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Question 1
Incorrect
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You perform an annual medication review of a 68-year-old man with chronic kidney disease (CKD) stage 5 (GFR <15 ml/min/1.73 m2) on dialysis.
Which of the following is the most likely cause of death in this group of patients?Your Answer: Hyperkalaemia
Correct Answer: Cardiovascular disease
Explanation:Common Causes of Mortality in Dialysis Patients
Cardiovascular disease is the leading cause of death in the dialysis population, with mortality rates 10-20 times higher than the general population. Hyperkalaemia, often resulting from missed dialysis or dietary indiscretion, is the most common cause of sudden death in end-stage renal disease patients. Hypocalcaemia is a common manifestation of CKD and should be treated with calcium supplements. While there is no known association between reduced renal function and overall cancer risk, some studies suggest an increased risk of urinary, endocrine, and digestive tract cancers among dialysis patients. Sepsis related to dialysis is rare with modern techniques, but minimizing the use of temporary catheters can further reduce the risk.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 2
Incorrect
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A 26 year-old woman, who is 36 weeks pregnant, presents to her GP with a blood pressure reading of 170/110 mmHg. She is feeling well otherwise and is currently taking 250 mg labetalol. Urinalysis shows 3+ proteinuria. Fetal monitoring is normal. Her blood tests reveal a hemoglobin level of 135 g/l, platelet count of 280 * 109/l, white blood cell count of 6.0 * 109/l, sodium level of 142 mmol/l, potassium level of 4.0 mmol/l, urea level of 2.8 mmol/l, and creatinine level of 24 µmol/l. What is the most appropriate course of action for her management?
Your Answer: Increase labetalol and organise a follow up with the community midwife
Correct Answer: Admit the patient to hospital as an emergency
Explanation:Despite the absence of symptoms, the patient’s blood pressure remains elevated at a level exceeding 160/100 mmHg, and there is also significant proteinuria, despite receiving labetalol treatment. As a result, emergency admission is necessary to monitor and manage the hypertension in a controlled setting. If there is no improvement, delivery may be considered as an option.
Hypertension during pregnancy is a common occurrence that requires careful management. In normal pregnancies, blood pressure tends to decrease in the first trimester and then gradually increase to pre-pregnancy levels by term. However, in cases of hypertension during pregnancy, the systolic blood pressure is usually above 140 mmHg or the diastolic blood pressure is above 90 mmHg. Additionally, an increase of more than 30 mmHg systolic or 15 mmHg diastolic from the initial readings may also indicate hypertension.
There are three categories of hypertension during pregnancy: pre-existing hypertension, pregnancy-induced hypertension (PIH), and pre-eclampsia. Pre-existing hypertension refers to a history of hypertension before pregnancy or elevated blood pressure before 20 weeks gestation. PIH occurs in the second half of pregnancy and resolves after birth. Pre-eclampsia is characterized by hypertension and proteinuria, and may also involve edema.
The management of hypertension during pregnancy involves the use of antihypertensive medications such as labetalol, nifedipine, and hydralazine. In cases of pre-existing hypertension, ACE inhibitors and angiotensin II receptor blockers should be stopped immediately and alternative medications should be prescribed. Women who are at high risk of developing pre-eclampsia should take aspirin from 12 weeks until the birth of the baby. It is important to carefully monitor blood pressure and proteinuria levels during pregnancy to ensure the health of both the mother and the baby.
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This question is part of the following fields:
- Reproductive Medicine
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Question 3
Correct
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A 45-year-old woman, with a history of gallstones, arrives at the emergency department complaining of central abdominal pain that radiates to her back. Upon conducting blood tests, you observe the following result:
Amylase 480 U/L (30 - 110). The patient is diagnosed with acute pancreatitis and inquires about the severity of her condition. What is the primary factor in determining the clinical severity of acute pancreatitis?Your Answer: Presence of any systemic or local complications
Explanation:When determining the severity of pancreatitis, the presence of systemic or local complications is the most important factor to consider. Mild acute pancreatitis is characterized by the absence of both organ failure and local complications. Local complications in severe cases may include peripancreatic fluid collections, pancreatic or peripancreatic necrosis, pseudocysts, and walled-off areas of necrosis. The Atlanta classification system categorizes acute pancreatitis as mild, moderate, or severe. Mild cases have no organ failure, local or systemic complications, and typically resolve within a week. Pain level and initial CRP levels are not used to classify severity, but a high white blood cell count may indicate an increased risk of severe pancreatitis. Serum amylase levels and pancreatic calcification on CT scans are also not reliable indicators of severity.
Managing Acute Pancreatitis in a Hospital Setting
Acute pancreatitis is a serious condition that requires management in a hospital setting. The severity of the condition can be stratified based on the presence of organ failure and local complications. Key aspects of care include fluid resuscitation, aggressive early hydration with crystalloids, and adequate pain management with intravenous opioids. Patients should not be made ‘nil-by-mouth’ unless there is a clear reason, and enteral nutrition should be offered within 72 hours of presentation. Antibiotics should not be used prophylactically, but may be indicated in cases of infected pancreatic necrosis. Surgery may be necessary for patients with acute pancreatitis due to gallstones or obstructed biliary systems, and those with infected necrosis may require radiological drainage or surgical necrosectomy.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 4
Incorrect
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A 32-year-old woman presents to the Emergency Department with complaints of a headache. She has been experiencing flu-like symptoms for the past three days and the headache started gradually yesterday. The headache is described as being all over and worsens when looking at bright light or bending her neck. Upon examination, her temperature is 38.2º, pulse is 96/min, and blood pressure is 116/78 mmHg. There is neck stiffness present, but no focal neurological signs are observed. During a closer inspection, several petechiae are noticed on her torso. The patient has been cannulated and bloods, including cultures, have been taken. What is the most appropriate next step?
Your Answer: Intramuscular benzypenicillin
Correct Answer: IV cefotaxime
Explanation:Immediate administration of appropriate intravenous antibiotics is crucial for this patient diagnosed with meningococcal meningitis. In light of modern PCR diagnostic techniques, there is no need to delay potentially life-saving treatment by conducting a lumbar puncture in suspected cases of meningococcal meningitis.
