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Question 1
Correct
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A 7-year-old boy comes to the doctor's office with his mother complaining of recurrent episodes of mouth, tongue, and lip itchiness shortly after eating bananas. The symptoms usually subside within half an hour. The child has a history of asthma and allergic rhinitis. He has undergone allergy testing before, which revealed a positive result for birch pollen.
What is the probable diagnosis?Your Answer: Oral allergy syndrome
Explanation:Angioedema can be triggered by drug-induced reactions or, in rare cases, other factors.
Understanding Oral Allergy Syndrome
Oral allergy syndrome, also known as pollen-food allergy, is a type of hypersensitivity reaction that occurs when a person with a pollen allergy eats certain raw, plant-based foods. This reaction is caused by cross-reaction with a non-food allergen, most commonly birch pollen, where the protein in the food is similar but not identical in structure to the original allergen. As a result, OAS is strongly linked with pollen allergies and presents with seasonal variation. Symptoms of OAS typically include mild tingling or itching of the lips, tongue, and mouth.
It is important to note that OAS is different from food allergies, which are caused by direct sensitivity to a protein present in food. Non-plant foods do not cause OAS because there are no cross-reactive allergens in pollen that would be structurally similar to meat. Food allergies may be caused by plant or non-plant foods and can lead to systemic symptoms such as vomiting and diarrhea, and even anaphylaxis.
OAS is a clinical diagnosis, but further tests can be used to rule out other diagnoses and confirm the diagnosis when the history is unclear. Treatment for OAS involves avoiding the culprit foods and taking oral antihistamines if symptoms develop. In severe cases, an ambulance should be called, and intramuscular adrenaline may be required.
In conclusion, understanding oral allergy syndrome is important for individuals with pollen allergies who may experience symptoms after eating certain raw, plant-based foods. By avoiding the culprit foods and seeking appropriate medical care when necessary, individuals with OAS can manage their symptoms effectively.
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This question is part of the following fields:
- Allergy And Immunology
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Question 2
Incorrect
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A 55-year-old man with a long history of type 2 diabetes associated with obesity would like to participate in an exercise program.
Which of the following would be a relative contraindication to him exercising?Your Answer: Peripheral vascular disease
Correct Answer: Proliferative diabetic retinopathy
Explanation:Exercise Recommendations for Different Diabetic Complications
Untreated diabetic proliferative retinopathy can lead to haemorrhage, which is why patients with this condition should avoid strenuous exercise until they have received photocoagulation therapy. On the other hand, exercise is actually encouraged for patients with peripheral vascular disease and ischaemic heart disease. It is important to understand the different exercise recommendations for various diabetic complications in order to promote optimal health and prevent further complications. By following these guidelines, patients can improve their overall well-being and reduce their risk of developing additional health issues.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 3
Incorrect
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Samantha is a 58-year-old woman who comes to see you with her husband John.
John has noticed that Samantha's left hand shakes, particularly when she is relaxed. This has been gradually worsening over the past few months and he has also noticed that she appears to be less steady when she is walking. On further questioning, you find that Samantha is also having trouble with her sleep.
On examination, Samantha has a resting tremor of her left hand and cogwheel rigidity is present. Her gait demonstrates a reduced arm swing and is slow.
What is the next best management step?Your Answer: Commence levodopa
Correct Answer: Refer Michael urgently to a specialist with expertise in movement disorders
Explanation:According to the NICE guidelines, only a specialist with expertise in movement disorders, such as a neurologist or elderly care physician, should diagnose Parkinson’s disease and initiate management. Therefore, further investigations such as an MRI or PET scan should not be carried out in primary care, as this will be decided upon by the specialist. Treatment should also not be initiated in primary care, including the use of levodopa or a dopamine agonist. However, if Parkinson’s disease is suspected but the person is taking a drug known to induce parkinsonism, it may be appropriate to reduce or stop the drug in primary care. It is important to refer all people with suspected Parkinson’s disease urgently and untreated to a specialist for confirmation of the diagnosis and exclusion of alternative diagnoses, without delaying assessment of the response.
Understanding the Mechanism of Action of Parkinson’s Drugs
Parkinson’s disease is a complex condition that requires specialized management. The first-line treatment for motor symptoms that affect a patient’s quality of life is levodopa, while dopamine agonists, levodopa, or monoamine oxidase B (MAO-B) inhibitors are recommended for those whose motor symptoms do not affect their quality of life. However, all drugs used to treat Parkinson’s can cause a wide variety of side effects, and it is important to be aware of these when making treatment decisions.
Levodopa is nearly always combined with a decarboxylase inhibitor to prevent the peripheral metabolism of levodopa to dopamine outside of the brain and reduce side effects. Dopamine receptor agonists, such as bromocriptine, ropinirole, cabergoline, and apomorphine, are more likely than levodopa to cause hallucinations in older patients. MAO-B inhibitors, such as selegiline, inhibit the breakdown of dopamine secreted by the dopaminergic neurons. Amantadine’s mechanism is not fully understood, but it probably increases dopamine release and inhibits its uptake at dopaminergic synapses. COMT inhibitors, such as entacapone and tolcapone, are used in conjunction with levodopa in patients with established PD. Antimuscarinics, such as procyclidine, benzotropine, and trihexyphenidyl (benzhexol), block cholinergic receptors and are now used more to treat drug-induced parkinsonism rather than idiopathic Parkinson’s disease.
