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  • Question 1 - A 50-year-old woman comes in with a complaint of experiencing dizzy spells for...

    Correct

    • A 50-year-old woman comes in with a complaint of experiencing dizzy spells for the past 4 days. She reports feeling nauseous and seeing the room spinning for a brief period before returning to normal. The patient specifically notes that looking down seems to trigger these episodes. Upon examination, there are no abnormalities found in the ears or cranial nerves. Her blood pressure measures at 126/82 mmHg. What diagnostic test can be conducted to confirm the diagnosis?

      Your Answer: Dix- Hallpike manoeuvre

      Explanation:

      The Dix-Hallpike manoeuvre is employed for the diagnosis of benign paroxysmal positional vertigo (BPPV), while the Epley manoeuvre or Brandt Daroff exercises are utilized for its treatment. It should be noted that these manoeuvres are not used for the diagnosis of BPPV. Simmond’s test is utilized for the diagnosis of Achilles tendon rupture, while Finkelstein’s test is employed for the diagnosis of De Quervain’s tenosynovitis.

      Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo that occurs suddenly when there is a change in head position. It is more prevalent in individuals over the age of 55 and is less common in younger patients. Symptoms of BPPV include dizziness and vertigo, which can be accompanied by nausea. Each episode typically lasts for 10-20 seconds and can be triggered by rolling over in bed or looking upwards. A positive Dix-Hallpike manoeuvre, which is indicated by vertigo and rotatory nystagmus, can confirm the diagnosis of BPPV.

      Fortunately, BPPV has a good prognosis and usually resolves on its own within a few weeks to months. Treatment options include the Epley manoeuvre, which is successful in around 80% of cases, and vestibular rehabilitation exercises such as the Brandt-Daroff exercises. While medication such as Betahistine may be prescribed, it tends to have limited effectiveness. However, it is important to note that around half of individuals with BPPV may experience a recurrence of symptoms 3-5 years after their initial diagnosis.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      230.4
      Seconds
  • Question 2 - One of the secretaries at your practice slips on loose carpet when coming...

    Incorrect

    • One of the secretaries at your practice slips on loose carpet when coming down the stairs in the surgery and hurts her back. Although she did not sustain any serious injury she took time off as sick leave as a result of this injury.

      According to Health & Safety law, for what duration of time would she need to be incapacitated for you to DOCUMENT the incident in your RIDDOR records?

      Your Answer: 7 days

      Correct Answer: 5 days

      Explanation:

      Understanding RIDDOR: Recording and Reporting Work-Related Injuries

      RIDDOR is a law that requires employers and those in control of work premises to report and keep records of work-related accidents, certain industrial diseases, and dangerous occurrences. When it comes to work-related injuries, employers must keep a record of any occupational accident that causes an employee to be away from work or incapacitated for more than three consecutive days, not including the day of the accident but including weekends or other rest days.

      It’s important to note that this threshold is for recording the incident, not reporting it. If an employee is incapacitated for seven days or more, the incident should be reported. By understanding the requirements of RIDDOR, employers can ensure they are meeting their legal obligations and promoting a safe working environment for their employees.

    • This question is part of the following fields:

      • Improving Quality, Safety And Prescribing
      19.7
      Seconds
  • Question 3 - Which statement is indicative of depression? ...

    Incorrect

    • Which statement is indicative of depression?

      Your Answer: Symptoms persisting for two weeks or more

      Correct Answer: Symptoms present five days of each week

      Explanation:

      Diagnosing Depression: ICD-10 and DSM-IV Classifications

      In diagnosing depression, both ICD-10 and DSM-IV classifications can be used alongside questionnaires. The ICD-10 classification requires four out of 10 depressive symptoms for a diagnosis, while the DSM-IV classification requires five out of nine symptoms. Common symptoms include loss of interest and pleasure, loss of energy, and low mood, which must be present most of every day to be counted.

      However, the NICE guidelines on depression acknowledge that many people may fall just below these criteria. This is known as sub-threshold depressive symptoms, which allows for only one of the key features to be present for less time than is necessary for the major depressive classification.

      It is important to note that once depression is diagnosed or suspected, patients should be offered help and support.

    • This question is part of the following fields:

      • Mental Health
      29.2
      Seconds
  • Question 4 - Samantha is a 58-year-old woman who works from home as a freelance writer....

    Incorrect

    • Samantha is a 58-year-old woman who works from home as a freelance writer. She owns her own home but requires assistance with daily tasks due to her severe osteoarthritis. She recently applied for Attendance Allowance but was informed that she is not eligible. What is the reason for Samantha's ineligibility for Attendance Allowance?

      Your Answer: Because Attendance Allowance is only available to those over 60 years

      Correct Answer: Because Greg is aged under 65 years

      Explanation:

      The reason why Greg is not eligible for Attendance Allowance is because he is under 65 years of age. This benefit is specifically for individuals who are over 65 and require assistance with personal care due to physical or mental disability. Those who are under 65 and require similar assistance should apply for Personal Independence Payment instead. To be eligible for Attendance Allowance, one must have a physical or mental disability that is severe enough to require assistance with personal care or supervision for safety reasons. The allowance is paid at different levels depending on the level of assistance required.

      Patients who suffer from chronic illnesses or cancer and require assistance with caring for themselves may be eligible for benefits. Those under the age of 65 can claim Personal Independence Payment (PIP), while those aged 65 and over can claim Attendance Allowance (AA). PIP is tax-free and divided into two components: daily living and mobility. Patients must have a long-term health condition or disability and have difficulties with activities related to daily living and/or mobility for at least 3 months, with an expectation that these difficulties will last for at least 9 months. AA is also tax-free and is for those who need help with personal care. Patients should have needed help for at least 6 months to claim AA.

      Patients who have a terminal illness and are not expected to live for more than 6 months can be fast-tracked through the system for claiming incapacity benefit (IB), employment support allowance (ESA), DLA or AA. A DS1500 form is completed by a hospital or hospice consultant, which contains questions about the diagnosis, clinical features, treatment, and whether the patient is aware of the condition/prognosis. The form is given directly to the patient and a fee is payable by the Department for Works and Pensions (DWP) for its completion. This ensures that the application is dealt with promptly and that the patient automatically receives the higher rate.