The investigation and management of suspected bacterial meningitis are intertwined due to the potential negative impact of delayed antibiotic treatment. Patients should be urgently transferred to the hospital, and an ABC approach should be taken initially. A lumbar puncture should be delayed in certain circumstances, and IV antibiotics should be given as a priority if there is any doubt. The bloods and CSF should be tested for various parameters, and prophylaxis should be offered to households and close contacts of patients affected with meningococcal meningitis.
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This question is part of the following fields:
- Infectious Diseases
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Question 5
Correct
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A 42-year-old woman with a history of rheumatic heart disease is urgently admitted with a fever, worsening shortness of breath, and a note from her primary care physician confirming the presence of a new heart murmur. During the examination, a harsh pansystolic murmur and early diastolic murmur are detected, and she has a temperature of 38.5 °C with fine basal crepitations in both lungs. Which one of the following should take immediate priority?
Your Answer: Administration of intravenous (IV) antibiotics
Explanation:Prioritizing Interventions in Suspected Infective Endocarditis
When a patient presents with suspected infective endocarditis, prompt intervention is crucial to limit valve destruction and prevent potentially life-threatening complications. The following interventions should be considered, prioritized, and administered as soon as possible:
Administration of intravenous (IV) antibiotics: Empirical treatment with gentamicin and benzylpenicillin may be initiated until microbiological advice suggests an alternative. Antibiotic delivery should take priority over other interventions.
Administration of paracetamol: Fever is a common symptom of infective endocarditis, and paracetamol can provide symptomatic relief. However, it should not take priority over antibiotic delivery.
Echocardiogram (ECHO): An ECHO is an important diagnostic tool for identifying infective endocarditis and detecting complications such as cardiac abscess and pseudoaneurysms. While it should be performed in all suspected cases, it does not take priority over antibiotic administration.
Electrocardiogram (ECG): An ECG can provide additional diagnostic information, including signs of paravalvular extension of infection and emboli in the coronary circulation. It should be part of the initial workup but does not take priority over antibiotic administration.
Throat swab: While a throat swab may be useful in identifying the causative organism of infective endocarditis, it should not take precedence over commencing antibiotics. Careful examination of the patient’s dentition is also crucial to evaluate for a possible infectious source.
In summary, when managing suspected infective endocarditis, prompt administration of IV antibiotics should take priority over other interventions. Other diagnostic and therapeutic interventions should be considered and prioritized based on the individual patient’s clinical presentation and needs.
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This question is part of the following fields:
- Cardiovascular
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Question 6
Correct
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A young lady requests for the 'morning after pill'. Within what timeframe after sexual intercourse is levonorgestrel approved for use?
Your Answer: 72 hours
Explanation:Levonorgestrel should be taken within 72 hours of unprotected sexual intercourse (UPSI). Administration of a single dose of levonorgestrel after this time is not licensed but may be considered.
Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.
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This question is part of the following fields:
- Reproductive Medicine
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Question 7
Correct
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A 35-year-old woman comes back from a trip. During her final day overseas, she had lunch from an unlicensed street food vendor. After eight days of returning home, she encounters bloating, abdominal discomfort, and non-bloody diarrhea, and she observes that her stools are floating in the toilet bowl. The patient's symptoms persist for nine weeks. What is the probable pathogen responsible for the patient's symptoms?
Your Answer: Giardia
Explanation:Chronic Giardia infection can lead to malabsorption.
Giardia is a type of protozoan that can be transmitted through the ingestion of contaminated fecal matter. While giardiasis typically resolves within a few weeks, if the infection persists for more than six weeks, it is considered chronic. Chronic Giardia infection can cause malabsorption of various nutrients, including vitamin A, B12, iron, zinc, and lipids. This malabsorption can result in steatorrhea, which is characterized by greasy, foul-smelling stools that float in the toilet bowl.
It is important to note that other pathogens, such as Entamoeba histolytica, Escherichia coli, and Salmonella, do not commonly cause malabsorption. While they may cause diarrhea and other gastrointestinal symptoms, they do not typically result in the malabsorption of nutrients.
Understanding Giardiasis
Giardiasis is a condition caused by a type of protozoan called Giardia lamblia. It is transmitted through the faeco-oral route and can be contracted through various means such as foreign travel, drinking water from rivers or lakes, and even male-male sexual contact. While some individuals may not experience any symptoms, others may suffer from non-bloody diarrhea, bloating, abdominal pain, lethargy, flatulence, and weight loss. In severe cases, malabsorption and lactose intolerance may occur. Diagnosis can be made through stool microscopy, stool antigen detection assay, or PCR assays. Treatment typically involves the use of metronidazole.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 8
Incorrect
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You are evaluating a patient who is experiencing hip discomfort. Do you suspect osteoarthritis as the diagnosis? If so, what signs or symptoms would warrant additional testing for a different diagnosis?
Your Answer: A history of development dysplasia of the hip
Correct Answer: Morning stiffness lasting 4 hours
Explanation:If morning stiffness persists for more than 2 hours, it could be a sign of inflammatory arthritis and should be investigated further.
Osteoarthritis (OA) of the hip is a prevalent condition, with the knee being the only joint more commonly affected. It is particularly prevalent in older individuals, and women are twice as likely to develop it. Obesity and developmental dysplasia of the hip are also risk factors. The condition is characterized by chronic groin pain that is exacerbated by exercise and relieved by rest. However, if the pain is present at rest, at night, or in the morning for more than two hours, it may indicate an alternative cause. The Oxford Hip Score is a widely used tool to assess the severity of the condition.
If the symptoms are typical, a clinical diagnosis can be made. Otherwise, plain x-rays are the first-line investigation. Management of OA of the hip includes oral analgesia and intra-articular injections, which provide short-term relief. However, total hip replacement is the definitive treatment.
Total hip replacement is a common operation in the developed world, but it is not without risks. Perioperative complications include venous thromboembolism, intraoperative fracture, nerve injury, surgical site infection, and leg length discrepancy. Postoperatively, posterior dislocation may occur during extremes of hip flexion, presenting with a clunk, pain, and inability to weight bear. Aseptic loosening is the most common reason for revision, and prosthetic joint infection is also a potential complication.
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This question is part of the following fields:
- Musculoskeletal
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Question 9
Incorrect
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A 45-year-old man complains of lower back pain and 'sciatica' that has been bothering him for the past few days. He reports feeling a sudden 'pop' while lifting a heavy object, and now experiences severe pain that radiates from his back down his left leg. During the examination, he reports experiencing paraesthesia on the lateral aspect of his left foot and the posterior aspect of his thigh. Muscle strength is normal, but the left knee reflex is reduced. The straight leg raise test is positive on the left side. Which nerve root is most likely affected?