It is important to note that all drugs used to treat Parkinson’s can cause adverse effects, and clinicians must be aware of these when making treatment decisions. Patients should also be warned about the potential for dopamine receptor agonists to cause impulse control disorders and excessive daytime somnolence. Understanding the mechanism of action of Parkinson’s drugs is crucial in managing the condition effectively.
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This question is part of the following fields:
- Neurology
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Question 4
Correct
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A 85-year-old man with chronic myeloid leukaemia presents with gout following treatment. His general practitioner prescribes allopurinol to treat the condition. How does allopurinol prevent the buildup of uric acid?
Your Answer: By inhibiting purine breakdown and synthesis
Explanation:Allopurinol and its Mechanism of Action
Allopurinol is a purine analogue that inhibits xanthine oxidase, an enzyme responsible for the oxidation of hypoxanthine and xanthine. By blocking this process, the production of uric acid is reduced. Additionally, the accumulation of hypoxanthine and xanthine leads to the inhibition of amidophosphoribosyl transferase, which is the rate-limiting enzyme of purine biosynthesis. As a result, both purine breakdown and synthesis are decreased. It is important to note that allopurinol should not be used in combination with Rasburicase as the two medications counteract each other.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 5
Incorrect
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An 80-year-old man presents with a vesicular rash around his right eye. The right eye is red and there is a degree of photophobia. A presumptive diagnosis of herpes zoster ophthalmicus is made and an urgent referral to ophthalmology is made.
What treatment is he most likely to receive?Your Answer:
Correct Answer: Oral aciclovir
Explanation:If systemic therapy is administered, topical antivirals are unnecessary. However, secondary inflammation may be treated with topical corticosteroids.
Herpes Zoster Ophthalmicus: Symptoms, Treatment, and Complications
Herpes zoster ophthalmicus (HZO) is a condition caused by the reactivation of the varicella-zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve. It is a type of shingles that affects around 10% of cases. The main symptom of HZO is a vesicular rash around the eye, which may or may not involve the eye itself. Hutchinson’s sign, a rash on the tip or side of the nose, is a strong risk factor for ocular involvement.
The management of HZO involves oral antiviral treatment for 7-10 days, ideally started within 72 hours of symptom onset. Intravenous antivirals may be given for severe infection or if the patient is immunocompromised. Topical antiviral treatment is not recommended for HZO, but topical corticosteroids may be used to treat any secondary inflammation of the eye. Ocular involvement requires urgent ophthalmology review.
Complications of HZO include conjunctivitis, keratitis, episcleritis, anterior uveitis, ptosis, and post-herpetic neuralgia.
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This question is part of the following fields:
- Eyes And Vision
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Question 6
Incorrect
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A 9-year-old boy comes to see you with his father; they have returned from a holiday to Egypt and the father is very concerned as his son is lethargic, tired and has most recently become jaundiced, with dark urine. He is nauseated all the time and hardly able to eat.
On examination he is pyrexial 38.2°C, with jaundice and evidence of scratch marks on his skin.
Investigations show:
Haemoglobin 118 g/L (135 - 180)
WCC 8.2 ×109/L (4 - 10)
Platelets 190 ×109/L (150 - 400)
Sodium 140 mmol/L (134 - 143)
Potassium 4.7 mmol/L (3.5 - 5.0)
Creatinine 105 µmol/L (60 - 120)
Bili 142 (<26)
ALT 680 (<36)
Which one of the following is true of his condition?Your Answer:
Correct Answer: You can reassure her mother that she will almost certainly make a full recovery
Explanation:Hepatitis A in North Africa
This child is suffering from hepatitis A, a common condition in North Africa where most people are exposed to it and develop immunity as children. However, children from the United Kingdom are not immune and may become infected while on holiday through the faeco-oral route.
Fortunately, supportive care is all that is needed, including bed rest, proper nutrition, fluid intake, and pain relief. Only a small percentage of patients progress to fulminant hepatic failure.
To prevent infection, it is recommended to get vaccinated for hepatitis A before traveling to areas where exposure is likely.
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This question is part of the following fields:
- Children And Young People
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Question 7
Incorrect
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A 62-year-old woman presents with recurrent attacks of the room spinning around her in a horizontal plane, which is happening on multiple occasions every day. Each attack lasts about ten seconds and seems to occur whenever she turns in bed, lies down or sits up from the supine position. There are no other associated symptoms. She is taking no medication. Standard neurological examination is normal.
Given the likely diagnosis, which of the following is the most appropriate management?
Your Answer:
Correct Answer: Epley manoeuvre
Explanation:Understanding Vertigo and Treatment Options
Vertigo is a common condition that can be triggered by head movement and is characterized by brief bouts of dizziness. The Dix-Hallpike maneuver can be used to diagnose benign paroxysmal positional vertigo (BPPV), which can be treated with the Epley maneuver. Sumatriptan is used to treat migraines, which may produce symptoms of vertigo but are not specifically related to head movement. Aspirin is used to manage acute stroke, which should be ruled out in patients with vertigo. Prochlorperazine can provide relief from vertigo symptoms, but it is not a curative measure for BPPV and the Epley maneuver should be tried first. Understanding the different causes and treatment options for vertigo can help patients manage their symptoms effectively.
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This question is part of the following fields:
- Neurology
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Question 8
Incorrect
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A father asks for some advice regarding the hearing test result of his 6-month-old baby. He tells you that he was told that the baby's hearing was 'not clear' in both ears when it was tested at the pediatrician's office. He says that the hearing test was repeated at the office and the repeat test gave the same result.