    • This question is part of the following fields:

      • Musculoskeletal Health
      78.7
      Seconds
  • Question 5 - A 50-year-old man complains of frequent palpitations. These usually occur when he eats...

    Correct

    • A 50-year-old man complains of frequent palpitations. These usually occur when he eats and subside abruptly after he finishes eating. They are not accompanied by chest pain, but, on occasion, he also feels lightheaded. He has no reflux symptoms or dyspepsia. He is otherwise well and on presentation his blood pressure is 136/84 mmHg, his pulse is in sinus rhythm, and examination of his heart and abdomen are normal. His electrocardiogram (ECG) is normal.
      What is the most appropriate investigation?

      Your Answer: 24 hour portable electrocardiogram (ECG)

      Explanation:

      The Most Appropriate Investigation for Palpitations and Dizziness: A Cardiac Investigation

      When a patient presents with palpitations and dizziness, a cardiac cause is often suspected. While the association with food may be a red herring, the combination of symptoms suggests a need for further investigation. An ECG or examination of the pulse may not reveal an underlying cause unless the patient is experiencing symptoms at that exact moment. Therefore, a 24 hour portable ECG is often recommended to assess the cardiac rhythm over a longer period of time.

      A chest X-ray is unlikely to be helpful in the absence of chest pain or respiratory symptoms. Similarly, an endoscopy may be indicated for dyspeptic symptoms, but the history of palpitations and dizziness suggests a cardiac cause. H. pylori testing is only relevant for dyspeptic symptoms, and thyroid function tests are important for anyone experiencing palpitations, as hyperthyroidism can be a cause.

      In summary, when a patient presents with palpitations and dizziness, a cardiac investigation is the most appropriate first step. A 24 hour portable ECG can provide valuable information about the cardiac rhythm over a longer period of time.

    • This question is part of the following fields:

      • Gastroenterology
      56.7
      Seconds
  • Question 6 - You are visiting a local nursing home to see a new resident who...

    Correct

    • You are visiting a local nursing home to see a new resident who is complaining of an itchy rash when you get an urgent call to see a 78-year-old lady who has collapsed in the dining room.

      The relief staff at the home tell you that she is a diabetic and has had a stroke some years ago, but they do not know much else about her.

      On examination, she is lying in the recovery position on the floor and her BP is 115/70 mmHg, pulse 95 she is bathed in sweat and is unresponsive. She has adequate air entry on auscultation of the chest and there is no danger in the immediate vicinity. Trained nursing staff are at hand to help you with her management and take any further action.

      What would be your first action in this situation?

      Your Answer: Check her finger prick glucose

      Explanation:

      Managing Hypoglycaemia in Nursing Homes

      Hypoglycaemia is a common occurrence in nursing homes and can lead to significant neurological impairment if not managed promptly. When a patient is suspected of having hypoglycaemia, the first step is to check their finger prick glucose level. This should be done after ensuring their airway, breathing, and circulation are stable.

      Early intervention with a glucagon injection can prevent further complications. It is important to note that nursing home ‘strokes’ are a common cause of admissions to emergency departments. Therefore, prompt management of hypoglycaemia can potentially avoid such admissions.

      If the patient is unconscious, they should be placed in the recovery position until medical help arrives. By following these steps, nursing home staff can effectively manage hypoglycaemia and prevent further complications.

    • This question is part of the following fields:

      • Older Adults
      31
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  • Question 7 - A 32-year-old woman has reached out for a telephone consultation regarding her recent...

    Correct

    • A 32-year-old woman has reached out for a telephone consultation regarding her recent cervical smear results. She underwent the routine screening programme and is currently not experiencing any symptoms. Her last cervical smear was conducted 3 years ago and was reported as normal. She has not been vaccinated against human papillomavirus (HPV). The results of her recent test are as follows:

      - High-risk human papillomavirus (hrHPV): POSITIVE.
      - Cytology: ABNORMAL (high-grade dyskaryosis).

      What would be the next course of action in managing her condition?

      Your Answer: Referral to colposcopy for consideration of large loop excision of the transformation zone (LLETZ)

      Explanation:

      The appropriate technique to treat cervical intraepithelial neoplasia (CIN2 or CIN3) is urgent large loop excision of the transformation zone (LLETZ). This procedure is commonly performed in the same appointment or in a prompt subsequent appointment. Cryotherapy may also be an option to remove the abnormal cells. Offering the HPV vaccination is not a correct answer as it is only offered to girls and boys aged 12 to 13. A repeat cervical smear within 3 months is also not a correct answer, as it is only offered if the high-risk human papillomavirus (hrHPV) test result is unavailable or cytology is inadequate. Routine referral to gynaecology is also not indicated, as the patient would already be followed up by the colposcopy service.

      Understanding Cervical Cancer Screening Results

      The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

      If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.

      If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.

      For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.

    • This question is part of the following fields:

      • Gynaecology And Breast
      26
      Seconds
  • Question 8 - A 35-year-old man has been admitted to the hospital for investigation of worsening...

    Incorrect

    • A 35-year-old man has been admitted to the hospital for investigation of worsening muscle weakness in his upper and lower limbs over the last 10 years. The patient says he had never been interested in sports at school and that his father had problems with his gait for years. On examination, cognition, bulbar function and cranial nerves are all normal. Examination of the limbs shows distal symmetrical wasting and weakness in his arms and legs. There is areflexia. Tone is normal. There are no visible fasciculation. Vibration, pain and temperature are impaired in both hands and feet. There is kyphoscoliosis and bilateral pes cavus.
      Select the single most likely diagnosis.