Your Answer: L3
Correct Answer: L4
Explanation:Understanding Prolapsed Disc and its Features
A prolapsed lumbar disc is a common cause of lower back pain that can lead to neurological deficits. It is characterized by clear dermatomal leg pain, which is usually worse than the back pain. The pain is often aggravated when sitting. The features of the prolapsed disc depend on the site of compression. For instance, L3 nerve root compression can cause sensory loss over the anterior thigh, weak quadriceps, reduced knee reflex, and a positive femoral stretch test. On the other hand, L4 nerve root compression can lead to sensory loss in the anterior aspect of the knee, weak quadriceps, reduced knee reflex, and a positive femoral stretch test.
The management of prolapsed disc is similar to that of other musculoskeletal lower back pain. It involves analgesia, physiotherapy, and exercises. According to NICE, the first-line treatment for back pain without sciatica symptoms is NSAIDs +/- proton pump inhibitors, rather than neuropathic analgesia. If the symptoms persist after 4-6 weeks, referral for consideration of MRI is appropriate. Understanding the features of prolapsed disc can help in the diagnosis and management of this condition.
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This question is part of the following fields:
- Musculoskeletal
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Question 10
Correct
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A 62-year-old man visits his GP complaining of recurring central chest pain during physical activity. He reports no chest pain while at rest. The patient was diagnosed with angina six months ago and has been taking verapamil and GTN spray. His medical history includes hypertension, asthma, and osteoarthritis of the right knee. What medication should the doctor prescribe?
Your Answer: Isosorbide mononitrate
Explanation:If a patient with symptomatic stable angina is already on a calcium channel blocker but cannot take a beta-blocker due to a contraindication, the next step in treatment should involve long-acting nitrates, ivabradine, nicorandil, or ranolazine. This scenario involves a 64-year-old man who experiences recurring chest pain during physical activity, which is likely due to poorly controlled stable angina. Although calcium channel blockers and beta-blockers are typically the first-line treatment for stable angina, the patient’s history of asthma makes beta-blockers unsuitable. As the initial treatment has not been effective, the patient should try the next line of therapy. Atenolol, bisoprolol, and diltiazem are not appropriate options for this patient due to their potential risks and lack of effectiveness in this case.
Angina pectoris is a condition that can be managed through various methods, including lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. The first-line medication should be either a beta-blocker or a calcium channel blocker, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If the initial treatment is not effective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, other drugs such as long-acting nitrates, ivabradine, nicorandil, or ranolazine can be considered. Nitrate tolerance is a common issue, and patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. This effect is not seen in patients who take once-daily modified-release isosorbide mononitrate. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.
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This question is part of the following fields:
- Cardiovascular
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Question 11
Incorrect
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A 65-year-old man with a history of Parkinson's disease comes to the clinic complaining of an itchy, red rash on his neck, behind his ears, and around the nasolabial folds. He experienced a similar outbreak last year but did not seek medical attention. What is the probable diagnosis?
Your Answer: Levodopa associated dermatitis
Correct Answer: Seborrhoeic dermatitis
Explanation:Patients with Parkinson’s disease are more likely to experience seborrhoeic dermatitis.
Understanding Seborrhoeic Dermatitis in Adults
Seborrhoeic dermatitis is a chronic skin condition that affects around 2% of the general population. It is caused by an inflammatory reaction related to the overgrowth of a fungus called Malassezia furfur, which is a normal inhabitant of the skin. The condition is characterized by eczematous lesions that appear on the sebum-rich areas of the body, such as the scalp, periorbital, auricular, and nasolabial folds. It can also lead to the development of otitis externa and blepharitis.
Seborrhoeic dermatitis is often associated with other medical conditions, such as HIV and Parkinson’s disease. The management of the condition depends on the affected area. For scalp disease, over-the-counter preparations containing zinc pyrithione and tar are usually the first-line treatment. If these are not effective, ketoconazole is the preferred second-line agent. Selenium sulphide and topical corticosteroids may also be useful.
For the face and body, topical antifungals such as ketoconazole and topical steroids are often used. However, it is important to use steroids for short periods only to avoid side effects. Seborrhoeic dermatitis can be difficult to treat, and recurrences are common. Therefore, it is important to work closely with a healthcare provider to manage the condition effectively.
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This question is part of the following fields:
- Dermatology
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Question 12
Correct
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Given that PKU is an autosomal-recessive condition that can be diagnosed at birth or in adolescence and adulthood, a teenager seeks genetic counselling. His mother and brother have PKU, while his father is a carrier but does not have the disease. The teenager himself does not have PKU. What is the probability that he is a carrier of the disease?
Your Answer: 100%
Explanation:Understanding Autosomal-Recessive Inheritance and Phenylketonuria (PKU)
Autosomal-recessive diseases require both parents to carry the gene, with one parent having the disease and the other being a carrier. In the case of Phenylketonuria (PKU), a specific enzyme deficiency leads to the accumulation of phenylalanine and a deficiency of tyrosine, resulting in reduced melanin and pigmented areas of the brain being affected. PKU is tested for at birth using the Guthrie test and can be treated by removing phenylalanine from the diet.
In the given scenario, the teenager’s mother has the disease and his father is a carrier. This means there is a 100% chance that the teenager has at least one abnormal copy of the gene, making him a carrier. It is important to understand the inheritance pattern of autosomal-recessive diseases to identify carriers and prevent mental retardation in affected children.
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This question is part of the following fields:
- Genetics
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Question 13
Correct
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You are on a GP placement and seeing a 44-year-old woman with a history of depression. She has recently gone through a divorce and admits to having thoughts of taking an overdose. She has never attempted suicide before, but feels like she has no other options. She has the pills at home and is considering taking them. She denies any substance abuse. What is the appropriate course of action in this situation?
Your Answer: Speak to the CRISIS team
Explanation:This scenario requires you to demonstrate your ability to evaluate and handle a patient who is contemplating suicide. The patient in question has several risk factors, including being male, having a history of depression, recently going through a separation, and expressing a desire to end his life in the future. It is crucial to respond appropriately in this situation. The most suitable team to evaluate and manage this patient is the CRISIS team, who can provide urgent assessment and care.