You check the clinical record and the screening result sent to the office confirms 'not clear' responses in both ears on both screening tests. He says that he was given some information at the time about the result of the hearing test but cannot remember what was said and cannot find the leaflet he was given.
Which of the following should you advise?Your Answer:
Correct Answer: She can be reassured that even with 'not clear' responses in both ears then the baby will be very unlikely have a hearing problem
Explanation:Newborn Hearing Screening in the UK
The newborn hearing screening is a routine test that takes place shortly after birth in hospitals across the UK. If a clear response is found in both ears, no further action is needed. However, if there is not a clear response in both ears, further testing may be required. The screening programmes differ between England, Scotland, and Wales. In Wales, a clear response in one ear doesn’t automatically prompt further investigation, but parents are given the option to have another hearing screening test or wait until their baby is nine months old for a hearing test. In England and Scotland, further testing is automatically arranged if there is a clear response in only one ear.
For newborns with ‘not clear’ responses bilaterally, further testing is necessary to determine if there is a significant hearing deficit. It is important to note that early detection and intervention for hearing loss can greatly improve a child’s language and communication skills. The UK National Screening Committee provides more information on newborn hearing screening across the UK.
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This question is part of the following fields:
- Children And Young People
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Question 9
Incorrect
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A 14-year old boy is brought to see his General Practitioner by his father as he is worried about his son's lack of motivation and poor academic performance. The boy has always struggled in school and has difficulty making friends. His teachers have suggested that he may have an undiagnosed learning disability. The father insists on a referral to a psychiatrist, but the boy is hesitant. Physical examination reveals no abnormalities.
What is the most appropriate management step for the GP to take in this situation?Your Answer:
Correct Answer: Assess her capacity and explain the benefits of a referral to specialist services
Explanation:Assessing Capacity and Referral to Specialist Services for a Teen with Possible Learning Disability
When dealing with a 16-year-old patient who may have an undiagnosed learning disability, it is important to assess their capacity to make decisions about their own healthcare. If the patient is deemed to have capacity, they should be fully informed of the benefits of a referral to specialist services, such as the learning disability team. However, if the patient lacks capacity, actions should be taken in their best interests. It is also good practice to offer to speak to the patient alone, but insisting on this may not be necessary unless there are safeguarding concerns. Referral to the Child and Adolescent Mental Health Service (CAMHS) may not be appropriate in this case, but referral to the learning disability team would be indicated. Ultimately, any referral should be consented to by the patient if they have the capacity.
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This question is part of the following fields:
- Neurodevelopmental Disorders, Intellectual And Social Disability
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Question 10
Incorrect
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A 12-year-old girl with profound learning disabilities is brought to her General Practitioner for her annual review. She is non-verbal and requires help with all personal care. She has recently moved into a care home and is accompanied by an experienced carer. She raises concerns that the patient might be depressed, as she has noticed behaviours common to other depressed patients in her care.
Which of the following features of depression is most likely to present in someone with a moderate-to-severe learning disability?Your Answer:
Correct Answer: Psychomotor retardation
Explanation:Identifying Depression in Individuals with Learning Disabilities
Individuals with learning disabilities may present with symptoms of depression, including psychomotor retardation, disturbed sleep, loss of appetite, loss of weight, and diurnal variation in symptoms. The Glasgow Depression Scale for learning disabilities and the Glasgow Depression Scale carer’s supplement can be used to assess these symptoms. However, some criteria for depression, such as feelings of worthlessness or guilt, may be difficult to assess without a certain level of developmental comprehension and communication. Lack of concentration and subjective reduction in energy may also be present. Suicidal ideation is challenging to assess in individuals with limited conceptual and language skills, and physical or behavioral cues may be the only indicators of depression.
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This question is part of the following fields:
- Neurodevelopmental Disorders, Intellectual And Social Disability
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Question 11
Incorrect
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Sophie is a 2-year-old girl who is brought in by her father. She has had a fever overnight, along with a sore throat and cough. Her father is worried that she seems more tired than usual today. During the examination, you note the following:
Temperature 38.5 degrees
Heart rate 160 bpm
Respiratory rate 40 / min
Oxygen saturation 95%
The lungs are clear, but there is inflammation and redness in the throat, and there are swollen lymph nodes in the neck.
According to the NICE traffic light system for assessing fever in children, which of the following is considered 'amber'?Your Answer:
Correct Answer: Heart rate 155 bpm
Explanation: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.
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This question is part of the following fields:
- Children And Young People
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Question 12
Incorrect
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A previously healthy 70-year-old woman presents with lethargy and breathlessness. She looks anaemic and significant blood results are as follows:
Investigation Result Normal value
Haemoglobin 72 g/l 135-175 g/l
White cell count 2.4 x 109/l 4.0-11.0 x 109/l
Platelets 155 x 109/l 150-400 x 109/l
Reticulocytes 0.80% 0.5%-1.5%
Mean corpuscular volume 92 fl 76-98 fl
Ferritin 8 μg/l 10-120 μg/l
Which of the following is the most appropriate next option for further investigation of this patient?
Your Answer:
Correct Answer: Serum vitamin B12 and folate
Explanation:The Importance of Checking B12 and Folate Levels in Iron Deficiency Anaemia
Iron deficiency anaemia can mask the development of macrocytic anaemia, leading to a normal mean cell volume despite anaemia and iron deficiency. To avoid missing a potential underlying condition, it is crucial to check serum B12 and folate levels. Thalassaemia trait can also mask macrocytosis, but ferritin levels are elevated in this case. A blood film may not be helpful if macrocytosis has not developed, but in megaloblastic anaemia, oval macrocytes and hypersegmented nuclei in neutrophils can be seen. Therefore, checking B12 and folate levels is essential in the diagnosis and management of iron deficiency anaemia.
