary care and requires referral to a respiratory specialist.

      Starting the patient on oral mucolytic therapy is not necessary as they do not have a chronic cough productive of sputum.

      The National Institute for Health and Care Excellence (NICE) updated its guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2018. The guidelines recommend general management strategies such as smoking cessation advice, annual influenza vaccination, and one-off pneumococcal vaccination. Pulmonary rehabilitation is also recommended for patients who view themselves as functionally disabled by COPD.

      Bronchodilator therapy is the first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators. The next step is determined by whether the patient has asthmatic features or features suggesting steroid responsiveness. NICE suggests several criteria to determine this, including a previous diagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time, and substantial diurnal variation in peak expiratory flow.

      If the patient doesn’t have asthmatic features or features suggesting steroid responsiveness, a long-acting beta2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) should be added. If the patient is already taking a short-acting muscarinic antagonist (SAMA), it should be discontinued and switched to a short-acting beta2-agonist (SABA). If the patient has asthmatic features or features suggesting steroid responsiveness, a LABA and inhaled corticosteroid (ICS) should be added. If the patient remains breathless or has exacerbations, triple therapy (LAMA + LABA + ICS) should be offered.

      NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients who have optimised standard treatments and continue to have exacerbations. Mucolytics should be considered in patients with a chronic productive cough and continued if symptoms improve.

      Cor pulmonale features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, and loud P2. Loop diuretics should be used for oedema, and long-term oxygen therapy should be considered. Smoking cessation, long-term oxygen therapy in eligible patients, and lung volume reduction surgery in selected patients may improve survival in patients with stable COPD. NICE doesn’t recommend the use of ACE-inhibitors, calcium channel blockers, or alpha blockers

    • This question is part of the following fields:

      • Respiratory Health
      110.3
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  • Question 5 - A 30-year-old man presents with a headache. He has never experienced significant headaches...

    Incorrect

    • A 30-year-old man presents with a headache. He has never experienced significant headaches before but developed this one about a week ago.

      He describes a vague headache on the left side of his head, starting above his left eye and extending to the parietal area. The headache has been fairly constant, and he has taken paracetamol and ibuprofen, which have only provided slight relief and have not significantly reduced the pain.

      There is no history of vomiting, drowsiness, loss of consciousness, seizures, postural related headache, or tinnitus. There are no mental or cognitive changes.

      On clinical examination, all cranial nerves are normal, and there is no focal limb neurological deficit or cerebellar signs. ENT examination is normal, and there is no scalp or temporal tenderness. There is no neck stiffness or restriction of neck movements. Observations, including blood pressure and temperature, are normal, and there is no anxiety, depression, or psychological upset.

      Despite the lack of a clear cause for this new headache, which of the following statements is true regarding papilloedema?

      Your Answer:

      Correct Answer: The absence of papilloedema rules out the presence of a brain tumour

      Explanation:

      Importance of Fundal Examination in Headache Assessment

      Fundal examination is a crucial part of headache assessment, particularly in cases of new and unexplained headaches. It helps to check for papilloedema, which may indicate raised intracranial pressure and requires urgent action, even in the absence of other symptoms or normal examination results. However, the absence of papilloedema doesn’t rule out the possibility of a brain tumor, and papilloedema is not always a sign of a brain tumor.

      According to the latest NICE guidelines, the predictive value of symptoms is more important than clinical signs in referring patients for suspected cancer. However, they recommend an urgent direct access MRI scan of the brain (or CT scan if MRI is contraindicated) within two weeks for adults with progressive, subacute loss of central neurological function. This is to assess for brain or central nervous system cancer and to speed up the diagnostic process for patients with a tumor.

      Some GPs may have direct access to MRI, while others may need to coordinate with secondary care colleagues through locally arranged pathways. Regardless of the means of acquiring an MRI, the finding of papilloedema warrants urgent MRI, regardless of other factors in the history or examination.

    • This question is part of the following fields:

      • Neurology
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  • Question 6 - A 72-year-old man with osteoarthritis affecting his left shoulder presents for follow-up. He...

    Incorrect

    • A 72-year-old man with osteoarthritis affecting his left shoulder presents for follow-up. He is currently on regular co-codamol 30/500 for pain relief and takes oral ibuprofen as needed. The patient has been experiencing shoulder problems for several years and has had to increase his pain medication to manage his symptoms. He has also tried using heat and cold packs and has purchased a TENS machine. Despite these interventions, he continues to experience significant daily pain and reduced function of his left arm due to restricted shoulder movement. The patient is hesitant to pursue surgical intervention. What would be an appropriate course of action?

      Your Answer:

      Correct Answer: Amitriptyline orally

      Explanation:

      Intra-Articular Corticosteroid Injections for Osteoarthritis Pain

      Intra-articular corticosteroid injections can be a helpful addition to treating moderate to severe osteoarthritis pain. If traditional treatments have failed, a corticosteroid injection may be an appropriate option for patients who are not interested in surgical intervention. While the injection provides short-term pain relief, it may also allow patients to engage in other interventions such as physiotherapy, which can provide longer-lasting benefits in terms of both pain and function. However, repeated injections over longer periods may cause joint damage and are generally not recommended.

      Other treatment options such as capsaicin, electro-acupuncture, amitriptyline, and glucosamine are not recommended for osteoarthritis pain. Capsaicin is not recommended for shoulder problems, electro-acupuncture is not recommended for any form of osteoarthritis, and amitriptyline is not a licensed or recommended treatment for osteoarthritis. Glucosamine has insufficient data of significant efficacy to justify its cost, but patients can try over-the-counter glucosamine sulfate at a dose of 1500 mg daily and monitor their symptoms before and after three months.

    • This question is part of the following fields:

      • Musculoskeletal Health
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  • Question 7 - A 56-year-old man collapses after complaining of palpitations and is admitted to the...

    Incorrect

    • A 56-year-old man collapses after complaining of palpitations and is admitted to the Emergency Department (ED). He is found to be in ventricular tachycardia and is successfully cardioverted. Further investigations reveal an underlying long QT syndrome, and an implantable cardioverter-defibrillator (ICD) is inserted. The man works as an HGV driver. What advice should be given regarding his ability to drive HGV vehicles?