The other options are not as effective. Transferring the patient to the Emergency Department would only delay the referral to the crisis team. CAMH, which stands for child and adolescent mental health, is not the appropriate team to handle this case. It is not within your professional scope to initiate relationship counseling. Given the patient’s numerous risk factors, it would not be safe to discharge him without a psychiatric evaluation.
In 2022, NICE updated its guidelines on managing depression and now classifies it as either less severe or more severe based on a patient’s PHQ-9 score. For less severe depression, NICE recommends discussing treatment options with patients and considering the least intrusive and resource-intensive treatment first. Antidepressant medication should not be routinely offered as first-line treatment unless it is the patient’s preference. Treatment options for less severe depression include guided self-help, group cognitive behavioral therapy, group behavioral activation, individual CBT or BA, group exercise, group mindfulness and meditation, interpersonal psychotherapy, SSRIs, counseling, and short-term psychodynamic psychotherapy. For more severe depression, NICE recommends a shared decision-making approach and suggests a combination of individual CBT and an antidepressant as the preferred treatment option. Other treatment options for more severe depression include individual CBT or BA, antidepressant medication, individual problem-solving, counseling, short-term psychodynamic psychotherapy, interpersonal psychotherapy, guided self-help, and group exercise.
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This question is part of the following fields:
- Psychiatry
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Question 14
Correct
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A 26-year-old female presents for follow-up. She was diagnosed with asthma four years ago and is currently utilizing a salbutamol inhaler 100mcg as needed in combination with beclometasone dipropionate inhaler 200 mcg twice daily. However, her asthma remains poorly controlled. Upon examination, her chest is clear and she demonstrates proper inhaler technique. In accordance with NICE recommendations, what is the most suitable course of action for further management?
Your Answer: Add a leukotriene receptor antagonist
Explanation:According to NICE 2017 guidelines, if a patient with asthma is not effectively managed with a SABA + ICS, the first step should be to add a LTRA rather than a LABA.
The management of asthma in adults has been updated by NICE in 2017, following the 2016 BTS guidelines. One of the significant changes is in ‘step 3’, where patients on a SABA + ICS whose asthma is not well controlled should be offered a leukotriene receptor antagonist instead of a LABA. NICE does not follow the stepwise approach of the previous BTS guidelines, but to make the guidelines easier to follow, we have added our own steps. The steps range from newly-diagnosed asthma to SABA +/- LTRA + one of the following options, including increasing ICS to high-dose, a trial of an additional drug, or seeking advice from a healthcare professional with expertise in asthma. Maintenance and reliever therapy (MART) is a form of combined ICS and LABA treatment that is only available for ICS and LABA combinations in which the LABA has a fast-acting component. It should be noted that NICE does not recommend changing treatment in patients who have well-controlled asthma simply to adhere to the latest guidance. The definitions of what constitutes a low, moderate, or high-dose ICS have also changed, with <= 400 micrograms budesonide or equivalent being a low dose, 400 micrograms - 800 micrograms budesonide or equivalent being a moderate dose, and > 800 micrograms budesonide or equivalent being a high dose for adults.
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This question is part of the following fields:
- Respiratory Medicine
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Question 15
Incorrect
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An 82-year-old man arrives at the emergency department with haematemesis that began 45 minutes ago. He has a history of chronic back pain and takes ibuprofen, as well as warfarin for his atrial fibrillation. The medical team initiates resuscitation and places two large-bore cannulas. What is the appropriate management for this patient in an acute setting?
Your Answer: IV proton pump inhibitors and prothrombin complex concentrate
Correct Answer: IV prothrombin complex concentrate
Explanation:There is insufficient evidence to support the use of PPIs in stopping bleeding, as in most cases, bleeding ceases without their administration. Administering IV proton pump inhibitors and fresh frozen plasma prior to endoscopy is incorrect, as PPIs should not be given and fresh frozen plasma should only be given to patients with specific blood clotting abnormalities.
Acute upper gastrointestinal bleeding is a common and significant medical issue that can be caused by various conditions, with oesophageal varices and peptic ulcer disease being the most common. The clinical features of this condition include haematemesis, melena, and a raised urea level due to the protein meal of the blood. The differential diagnosis for acute upper gastrointestinal bleeding includes oesophageal, gastric, and duodenal causes.
The management of acute upper gastrointestinal bleeding involves risk assessment using the Glasgow-Blatchford score, which helps clinicians decide whether patients can be managed as outpatients or not. Resuscitation is also necessary, including ABC, wide-bore intravenous access, and platelet transfusion if actively bleeding platelet count is less than 50 x 10*9/litre. Endoscopy should be offered immediately after resuscitation in patients with a severe bleed, and all patients should have endoscopy within 24 hours.
For non-variceal bleeding, proton pump inhibitors (PPIs) should not be given before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding. However, PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy. If further bleeding occurs, options include repeat endoscopy, interventional radiology, and surgery. For variceal bleeding, terlipressin and prophylactic antibiotics should be given to patients at presentation, and band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices. Transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 16
Incorrect
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A 36-year-old entrepreneur arrives at Eye Casualty complaining of blurred vision in both eyes that started an hour ago. He reports seeing multiple wavy and shimmering lines in his peripheral vision that are gradually getting bigger. Upon examination with a slit lamp, the anterior chamber is clear and the fundus appears normal. What is the probable reason for his symptoms?
Your Answer: Posterior vitreous detachment
Correct Answer: Migraine with aura
Explanation:Migraine sufferers often experience visual symptoms before the onset of a headache, such as wavy or shimmering lines known as a scintillating scotoma. It is important to obtain a thorough medical history as the patient may not mention a history of headaches. A normal eye exam is crucial for proper diagnosis. The other conditions listed have associated exam findings, such as cells in the anterior chamber for uveitis, a pale disc and relative afferent pupillary defect for optic neuritis, and a Weiss ring appearance with occasional hemorrhage for posterior vitreous detachment.
Diagnostic Criteria for Migraine
Migraine is a neurological disorder that affects millions of people worldwide. The International Headache Society has established diagnostic criteria for migraine without aura, which includes at least five attacks lasting between 4-72 hours and having at least two of the following characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, and aggravation by routine physical activity. During the headache, there must be at least one of the following: nausea and/or vomiting, photophobia, and phonophobia. The headache cannot be attributed to another disorder.