      Your Answer: Acquired chronic inflammatory demyelinating polyneuropathy (CIDP)

      Correct Answer: Charcot–Marie–Tooth disease

      Explanation:

      Neurological Disorders: A Comparison

      When presented with a patient exhibiting neuromuscular symptoms and signs, it is important to consider various possible diagnoses. In this case, the presence of musculoskeletal deformities and a family history of gait difficulties suggest a hereditary basis for the patient’s condition. The following are some potential diagnoses to consider:

      Charcot-Marie-Tooth Disease (CMT): This is the most common inherited polyneuropathy, affecting approximately 1 in 2500 people. It typically presents with distal limb muscle wasting and sensory loss, with proximal progression over time. However, the disease course can vary greatly.

      Vitamin B12 Deficiency: Neurological features of this deficiency may include peripheral neuropathy and subacute combined degeneration of the spinal cord. However, skeletal defects will be absent.

      Acquired Chronic Inflammatory Demyelinating Polyneuropathy (CIDP): This is a chronically progressive or relapsing symmetric sensorimotor disorder that lacks the skeletal deformities of CMT.

      Motor Neurone Disease (MND): This tends to present with early signs of weakness in an ankle or leg, or a weak grip. It then progresses, leading to problems with slurred speech or swallowing. However, this patient’s relatively young age and symptoms suggest an inherited neurological problem rather than MND.

      Spinal Muscular Atrophy: This is a spectrum of genetically inherited disorders that present with muscle weakness and wasting. It lacks the sensory loss of CMT.

      In conclusion, a thorough evaluation of the patient’s symptoms and medical history is necessary to determine the most likely diagnosis and appropriate treatment plan.

    • This question is part of the following fields:

      • Neurology
      55.1
      Seconds
  • Question 9 - A 76-year-old woman presents for review. Her daughter is very concerned because her...

    Incorrect

    • A 76-year-old woman presents for review. Her daughter is very concerned because her mother is becoming increasingly apathetic, some days not getting out of bed and wearing the same clothes for a number of days in a row. She appears to be having difficulty with word finding. You understand that her husband died three months earlier. Apart from hypertension, she is otherwise physically well.
      Physical examination is unremarkable. Her body mass index is 23 kg/m2. Her heart rate is 72 bpm and regular.
      Which of the following is the most likely diagnosis?

      Your Answer: Alzheimer’s dementia

      Correct Answer: Depression

      Explanation:

      Differentiating between types of dementia and depression

      When assessing a patient with cognitive decline, it is important to consider the various possible diagnoses. In the case of a patient who recently lost their spouse and is experiencing symptoms such as apathy and sleep disturbance, depression is the most likely diagnosis. Cognitive behavioural therapy is the recommended intervention in this situation.

      Multi-infarct dementia, on the other hand, is typically seen in patients with vascular risk factors such as diabetes and atrial fibrillation. This type of dementia is characterized by a stepwise decline in functioning, with personality traits remaining relatively intact until late in the disease.

      Alcohol abuse can also lead to cognitive decline, with weight loss and signs of chronic liver disease being common physical manifestations.

      Alzheimer’s dementia is associated with progressive short-term memory loss, difficulties with language and decision-making, and problems with planning. While patients may present with dementia after the death of a partner, the symptoms described here are more consistent with depression.

      Finally, frontal lobe dementia is characterized by early symptoms of inappropriate social behaviour, disinhibition, and loss of empathy and sympathy. Memory loss is a late feature of this disease. By carefully considering the patient’s symptoms and medical history, healthcare professionals can make an accurate diagnosis and provide appropriate treatment.

    • This question is part of the following fields:

      • Mental Health
      31.3
      Seconds
  • Question 10 - You are conducting an asthma review on a 20-year-old man who is currently...

    Correct

    • You are conducting an asthma review on a 20-year-old man who is currently only using a short-acting beta-2-agonist (SABA). In what situations does NICE recommend prescribing an inhaled corticosteroid for this patient?

      Your Answer: Being woken by asthma symptoms once weekly or more

      Explanation:

      NICE Recommendations for Prescribing Inhaled Corticosteroids in Asthma Patients

      NICE advises prescribing an inhaled corticosteroid in patients with asthma who use an inhaled SABA three times a week or more, experience asthma symptoms three times a week or more, or are woken up by asthma symptoms once a week or more. Additionally, NICE recommends considering an ICS if the patient has had an asthma attack requiring oral corticosteroids in the past two years. These recommendations aim to improve asthma control and reduce the risk of exacerbations. By following these guidelines, healthcare professionals can ensure that their patients receive appropriate treatment for their asthma symptoms.

    • This question is part of the following fields:

      • Respiratory Health
      22.3
      Seconds
  • Question 11 - A 35-year-old female attends the diabetic annual review clinic.

    Her body mass index has...

    Correct

    • A 35-year-old female attends the diabetic annual review clinic.

      Her body mass index has increased over the year to 33.3 kg/m2.

      How do you calculate body mass index?

      Your Answer: Weight/(Height)2

      Explanation:

      Understanding BMI and its Implications

      Body:

      BMI, or Body Mass Index, is a crucial calculation in the field of anthropometry. It is determined by dividing an individual’s weight by the square of their height, and is measured in kg/m2. The resulting number can be used to categorize a person’s weight status into four groups: underweight (less than 18.5), normal (18.5-24.9), overweight (25-29.9), and obese (greater than 30).

      It is important to note that a BMI above 30 is considered obese and can have serious implications for an individual’s health. Studies have shown that obesity is linked to an increased risk of developing diabetes, cancer, osteoarthritis, and depression. Additionally, obesity can increase the risk of surgical complications, such as wound infection and dehiscence, venous thrombolembolism, incisional hernia, MI, and even death.

      Therefore, understanding BMI and its implications is crucial for maintaining good health and preventing potential health risks. It is important to consult with a healthcare professional to determine an appropriate BMI range for an individual’s unique needs and circumstances.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
      16.8
      Seconds
  • Question 12 - You have a male patient aged 45 who has recently had a myocardial...

    Correct

    • You have a male patient aged 45 who has recently had a myocardial infarction.