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This question is part of the following fields:
- Haematology
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Question 13
Incorrect
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A 63-year-old man presents to the emergency department with a three day history of feeling unwell, dysuria, and increased frequency of urination. He denies any macroscopic hematuria. Upon further questioning, he reports having long-standing lower urinary tract symptoms such as weakened urinary stream, hesitancy, urgency, and nocturia for the past year, which have slowly worsened. On examination, he appears well with no abdominal or loin tenderness. Urine dipstick shows nitrites positive and leukocytes+++. A diagnosis of urinary tract infection is made, and he is treated with oral antibiotics. The patient expresses interest in having a digital rectal examination and prostate-specific antigen (PSA) blood test to evaluate his lower urinary tract symptoms. A digital rectal examination reveals a smoothly enlarged benign-feeling prostate. When would be the most appropriate time to perform a PSA blood test in this case?
Your Answer:
Correct Answer: Postpone the test for at least 48 hours
Explanation:Factors Affecting Prostate-Specific Antigen Blood Test
The prostate-specific antigen (PSA) blood test is a common diagnostic tool used to detect prostate cancer. However, the test results can be influenced by various factors, including benign prostatic hypertrophy, prostatitis, urinary retention, urinary tract infection, old age, urethral or rectal instrumentation/examination, recent vigorous exercise, and recent ejaculation.
It is important to note that the PSA test should be deferred for at least a month in individuals with a proven urinary tract infection. Additionally, if a man has ejaculated or exercised vigorously in the previous 48 hours, the test should also be deferred. While some sources suggest delaying PSA testing for at least a week after a digital rectal examination, data suggest that rectal examination has minimal effect on PSA levels.
In summary, it is crucial to consider these factors when interpreting PSA test results to ensure accurate diagnosis and treatment.
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This question is part of the following fields:
- Kidney And Urology
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Question 14
Incorrect
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A 50-year-old woman presents to you with complaints of severe menopausal symptoms such as hot flashes, night sweats, low mood and anxiety, and difficulties with memory and concentration. She has a history of an inherited thrombophilia and has previously experienced one pulmonary embolism and three deep vein thromboses that required treatment. Despite trying various home remedies suggested by reliable websites, she is still struggling and is interested in starting hormone replacement therapy (HRT) to alleviate her symptoms.
What would be your approach to managing this patient?Your Answer:
Correct Answer: Refer to haematology for review
Explanation:According to NICE guidelines, women who are at high risk of VTE and are seeking HRT should be referred to a haematologist before starting any treatment, even if it is transdermal. While the risk of VTE associated with HRT is higher for oral preparations than transdermal ones, the risk for transdermal HRT at standard therapeutic doses is not greater than the baseline risk. However, for women with a significant baseline risk, such as those with a strong family history of VTE or a hereditary thrombophilia, referral to a haematologist for assessment is recommended before considering HRT. Therefore, all options that suggest prescribing HRT are incorrect, with oral prescription being the most problematic. It is not enough to advise this woman to manage her symptoms conservatively, as there is clear guidance to refer her to a specialist for additional help.
Adverse Effects of Hormone Replacement Therapy
Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progestogen, to alleviate menopausal symptoms. However, this treatment can have side-effects such as nausea, breast tenderness, fluid retention, and weight gain.
Moreover, there are potential complications associated with HRT. One of the most significant risks is an increased likelihood of breast cancer, particularly when a progestogen is added. The Women’s Health Initiative (WHI) study found that the relative risk of developing breast cancer was 1.26 after five years of HRT use. The risk of breast cancer is related to the duration of HRT use, and it begins to decline when the treatment is stopped. Additionally, HRT use can increase the risk of endometrial cancer, which can be reduced but not eliminated by adding a progestogen.
Another potential complication of HRT is an increased risk of venous thromboembolism (VTE), particularly when a progestogen is added. However, transdermal HRT doesn’t appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any HRT treatment, even transdermal. Finally, HRT use can increase the risk of stroke and ischaemic heart disease if taken more than ten years after menopause.
In conclusion, while HRT can be an effective treatment for menopausal symptoms, it is essential to be aware of the potential adverse effects and complications associated with this treatment. Women should discuss the risks and benefits of HRT with their healthcare provider before starting any treatment.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 15
Incorrect
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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.
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This question is part of the following fields:
- Gastroenterology
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Question 16
Incorrect
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Which of the following is the least commonly associated with antiphospholipid syndrome during pregnancy?
Your Answer:
Correct Answer: Placenta praevia
Explanation:Antiphospholipid Syndrome and Pregnancy: Risks and Management
Antiphospholipid syndrome is a condition that increases the risk of both venous and arterial blood clots, recurrent miscarriage, and low platelet count. It can occur as a primary disorder or as a secondary condition to other illnesses, such as systemic lupus erythematosus. When a woman with antiphospholipid syndrome becomes pregnant, there are several potential complications that may arise, including pre-eclampsia, placental abruption, and preterm delivery.
To manage these risks, low-dose aspirin is typically prescribed as soon as the pregnancy is confirmed through a urine test. Once a fetal heartbeat is detected on ultrasound, low molecular weight heparin is added to the treatment plan. This medication is usually discontinued at 34 weeks gestation. These interventions have been shown to increase the live birth rate by seven-fold. It is important for women with antiphospholipid syndrome to work closely with their healthcare provider to ensure the best possible outcome for both mother and baby.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 17
Incorrect
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A 65-year-old man has just been released from the hospital following a heart attack. He has a history of depression and is currently experiencing low mood. What is the antidepressant with the most safety evidence for patients with recent unstable angina or myocardial infarction?