Migraine with aura, which is seen in around 25% of migraine patients, tends to be easier to diagnose with a typical aura being progressive in nature and may occur hours prior to the headache. Typical aura include a transient hemianopic disturbance or a spreading scintillating scotoma (‘jagged crescent’). Sensory symptoms may also occur. NICE criteria suggest that migraines may be unilateral or bilateral and give more detail about typical auras, which may occur with or without headache and are fully reversible, develop over at least 5 minutes, and last 5-60 minutes. Atypical aura symptoms such as motor weakness, double vision, visual symptoms affecting only one eye, poor balance, and decreased level of consciousness may prompt further investigation or referral.
In summary, the diagnostic criteria for migraine without aura include specific characteristics of the headache and associated symptoms, while migraine with aura is characterized by typical aura symptoms that may occur prior to the headache. It is important to accurately diagnose migraine to provide appropriate treatment and management for those who suffer from this debilitating condition.
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This question is part of the following fields:
- Ophthalmology
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Question 17
Correct
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Sarah is a 54-year-old woman presenting with painful hand movement. She had recently moved homes and had been carrying multiple heavy boxes during this time when the pain came on along her forearm. The pain is acutely worse when she is carrying objects but improves on rest.
Physical examination reveals that the pain was recreated with wrist extension and forearm supination when the elbow is extended. Maximal pain is palpated over the insertion of the common extensor tendon. No sensory or motor deficits were noted on examination.
What could be the possible cause of her pain?Your Answer: Lateral epicondylitis
Explanation:Understanding Lateral Epicondylitis
Lateral epicondylitis, commonly known as tennis elbow, is a condition that often occurs after engaging in activities that the body is not accustomed to, such as painting or playing tennis. It is most prevalent in individuals aged 45-55 years and typically affects the dominant arm. The primary symptom of this condition is pain and tenderness localized to the lateral epicondyle. The pain is often exacerbated by wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended. Episodes of lateral epicondylitis can last between 6 months and 2 years, with patients experiencing acute pain for 6-12 weeks.
To manage lateral epicondylitis, it is essential to avoid muscle overload and engage in simple analgesia. Steroid injections and physiotherapy are also viable options for managing the condition. By understanding the symptoms and management options for lateral epicondylitis, individuals can take the necessary steps to alleviate pain and discomfort associated with this condition.
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This question is part of the following fields:
- Musculoskeletal
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Question 18
Incorrect
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A 30-year-old woman presents with neck pain and swelling. She reports having symptoms of an upper respiratory tract infection followed by neck pain and swelling for the past 2 weeks. During examination, she appears anxious, her heart rate is 98/min, and her thyroid gland is tender and diffusely swollen.
Her blood tests reveal the following results:
Thyroid-stimulating hormone (TSH) 0.4 mU/L (0.5-5.5)
Free thyroxine (T4) 42 pmol/L (9.0 - 18)
ESR 65 mm/h (1-20)
What is the most likely diagnosis?Your Answer: Graves' disease
Correct Answer: Subacute thyroiditis (de Quervain's thyroiditis)
Explanation:Subacute (De Quervain’s) thyroiditis is the likely diagnosis for this woman who presents with hyperthyroidism and a tender goitre following an upper respiratory tract infection. This condition is characterized by high ESR and painful thyroid gland. Graves’ disease, Hashimoto’s thyroiditis, and thyroid cancer are less likely causes as they do not present with these specific symptoms.
Subacute Thyroiditis: A Self-Limiting Condition with Four Phases
Subacute thyroiditis, also known as De Quervain’s thyroiditis or subacute granulomatous thyroiditis, is a condition that is believed to occur after a viral infection. It is characterized by hyperthyroidism, a painful goitre, and raised ESR during the first phase, which lasts for 3-6 weeks. The second phase, which lasts for 1-3 weeks, is characterized by euthyroidism. The third phase, which can last for weeks to months, is characterized by hypothyroidism. Finally, in the fourth phase, the thyroid structure and function return to normal.
To diagnose subacute thyroiditis, thyroid scintigraphy is used to show a globally reduced uptake of iodine-131. However, most patients do not require treatment as the condition is self-limiting. Thyroid pain may respond to aspirin or other NSAIDs, but in more severe cases, steroids may be used, particularly if hypothyroidism develops.
It is important to note that subacute thyroiditis is just one of the many causes of thyroid dysfunction. A Venn diagram can be used to show how different causes of thyroid dysfunction may manifest. It is interesting to note that many causes of hypothyroidism may have an initial thyrotoxic phase. Proper diagnosis and management of thyroid dysfunction are crucial to ensure optimal patient outcomes.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 19
Incorrect
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A 55-year-old man has an HbA1c of 54 mmol/mol after 3 months of lifestyle changes, following a previous reading of HbA1c of 52 mmol/mol. You suggest that he should begin taking metformin standard release in addition to lifestyle interventions. He has normal renal function and no other medical issues. You inform him of the possibility of gastrointestinal discomfort.
What is the typical duration before considering increasing the dosage to alleviate these symptoms for this patient?Your Answer: 14 days
Correct Answer: 7 days
Explanation:It is recommended to increase the dose of metformin gradually, with a minimum of one week between each increase.
Metformin is a medication commonly used to treat type 2 diabetes mellitus. It belongs to a class of drugs called biguanides and works by activating the AMP-activated protein kinase (AMPK), which increases insulin sensitivity and reduces hepatic gluconeogenesis. Additionally, it may decrease the absorption of carbohydrates in the gastrointestinal tract. Unlike other diabetes medications, such as sulphonylureas, metformin does not cause hypoglycemia or weight gain, making it a first-line treatment option, especially for overweight patients. It is also used to treat polycystic ovarian syndrome and non-alcoholic fatty liver disease.
While metformin is generally well-tolerated, gastrointestinal side effects such as nausea, anorexia, and diarrhea are common and can be intolerable for some patients. Reduced absorption of vitamin B12 is also a potential side effect, although it rarely causes clinical problems. In rare cases, metformin can cause lactic acidosis, particularly in patients with severe liver disease or renal failure. However, it is important to note that lactic acidosis is now recognized as a rare side effect of metformin.