      He attends for follow up and says he was told in hospital that he has familial hypercholesterolaemia (FH). He says several relatives in previous generations died young of heart problems. He has three children and wants to know what are the risks of their being affected.

      FH is inherited as an autosomal dominant, so what is the risk of each of his children being affected?

      Your Answer: 50%

      Explanation:

      Familial Hypercholesterolemia Inheritance

      Familial Hypercholesterolemia (FH) is an inherited condition that affects the body’s ability to remove cholesterol from the blood. It is caused by a mutation in the LDL receptor gene, which is responsible for removing low-density lipoprotein (LDL) cholesterol from the bloodstream. Autosomal dominant inheritance means that if one parent has FH, there is a 50% chance that each child will inherit the gene and be affected.

      Most people with FH inherit the gene from only one parent, making them heterozygous. This means that they have one normal copy of the LDL receptor gene and one mutated copy. However, in rare cases, individuals can inherit the gene from both parents, making them homozygous. In these cases, symptoms of FH can appear in childhood and can be more severe.

      Overall, understanding the inheritance pattern of FH is important for individuals and families affected by this condition. It can help with early diagnosis and treatment, as well as genetic counseling for future generations.

    • This question is part of the following fields:

      • Genomic Medicine
      17
      Seconds
  • Question 13 - A 68-year-old woman presents to the GP clinic for a follow-up on her...

    Correct

    • A 68-year-old woman presents to the GP clinic for a follow-up on her heart failure management. She is currently on lisinopril 20 mg and carvedilol 25 mg BD. Her main symptoms include shortness of breath on minimal exercise and occasional episodes of paroxysmal nocturnal dyspnoea. During the examination, her BP is 136/74, her pulse is 80 and regular. There are bibasal crackles but no other significant findings. The test results show a haemoglobin level of 128 g/L (115-165), white cells count of 7.9 ×109/L (4-11), platelets count of 201 ×109/L (150-400), sodium level of 139 mmol/L (135-146), potassium level of 4.2 mmol/L (3.5-5), creatinine level of 149 μmol/L (79-118), and an ejection fraction of 38% on echocardiogram. What is the most appropriate next step?

      Your Answer: Add spironolactone to her regime

      Explanation:

      Treatment Guidelines for Chronic Heart Failure

      Chronic heart failure can be managed with a combination of medications, including beta blockers and ACE inhibitors. However, if heart failure control is not optimised on this dual therapy, NICE guidelines (NG106) recommend adding an ARB or aldosterone antagonist. For patients who cannot tolerate ACE inhibitors or ARBs, nitrate and hydralazine can be used earlier in the treatment pathway.

      It is important to note that routine referral for revascularisation is not recommended in patients without symptoms of angina. Additionally, cardiac resynchronisation therapy should not be recommended until the patient’s therapy is further optimised. By following these guidelines, healthcare professionals can effectively manage chronic heart failure and improve patient outcomes.

    • This question is part of the following fields:

      • Cardiovascular Health
      34.5
      Seconds
  • Question 14 - A 36-year-old man presents with sudden onset pain in the left flank radiating...

    Correct

    • A 36-year-old man presents with sudden onset pain in the left flank radiating to the left groin and testis. The pain is accompanied by vomiting. You suspect the patient may have ureteric colic.
      Select from the list the single other feature that would support this diagnosis.

      Your Answer: Haematuria

      Explanation:

      Renal/Ureteric Colic: Symptoms and Characteristics

      Renal/ureteric colic is characterized by sudden and severe pain, often caused by stones. However, in some cases, no obvious cause is found. Unlike biliary or intestinal colic, the pain of renal colic is constant, with periods of relief or dull aches before it returns. The location of the pain changes as the stone moves. Patients with renal colic experience intense pain and may writhe around in agony, while those with peritoneal irritation lie still. Although there may be severe pain in the testis, it should not be tender. Uncomplicated renal colic doesn’t cause fever, which suggests pyelonephritis. Haematuria, often detected only on dipstick testing, is a common symptom.

    • This question is part of the following fields:

      • Kidney And Urology
      15
      Seconds
  • Question 15 - You have recommended a patient in their 60s to purchase vitamin D over-the-counter...

    Incorrect

    • You have recommended a patient in their 60s to purchase vitamin D over-the-counter at a dose of 800 units. Later that day, the patient contacts you to inquire about the equivalent dose in micrograms since all medication labels at their local pharmacy are in this form.

      Which of the following is equal to 800 units of vitamin D?

      Your Answer: 10 mcg

      Correct Answer: 5 mcg

      Explanation:

      Converting Vitamin D Units to Micrograms

      Many CCG pathways recommend taking vitamin D supplements in units, but the packaging of many vitamin D suppliers lists the dose in micrograms. To convert units to micrograms for vitamin D, simply divide by 40. For example, 400 units of vitamin D is equivalent to 10 micrograms. Remember to check the packaging for the correct dosage and always consult with a healthcare professional before starting any new supplement regimen.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
      15.9
      Seconds
  • Question 16 - A 23-year-old female presents with severe right-sided ear pain, muffled hearing, and watery...

    Incorrect

    • A 23-year-old female presents with severe right-sided ear pain, muffled hearing, and watery discharge for the past 3 days. The patient also reports intense itching in the affected ear. Upon examination, the tympanic membrane is intact, but the external auditory canal is inflamed, red, and swollen with purulent debris and wax. Pulling the pinna causes the patient significant pain. The mastoid process is normal and not tender to palpation. Rinne's and Weber's tests confirm conductive hearing loss. What is the recommended first-line treatment for this patient?

      Your Answer: Topical antifungal + a topical antibiotic + a topical steroid for 1-2 weeks

      Correct Answer: Topical antibiotic + a topical steroid for 1-2 weeks

      Explanation:

      Understanding Otitis Externa: Causes, Features, and Management

      Otitis externa is a prevalent condition that often prompts primary care visits in the UK. It is characterized by ear pain, itch, and discharge, and can be caused by bacterial or fungal infections, seborrhoeic dermatitis, or contact dermatitis. Swimming is also a common trigger for otitis externa. Upon examination, the ear canal may appear red, swollen, or eczematous.

