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Question 1
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You evaluate a 45-year-old woman who presents with lower abdominal and pelvic pain. During a bimanual vaginal examination, you detect a significant pelvic mass. She has no significant medical history or gynecological issues, such as uterine fibroids.
What would be the MOST suitable next step in managing this patient?Your Answer: Urgent referral to gynaecology service (for an appointment within 2 weeks)
Explanation:Women who are 18 years or older and have a pelvic mass that is not clearly uterine fibroids should be promptly referred for assessment. In this case, an abdominal X-ray would not provide much useful information, and it is not advisable to take no action at this point. For more information, please refer to the NICE referral guidelines for suspected cancer.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 2
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A 55-year-old man presents with a history of excessive urination and increased thirst. A diagnosis of type 2 diabetes mellitus is suspected.
Select from the options below the SINGLE result that is most indicative of a diagnosis of diabetes mellitus.Your Answer: An HbA1c of 50 mmol/mol
Explanation:According to the 2011 recommendations from the World Health Organization (WHO), HbA1c can now be used as a diagnostic test for diabetes. However, this is only applicable if stringent quality assurance tests are in place and the assays are standardized to criteria aligned with international reference values. Additionally, accurate measurement of HbA1c is only possible if there are no conditions present that could hinder its accuracy.
To diagnose diabetes using HbA1c, a value of 48 mmol/mol (6.5%) is recommended as the cut-off point. It’s important to note that a value lower than 48 mmol/mol (6.5%) does not exclude the possibility of diabetes, as glucose tests are still necessary for a definitive diagnosis.
When using glucose tests, the following criteria are considered diagnostic for diabetes mellitus:
– A random venous plasma glucose concentration greater than 11.1 mmol/l
– A fasting plasma glucose concentration greater than 7.0 mmol/l
– A two-hour plasma glucose concentration greater than 11.1 mmol/l, two hours after consuming 75g of anhydrous glucose in an oral glucose tolerance test (OGTT)However, there are certain circumstances where HbA1c is not appropriate for diagnosing diabetes mellitus. These include:
– ALL children and young people
– Patients of any age suspected of having Type 1 diabetes
– Patients with symptoms of diabetes for less than two months
– Patients at high risk of diabetes who are acutely ill, such as those requiring hospital admission
– Patients taking medication that may cause a rapid rise in glucose levels, such as steroids or antipsychotics
– Patients with acute pancreatic damage, including those who have undergone pancreatic surgery
– Pregnant individuals
– Presence of genetic, hematologic, and illness-related factors that can influence HbA1c and its measurement. -
This question is part of the following fields:
- Endocrinology
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Question 3
Correct
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A 72-year-old woman comes in with a history of passing fresh red blood mixed in with her last three bowel movements. She is experiencing low blood pressure, and her shock index is calculated to be 1.4.
Which initial investigation is recommended for hospitalized patients with lower gastrointestinal bleeding who are in a state of hemodynamic instability?Your Answer: CT angiography
Explanation:The British Society of Gastroenterology (BSG) has developed guidelines for healthcare professionals who are assessing cases of acute lower intestinal bleeding in a hospital setting. These guidelines are particularly useful when determining which patients should be referred for further evaluation.
When patients present with lower gastrointestinal bleeding (LGIB), they should be categorized as either unstable or stable. Unstable patients are defined as those with a shock index greater than 1, which is calculated by dividing the heart rate by the systolic blood pressure (HR/SBP).
For stable patients, the next step is to determine whether their bleed is major (requiring hospitalization) or minor (suitable for outpatient management). This can be determined using a risk assessment tool called the Oakland risk score, which takes into account factors such as age, hemoglobin level, and findings from a digital rectal examination.
Patients with a minor self-limiting bleed (e.g., an Oakland score of less than 8 points) and no other indications for hospital admission can be discharged with urgent follow-up for further investigation as an outpatient.
Patients with a major bleed should be admitted to the hospital and scheduled for a colonoscopy as soon as possible.