There are several contraindications to using metformin, including chronic kidney disease, recent myocardial infarction, sepsis, acute kidney injury, severe dehydration, and alcohol abuse. Additionally, metformin should be discontinued before and after procedures involving iodine-containing x-ray contrast media to reduce the risk of contrast nephropathy.
When starting metformin, it is important to titrate the dose slowly to reduce the incidence of gastrointestinal side effects. If patients experience intolerable side effects, modified-release metformin may be considered as an alternative.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 20
Incorrect
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A 30-year-old male patient comes to you with a rash that has spread all over his body. He has multiple erythematous lesions less than 1 cm in diameter on his torso and limbs, some of which are covered by a fine scale. Two weeks ago, he had exudative tonsillitis when he was seen with a sore throat. Apart from asthma, he has no other medical history. What is the probable diagnosis?
Your Answer: Pityriasis versicolor
Correct Answer: Guttate psoriasis
Explanation:Tear-drop scaly papules suddenly appearing on the trunk and limbs may indicate guttate psoriasis.
Guttate psoriasis is a type of psoriasis that is more commonly seen in children and adolescents. It is often triggered by a streptococcal infection that occurred 2-4 weeks prior to the appearance of the lesions. The name guttate comes from the Latin word for drop, as the lesions appear as small, tear-shaped papules on the trunk and limbs. These papules are pink and scaly, and the onset of the condition is usually acute, occurring over a few days.
In most cases, guttate psoriasis will resolve on its own within 2-3 months. There is no clear evidence to support the use of antibiotics to treat the underlying streptococcal infection. Treatment options for guttate psoriasis include topical agents commonly used for psoriasis and UVB phototherapy. In cases where the condition recurs, a tonsillectomy may be necessary.
It is important to differentiate guttate psoriasis from pityriasis rosea, another skin condition that can present with similar symptoms. Guttate psoriasis is often preceded by a streptococcal sore throat, while pityriasis rosea may be preceded by a respiratory tract infection. The appearance of guttate psoriasis is characterized by tear-shaped papules on the trunk and limbs, while pityriasis rosea presents with a herald patch followed by multiple oval lesions with a fine scale. While guttate psoriasis resolves within a few months, pityriasis rosea typically resolves after around 6 weeks.
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This question is part of the following fields:
- Dermatology
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Question 21
Incorrect
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A 32-year-old man has, over the course of two days, developed weakness and numbness in his arms. He has no previous medical history of note apart from treated asthma. He smokes cigarettes ‘occasionally’. His father died of a ‘heart problem’ in his early 50s. On examination, the cranial nerves and lower limbs are normal to examination. There is an increased tone in his arms bilaterally, with brisk reflexes. Power is reduced to three-fifths in all modalities above the elbows. Vibration and joint position sense are normal.
Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Anterior spinal artery thrombosis
Explanation:The anterior spinal artery supplies the anterior two-thirds of the spinal cord, causing anterior cord syndrome when there is ischaemia/infarct. This results in complete motor paralysis below the lesion, loss of pain/temperature sensation at and below the lesion, and some autonomic and bowel/bladder dysfunction. A lesion at the conus medullaris presents with back pain, saddle anaesthesia, urinary retention, faecal incontinence, lower limb weakness and numbness, and mixed UMN and LMN palsies. Friedreich’s ataxia presents with a slowly progressive gait ataxia, while MND is slowly progressive with combined UMN and LMN signs. Subacute combined degeneration of the spinal cord is due to vitamin B12 deficiency and has a subacute or gradual onset with degeneration of the dorsal and lateral columns of the spinal cord. Syndrome and lesion affected presentations are summarized in a table.
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This question is part of the following fields:
- Neurology
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Question 22
Incorrect
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A 10-year-old girl became acutely ill last week with vomiting, high fevers (maximum temperature of 39.5 °C) and weakness. Her mother took the girl to the general practitioner (GP) on day two of the illness, and he suggested she had gastroenteritis and that it should resolve itself in a week. However, the girl continues to be very ill and has now developed a non-blanching petechial rash on her abdomen.
Blood tests show many blasts in the periphery, low platelets and severe anaemia.
What is the most likely diagnosis?Your Answer:
Correct Answer: Acute lymphoblastic leukaemia (ALL)
Explanation:Types of Leukaemia: Characteristics and Symptoms
Leukaemia is a type of cancer that affects the blood and bone marrow. There are different types of leukaemia, each with its own characteristics and symptoms. Here are some of the most common types:
Acute lymphoblastic leukaemia (ALL): This is the most common type of leukaemia in children, usually presenting before the age of five. It is associated with a clonal expansion of immature lymphoid progenitor cells, leading to anaemia, thrombocytopenia, and increased susceptibility to infections. Symptoms include hepatosplenomegaly, generalised lymphadenopathy, new-onset bruising, fatigue, joint and bone pain, bleeding, and superimposed infections. Treatment is with pegaspargase.
Hairy-cell leukaemia: This is a B-cell leukaemia usually affecting middle-aged men. The malignant cells have cytoplasmic projections that make them look hairy, hence the name.
Acute myeloblastic leukaemia (AML): This is a type of leukaemia that is most commonly seen in adults. It can be of various types, but one that is commonly assessed is promyelocytic leukaemia M3 that is characterised by cells with dark, pink, needle-like intracytoplasmic inclusions called Auer rods. This is a very aggressive form of leukaemia.
Chronic lymphocytic leukemia (CLL): This is a disease most commonly seen in the elderly and is usually of B-cell origin. Blood smear findings commonly refer to ‘smudge cells’, which is a result of the fragile cells breaking during preparation of the smear.
Chronic myelogenous leukemia (CML): This is a disease most commonly seen in middle-aged adults and is associated with the Philadelphia chromosome, a chimeric chromosome formed by the translocation of part of chromosome 9 to chromosome 22.
In conclusion, leukaemia is a serious disease that requires prompt diagnosis and treatment. Knowing the characteristics and symptoms of each type can help in early detection and management.
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This question is part of the following fields:
- Haematology/Oncology
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Question 23
Incorrect
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A 48-year-old woman is seen in the diabetes clinic with poorly controlled type 2 diabetes mellitus (HbA1c 63 mmol/mol). She had to discontinue gliclazide due to recurrent hypoglycaemia and is currently on maximum dose metformin. Her BMI is 26 kg/m^2. What is the best course of action for further management?