      The recommended initial management for otitis externa is the use of topical antibiotics or a combination of topical antibiotics with a steroid. However, if the tympanic membrane is perforated, aminoglycosides are traditionally not used. If there is canal debris, removal may be necessary, and if the canal is extensively swollen, an ear wick may be inserted. Second-line options include taking a swab inside the ear canal, considering contact dermatitis secondary to neomycin, or using oral antibiotics such as flucloxacillin if the infection is spreading. Empirical use of an antifungal agent may also be considered.

      It is important to note that if a patient fails to respond to topical antibiotics, they should be referred to an ENT specialist. Malignant otitis externa is a more severe form of the condition that is more common in elderly diabetics. It involves the extension of infection into the bony ear canal and the soft tissues deep to the bony canal, and may require intravenous antibiotics. While some ENT doctors disagree, concerns about ototoxicity may arise with the use of aminoglycosides in patients with perforated tympanic membranes.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      31.6
      Seconds
  • Question 17 - A 45-year-old male with type 1 diabetes has been diagnosed with microalbuminuria during...

    Incorrect

    • A 45-year-old male with type 1 diabetes has been diagnosed with microalbuminuria during his yearly check-up. He is aware of other patients with type 1 diabetes who have developed renal failure and required dialysis a few years after being diagnosed with nephropathy. When examining his vascular risk profile, which parameter is most likely to decrease the risk of future renal failure?

      Your Answer: HbA1c <53 mmol/mol

      Correct Answer:

      Explanation:

      Managing Nephropathy Progression

      Tight control of blood pressure and glucose levels is crucial in managing the progression of nephropathy. The recommended target for systolic blood pressure is 130 or less, while the HbA1c target should be less than 53 mmol/mol. Although BMI, diastolic blood pressure, and cholesterol are relevant factors, they are less significant compared to blood pressure and glucose control.

      Among all antihypertensives, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) have the strongest evidence for reducing nephropathy progression. Therefore, it is important to prioritize these medications in the management of nephropathy. Proper management of blood pressure and glucose levels, along with the use of ACE inhibitors and ARBs, can significantly slow down the progression of nephropathy.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
      37.1
      Seconds
  • Question 18 - Each of the following is linked to hypertrichosis, except for which one? ...

    Incorrect

    • Each of the following is linked to hypertrichosis, except for which one?

      Your Answer: Cushing's syndrome

      Correct Answer: Porphyria cutanea tarda

      Explanation:

      Hypertrichosis is the result of Porphyria cutanea tarda, not hirsutism.

      Understanding Hirsutism and Hypertrichosis

      Hirsutism is a term used to describe excessive hair growth in women that is dependent on androgens, while hypertrichosis refers to hair growth that is not androgen-dependent. Polycystic ovarian syndrome is the most common cause of hirsutism, but other factors such as Cushing’s syndrome, obesity, and certain medications can also contribute to this condition. To assess hirsutism, the Ferriman-Gallwey scoring system is often used, which assigns scores to nine different body areas. Management of hirsutism may involve weight loss, cosmetic techniques, or the use of oral contraceptive pills or topical medications.

      Hypertrichosis, on the other hand, can be caused by a variety of factors such as certain medications, congenital conditions, and even anorexia nervosa. It is important to identify the underlying cause of excessive hair growth in order to determine the most appropriate treatment approach. By understanding the differences between hirsutism and hypertrichosis, individuals can better manage these conditions and improve their quality of life.

    • This question is part of the following fields:

      • Dermatology
      14.6
      Seconds
  • Question 19 - A 30-year-old office worker has come to the clinic with a painful swollen...

    Incorrect

    • A 30-year-old office worker has come to the clinic with a painful swollen face that has developed over 24 hours. He is particularly swollen in the parotid area on the left. He has a fever of 38.2oC. He also has malaise, headache and has lost his appetite.
      What is the most probable diagnosis?

      Your Answer: Parotid adenoma

      Correct Answer: Mumps

      Explanation:

      Mumps: Symptoms, Complications, and Differential Diagnosis

      Mumps is a viral infection that is rare in vaccinated individuals but can affect those who have not been vaccinated or exposed to the virus. The onset of mumps can be sudden, and one-third of cases present with unilateral parotitis. Unlike parotid adenomas, which develop slowly, mumps is characterized by acute inflammation of the parotid gland. Glandular fever, on the other hand, typically affects the neck glands and is often accompanied by a sore throat. In children, parvovirus can cause slapped cheek syndrome, which is characterized by nonspecific viral symptoms followed by the appearance of firm red cheeks a few days later. Sialadenosis, a generalized swelling of the glands, is associated with hypertrophy of the acinar component of the gland and is commonly seen in individuals with systemic diseases such as Sjogren syndrome. Complications of mumps can include epididymo-orchitis, viral meningitis, pancreatitis, and, in rare cases, myocarditis. It is important to differentiate mumps from other conditions with similar symptoms to ensure proper diagnosis and treatment.

    • This question is part of the following fields:

      • Infectious Disease And Travel Health
      20.6
      Seconds
  • Question 20 - A case-control study is being designed to investigate the association between hypertension and...

    Correct

    • A case-control study is being designed to investigate the association between hypertension and a new medication. What is the typical outcome measure in a case-control study?

      Your Answer: Odds ratio

      Explanation:

      The odds ratio is typically the outcome measure in a case-control study.

      There are different types of studies that researchers can use to investigate various phenomena. One of the most rigorous types of study is the randomised controlled trial, where participants are randomly assigned to either an intervention or control group. However, practical or ethical issues may limit the use of this type of study. Another type of study is the cohort study, which is observational and prospective. Researchers select two or more groups based on their exposure to a particular agent and follow them up to see how many develop a disease or other outcome. The usual outcome measure is the relative risk. Examples of cohort studies include the Framingham Heart Study.