Your Answer:
Correct Answer: Citalopram
Explanation:Sertraline as the Treatment of Choice for CHD Patients
NICE guidance recommends sertraline as the treatment of choice for patients with coronary heart disease (CHD) due to its safety and efficacy. Sertraline has been found to be cost-effective in a study conducted by O’Connor and colleagues in a hospitalised population with acute coronary syndrome. Although limited to one study, this evidence supports the use of sertraline in this population. Additionally, the SPS recommends sertraline as the selective serotonin reuptake inhibitor (SSRI) of choice for CHD patients due to its lower propensity for interactions and the availability of more data on its use in a population with pre-existing heart disease compared to other SSRIs. Overall, sertraline is a safe and effective treatment option for CHD patients with depression or anxiety.
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This question is part of the following fields:
- Mental Health
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Question 18
Incorrect
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A 72-year-old lady comes to your clinic complaining of headaches that have been bothering her for the past four months. She reports that the pain is located over the right fronto-parietal area and describes it as a constant dull ache that is worse at night and sometimes wakes her up from sleep. She has tried taking paracetamol, but it hasn't provided much relief. She denies experiencing any nausea, vomiting, loss of consciousness, seizures, forgetfulness, or tinnitus. Her medical history includes breast cancer at the age of 35, which required a right mastectomy. She has been managing her hypertension with amlodipine 10 mg daily for the past ten years. On examination, there is evidence of mild osteoarthritis in several joints, a right-sided mastectomy scar, and no neurological abnormalities or papilloedema. What is the next step in managing this patient?
Your Answer:
Correct Answer: Reassure the patient and advise her to re-attend if the symptoms worsen or she notices new signs or symptoms
Explanation:Urgent Referral for Cancer Patients with Neurological Symptoms
In patients previously diagnosed with cancer, urgent referral is necessary if they develop any new neurological symptoms such as recent onset seizure, persistent headache, progressive neurological deficit, new mental or cognitive changes, or new neurological signs. Although amlodipine can cause headaches, if the patient has been taking the medication for a long time without problems, it is unlikely to be the cause of the symptoms.
The referral pathway may vary by region, but the NICE guidance on suspected cancer: recognition and referral (NG12) recommends direct access for urgent MRI instead of referral to a neurologist. This is because it results in a faster diagnostic process for adults with a tumor, as they will be referred straight to a neurosurgeon after the scan instead of first to neurology, then for a scan, and then to neurosurgery.
It is important to note that these recommendations are not requirements and do not override clinical judgment. Primary care clinicians have expertise in recognizing patients who are ill and knowing when something is wrong. Therefore, clinicians should trust their clinical experience where there are particular reasons that this guidance doesn’t pertain to the specific presentation of the patient.
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This question is part of the following fields:
- Older Adults
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Question 19
Incorrect
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A 5-year-old boy with chronic cough and failure to thrive has been referred for a sweat test by the paediatricians. His parents come to see you to discuss what is involved in this test and how accurate it is.
Select the single statement that is true regarding this procedure.Your Answer:
Correct Answer: False positives are seen in patients with hypothyroidism
Explanation:Understanding Cystic Fibrosis: Diagnosis and Testing Methods
Cystic fibrosis (CF) is a genetic disorder caused by a mutation in the CFTR gene, which is responsible for regulating sweat, digestive juices, and mucous in the body. CFTR controls the movement of chloride and sodium ions across epithelial membranes, such as those found in the lungs. While most people have two working copies of the CFTR gene, only one is needed to prevent CF due to its recessive nature.
Diagnosing CF involves identifying mutations in the CFTR gene, but this method has not replaced sweat testing as the primary diagnostic tool. Sweat testing involves injecting pilocarpine and collecting sweat to analyze sodium and chloride levels. This test is 98% sensitive, but it may be unreliable in patients under three weeks of age or those with hormonal issues like hypothyroidism, hypopituitarism, or adrenal insufficiency.
The Guthrie test is a screening test that can detect immunoreactive trypsinogen, which may be associated with CF, but it is not diagnostic. Further testing is required to confirm a diagnosis.
In summary, understanding the diagnosis and testing methods for CF is crucial in identifying and managing this genetic disorder.
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This question is part of the following fields:
- Genomic Medicine
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Question 20
Incorrect
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You take a telephone call at the end of surgery from a childminder who is looking after a 5-year-old boy who she feels has suspicious injuries.
She says that when she commented on the injuries to his mother, when he was dropped off earlier in the morning, she gave an unconvincing account of what might have happened to him. She suspects non-accidental injury and from the history given, you do too, but are not sure. You arrange to see the child with his mother later that same day.
When should you make notes about this first consultation?Your Answer:
Correct Answer: Immediately
Explanation:Importance of Timely and Accurate Note-Taking in Medical Practice
Making notes immediately after a consultation with a patient is crucial in medical practice. It is equally important to make further contemporaneous notes whenever you see the patient again. This ensures that all relevant information is recorded accurately and in a timely manner.
It is easy to forget or omit making notes about telephone consultations, which can lead to repeat prescribing of the wrong drug in the future. Therefore, it is essential to record all encounters with patients, including telephone consultations, in the clinical record.