      Your Answer:

      Correct Answer: Permanent bar

      Explanation:

      Regardless of the circumstances, the loss of HGV licence is indicated by ICD.

      DVLA Guidelines for Cardiovascular Disorders and Driving

      The DVLA has specific guidelines for individuals with cardiovascular disorders who wish to drive a car or motorcycle. For those with hypertension, driving is permitted unless the treatment causes unacceptable side effects, and there is no need to notify the DVLA. However, if the individual has Group 2 Entitlement, they will be disqualified from driving if their resting blood pressure consistently measures 180 mmHg systolic or more and/or 100 mm Hg diastolic or more.

      Individuals who have undergone elective angioplasty must refrain from driving for one week, while those who have undergone CABG or acute coronary syndrome must wait four weeks before driving. If an individual experiences angina symptoms at rest or while driving, they must cease driving altogether. Pacemaker insertion requires a one-week break from driving, while implantable cardioverter-defibrillator (ICD) implantation results in a six-month driving ban if implanted for sustained ventricular arrhythmia. If implanted prophylactically, the individual must cease driving for one month, and Group 2 drivers are permanently barred from driving with an ICD.

      Successful catheter ablation for an arrhythmia requires a two-day break from driving, while an aortic aneurysm of 6 cm or more must be reported to the DVLA. Licensing will be permitted subject to annual review, but an aortic diameter of 6.5 cm or more disqualifies patients from driving. Finally, individuals who have undergone a heart transplant must refrain from driving for six weeks, but there is no need to notify the DVLA.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 8 - Your surgery serves an area of West London that is frequented by large...

    Incorrect

    • Your surgery serves an area of West London that is frequented by large numbers of tourists and economic migrants who come to the UK for a few months for work.
      With respect to health service provision, which one of the following is true with respect to provision of health services and charging to elderly visitors?

      Your Answer:

      Correct Answer: NATO staff are only partially eligible for free treatment

      Explanation:

      Eligibility for Free NHS Care

      The rules for receiving free NHS care can be complex and detailed, but in general, patients from the European Economic Area (EEA), certain Commonwealth countries, and Ukraine are entitled to free healthcare. Additionally, there is a list of procedures and consultations, such as family planning, that are also covered under free healthcare.

      If a patient has been accepted for permanent residence, they are not charged for NHS care, regardless of their home country. It is important to note that eligibility for free NHS care can vary depending on individual circumstances, so it is always best to check with the NHS or a healthcare professional to confirm eligibility.

    • This question is part of the following fields:

      • Improving Quality, Safety And Prescribing
      0
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  • Question 9 - A 54-year-old woman with a BMI of 26 presents to the diabetic clinic...

    Incorrect

    • A 54-year-old woman with a BMI of 26 presents to the diabetic clinic with poor glycaemic control while on gliclazide 160mg bd. Her latest blood results reveal a HbA1c of 9.4%. Her laboratory values are as follows: Na+ 139 mmol/l, K+ 4.1 mmol/l, urea 8.4 mmol/l, creatinine 180 µmol/l, ALT 25 iu/l, and yGT 33 iu/l. What medication should be added to her treatment plan?

      Your Answer:

      Correct Answer: Pioglitazone

      Explanation:

      Considering her overweight status, adding metformin would be a logical choice. However, due to the elevated creatinine levels, pioglitazone would be a more suitable alternative. It is important to note that if the creatinine level exceeds 130 µmol/l (or eGFR falls below 45 ml/min), the metformin dosage should be reassessed and discontinued if the creatinine level exceeds 150 µmol/l (or eGFR falls below 30 ml/min). It is worth noting that pioglitazone may cause weight gain, which could be problematic given her BMI of 26.

      Thiazolidinediones: A Class of Diabetes Medications

      Thiazolidinediones are a type of medication used to treat type 2 diabetes. They work by activating the PPAR-gamma receptor, which helps to reduce insulin resistance in the body. However, one medication in this class, rosiglitazone, was withdrawn in 2010 due to concerns about its cardiovascular side effects.

      The PPAR-gamma receptor is a type of nuclear receptor found inside cells. It is normally activated by free fatty acids and is involved in regulating the function and development of fat cells.

      While thiazolidinediones can be effective in treating diabetes, they can also have some adverse effects. These can include weight gain, liver problems (which should be monitored with regular liver function tests), and fluid retention. Because of the risk of fluid retention, these medications are not recommended for people with heart failure. Recent studies have also suggested that there may be an increased risk of fractures and bladder cancer in people taking thiazolidinediones, particularly pioglitazone.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
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  • Question 10 - A 65-year-old man with type 1 diabetes mellitus reports decreased hypoglycemic awareness following...

    Incorrect

    • A 65-year-old man with type 1 diabetes mellitus reports decreased hypoglycemic awareness following his recent hospital discharge. He was started on several new medications during his admission. Which medication is the most probable cause of this issue?

      Your Answer:

      Correct Answer: Atenolol

      Explanation:

      Insulin therapy can have side-effects that patients should be aware of. One of the most common side-effects is hypoglycaemia, which can cause sweating, anxiety, blurred vision, confusion, and aggression. Patients should be taught to recognize these symptoms and take 10-20g of a short-acting carbohydrate, such as a glass of Lucozade or non-diet drink, three or more glucose tablets, or glucose gel. It is also important for every person treated with insulin to have a glucagon kit for emergencies where the patient is not able to orally ingest a short-acting carbohydrate. Patients who have frequent hypoglycaemic episodes may develop reduced awareness, and beta-blockers can further reduce hypoglycaemic awareness.

      Another potential side-effect of insulin therapy is lipodystrophy, which typically presents as atrophy or lumps of subcutaneous fat. This can be prevented by rotating the injection site, as using the same site repeatedly can cause erratic insulin absorption. It is important for patients to be aware of these potential side-effects and to discuss any concerns with their healthcare provider. By monitoring their blood sugar levels and following their treatment plan, patients can manage the risks associated with insulin therapy and maintain good health.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
      0
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  • Question 11 - A 25-year-old asthmatic woman has a disabling headache syndrome consisting of recurrent, severe,...