      On the other hand, case-control studies are observational and retrospective. Researchers identify patients with a particular condition (cases) and match them with controls. Data is then collected on past exposure to a possible causal agent for the condition. The usual outcome measure is the odds ratio. Case-control studies are inexpensive and produce quick results, making them useful for studying rare conditions. However, they are prone to confounding. Lastly, cross-sectional surveys provide a snapshot of a population and are sometimes called prevalence studies. They provide weak evidence of cause and effect.

    • This question is part of the following fields:

      • Evidence Based Practice, Research And Sharing Knowledge
      8.3
      Seconds
  • Question 21 - A 55-year-old smoker presents with a persistent hoarse voice for the past three...

    Correct

    • A 55-year-old smoker presents with a persistent hoarse voice for the past three to four weeks. He saw a colleague two weeks ago who found nothing focal on examination and advised him to seek review if his hoarseness did not settle after a further week. He has no significant past medical history, is not on any regular medication, and has no known drug allergies. He denies any cough, haemoptysis, swallowing problems, weight loss, or any systemic unwellness. Clinical examination reveals no anaemia, clubbing, lymphadenopathy or neck masses. His chest sounds clear, and an urgent chest x-ray is reported as 'normal'. What is the most appropriate next step in this patient's management?

      Your Answer: Refer urgently to an ear, nose and throat specialist

      Explanation:

      Recognizing and Referring Suspected Cancer: The Case of a Persisting Hoarse Voice

      The NICE guidelines on recognizing and referring suspected cancer do not provide a specific time period for what constitutes persistent symptoms. However, most references suggest that further action should be taken if hoarseness persists for three or more weeks. This could indicate a laryngeal cancer or a lung tumor that has infiltrated the recurrent laryngeal nerve. In such cases, an urgent chest x-ray may help direct referral.

      If the chest x-ray is normal, urgent referral to an ENT (or head and neck) specialist is needed to investigate the persisting hoarse voice. However, if the chest x-ray is abnormal and suggestive of lung malignancy, urgent referral to a lung cancer specialist is warranted.

      In summary, recognizing and referring suspected cancer is crucial in cases of persisting hoarseness. While the NICE guidelines do not provide a specific time period for what constitutes persistent symptoms, most references suggest that three or more weeks of hoarseness warrants further action. A normal chest x-ray requires urgent referral to an ENT (or head and neck) specialist, while an abnormal chest x-ray warrants urgent referral to a lung cancer specialist.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      26.6
      Seconds
  • Question 22 - A 6-year-old boy comes to his General Practitioner with his mother and stepfather....

    Incorrect

    • A 6-year-old boy comes to his General Practitioner with his mother and stepfather. He has a 2-month history of intermittent abdominal pain. The pain is colicky in nature and periumbilical. His appetite is slightly reduced. He is not constipated. The pain is causing him to miss some school, but he also experiences it at the weekend. The patient is otherwise normal and his height and weight are on the 50th centile.
      What is the most likely diagnosis?

      Your Answer: Abdominal migraine

      Correct Answer: Functional abdominal pain

      Explanation:

      Functional abdominal pain is a common condition among children, affecting up to 25% of them. It is characterized by pain in the abdominal area that is not caused by any organic factors. Symptoms that may indicate a non-organic cause include pain near the belly button, absence of other gastrointestinal symptoms, no disturbance in sleep, normal physical examination, and the child’s overall well-being. In most cases, a thorough history, examination, and explanation are sufficient to manage the condition. However, if the symptoms persist, referral to a pediatrician and further investigations may be necessary to rule out organic causes. School refusal is a psychological disorder that causes severe anxiety in children when attending school or being separated from their parents. Abdominal pain may be a symptom, but it is not usually experienced on weekends. Abdominal migraine is characterized by sudden episodes of intense pain in the periumbilical area, lasting for at least an hour, accompanied by anorexia, nausea, vomiting, headache, photophobia, or pallor. Intussusception is a rare condition that occurs mostly in infants aged five to ten months, making it unlikely to be the diagnosis for this patient. Irritable bowel syndrome is also unlikely as the patient has no changes in bowel habits.

    • This question is part of the following fields:

      • Children And Young People
      31
      Seconds
  • Question 23 - A 76-year-old male presents to your clinic with complaints of overactive bladder symptoms....

    Incorrect

    • A 76-year-old male presents to your clinic with complaints of overactive bladder symptoms. After a thorough investigation, you decide to initiate medication for his symptoms. His blood pressure is 130/80 mm Hg, his pulse is 72 bpm and regular. Urodynamic studies reveal no urinary retention, and recent blood tests show normal renal and liver function. The patient is currently taking medications for hypertension and benign prostatic hyperplasia. However, due to his age and medication regimen, you want to avoid prescribing a medication with a high anticholinergic burden. What medication would you consider starting for this patient's overactive bladder symptoms?

      Your Answer: Tolterodine

      Correct Answer: Mirabegron

      Explanation:

      Mirabegron, a beta 3 agonist, is recommended by NICE as a second option medication for overactive bladder symptoms, following antimuscarinics. However, it is important to be aware of potential side effects such as hypertension (including severe cases) and tachycardia. The other drugs listed are also used for overactive bladder symptoms, but they are anticholinergics.

      Urinary incontinence is a common condition that affects approximately 4-5% of the population, with elderly females being more susceptible. There are several risk factors that can contribute to the development of urinary incontinence, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. The condition can be classified into different types, such as overactive bladder, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

      Initial investigation of urinary incontinence involves completing bladder diaries for at least three days, performing a vaginal examination to exclude pelvic organ prolapse, and conducting urine dipstick and culture tests. Urodynamic studies may also be necessary. Management of urinary incontinence depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures may be necessary. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be offered to women who decline surgical procedures.

      In summary, urinary incontinence is a common condition that can be caused by various risk factors. It can be classified into different types, and management depends on the predominant type of incontinence. Initial investigation involves completing bladder diaries, performing a vaginal examination, and conducting urine tests. Treatment options include bladder retraining, bladder stabilizing drugs, pelvic floor muscle training, surgical procedures, and duloxetine.