Your Answer:
Correct Answer: Add either pioglitazone, a DPP-4 inhibitor or a SGLT-2 inhibitor
Explanation:NICE updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022, reflecting advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. The first-line drug of choice remains metformin, which should be titrated up slowly to minimize gastrointestinal upset. HbA1c targets should be agreed upon with patients and checked every 3-6 months until stable, with consideration for relaxing targets on a case-by-case basis. Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates and controlling intake of foods containing saturated fats and trans fatty acids. Blood pressure targets are the same as for patients without type 2 diabetes, and antiplatelets should not be offered unless a patient has existing cardiovascular disease. Only patients with a 10-year cardiovascular risk > 10% should be offered a statin, with atorvastatin 20mg as the first-line choice.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 24
Incorrect
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You are asked to review an elderly nursing home resident who has generalised inflammation of his oropharynx and is finding it difficult to eat. His past history of note includes the use of a steroid inhaler for chronic obstructive pulmonary disease (COPD). On examination, there are areas of erythema and a number of white plaques accompanied by some white, curd-like material.
Which diagnosis best fits this clinical picture?Your Answer:
Correct Answer: Oropharyngeal candidiasis
Explanation:Differential Diagnosis of Oral Lesions: Candidiasis, HIV Infection, Hairy Leukoplakia, Darier’s Disease, and Leukoedema
Oral lesions can present in various forms and have different underlying causes. In the case of an elderly man with long-term use of a steroid inhaler for COPD, poor oral hygiene, and possibly poorly fitting prosthetics, the most likely diagnosis is oropharyngeal candidiasis. This yeast-like fungal infection can be treated with antifungal medication, applied to the oral mucosa and any removable oral prostheses, and soaking the latter in an antifungal denture-soaking solution.
HIV infection can also cause oral lesions, primarily in patients with advanced disease. Candidiasis is a common opportunistic infection in these patients, but hairy leukoplakia, associated with Epstein-Barr virus, can also occur. Hairy leukoplakia presents as painless white lesions on the tongue or buccal mucosa, with a characteristic hairy appearance that cannot be scraped off.
Darier’s disease is a rare genetic disorder that causes greasy hyperkeratotic papules in seborrhoeic regions, nail abnormalities, and mucous membrane changes. Mucosal lesions are found in approximately 15% of patients, appearing as white papules with a central depression, most commonly in the mouth.
Leukoedema is a benign condition characterized by a blue, grey, or white appearance of the oral mucosa, with wrinkled, streaky lesions, mostly found on the inside of the cheeks. It is more common and pronounced in smokers.
In summary, the differential diagnosis of oral lesions includes candidiasis, HIV infection, hairy leukoplakia, Darier’s disease, and leukoedema. A thorough examination and consideration of the patient’s medical history can help determine the underlying cause and appropriate treatment.
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This question is part of the following fields:
- Infectious Diseases
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Question 25
Incorrect
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A 65-year-old man is scheduled for an elective knee replacement and presents to the orthopaedic surgery ward. He has osteoarthritis and hypertension and is currently being treated for an episode of giant cell arteritis that occurred four months ago with 20 mg prednisolone daily. This will be his first surgery and he is feeling anxious about the anaesthetic. What is the most crucial medication to prescribe before the operation?
Your Answer:
Correct Answer: Hydrocortisone
Explanation:Patients who are on chronic glucocorticoid therapy, such as prednisolone for the treatment of conditions like giant cell arteritis, may require hydrocortisone supplementation before undergoing surgery. This is because long-term use of glucocorticoids can suppress the hypothalamic-pituitary-adrenal axis, which can lead to inadequate adrenal gland response during times of stress, such as surgery. The amount of hydrocortisone required depends on the type of surgery being performed, with minor procedures under local anesthesia not requiring supplementation. For moderate to major surgeries, 50mg to 100mg of hydrocortisone should be given before induction, followed by additional doses every 8 hours for 24 hours. Diazepam should not be routinely given to control anxiety, and there is no indication that this patient requires additional medications for her hypertension preoperatively. Instead, the patient may benefit from speaking with someone who can provide reassurance about the procedure.
Preparation for surgery varies depending on whether the patient is undergoing an elective or emergency procedure. For elective cases, it is important to address any medical issues beforehand through a pre-admission clinic. Blood tests, urine analysis, and other diagnostic tests may be necessary depending on the proposed procedure and patient fitness. Risk factors for deep vein thrombosis should also be assessed, and a plan for thromboprophylaxis formulated. Patients are advised to fast from non-clear liquids and food for at least 6 hours before surgery, and those with diabetes require special management to avoid potential complications. Emergency cases require stabilization and resuscitation as needed, and antibiotics may be necessary. Special preparation may also be required for certain procedures, such as vocal cord checks for thyroid surgery or bowel preparation for colorectal cases.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 26
Incorrect
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A 42-year-old patient with ankylosing spondylitis complains of sudden pain in the right eye and blurry vision. During examination, you observe redness around the cornea and a constricted pupil. Ophthalmoscopy reveals difficulty in visualizing the retina due to the patient's intolerance to bright light, but you do notice a fluid level at the front of the eye. What is the probable diagnosis?
Your Answer:
Correct Answer: Anterior uveitis
Explanation:Anterior uveitis, also known as iritis, is a type of inflammation that affects the iris and ciliary body in the front part of the uvea. It is a common cause of red eye and is associated with HLA-B27, which may also be linked to other conditions. Symptoms of anterior uveitis include sudden onset of eye discomfort and pain, small or irregular pupils, intense sensitivity to light, blurred vision, redness, tearing, and the presence of pus and inflammatory cells in the front part of the eye. This condition may be associated with ankylosing spondylitis, reactive arthritis, ulcerative colitis, Crohn’s disease, Behcet’s disease, and sarcoidosis. Urgent review by an ophthalmologist is necessary, and treatment may involve the use of cycloplegics and steroid eye drops.
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This question is part of the following fields:
- Ophthalmology
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Question 27
Incorrect
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As a foundation doctor in general practice, you encounter a patient who is fifty-five years old and has a past medical history of prostatitis. He is interested in getting a prostate specific antigen test done due to his family's history of prostate cancer. What would be an appropriate time to conduct the test?