    Incorrect

    • A 25-year-old asthmatic woman has a disabling headache syndrome consisting of recurrent, severe, unilateral (either right or left) headaches twice a week lasting for 8 hours each. The pain is constant and associated with nausea. It has not responded to ibuprofen or paracetamol. The headaches frequently disturb sleep. She has identified no dietary triggers and there is no family history of migraine. She is very worried about her increasing weight.
      Select the most sensible treatment course.

      Your Answer:

      Correct Answer: Amitriptyline (for prophylaxis) and a triptan (for the acute attacks)

      Explanation:

      Prophylactic Treatment for Common Migraine: A Clinical Scenario

      The history of a patient is consistent with common migraine, which justifies prophylaxis due to the frequency of attacks. Pizotifen, which has been widely used for many years, is no longer recommended due to little clinical trial evidence of efficacy and weight gain side effects. Ergotamine and Methysergide are also not commonly used for acute treatment due to associated side effects. Regular analgesics can lead to chronic daily headache, especially those containing opiates.

      The British Association for the Study of Headache (BASH) guidelines recommend amitriptyline as a first-line prophylactic drug for migraine coexisting with other chronic pain conditions, disturbed sleep, or depression. Topiramate and sodium valproate are second-line prophylactic drugs with significant side effect profiles. NICE (2012) recommends topiramate and propranolol as first-line drugs, but neither are given as an answer to this clinical scenario. Therefore, the best available option should be sought for this patient.

    • This question is part of the following fields:

      • Neurology
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  • Question 12 - A child vomits in the phlebotomy room during a blood draw. What type...

    Incorrect

    • A child vomits in the phlebotomy room during a blood draw. What type of chemical should be used to clean up the vomit?

      Your Answer:

      Correct Answer: Hypochlorite

      Explanation:

      Managing Body Fluid Spillages

      When it comes to managing body fluid spillages, hypochlorite is often recommended. This chlorine-based agent is typically used in granular or powder form and spread over the affected area. However, it’s important to note that chlorine-releasing agents can be hazardous if used in large volumes in confined spaces or mixed with urine. Adequate ventilation is crucial to ensure safety.

      In addition to using hypochlorite, it’s recommended that staff wear personal protective equipment such as plastic aprons, gloves, masks, and eye protection when cleaning up body fluids. It’s also important to avoid using mops, as they can spread the contamination further.

      Some NHS trusts recommend the use of Virkon, a multipurpose disinfectant that contains oxone, potassium peroxymonosulphate, sodium dodecylbenzenesulfonate, sulphamic acid, and inorganic buffers. Virkon is believed to be effective against HIV, hepatitis, and MRSA. By following these guidelines and using appropriate disinfectants, healthcare professionals can effectively manage body fluid spillages and minimize the risk of infection.

    • This question is part of the following fields:

      • Infectious Disease And Travel Health
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  • Question 13 - You are working as a clinical research fellow. You design a case-control study...

    Incorrect

    • You are working as a clinical research fellow. You design a case-control study to investigate the association between maternal diet during pregnancy and adolescent obesity.

      What kind of bias is this study most susceptible to?

      Your Answer:

      Correct Answer: Recall bias

      Explanation:

      Recall bias is a significant concern in case-control studies, particularly those conducted retrospectively. Participants may be asked to recall past exposures, leading to the risk of certain events being forgotten or over-remembered.

      Expectation bias is more likely to occur in non-blinded trials, where the observer’s cognitive biases can influence the recorded data. However, this is unlikely to be an issue in this retrospective study.

      Late look bias can arise when there is a significant delay in gathering data. For example, if data were collected when the children were in their 40s, mothers who were particularly unhealthy during pregnancy may have died, leading to underrepresentation in the study.

      Measurement bias can occur when the outcome of interest is poorly measured. In this study, for instance, measurement bias could arise if the children’s obesity status was determined based on the measurement of incorrectly calibrated scales.

      Understanding Bias in Clinical Trials

      Bias refers to the systematic favoring of one outcome over another in a clinical trial. There are various types of bias, including selection bias, recall bias, publication bias, work-up bias, expectation bias, Hawthorne effect, late-look bias, procedure bias, and lead-time bias. Selection bias occurs when individuals are assigned to groups in a way that may influence the outcome. Sampling bias, volunteer bias, and non-responder bias are subtypes of selection bias. Recall bias refers to the difference in accuracy of recollections retrieved by study participants, which may be influenced by whether they have a disorder or not. Publication bias occurs when valid studies are not published, often because they showed negative or uninteresting results. Work-up bias is an issue in studies comparing new diagnostic tests with gold standard tests, where clinicians may be reluctant to order the gold standard test unless the new test is positive. Expectation bias occurs when observers subconsciously measure or report data in a way that favors the expected study outcome. The Hawthorne effect describes a group changing its behavior due to the knowledge that it is being studied. Late-look bias occurs when information is gathered at an inappropriate time, and procedure bias occurs when subjects in different groups receive different treatment. Finally, lead-time bias occurs when two tests for a disease are compared, and the new test diagnosis the disease earlier, but there is no effect on the outcome of the disease. Understanding these types of bias is crucial in designing and interpreting clinical trials.

    • This question is part of the following fields:

      • Evidence Based Practice, Research And Sharing Knowledge
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  • Question 14 - A 50-year-old man visits his General Practitioner with complaints of numbness and pain...

    Incorrect

    • A 50-year-old man visits his General Practitioner with complaints of numbness and pain in his left thigh. He reports feeling unsteady on his feet and has gained more than 6 kg in weight over the past six months. He also has chronic lower back pain. His family has a history of a neurological condition, with his uncle having multiple sclerosis (MS). He has no other medical conditions.
      During the examination, the patient is found to be overweight. He has reduced pinprick sensation over the anterior part of his left thigh, but no motor signs. His tendor reflexes are normal and there are no cerebellar signs.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Meralgia paraesthetica

      Explanation:

      Differentiating between causes of lower limb pain: A brief overview

      Lower limb pain can be caused by a variety of conditions, each with their own unique symptoms and diagnostic criteria. Here, we will briefly discuss four potential causes of lower limb pain and how they can be differentiated.