If a patient is hemodynamically unstable or has a shock index greater than 1 even after initial resuscitation, and there is suspicion of active bleeding, a CT angiography (CTA) should be considered. This can be followed by endoscopic or radiological therapy.
If no bleeding source is identified by the initial CTA and the patient remains stable after resuscitation, an upper endoscopy should be performed immediately, as LGIB associated with hemodynamic instability may indicate an upper gastrointestinal bleeding source. Gastroscopy may be the first investigation if the patient stabilizes after initial resuscitation.
If indicated, catheter angiography with the possibility of embolization should be performed as soon as possible after a positive CTA to increase the chances of success. In centers with a 24/7 interventional radiology service, this procedure should be available within 60 minutes for hemodynamically unstable patients.
Emergency laparotomy should only be considered if all efforts to locate the bleeding using radiological and/or endoscopic methods have been exhausted, except in exceptional circumstances.
In some cases, red blood cell transfusion may be necessary. It is recommended to use restrictive blood transfusion thresholds, such as a hemoglobin trigger of 7 g/dL and a target of 7-9 g/d
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This question is part of the following fields:
- Surgical Emergencies
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Question 4
Incorrect
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You evaluate a 78-year-old woman who has come in after a fall. She is frail and exhibits signs of recent memory loss. You administer an abbreviated mental test score (AMTS) and record the findings in her medical records.
Which ONE of the following is NOT included in the AMTS assessment?Your Answer: Name of present monarch
Correct Answer: Subtraction of serial 7s
Explanation:The subtraction of serial 7s is included in the 30-point Folstein mini-mental state examination (MMSE), but it is not included in the AMTS. The AMTS consists of ten questions that assess various cognitive abilities. These questions include asking about age, the nearest hour, the current year, the name of the hospital or location, the ability to recognize two people, date of birth, knowledge of historical events, knowledge of the present monarch or prime minister, counting backwards from 20 to 1, and recalling an address given earlier in the test. The AMTS is referenced in the RCEM syllabus under the topic of memory loss.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 5
Correct
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A 21 year old male comes to the emergency department complaining of a sore throat that has been bothering him for the past 2 days. The patient denies having a cough. Upon examination, the patient's temperature is measured at 38.3°C, blood pressure at 122/78 mmHg, and pulse rate at 92 bpm. There is visible white exudate on both tonsils and tenderness and swelling when palpating the lymph nodes around the sternocleidomastoid muscles on both sides.
What is the CENTOR score for this patient?Your Answer: 4
Explanation:The CENTOR score is a clinical prediction rule used to assess the likelihood of a patient having a streptococcal infection, which is commonly associated with sore throat. It is based on the presence or absence of four clinical criteria: fever, tonsillar exudate, tender anterior cervical lymphadenopathy, and absence of cough. Each criterion is assigned one point, and the total score ranges from 0 to 4. In this case, the patient has a fever, tonsillar exudate, tender anterior cervical lymphadenopathy, and no cough, resulting in a CENTOR score of 4. A higher score indicates a higher likelihood of a streptococcal infection, and further diagnostic testing or treatment may be warranted.
Further Reading:
Pharyngitis and tonsillitis are common conditions that cause inflammation in the throat. Pharyngitis refers to inflammation of the oropharynx, which is located behind the soft palate, while tonsillitis refers to inflammation of the tonsils. These conditions can be caused by a variety of pathogens, including viruses and bacteria. The most common viral causes include rhinovirus, coronavirus, parainfluenza virus, influenza types A and B, adenovirus, herpes simplex virus type 1, and Epstein Barr virus. The most common bacterial cause is Streptococcus pyogenes, also known as Group A beta-hemolytic streptococcus (GABHS). Other bacterial causes include Group C and G beta-hemolytic streptococci and Fusobacterium necrophorum.