Cases involving child protection are particularly important, and it is good practice to record the contents of the consultation immediately, even if the eventual diagnosis is uncertain. This ensures that all relevant information is documented and can be used to inform future decisions.
In summary, timely and accurate note-taking is essential in medical practice to ensure that all relevant information is recorded and can be used to inform future decisions.
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This question is part of the following fields:
- Children And Young People
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Question 21
Incorrect
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A 62-year-old woman presents to her General Practitioner with complaints of epigastric pain and waterbrash that have lasted for four months. It is not worsening, but neither is it resolving. She has been taking alendronic acid tablets for osteoporosis over a similar timeframe. There is no history of dysphagia or weight loss and an examination of her abdomen is normal. Full blood count, inflammatory markers, urea and electrolytes, and liver function tests are all normal.
Which of the following is the single most likely diagnosis?Your Answer:
Correct Answer: Oesophagitis
Explanation:Possible Causes of Epigastric Pain: A Case Study
Epigastric pain is a common complaint among adults, with up to 60% experiencing heartburn and using over-the-counter products to relieve indigestion. However, it can also be a symptom of more serious conditions such as oesophagitis, gastric carcinoma, pancreatic carcinoma, peptic ulcer disease, and oesophageal carcinoma.
In a case study, a patient presented with stable epigastric pain for four months, accompanied by waterbrash and a history of alendronate use. While gastric and pancreatic carcinomas were deemed unlikely due to the absence of red flag symptoms and deterioration in clinical condition, oesophagitis was considered the most likely diagnosis. Contributing factors such as alcohol, NSAIDs, bisphosphonates, and smoking were identified, and treatment involved eliminating these factors and using proton pump inhibitors like omeprazole.
Overall, it is important to consider various possible causes of epigastric pain and conduct a thorough evaluation to determine the appropriate diagnosis and treatment.
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This question is part of the following fields:
- Gastroenterology
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Question 22
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A 65-year-old man presents to his General Practitioner with a fever, headache and body aches. On questioning, he complains of a recent onset of jaw pain while chewing food. Physical examination reveals normal temporal arteries. Fundal examination shows a pale, swollen optic disc on the right side. Blood tests reveal mild normocytic anaemia and an erythrocyte sedimentation rate of 120 mm per hour (normal 0–22 mm per hour).
Which of the following is the most appropriate management option?
Your Answer:
Correct Answer: Start treatment immediately, urgent referral to rheumatology
Explanation:The Importance of Prompt Diagnosis and Treatment for Giant Cell Arteritis
Giant cell arteritis (GCA) is a serious condition that can lead to irreversible visual loss if left untreated. Symptoms include headache, scalp tenderness, and jaw claudication. While abnormalities in the temporal artery are only found in about 30% of patients on examination, a normal examination doesn’t exclude the condition.
Immediate treatment with high-dose steroids is recommended by the National Institute for Health and Care Excellence (NICE) on suspicion of GCA, and an urgent referral to a specialist, usually a rheumatologist, should be made within 72 hours. Delay in treatment can have serious consequences, so it is important to start treatment promptly.
While a temporal artery biopsy may be necessary to confirm the diagnosis, treatment should not be postponed until this can be arranged. Ultrasound can also be used as a diagnostic tool, which is less invasive. Long-term oral steroids carry risks and side effects, so it is important to confirm the diagnosis with a specialist to ensure that treatment is indicated.
Prompt diagnosis and treatment are crucial in cases of suspected GCA to prevent irreversible visual loss and other serious complications.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 23
Incorrect
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A 67-year old man with hypertension visited his general practitioner after an ambulatory blood pressure monitor showed a daytime average blood pressure of 155/98 mmHg. Despite taking optimal doses of ramipril and amlodipine with good adherence, which medication should be introduced to his treatment plan?
Your Answer:
Correct Answer: Indapamide
Explanation:To improve the management of hypertension that is not well-controlled despite the use of an ACE inhibitor and a calcium channel blocker, it is recommended to include a thiazide-like diuretic.
Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.
Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.
Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.
The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.
If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.
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This question is part of the following fields:
- Cardiovascular Health
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Question 24
Incorrect
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Olivia is a 27 year old who comes to you with symptoms of severe obsessive compulsive disorder (OCD). As per NICE guidelines, what is the recommended first line pharmacological treatment for OCD?
Your Answer:
Correct Answer: Sertraline
Explanation:According to the 2005 NICE Guidance on the treatment of obsessive-compulsive disorder and body dysmorphic disorder, adults with OCD should be prescribed one of the following SSRIs as their first pharmacological treatment: fluoxetine, fluvoxamine, paroxetine, sertraline, or citalopram.
Understanding Obsessive-Compulsive Disorder (OCD)
Obsessive-compulsive disorder (OCD) is a mental health condition that affects 1 to 3% of the population. It is characterized by the presence of obsessions, which are unwanted intrusive thoughts, images, or urges, and compulsions, which are repetitive behaviors or mental acts that a person feels driven to perform. These symptoms can cause significant functional impairment and distress.
Risk factors for OCD include a family history of the condition, age (with peak onset between 10-20 years), pregnancy/postnatal period, and a history of abuse, bullying, or neglect.
The management of OCD involves classifying the level of impairment as mild, moderate, or severe using the Y-BOCS scale. For mild impairment, low-intensity psychological treatments such as cognitive behavioral therapy (CBT) including exposure and response prevention (ERP) are recommended. If this is insufficient, a course of an SSRI or more intensive CBT (including ERP) can be offered. For moderate impairment, a choice of either an SSRI or more intensive CBT (including ERP) is recommended, with clomipramine as an alternative first-line drug treatment to an SSRI if necessary. For severe impairment, referral to the secondary care mental health team for assessment is necessary, with combined treatment of an SSRI and CBT (including ERP) or clomipramine as an alternative while awaiting assessment.