      Meralgia paraesthetica is a condition characterized by numbness, paraesthesia, and pain in the anterolateral thigh. It is caused by either an entrapment neuropathy or a neuroma of the lateral femoral cutaneous nerve. The pain can be reproduced by deep palpation just below the anterior superior iliac spine and by extension of the hip. Obesity and weight gain are risk factors.

      Diabetic lumbosacral plexopathy is a condition in which patients develop severe pain in the hip and thigh, followed by weakness and wasting of the thigh muscles. This often occurs asymmetrically and is accompanied by distal sensory neuropathy. However, this patient has no diagnosis of diabetes.

      Familial MS is a form of multiple sclerosis that usually presents as intermittent episodic sensory, motor, or autonomic disturbances. While a family history of MS may be present, it is not a definitive diagnostic criterion.

      Lumbar canal stenosis with nerve root entrapment typically causes pain in the buttocks or lower extremities, with or without back pain. Standing, walking, or lumbar extension often exacerbate the condition, while forward flexion, sitting, or lying flat often relieves the pain.

      Finally, lumbar facet arthropathy is characterized by facet joints causing back pain that can radiate to the buttocks and legs. The pain is worsened by retroflexion and lateral flexion of the spine and prolonged standing or walking. However, facet syndrome would not usually cause reduced sensation.

      In conclusion, a thorough clinical evaluation and diagnostic testing can help differentiate between these potential causes of lower limb pain.

    • This question is part of the following fields:

      • Neurology
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  • Question 15 - A 58-year-old woman comes to her General Practitioner with complaints of abdominal pain,...

    Incorrect

    • A 58-year-old woman comes to her General Practitioner with complaints of abdominal pain, nausea and weight loss for the past four months. She describes the pain as dull, piercing and it radiates to her back. She has a history of anorexia. On physical examination, there is mild tenderness in the epigastric region but no palpable masses. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Carcinoma of the pancreas

      Explanation:

      Differential Diagnosis of Abdominal Pain: A Case Study

      The patient presents with abdominal pain, and a differential diagnosis must be considered. The symptoms suggest carcinoma of the body or tail of the pancreas, as obstructive jaundice is not present. The pain is located in the epigastric region and radiates to the back, indicating retroperitoneal invasion of the splanchnic nerve plexus by the tumour.

      Cholangiocarcinoma, a malignancy of the biliary duct system, is unlikely as jaundice is not present. Pain in the right upper quadrant may occur in advanced disease. Early gastric carcinoma often presents with symptoms of uncomplicated dyspepsia, while advanced disease presents with weight loss, vomiting, anorexia, upper abdominal pain, and anaemia.

      Peptic ulcer disease is a possibility, with epigastric pain being the most common symptom. Duodenal ulcer pain often awakens the patient at night, and pain with radiation to the back can occur with posterior penetrating gastric ulcer complicated by pancreatitis. However, the presence of weight loss makes pancreatic carcinoma more likely.

      Zollinger-Ellison syndrome, caused by a non-beta-islet-cell, gastrin-secreting tumour of the pancreas, is also a possibility. Epigastric pain due to ulceration is a common symptom, particularly in sporadic cases and in men. Diarrhoea is the most common symptom in patients with multiple endocrine neoplasia type 1, as well as in female patients.

      In conclusion, the differential diagnosis of abdominal pain in this case includes carcinoma of the pancreas, peptic ulcer disease, and Zollinger-Ellison syndrome. Further diagnostic tests are necessary to confirm the diagnosis and determine the appropriate treatment plan.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 16 - A 29-year-old man with a history of ulcerative colitis presents to his primary...

    Incorrect

    • A 29-year-old man with a history of ulcerative colitis presents to his primary care physician complaining of loose non-bloody stools and abdominal discomfort for the past 6 days. He has not been taking any regular medication and his disease has been quiescent for many years. A colonoscopy performed 5 years ago showed proctitis. On examination, his vital signs are within normal limits and his abdomen is diffusely soft with no peritonism. A stool culture is negative. What is the most appropriate treatment for this patient?

      Your Answer:

      Correct Answer: Mesalazine suppository

      Explanation:

      For a patient experiencing mild-to-moderate symptoms of distal ulcerative colitis, the recommended first-line treatment is topical (rectal) aminosalicylates, such as mesalazine suppositories. This is particularly effective for patients with left-sided disease, such as proctitis or proctosigmoiditis. While budesonide foam enema is sometimes used as an additional treatment for mild-to-moderate disease, it is generally less effective at inducing remission. Oral azathioprine is not recommended for inducing remission, but may be used to maintain remission in patients who have had multiple inflammatory exacerbations or if remission is not maintained by aminosalicylates alone. Oral mesalazine is less effective than topical mesalazine for mild or moderate proctitis, but may be offered as an additional treatment if symptoms persist after 4 weeks of topical mesalazine. For patients with pancolitis or extensive disease, oral mesalazine may be offered as a first-line treatment.

      Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools per day, the amount of blood, and the presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Severe cases should be treated in a hospital setting with intravenous steroids or ciclosporin.

      To maintain remission, patients with proctitis and proctosigmoiditis may use topical aminosalicylate alone or in combination with an oral aminosalicylate. Those with left-sided and extensive ulcerative colitis may require a low maintenance dose of an oral aminosalicylate. Patients who have experienced severe relapses or multiple exacerbations may benefit from oral azathioprine or mercaptopurine. Methotrexate is not recommended for UC management, but probiotics may help prevent relapse in mild to moderate cases.