    • This question is part of the following fields:

      • Kidney And Urology
      5.3
      Seconds
  • Question 24 - A 50-year-old woman comes to her General Practitioner with concerns about a lump...

    Incorrect

    • A 50-year-old woman comes to her General Practitioner with concerns about a lump in her throat that she has been feeling for the past six months. She reports feeling the lump even when she is not swallowing. Upon examination, her oropharynx, ears, nose, and neck appear normal. She is also a non-smoker.
      What would be a significant cause for worry in a patient with these symptoms who is 50 years old?

      Your Answer: The feeling comes and goes

      Correct Answer: Left-sided ear pain

      Explanation:

      Understanding Unilateral Ear Pain and Globus Sensation

      Unilateral ear pain in adults with normal otoscopy findings may indicate cancer of the base of the tongue, especially if accompanied by persistent hoarseness, dysphagia, weight loss, or a swelling in the neck. Risk factors for head and neck cancers include smoking and alcohol consumption. However, if the pain is worse between meals and eating or drinking alleviates the symptoms, it is more likely to be globus sensation, which is the feeling of a lump in the throat that doesn’t affect swallowing function. If the symptom persists for six months without affecting swallowing, it is less likely to be a worrying cause such as laryngeal or esophageal cancer. Intermittent symptoms are also less likely to indicate a malignant cause, as they are typical for globus and often exacerbated by stress.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      21.7
      Seconds
  • Question 25 - What are the reasons for performing circumcision in children? ...

    Incorrect

    • What are the reasons for performing circumcision in children?

      Your Answer: Acute balantitis

      Correct Answer: Phimosis

      Explanation:

      Indications for Paediatric Circumcision

      Paediatric circumcision is a surgical procedure that involves the removal of the foreskin covering the head of the penis. While it is not a routine procedure, there are certain indications that may require it.

      The most common indication for paediatric circumcision is pathological phimosis, which is scarring of the foreskin opening that makes it non-retractable. However, this condition is rare before the age of 5 years. It is important to note that a non-retractile prepuce without inflammation is a normal variant in the first few years of life.

      Recurrent episodes of infection beneath the foreskin, known as balanoposthitis, may also be an indication for circumcision. This condition can be troublesome and may require surgical intervention to prevent further complications.

      In rare cases, paediatric circumcisions may be required for other conditions. It is important to consult with a healthcare provider to determine if circumcision is necessary for your child.

    • This question is part of the following fields:

      • Children And Young People
      8.2
      Seconds
  • Question 26 - A 35-year-old former paratrooper has joined your practice. He lost his leg during...

    Incorrect

    • A 35-year-old former paratrooper has joined your practice. He lost his leg during a tour of duty in Afghanistan when he was shelled by opposing forces and witnessed the death of two of his colleagues.

      In recent months, he has been experiencing flashbacks, and his wife has noticed that he has become emotionally distant and insensitive towards her. He has also been struggling with sleep and concentration, and has been prone to sudden outbursts of anger.

      You suspect that he may be suffering from PTSD and have recommended that he seek psychiatric help. Although he has declined counseling, he is interested in learning more about medication options, having seen the positive effects of sertraline on his wife's depression a few years ago.

      According to NICE guidelines, which antidepressant is recommended as a second-line treatment for PTSD after psychological therapy has been refused or proven ineffective?

      Your Answer: Mirtazapine

      Correct Answer: Diazepam

      Explanation:

      NICE’s Guidance on Drug Treatments for PTSD in Adults

      According to the latest guidance from the National Institute for Health and Care Excellence (NICE) updated in 2018, drug treatments, including benzodiazepines, should not be offered to prevent PTSD in adults. However, for those with a diagnosis of PTSD who prefer drug treatment, venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline, may be considered and should be reviewed regularly.

      In addition, antipsychotics such as risperidone may be considered for adults with a diagnosis of PTSD who have disabling symptoms and behaviors, such as severe hyperarousal or psychotic symptoms, and have not responded to other drug or psychological treatments. It is important to note that antipsychotic treatment should be started and reviewed regularly by a specialist.

      Overall, NICE’s guidance emphasizes the importance of individualized treatment plans for adults with PTSD, taking into account their preferences and response to previous treatments.

    • This question is part of the following fields:

      • Mental Health
      12.7
      Seconds
  • Question 27 - A 25-year-old man has become withdrawn and is receiving messages via the television....

    Incorrect

    • A 25-year-old man has become withdrawn and is receiving messages via the television. You suspect he may have schizophrenia.
      Select from the list the single correct statement regarding the treatment of schizophrenia.

      Your Answer: Compliance is usually problematic upon switching to intramuscular depot antipsychotics

      Correct Answer: Clozapine is indicated for treatment-resistant schizophrenia

      Explanation:

      Antipsychotic Medication for Schizophrenia: Types, Side-Effects, and Treatment Options

      Antipsychotic medication is commonly used to alleviate the symptoms of schizophrenia, particularly positive symptoms. However, they may not be as effective for negative symptoms. Newer or atypical antipsychotics, such as amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone, and sertindole, are often preferred as they have a better balance between efficacy and side-effects.

      First-generation antipsychotic drugs, also known as typical antipsychotics, primarily block dopamine D2 receptors in the brain, which can lead to extrapyramidal symptoms and elevated prolactin. Second-generation antipsychotic drugs, or atypical antipsychotics, act on a wider range of receptors and have more distinct clinical profiles. Both types of antipsychotics are effective in treating schizophrenia.

      Early treatment is recommended to prevent further deterioration of brain functioning. In some cases, long-acting antipsychotic injections may be used to improve compliance. Benzodiazepines may also be used as a short-term adjunct therapy for behavior disturbances, insomnia, aggression, and agitation, although the evidence supporting this is limited.