Group A beta-hemolytic streptococcus is the most concerning pathogen as it can lead to serious complications such as rheumatic fever and glomerulonephritis. These complications can occur due to an autoimmune reaction triggered by antigen/antibody complex formation or from cell damage caused by bacterial exotoxins.
When assessing a patient with a sore throat, the clinician should inquire about the duration and severity of the illness, as well as associated symptoms such as fever, malaise, headache, and joint pain. It is important to identify any red flags and determine if the patient is immunocompromised. Previous non-suppurative complications of Group A beta-hemolytic streptococcus infection should also be considered, as there is an increased risk of further complications with subsequent infections.
Red flags that may indicate a more serious condition include severe pain, neck stiffness, or difficulty swallowing. These symptoms may suggest epiglottitis or a retropharyngeal abscess, which require immediate attention.
To determine the likelihood of a streptococcal infection and the need for antibiotic treatment, two scoring systems can be used: CENTOR and FeverPAIN. The CENTOR criteria include tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever, and absence of cough. The FeverPAIN criteria include fever, purulence, rapid onset of symptoms, severely inflamed tonsils, and absence of cough or coryza. Based on the scores from these criteria, the likelihood of a streptococcal infection can be estimated, and appropriate management can be undertaken. can
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 6
Correct
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A 25-year-old woman comes in with a complaint of palpitations that occur during her regular jogging routine. Her mother passed away at a young age from an unknown cause. During the examination, her pulse feels irregular and there is a presence of a double apical impulse. A systolic murmur can be heard at the left sternal edge that spreads throughout the praecordium.
What is the SINGLE most probable diagnosis?Your Answer: Hypertrophic obstructive cardiomyopathy (HOCM)
Explanation:Hypertrophic obstructive cardiomyopathy (HOCM) is a primary heart disease characterized by the enlargement of the myocardium in the left and right ventricles. It is the most common reason for sudden cardiac death in young individuals and athletes. HOCM can be inherited in an autosomal dominant manner, and a family history of unexplained sudden death is often present.
Symptoms that may be experienced in HOCM include palpitations, breathlessness, chest pain, and syncope. Clinical signs that can be observed in HOCM include a jerky pulse character, a double apical impulse (where both atrial and ventricular contractions can be felt), a thrill at the left sternal edge, and an ejection systolic murmur at the left sternal edge that radiates throughout the praecordium. Additionally, a 4th heart sound may be present due to blood hitting a stiff and enlarged left ventricle during atrial systole.
On the other hand, Brugada syndrome is another cause of sudden cardiac death, but patients with this condition are typically asymptomatic and have a normal clinical examination.
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This question is part of the following fields:
- Cardiology
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Question 7
Correct
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A 25-year-old traveler comes to the clinic complaining of a fever, cough, and headache that have persisted for the last week. He recently returned from a backpacking adventure in India. Additionally, he started experiencing diarrhea a few days ago, and a stool sample was sent for testing, which revealed the presence of Salmonella typhi. Which antibacterial medication would be the most suitable to prescribe for this patient?
Your Answer: Cefotaxime
Explanation:According to the latest guidelines from NICE and the BNF, the recommended initial treatment for typhoid fever is cefotaxime. It is important to note that infections originating from the Middle-East, South Asia, and South-East Asia may have multiple antibiotic resistance, so it is advisable to test for sensitivity. In cases where the microorganism is found to be sensitive, ciprofloxacin can be considered as a suitable alternative.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 8
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A one-month-old infant develops eyelid swelling and a mucopurulent discharge from both of his eyes approximately two weeks after birth. His mother is currently being treated for a chlamydia infection.
What is the baby's highest risk of complications?Your Answer: Pneumonia
Explanation:Conjunctivitis is the most frequent occurrence of Chlamydia trachomatis infection in newborns. Ophthalmia neonatorum refers to any cause of conjunctivitis during the newborn period, regardless of the specific organism responsible. Chlamydia is now the leading cause, accounting for up to 40% of cases. Neisseria gonorrhoea, on the other hand, only accounts for less than 1% of reported cases. The remaining cases are caused by non-sexually transmitted bacteria like Staphylococcus, Streptococcus, Haemophilus species, and viruses.