      In summary, the management of ulcerative colitis involves a combination of inducing and maintaining remission. Treatment options vary depending on the severity and location of the condition, with mild-to-moderate cases typically treated with topical aminosalicylate and severe cases requiring hospitalization and intravenous medication. Maintaining remission may involve using a combination of oral and topical medications or a low maintenance dose of an oral aminosalicylate. While methotrexate is not recommended, probiotics may be helpful in preventing relapse in mild to moderate cases.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 17 - Which of the following is MOST LIKELY to be a feature of uncomplicated...

    Incorrect

    • Which of the following is MOST LIKELY to be a feature of uncomplicated cholesteatoma in elderly patients?

      Your Answer:

      Correct Answer: Otorrhoea

      Explanation:

      Cholesteatoma: Symptoms and Complications

      Cholesteatoma is a condition characterized by the collection of epidermal and connective tissues within the middle ear. It can be dangerous as it may cause damage to adjacent vital structures such as the dura, lateral sinus, facial nerve, and semi-circular canal. In severe cases, it may lead to fatal central nervous system complications such as brain abscess and meningitis.

      The hallmark symptom of cholesteatoma is a painless otorrhoea, which may be continuous or recurrent. When infected, the infection may be difficult to treat. Hearing loss is also a common symptom, as the cholesteatoma can fill the middle ear space with desquamated epithelium, interfering with sound transmission and causing ossicular damage.

      Dizziness and facial nerve palsy may occur as the cholesteatoma grows and erodes into adjacent structures. These symptoms are worrisome as they may indicate more serious complications.

      A retracted intact tympanic membrane is not a specific feature of cholesteatoma and may be seen in other conditions such as otitis media with effusion. In cholesteatoma, pearly, white, glistening debris may be visible through the otorrhoea, occupying a perforation in the tympanic membrane, usually in the pars flaccida. Alternatively, there may just be crusting in the uppermost part of the drum beneath which lies a cholesteatoma.

      Rhinorrhoea is not a feature of cholesteatoma.

      In summary, cholesteatoma is a serious condition that requires prompt medical attention. Its symptoms include painless otorrhoea, hearing loss, and possible complications such as dizziness and facial nerve palsy.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 18 - A 28-year-old woman complains of multiple occurrences of vaginal candidiasis that have not...

    Incorrect

    • A 28-year-old woman complains of multiple occurrences of vaginal candidiasis that have not responded to OTC or prescribed treatments. As per the guidelines of the British Association of Sexual Health and HIV (BASHH), what is the minimum frequency of yearly episodes required to diagnose recurrent vaginal candidiasis?

      Your Answer:

      Correct Answer: Four or more episodes per year

      Explanation:

      According to BASHH, recurrent vaginal candidiasis is characterized by experiencing four or more episodes per year. This criterion is significant as it helps determine the need for prophylactic treatment to prevent future recurrences.

      Vaginal candidiasis, commonly known as ‘thrush’, is a prevalent condition that many women self-diagnose and treat. Candida albicans is responsible for 80% of cases, while other candida species cause the remaining 20%. Although most women have no predisposing factors, certain conditions such as diabetes mellitus, drug use (antibiotics, steroids), pregnancy, and immunosuppression (HIV) may increase the likelihood of developing vaginal candidiasis. Symptoms include non-offensive discharge resembling cottage cheese, vulvitis, dyspareunia, dysuria, itching, vulval erythema, fissuring, and satellite lesions.

      Routine high vaginal swabs are not necessary if the clinical features are consistent with candidiasis. Treatment options include local or oral therapy. The NICE Clinical Knowledge Summaries recommends oral fluconazole 150 mg as a single dose as the first-line treatment. If oral therapy is contraindicated, a single dose of clotrimazole 500 mg intravaginal pessary may be used. If vulval symptoms are present, a topical imidazole may be added to an oral or intravaginal antifungal. Pregnant women should only use local treatments such as cream or pessaries, as oral treatments are not recommended.

      Recurrent vaginal candidiasis is defined as four or more episodes per year by BASHH. Compliance with previous treatment should be checked, and the diagnosis of candidiasis should be confirmed. A high vaginal swab for microscopy and culture may be necessary, and a blood glucose test should be performed to exclude diabetes. Differential diagnoses such as lichen sclerosus should also be ruled out. An induction-maintenance regime may be used, consisting of oral fluconazole every three days for three doses as induction, followed by oral fluconazole weekly for six months as maintenance.

    • This question is part of the following fields:

      • Gynaecology And Breast
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  • Question 19 - A 42-year-old male presents with jaundice and pruritus. He has a history of...

    Incorrect

    • A 42-year-old male presents with jaundice and pruritus. He has a history of ulcerative colitis and is currently taking sulfasalazine. He reports feeling increasingly tired and has noticed a yellow tint to his eyes. On examination, he has scratch marks on his skin, hepatomegaly, and his blood pressure is 136/88 mmHg with a pulse rate of 74. Blood tests reveal elevated levels of bilirubin, ALT, and ALP. What is the most likely underlying diagnosis?

      Your Answer:

      Correct Answer: Gallstones

      Explanation:

      Primary Sclerosing Cholangitis in Patients with Ulcerative Colitis

      Patients with elevated ALP levels may be incidentally picked up and require further investigation. However, those who are symptomatic may present with jaundice, pruritus, fatigue, and abdominal pain. Clinically, patients may also have hepatomegaly and be jaundiced.

      In the case of a patient with ulcerative colitis, the likelihood of primary sclerosing cholangitis (PSC) is significantly increased. Approximately 3% of UC sufferers have PSC, and 80% of those with PSC have UC. While gallstones in the common bile duct and liver cysts of hydatid disease can present with similar symptoms, the history of UC makes PSC a more likely diagnosis. Haemolytic anaemia and osteomalacia can cause elevated ALP levels, but they would not account for the cholestatic liver function and hepatomegaly seen in PSC.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 20 - A 55-year-old man presents to his General Practitioner concerned that he may be...

    Incorrect

    • A 55-year-old man presents to his General Practitioner concerned that he may be at an increased risk of developing colon cancer. His father died at the age of 56 from a sigmoid colon adenocarcinoma. His brother, aged 61, has just undergone a colectomy for a caecal carcinoma.
      What is the most appropriate management for this patient?