      Clozapine is indicated for patients with schizophrenia who are unresponsive to or intolerant of conventional antipsychotic drugs. It can only be prescribed by a specialist and requires at least two previous trials of antipsychotics, including one newer/atypical antipsychotic, at adequate dosages and treatment periods. However, it carries a risk of life-threatening neutropenia as a potential side-effect.

    • This question is part of the following fields:

      • Mental Health
      26.9
      Seconds
  • Question 28 - A 56-year-old female arrives at the Emergency Department with complaints of double vision....

    Correct

    • A 56-year-old female arrives at the Emergency Department with complaints of double vision. Upon examination, she displays exophthalmos and conjunctival oedema, leading to a suspicion of thyroid eye disease. What can be inferred about her thyroid condition?

      Your Answer: Eu-, hypo- or hyperthyroid

      Explanation:

      Thyroid eye disease is often linked to hyperthyroidism from Graves’ disease, but it can also occur in euthyroid or hypothyroid patients. The severity of the eye disease is not necessarily related to the level of thyrotoxicosis.

      Thyroid eye disease is a condition that affects a significant proportion of patients with Graves’ disease. It is believed to be caused by an autoimmune response against an autoantigen, possibly the TSH receptor, which leads to inflammation behind the eyes. This inflammation causes the deposition of glycosaminoglycan and collagen in the muscles, resulting in symptoms such as exophthalmos, conjunctival oedema, optic disc swelling, and ophthalmoplegia. In severe cases, patients may be unable to close their eyelids, leading to sore, dry eyes and a risk of exposure keratopathy.

      Prevention of thyroid eye disease is important, and smoking is the most significant modifiable risk factor. Radioiodine treatment may also increase the risk of developing or worsening eye disease, but prednisolone may help reduce this risk. Management of established thyroid eye disease may involve topical lubricants to prevent corneal inflammation, steroids, radiotherapy, or surgery.

      Patients with established thyroid eye disease should be monitored closely for any signs of deterioration, such as unexplained changes in vision, corneal opacity, or disc swelling. Urgent review by an ophthalmologist is necessary in these cases to prevent further complications. Overall, thyroid eye disease is a complex condition that requires careful management and monitoring to ensure the best possible outcomes for patients.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
      15.4
      Seconds
  • Question 29 - A 7-year-old girl is brought in by her worried parent who has observed...

    Correct

    • A 7-year-old girl is brought in by her worried parent who has observed a significant space between her ankles and is anxious as her knees seem to be close together while standing. The parent mentions that the girl has a balanced diet and gets enough exposure to sunlight and is healthy otherwise.

      What would be the most suitable course of action to manage this situation?

      Your Answer: Reassure the parent that knock knees are a usual variant and usually resolve by the age of 8 years

      Explanation:

      Genu valgum, commonly known as knock knees, is a typical condition that typically resolves on its own by the age of 8 years. As such, there is no need to refer the patient to an orthopaedic clinic or provide specific physiotherapy. Supportive shoes or leg braces are not recommended.

      Common Variations in Lower Limb Development in Children

      Parents may become concerned when they notice what appears to be abnormalities in their child’s lower limbs. This often leads to a visit to the primary care physician and a referral to a specialist. However, many of these variations are actually normal and will resolve on their own as the child grows.

      One common variation is flat feet, where the medial arch is absent when the child is standing. This is typically seen in children of all ages and usually resolves between the ages of 4-8 years. Orthotics are not recommended, and parental reassurance is appropriate.

      Another variation is in-toeing, which can be caused by metatarsus adductus, internal tibial torsion, or femoral anteversion. In most cases, these will resolve on their own, but severe or persistent cases may require intervention such as serial casting or surgical intervention. Out-toeing is also common in early infancy and usually resolves by the age of 2 years.

      Bow legs, or genu varum, are typically seen in the first or second year of life and are characterized by an increased intercondylar distance. This variation usually resolves by the age of 4-5 years. Knock knees, or genu valgum, are seen in the third or fourth year of life and are characterized by an increased intermalleolar distance. This variation also typically resolves on its own.

      In summary, many variations in lower limb development in children are normal and will resolve on their own. However, if there is concern or persistent symptoms, intervention may be appropriate.

    • This question is part of the following fields:

      • Children And Young People
      16.8
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  • Question 30 - Which drug from the list provides the LEAST mortality benefit in chronic heart...

    Correct

    • Which drug from the list provides the LEAST mortality benefit in chronic heart failure?

      Your Answer: Digoxin

      Explanation:

      The Role of Digoxin in Congestive Heart Failure Treatment

      Digoxin, a medication commonly used in the past for congestive heart failure, has lost its popularity due to the lack of demonstrated mortality benefit in patients with this condition. However, it has shown a reduction in hospitalizations for congestive heart failure. Therefore, it is recommended to maximize the use of other therapies such as ACE inhibitors, β blockers, and spironolactone before considering digoxin. If the ACE inhibitor cannot be tolerated, an angiotensin II receptor antagonist like candesartan can be used as an alternative. Digoxin should only be considered as a third-line treatment for severe heart failure due to left ventricular systolic dysfunction after first- and second-line treatments have been exhausted.

    • This question is part of the following fields:

      • Cardiovascular Health
      5.1
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SESSION STATS - PERFORMANCE PER SPECIALTY

Ear, Nose And Throat, Speech And Hearing (2/4) 50%
Improving Quality, Safety And Prescribing (0/1) 0%
Mental Health (0/4) 0%
Musculoskeletal Health (0/1) 0%
Gastroenterology (1/1) 100%
Older Adults (1/1) 100%
Gynaecology And Breast (1/1) 100%
Neurology (0/1) 0%
Respiratory Health (1/1) 100%
Metabolic Problems And Endocrinology (2/4) 50%
Genomic Medicine (1/1) 100%
Cardiovascular Health (2/2) 100%
Kidney And Urology (1/2) 50%
Dermatology (0/1) 0%
Infectious Disease And Travel Health (0/1) 0%
Evidence Based Practice, Research And Sharing Knowledge (1/1) 100%
Children And Young People (1/3) 33%
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