Gonorrhoeal ophthalmia neonatorum typically presents within 1 to 5 days after birth. It is characterized by intense redness and swelling of the conjunctiva, eyelid swelling, and a severe discharge of pus. Corneal ulceration and perforation may also be present.
Chlamydial ophthalmia neonatorum, on the other hand, usually appears between 5 to 14 days after birth. It is characterized by a gradually increasing watery discharge that eventually becomes purulent. The inflammation in the eyes is usually less severe compared to gonococcal infection, and there is a lower risk of corneal ulceration and perforation.
The second most common manifestation of Chlamydia trachomatis infection in newborns is pneumonia. Approximately 5-30% of infected neonates will develop pneumonia. About half of these infants will also have a history of ophthalmia neonatorum.
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This question is part of the following fields:
- Ophthalmology
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Question 9
Incorrect
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A 32-year-old individual presents with a sudden worsening of asthma symptoms. You conduct an arterial blood gas test, and their PaCO2 level is 6.3 kPa.
How would you categorize this asthma exacerbation?Your Answer: Acute severe asthma
Correct Answer: Near-fatal asthma
Explanation:This individual has presented with an episode of acute asthma. Their PaCO2 levels are elevated at 6.3 kPa, indicating a near-fatal exacerbation. According to the BTS guidelines, acute asthma can be classified as moderate, acute severe, life-threatening, or near-fatal.
Moderate asthma is characterized by increasing symptoms and a PEFR (peak expiratory flow rate) of 50-75% of the best or predicted value. There are no features of acute severe asthma present in this classification.
Acute severe asthma can be identified by any one of the following criteria: a PEFR of 33-50% of the best or predicted value, a respiratory rate exceeding 25 breaths per minute, a heart rate surpassing 110 beats per minute, or the inability to complete sentences in one breath.
Life-threatening asthma is determined by any one of the following indicators: a PEFR below 33% of the best or predicted value, an SpO2 (oxygen saturation) level below 92%, a PaO2 (partial pressure of oxygen) below 8 kPa, normal PaCO2 levels (ranging from 4.6-6.0 kPa), a silent chest, cyanosis, poor respiratory effort, arrhythmia, exhaustion, altered conscious level, or hypotension.
Near-fatal asthma is characterized by a raised PaCO2 level and/or the need for mechanical ventilation with elevated inflation pressures.
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This question is part of the following fields:
- Respiratory
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Question 10
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A 25-year-old man is given a medication for a health condition during the 2nd trimester of his partner's pregnancy. As a result, the newborn developed kernicterus and early closure of the ductus arteriosus.
Which of the following medications is the most probable cause of these abnormalities?Your Answer: Aspirin
Explanation:The use of low-dose aspirin during pregnancy is considered safe and can be used to manage recurrent miscarriage, clotting disorders, and pre-eclampsia. On the other hand, high-dose aspirin carries several risks, especially if used in the third trimester. These risks include delayed onset of labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus (a condition that affects the brain due to high levels of bilirubin). Additionally, there is a slight increase in the risk of first-trimester abortion if high-dose aspirin is used early in pregnancy.
Below is a list outlining commonly encountered drugs that have adverse effects during pregnancy:
Drug: ACE inhibitors (e.g. ramipril)
Adverse effects: If given in the second and third trimester, ACE inhibitors can cause hypoperfusion, renal failure, and the oligohydramnios sequence.Drug: Aminoglycosides (e.g. gentamicin)
Adverse effects: Aminoglycosides can cause ototoxicity (damage to the ear) and deafness.Drug: Aspirin
Adverse effects: High doses of aspirin can cause first-trimester abortions, delayed onset of labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) have no significant associated risk. -
This question is part of the following fields:
- Pharmacology & Poisoning
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