      Your Answer:

      Correct Answer: Refer for one-off colonoscopy aged 55

      Explanation:

      Screening Recommendations for Patients with Family History of Colorectal Cancer

      Patients with a family history of colorectal cancer may be at an increased risk of developing the disease. The British Society of Gastroenterology and the Association of Coloproctology for Great Britain and Ireland have produced screening guidelines for patients with family history profiles that place them in a moderate-risk category.

      Colonoscopy is recommended for patients with a family history of two first-degree relatives with a mean age of less than 60 years with colorectal cancer, starting at the age of 55. Abdominal ultrasound examination doesn’t have a role in screening for or diagnosing colorectal cancer.

      Patients with an increased risk should not be advised that they have no increased risk. Instead, they should be screened appropriately. Faecal immunochemical tests (FIT) are used to detect blood in the stool and are used in the national bowel cancer screening programme. However, patients with a higher risk, given their family history, should be offered earlier screening with colonoscopy rather than waiting until they are eligible for the national screening programme. False positives and negatives are possible with FIT, making colonoscopy a more reliable screening option for high-risk patients.

      Therefore, it is important for patients with a family history of colorectal cancer to be aware of the screening recommendations and to discuss their individual risk and screening options with their healthcare provider.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 21 - A 35-year-old man presents to the Emergency Department claiming to have lost the...

    Incorrect

    • A 35-year-old man presents to the Emergency Department claiming to have lost the vision in his left eye. While sitting at his desk he started to see a shower of black spots in his vision. These rapidly increased, becoming larger and more numerous until he could not see at all. This has persisted over a period of five hours. He has diabetes, which has been very poorly controlled in the past. He previously had laser treatment to both eyes; however, he has not attended follow-up appointments in the last 12 months.
      What is the most likely explanation for this patient's presentation?

      Your Answer:

      Correct Answer: He has had a vitreous haemorrhage due to diabetic retinopathy

      Explanation:

      Differentiating Causes of Visual Disturbances in a Diabetic Patient

      Visual disturbances in diabetic patients can have various causes, and it is important to differentiate between them to provide appropriate treatment. In the case of proliferative diabetic retinopathy, new blood vessels grow in the eyes and can bleed spontaneously, causing visual disturbances. Laser treatment is necessary, and follow-up is crucial to ensure sufficient therapy. Acute retinal detachment requires urgent surgery to prevent further vision loss. Fungal eye infections are rare and usually follow an injury. Visual disturbances due to hypoglycaemia are transient and resolve when blood glucose stabilises. In contrast, persistent and progressive loss of vision suggests a vitreous haemorrhage, as seen in poorly controlled diabetic retinopathy. Proper diagnosis and treatment can prevent further vision loss in diabetic patients.

    • This question is part of the following fields:

      • Eyes And Vision
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  • Question 22 - A young woman who is ten weeks pregnant comes to you with an...

    Incorrect

    • A young woman who is ten weeks pregnant comes to you with an erythematous rash, mild fever and enlarged glands in her neck. You suggest taking a blood test to check if she is immune to rubella since there is no record of her being immunised. She asks about the potential risk to her baby if she does have rubella. What is the percentage of infants that may develop congenital rubella syndrome and potential birth defects if a woman contracts rubella at ten weeks gestation?

      Your Answer:

      Correct Answer: Up to 90%

      Explanation:

      Maternal Rubella Infection in Pregnancy

      Maternal rubella infection during pregnancy can lead to fetal loss or congenital rubella syndrome (CRS). CRS is characterized by various abnormalities such as cataracts, deafness, cardiac defects, microcephaly, retardation of intrauterine growth, and inflammatory lesions in the brain, liver, lungs, and bone marrow.

      If the infection occurs within the first eight to ten weeks of pregnancy, up to 90% of surviving infants may experience damage, often with multiple defects. However, the risk of damage decreases to about 10-20% if the infection occurs between 11 and 16 weeks of gestation. Infections after 16 weeks of pregnancy are rare and typically only result in deafness, with no other fetal damage reported up to 20 weeks of pregnancy.

      Overall, maternal rubella infection during pregnancy can have severe consequences for the developing fetus, highlighting the importance of vaccination and prevention measures.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 23 - You decide to do a practice audit of your pediatric repeat prescribing system.
    You...

    Incorrect

    • You decide to do a practice audit of your pediatric repeat prescribing system.
      You have a discussion with your colleagues about the expected rate of prescribing errors in this population.
      What percentage of pediatric prescriptions, upon evaluation, exhibit a prescribing or monitoring mistake?

      Your Answer:

      Correct Answer: Around 75%

      Explanation:

      GMC Study on Prescribing and Monitoring Errors in the UK

      A recent study conducted by the General Medical Council (GMC) in the UK has shed light on the frequency and causes of prescribing and monitoring errors. The study analyzed 6,000 prescriptions and found that nearly 5% of them contained errors related to prescribing or monitoring. The most common cause of these errors was incomplete information on the prescription, accounting for a third of all errors identified.

      This study provides valuable insights into the activities that can lead to prescribing and monitoring errors, helping to guide healthcare professionals towards safer practices. While exact figures may not be expected in an AKT examination, knowledge of the general outcomes of this study is reasonable and can be useful in clinical practice. By understanding the common causes of prescribing and monitoring errors, healthcare professionals can take steps to minimize the risk of such errors occurring in the future.

    • This question is part of the following fields:

      • Improving Quality, Safety And Prescribing
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  • Question 24 - Which of the following side-effects is often overlooked in individuals undergoing ciclosporin treatment?...

    Incorrect

    • Which of the following side-effects is often overlooked in individuals undergoing ciclosporin treatment?

      Your Answer:

      Correct Answer: Hypokalaemia

      Explanation:

      Ciclosporin usage leads to an increase in various bodily functions such as fluid retention, blood pressure, potassium levels, hair growth, gum health, and glucose levels. Interestingly, hyperkalaemia is more commonly observed than hypokalaemia with the use of ciclosporin.