ERP is a psychological method that involves exposing a patient to an anxiety-provoking situation and stopping them from engaging in their usual safety behavior. This helps them confront their anxiety, leading to the eventual extinction of the response. Treatment with an SSRI should continue for at least 12 months to prevent relapse and allow time for improvement. Compared to depression, the SSRI usually requires a higher dose and a longer duration of treatment (at least 12 weeks) for an initial response.
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This question is part of the following fields:
- Mental Health
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Question 25
Incorrect
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A 25-year-old woman presented to the Emergency Department from her workplace, for the second time in the span of three months, after experiencing a syncopal episode. She also reported feeling extremely fatigued for the past few months and having bouts of dizziness. Upon examination, she appeared slender and sun-kissed, with a blood pressure of 112/72 mmHg while lying down, but it dropped to 87/63 mmHg upon standing. Her baseline serum cortisol was low (<100 nmol/l) and her free thyroxine (T4) level was also low.
What is the most appropriate diagnosis for the clinical presentation described above? Choose ONE option only.Your Answer:
Correct Answer: Primary hypoadrenalism
Explanation:Diagnosis of Primary Hypoadrenalism: A Case Study
A woman presents with a marked postural drop in blood pressure, increased pigmentation, and low cortisol levels, indicating primary hypoadrenalism as the most likely diagnosis. The high adrenocorticotropic hormone (ACTH) level causes pigmentation, and autoimmune destruction of the adrenal glands is responsible for 80% of cases. Hyponatremia and hyperkalemia are common in established cases. The National Institute for Health and Care Excellence recommends hospital admission for serum cortisol levels below 100 nmol/l and referral to an endocrinologist for levels between 100 and 500 nmol/l. Hypovolemia, HIV, hypothyroidism, and psychiatric symptoms are unlikely causes based on the case history.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 26
Incorrect
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A 2-year-old girl is brought to the clinic by her parents who are worried about her constant tugging on her left ear and increased fussiness over the past 24 hours.
During the examination, the child's temperature is found to be 38.5ºC, and the left tympanic membrane appears red. There is no discharge in the ear canal, the right ear is normal, and there are no signs of mastoiditis. The child has no significant medical history and is not taking any medications.
What is the most appropriate course of action for managing this patient?Your Answer:
Correct Answer: Regular analgesia, call back in 3 days time if the symptoms are not resolving
Explanation:Parents should be informed that antibiotics are not always necessary for treating acute otitis media in children. The condition typically resolves on its own within 24-72 hours without the need for antibiotics. Pain relief medication can be used to alleviate discomfort and reduce fever during this time. However, if symptoms persist for more than 4 days or worsen, parents should seek medical attention. Immediate antibiotic prescription is not recommended unless the child is under 2 years old, has bilateral otitis media, otorrhoea, or is immunocompromised. Amoxicillin is the first-line therapy, while erythromycin and clarithromycin are alternative options for children allergic to penicillin. Topical antibiotics are not recommended for treating otitis media, and oral antibiotics should be used if necessary. Referral to the emergency department is not necessary unless there are signs of complications such as acute mastoiditis, meningitis, or facial nerve paralysis. Swabbing the ear is not useful, even if there is discharge present, as the condition is likely to have resolved before culture results become available.
Acute otitis media is a common condition in young children, often caused by bacterial infections following viral upper respiratory tract infections. Symptoms include ear pain, fever, and hearing loss, and diagnosis is based on criteria such as the presence of a middle ear effusion and inflammation of the tympanic membrane. Antibiotics may be prescribed in certain cases, and complications can include perforation of the tympanic membrane, hearing loss, and more serious conditions such as meningitis and brain abscess.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 27
Incorrect
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A 68-year-old man with type 2 diabetic attends annual review at the GP practice.
His current treatment consists of: aspirin 75 mg OD, ramipril 10 mg OD, simvastatin 40 mg ON, metformin 1g BD, pioglitazone 45 mg OD and glibenclamide 15 mg OD.
He complains of episodes of blurred vision and feeling lightheaded. He has taken his blood sugar during one of these episodes and it was 2.3.
Which one of his medicines is the most likely cause of his symptoms?Your Answer:
Correct Answer: Glibenclamide
Explanation:Understanding Hypoglycaemic Episodes and Sulphonylureas
This gentleman is experiencing hypoglycaemic episodes that are causing symptoms of blurred vision and lightheadedness. The most likely cause of these episodes is the sulphonylurea he is taking. Sulphonylureas stimulate insulin secretion, which can cause significant problems with hypoglycaemia. On the other hand, metformin increases insulin sensitivity and reduces hepatic gluconeogenesis, while pioglitazone reduces insulin resistance. Hypoglycaemia is uncommon with pioglitazone, and metformin doesn’t cause it.
Glibenclamide is a long-acting sulphonylurea that is associated with a greater risk of hypoglycaemia. It should be avoided in the elderly, and shorter-acting alternatives, such as gliclazide, are more appropriate. The above patient is also on the maximum dose, which increases the risk of hypoglycaemia further. Therefore, glibenclamide is the correct answer. Understanding the relationship between hypoglycaemic episodes and sulphonylureas is crucial in managing diabetes and preventing complications.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 28
Incorrect
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A 42-year-old man with known asthma visits your clinic with complaints of worsening wheezing over the past few hours. He seldom attends asthma clinic. During previous consultations, his best peak flow measurements have been 500 L/min. What is the indication of acute severe asthma in this patient?