Your Answer:
Correct Answer: One month after his prostatitis diagnosis
Explanation:To prevent false results, it is recommended to refrain from conducting a prostate specific antigen test within a month of prostatitis. This is because prostatitis can cause an increase in PSA levels. It is important to note that a digital rectal examination cannot replace a PSA test. Additionally, if a patient is not experiencing any symptoms, conducting the test may lead to unnecessary investigations. It is also important to keep in mind that a normal PSA level does not necessarily rule out the possibility of prostate cancer.
Prostate specific antigen (PSA) is an enzyme produced by both normal and cancerous prostate cells. It is commonly used as a marker for prostate cancer, but its effectiveness as a screening tool is still debated. The NHS Prostate Cancer Risk Management Programme (PCRMP) has released guidelines for handling requests for PSA testing in asymptomatic men. While a recent European trial showed a reduction in prostate cancer deaths, it also revealed a high risk of over-diagnosis and over-treatment. As a result, the National Screening Committee has decided not to introduce a screening programme, but rather allow men to make an informed decision. The PCRMP recommends age-adjusted upper limits for PSA levels, while NICE Clinical Knowledge Summaries suggest a lower threshold for referral. PSA levels can also be raised by factors such as benign prostatic hyperplasia, prostatitis, and urinary tract infections.
The specificity and sensitivity of PSA testing are poor, with a significant number of men with elevated PSA levels not having prostate cancer, and some with normal PSA levels having the disease. Various methods are used to add meaning to PSA levels, including age-adjusted upper limits and monitoring changes in PSA levels over time. It is also debated whether digital rectal examination causes a rise in PSA levels. It is important to note that PSA testing should be postponed after certain events, such as ejaculation or instrumentation of the urinary tract.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 28
Incorrect
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A patient who has recently returned from a camping trip is worried about having contracted Lyme disease. She has developed a rash and feels fatigued and achy. What is the most suitable test to investigate Lyme disease in a patient like her?
Your Answer:
Correct Answer: Blood test for serology
Explanation:When there is no history of erythema migrans, ELISA is the primary test used to investigate suspected cases of Lyme disease.
Understanding Lyme Disease
Lyme disease is a bacterial infection caused by Borrelia burgdorferi and is transmitted through tick bites. The early symptoms of Lyme disease include erythema migrans, a characteristic bulls-eye rash that appears at the site of the tick bite. This rash is painless, slowly increases in size, and can be more than 5 cm in diameter. Other early symptoms include headache, lethargy, fever, and joint pain.
If erythema migrans is present, Lyme disease can be diagnosed clinically, and antibiotics should be started immediately. The first-line test for Lyme disease is an enzyme-linked immunosorbent assay (ELISA) to detect antibodies to Borrelia burgdorferi. If the ELISA is negative but Lyme disease is still suspected, it should be repeated 4-6 weeks later. If Lyme disease is suspected in patients who have had symptoms for 12 weeks or more, an immunoblot test should be done.
Tick bites can cause significant anxiety, but routine antibiotic treatment is not recommended by NICE. If the tick is still present, it should be removed using fine-tipped tweezers, and the area should be washed. In cases of suspected or confirmed Lyme disease, doxycycline is the preferred treatment for early disease, while ceftriaxone is used for disseminated disease. A Jarisch-Herxheimer reaction may occur after initiating therapy, which can cause fever, rash, and tachycardia.
In summary, Lyme disease is a bacterial infection transmitted through tick bites. Early symptoms include erythema migrans, headache, lethargy, fever, and joint pain. Diagnosis is made through clinical presentation and ELISA testing, and treatment involves antibiotics. Tick bites do not require routine antibiotic treatment, and ticks should be removed using fine-tipped tweezers.
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This question is part of the following fields:
- Infectious Diseases
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Question 29
Incorrect
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A 72-year-old male presents to the surgical assessment unit with lower abdominal pain and inability to pass urine for the past 12 hours. He has a palpable bladder and tenderness in the suprapubic region. On PR examination, his prostate is smooth and not enlarged. He has a medical history of high blood pressure, depression, neuropathic pain, and diabetes. What could be the probable cause of his presentation?
Your Answer:
Correct Answer: Amitriptyline
Explanation:Urinary retention can be caused by Amitriptyline due to its anticholinergic activity. The patient, who has a small prostate on PR examination, is currently experiencing urinary retention. None of the other medications are known to cause this condition.
Drugs that can cause urinary retention
Urinary retention is a condition where a person is unable to empty their bladder completely. This can be caused by various factors, including certain medications. Some drugs that may lead to urinary retention include tricyclic antidepressants like amitriptyline, anticholinergics such as antipsychotics and antihistamines, opioids, NSAIDs, and disopyramide. These drugs can affect the muscles that control the bladder, making it difficult to urinate.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 30
Incorrect
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A 75-year-old man presents to his GP with persistent itch that has been bothering him for several months. The itch is widespread, affecting his torso and back, and he has not noticed any changes in his skin or overall health. Despite having an extensive medical history, there have been no recent changes to his medications. Upon examination, there are no focal skin changes other than widespread excoriation marks. The GP suspects that a systemic condition may be the underlying cause of the patient's itch. Based on his medical history, which of the following conditions is most likely to be responsible for his symptoms?
Your Answer:
Correct Answer: Chronic kidney disease
Explanation:Pruritus is a symptom of chronic kidney disease, which can cause severe itching and distress for patients. Even in the early stages of the disease, hyperuricemia can lead to intense itchiness.
Causes of Pruritus and their Characteristics
Pruritus, commonly known as itching, can be caused by various underlying conditions. Liver disease, often associated with a history of alcohol excess, can present with stigmata of chronic liver disease such as spider naevi, bruising, palmar erythema, and gynaecomastia. Iron deficiency anaemia can cause pallor and other signs such as koilonychia, atrophic glossitis, post-cricoid webs, and angular stomatitis. Pruritus in polycythaemia is particularly noticeable after a warm bath and is accompanied by a ruddy complexion. Chronic kidney disease can present with lethargy, pallor, oedema, weight gain, hypertension, and fatigue. Lymphoma can cause night sweats, lymphadenopathy, splenomegaly, hepatomegaly, and fatigue. Other causes of pruritus include hyper- and hypothyroidism, diabetes, pregnancy, senile pruritus, urticaria, and skin disorders such as eczema, scabies, psoriasis, and pityriasis rosea. It is important to identify the underlying cause of pruritus to provide appropriate treatment and alleviate symptoms.
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This question is part of the following fields:
- Dermatology
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