      Understanding Ciclosporin: An Immunosuppressant Drug

      Ciclosporin is a medication that is used as an immunosuppressant. It works by reducing the clonal proliferation of T cells by decreasing the release of IL-2. The drug binds to cyclophilin, forming a complex that inhibits calcineurin, a phosphatase that activates various transcription factors in T cells.

      Despite its effectiveness, Ciclosporin has several adverse effects. It can cause nephrotoxicity, hepatotoxicity, fluid retention, hypertension, hyperkalaemia, hypertrichosis, gingival hyperplasia, tremors, impaired glucose tolerance, hyperlipidaemia, and increased susceptibility to severe infection. However, it is interesting to note that Ciclosporin is virtually non-myelotoxic, which means it doesn’t affect the bone marrow.

      Ciclosporin is used to treat various conditions such as following organ transplantation, rheumatoid arthritis, psoriasis, ulcerative colitis, and pure red cell aplasia. It has a direct effect on keratinocytes and modulates T cell function, making it an effective treatment for psoriasis.

      In conclusion, Ciclosporin is a potent immunosuppressant drug that can effectively treat various conditions. However, it is essential to monitor patients for adverse effects and adjust the dosage accordingly.

    • This question is part of the following fields:

      • Improving Quality, Safety And Prescribing
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  • Question 25 - A 35-year-old primiparous woman is concerned about her risk of developing gestational diabetes...

    Incorrect

    • A 35-year-old primiparous woman is concerned about her risk of developing gestational diabetes due to a friend's experience. According to NICE, what risk factor would require an oral glucose tolerance test to investigate for gestational diabetes?

      Your Answer:

      Correct Answer: Father has non-insulin dependent diabetes

      Explanation:

      According to NICE guidelines, screening for gestational diabetes should be done for women who have a first degree relative with non-insulin dependent diabetes. Additionally, if a second urine dipstick test is positive for glucose, it may also indicate the need for further investigation. However, a birth weight of 4.3kg falls within the normal range of 2.5-4.5kg and would not be a sufficient reason to conduct a glucose tolerance test.

      Gestational diabetes is a common medical disorder that affects around 4% of pregnancies. It can develop during pregnancy or be a pre-existing condition. According to NICE, 87.5% of cases are gestational diabetes, 7.5% are type 1 diabetes, and 5% are type 2 diabetes. Risk factors for gestational diabetes include a BMI of > 30 kg/m², previous gestational diabetes, a family history of diabetes, and family origin with a high prevalence of diabetes. Screening for gestational diabetes involves an oral glucose tolerance test (OGTT), which should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal.

      To diagnose gestational diabetes, NICE recommends using the following thresholds: fasting glucose is >= 5.6 mmol/L or 2-hour glucose is >= 7.8 mmol/L. Newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week and taught about self-monitoring of blood glucose. Advice about diet and exercise should be given, and if glucose targets are not met within 1-2 weeks of altering diet/exercise, metformin should be started. If glucose targets are still not met, insulin should be added to the treatment plan.

      For women with pre-existing diabetes, weight loss is recommended for those with a BMI of > 27 kg/m^2. Oral hypoglycaemic agents, apart from metformin, should be stopped, and insulin should be commenced. Folic acid 5 mg/day should be taken from preconception to 12 weeks gestation, and a detailed anomaly scan at 20 weeks, including four-chamber view of the heart and outflow tracts, should be performed. Tight glycaemic control reduces complication rates, and retinopathy should be treated as it can worsen during pregnancy.

      Targets for self-monitoring of pregnant women with diabetes include a fasting glucose level of 5.3 mmol/l and a 1-hour or 2-hour glucose level after meals of 7.8 mmol/l or 6.4 mmol/l, respectively. It is important to manage gestational diabetes and pre-existing diabetes during pregnancy to reduce the risk of complications for both the mother and baby.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
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  • Question 26 - An 80-year-old gentleman presents with an infective exacerbation of his bronchiectasis. Following clinical...

    Incorrect

    • An 80-year-old gentleman presents with an infective exacerbation of his bronchiectasis. Following clinical assessment you decide to treat him with a course of antibiotics. He has a past medical history of atrial fibrillation for which he takes lifelong warfarin. His notes state he is penicillin allergic and the patient confirms a history of a true allergy.

      You decide to prescribe a course of doxycycline, 200 mg on day 1 then 100 mg daily to complete a 14 day course.

      You can see his INR is very well managed and is consistently between 2.0 and 3.0 and he has been taking 3 mg and 4 mg on alternate days for the last six months without the need for any dose changes.

      What is the most appropriate management of his warfarin therapy during the treatment of this acute exacerbation?

      Your Answer:

      Correct Answer: Check his INR three to five days after starting the doxycycline

      Explanation:

      Managing Warfarin Patients on Antibiotics

      When a patient on warfarin requires antibiotics, it is a common clinical scenario that requires careful management. While there is no need to stop warfarin or switch to aspirin, it is important to monitor the patient’s INR levels closely. Typically, extra INR monitoring should be performed three to five days after starting the antibiotics to check for any potential impact on the INR. If necessary, a dosing change for warfarin may be needed.

      According to the British Committee for Standards in Haematology Guidelines for oral anticoagulation with warfarin (2011), it is important to follow specific recommendations for INR testing when a potential drug interaction occurs. By carefully monitoring INR levels and adjusting warfarin dosing as needed, healthcare providers can help ensure the safety and efficacy of treatment for patients on warfarin who require antibiotics.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 27 - 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:

      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.

    • This question is part of the following fields:

      • Infectious Disease And Travel Health
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  • Question 28 - A 59-year-old woman has been experiencing fatigue and difficulty breathing. She follows a...

    Incorrect

    • A 59-year-old woman has been experiencing fatigue and difficulty breathing. She follows a lacto-vegetarian diet and takes ramipril and indapamide for high blood pressure. Upon examination, she appears pale and has glossitis, but no neurological symptoms. Her blood test results show a low hemoglobin level, low white blood cell count, low platelet count, high mean corpuscular volume, and the presence of oval macrocytes, hypersegmented neutrophils, and circulating megaloblasts. Her ferritin level is within normal range, but her serum folate and vitamin B12 levels are low. What is the most likely cause of her symptoms?