Your Answer:
Correct Answer: Heart rate 105/min
Explanation:Assessment and Severity of Acute Asthma
The British Thoracic Society provides clear guidance on the assessment and management of acute asthma. It is important to familiarize oneself with this document, as questions about the assessment and severity of acute asthma are common in exams.
Indicators of acute severe asthma include a peak expiratory flow rate of 33-50% of the patient’s best or predicted rate, a respiratory rate of 25 or greater, a heart rate of 110/min or greater, or the inability to complete sentences in one breath. The goal of oxygen therapy is to maintain SpO2 levels between 94-98%.
It is important to note that there is no fixed numerical peak flow rate for all patients to determine the severity of their asthma. It depends on their personal best reading or predicted peak flow reading. If their actual peak flow is 33-50% of this figure, it is a marker of an acute severe attack.
For example, a peak flow rate of 400 L/min in a patient with a personal best of 500 L/min equates to 80% of their best and would not be considered a marker of an acute severe attack. However, a pulse of 115 would be considered a marker of acute severe asthma because the threshold is 110/min or greater.
If any of these features of an acute severe asthma attack persist after initial treatment, the patient should be admitted.
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This question is part of the following fields:
- Urgent And Unscheduled Care
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Question 29
Incorrect
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A 55-year-old woman presents with shortness of breath. She has been prone to periodic chest infections but over the last 6 months has noticed slowly progressively worsening shortness of breath. She feels fatigued and reports generalised arthralgia.
She has a history of dry eyes and dry mouth for which she is prescribed lubricant medication. She is also treated for Raynaud's phenomenon.
On examination of the chest fine end inspiratory crepitations are heard at both lung bases.
Which of the following blood tests is most likely to yield useful diagnostic information?Your Answer:
Correct Answer: Anti-Ro and anti-La antibodies
Explanation:Sjogren’s Syndrome: A Multi-System Diagnosis
This patient’s chest symptoms, along with systemic symptoms and dry eyes and mouth, suggest a possible multi-system diagnosis. Sjogren’s syndrome is a condition that should be considered, especially if the patient is a woman in her 5th or 6th decade. Men and younger people can also be affected.
Sjogren’s syndrome is characterized by various symptoms, including pulmonary fibrosis, sicca symptoms (dry eyes and mouth), Raynaud’s phenomenon, and arthralgia. Anti-Ro and anti-La antibodies are useful diagnostic tools in identifying this condition.
It is important to recognize the potential for a multi-system diagnosis in patients presenting with a combination of symptoms. In this case, Sjogren’s syndrome should be considered and appropriate testing should be performed to confirm the diagnosis.
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This question is part of the following fields:
- Respiratory Health
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Question 30
Incorrect
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You see a 70-year-old patient with diabetes, hypertension, and chronic kidney disease (CKD). He had an anterior myocardial infarction (MI) 2 months ago for which he had a stent. He is having his annual review when he mentions that he has suffered from erectile dysfunction for the last 2 years. He says that it came on gradually and that he now never has erections anymore, in any situation. He has been married for 45 years and this is having an effect on his relationship with his wife.
His blood pressure today is 135/85 mmHg. Recent blood tests reveal that his blood glucose levels are well controlled on oral medications and his CKD is stable. He takes regular exercise.
What is the recommended first-line treatment for this patient's erectile dysfunction?Your Answer:
Correct Answer: A vacuum erection device along with lifestyle advice
Explanation:The NICE clinical knowledge summary (CKS) guidelines recommend phosphodiesterase (PDE-5) inhibitors, such as sildenafil and tadalafil, as the first-line treatment for erectile dysfunction (ED) unless there are contraindications. However, those who cannot or will not take PDE-5 inhibitors may benefit from vacuum erection devices, which are recommended as the first-line treatment for well-informed older men with infrequent sexual intercourse and comorbidity requiring non-invasive, drug-free management of ED. Lifestyle changes and risk factor modification should also be considered, but this patient already has good control of his risk factors and regularly exercises. Intracavernous injections may be a second-line option for men with pelvic trauma or spinal cord injury. Vasculogenic causes, such as cardiovascular disease, are the most common organic cause of ED, and lifestyle changes and drug treatment can be effective in managing this condition.
Erectile dysfunction (ED) is a condition where a man is unable to achieve or maintain an erection that is sufficient for sexual performance. It is not a disease but a symptom that can be caused by organic, psychogenic, or mixed factors. It is important to differentiate between the causes of ED, with factors such as a gradual onset of symptoms and lack of tumescence favoring an organic cause, while sudden onset of symptoms and decreased libido favoring a psychogenic cause. Risk factors for ED include cardiovascular disease, alcohol use, and certain medications.
To assess for ED, it is recommended to measure lipid and fasting glucose serum levels to calculate cardiovascular risk. Free testosterone should also be measured in the morning, and if low or borderline, further assessment may be needed. PDE-5 inhibitors, such as sildenafil, are the first-line treatment for ED and should be prescribed to all patients regardless of the cause. Vacuum erection devices can be used as an alternative for those who cannot or will not take PDE-5 inhibitors. Referral to urology may be appropriate for young men who have always had difficulty achieving an erection, and those who cycle for more than three hours per week should be advised to stop.
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This question is part of the following fields:
- Kidney And Urology
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