      Your Answer:

      Correct Answer: Pernicious anaemia

      Explanation:

      Causes of Vitamin B12 Deficiency and Pernicious Anaemia

      Vitamin B12 deficiency can lead to megaloblastic anaemia, with pernicious anaemia being the most common cause due to impaired absorption of the vitamin. Other causes include coeliac disease, pancreatic disease, malabsorption, ileal resection, Crohn’s disease, chronic tropical sprue, HIV, and radiotherapy affecting the ileum. Folate and iron deficiency may also be present. Helicobacter pylori infection, gastrectomy, gastric resection, and atrophic gastritis can also cause B12 deficiency. A vegan diet may result in deficiency, but many vegan foods are now fortified with vitamins, including B12. Drug-induced deficiency can occur with colchicine, metformin, and long-term use of drugs affecting gastric acid production. This patient has no history or symptoms suggestive of these causes.

    • This question is part of the following fields:

      • Haematology
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  • Question 29 - Sophie is a 4-year-old girl who has been brought in by her father...

    Incorrect

    • Sophie is a 4-year-old girl who has been brought in by her father with a 2 day history of cough and fever. Her father describes the cough sounds like a bark and today Sophie has appeared more breathless.

      On examination, Sophie appears alert with moist mucous membranes. You observe nasal flaring and moderate intercostal recession. You check Sophie's temperature which is 38.2°C and oxygen saturation is 97% in air. Her respiratory rate is 52 breaths per minute and heart rate is 138 beats per minute.

      What red flag symptoms have you observed in Sophie?

      Your Answer:

      Correct Answer: Moderate intercostal recession

      Explanation:

      When a child has a fever, moderate or severe intercostal recession is a concerning symptom. This is considered a red flag according to NICE guidelines, which indicate a high risk of serious illness. Other red flag symptoms include those in the amber risk category, such as nasal flaring and a respiratory rate over 40 breaths per minute for children over 12 months old. A heart rate of 138 beats per minute is not a red flag symptom, but a heart rate over 140 beats per minute for children aged 2-5 years is considered an amber symptom. A temperature of 38°C or higher is only a red flag symptom for infants aged 0-3 months.

      The NICE Feverish illness in children guidelines were introduced in 2007 and updated in 2013 to provide a ‘traffic light’ system for assessing the risk of febrile illness in children under 5 years old. The guidelines recommend recording the child’s temperature, heart rate, respiratory rate, and capillary refill time, as well as looking for signs of dehydration. Measuring temperature should be done with an electronic thermometer in the axilla for children under 4 weeks or with an electronic/chemical dot thermometer in the axilla or an infra-red tympanic thermometer. The risk stratification table categorizes children as green (low risk), amber (intermediate risk), or red (high risk) based on their symptoms. Management recommendations vary depending on the risk level, with green children managed at home, amber children provided with a safety net or referred to a specialist, and red children urgently referred to a specialist. The guidelines also advise against prescribing oral antibiotics without an apparent source of fever and note that a chest x-ray is not necessary if a child with suspected pneumonia is not being referred to the hospital.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 30 - A 27-year-old female with epilepsy controlled on topiramate is seeking advice on contraception...

    Incorrect

    • A 27-year-old female with epilepsy controlled on topiramate is seeking advice on contraception options that will not interfere with her medication. She desires a reliable method due to concerns about teratogenicity. What type of contraception would be suitable to recommend while taking an enzyme-inducing medication?

      Your Answer:

      Correct Answer: Injectable progesterone (Depo- provera)

      Explanation:

      According to the guidelines of the Faculty of Sexual and Reproductive Health and the BNF, the recommended contraceptive method in this case is injectable progesterone. This method is not affected by drug interactions. However, as topiramate is an enzyme inducer, it can reduce the effectiveness of oestrogens and progesterone, which are components of combined contraceptive pills. Therefore, if a combined contraceptive pill is to be used, it should contain at least 50 micrograms of ethinyl estradiol. Barrier methods alone are not reliable and should not be used as the sole form of contraception. Progesterone-only pills and implants are not suitable due to the enhanced first pass metabolism of progesterone, which can result in decreased contraceptive efficacy.

      Contraception for Women with Epilepsy

      Women with epilepsy need to consider several factors when choosing a contraceptive method. The effectiveness of anti-epileptic medication can be affected by the contraceptive, and vice versa. Additionally, if a woman becomes pregnant while taking anti-epileptic medication, there is a risk of teratogenic effects on the fetus. To address these concerns, the Faculty of Sexual & Reproductive Healthcare (FSRH) recommends the consistent use of condoms in addition to other forms of contraception.

      For women taking certain anti-epileptic medications such as phenytoin, carbamazepine, barbiturates, primidone, topiramate, and oxcarbazepine, the FSRH recommends using the combined oral contraceptive pill (COCP) or progestogen-only pill (POP) with a UK Medical Eligibility Criteria (UKMEC) rating of 3. The implant has a UKMEC rating of 2, while the Depo-Provera injection, intrauterine device (IUD), and intrauterine system (IUS) have a UKMEC rating of 1.

      For women taking lamotrigine, the FSRH recommends using the COCP with a UKMEC rating of 3 or the POP, implant, Depo-Provera injection, IUD, or IUS with a UKMEC rating of 1. If a COCP is chosen, it should contain a minimum of 30 µg of ethinylestradiol.

      In summary, women with epilepsy should carefully consider the potential interactions between their anti-epileptic medication and their chosen contraceptive method. Using condoms consistently in addition to other forms of contraception can help reduce the risk of unintended pregnancy and potential teratogenic effects on the fetus.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
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SESSION STATS - PERFORMANCE PER SPECIALTY

Dermatology (1/1) 100%
Children And Young People (1/1) 100%
End Of Life (0/1) 0%
Respiratory Health (1/1) 100%
Passmed