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Question 1
Correct
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In which joint is recurrent dislocation most frequently observed?
Your Answer: Shoulder
Explanation:The Shoulder Joint: Flexible and Unstable
The shoulder joint is known for its remarkable flexibility, allowing for a wide range of motion. This is due to the small area of contact between the upper arm bone and the socket on the scapula, which is also shallow. However, this same feature also makes the shoulder joint unstable, making it the most susceptible to dislocation.
In summary, the shoulder joint flexibility is due to its small contact area and shallow socket, but this also makes it unstable and prone to dislocation.
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This question is part of the following fields:
- Surgery
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Question 2
Incorrect
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A 21-year-old male presents to the medical assessment unit with a 6-week history of increasing frequency of diarrhoea and abdominal pain. The patient is now opening his bowels up to eight times a day, and he is also needing to get up during the night to pass motions. He describes the stool as watery, with some mucous and blood. He is also suffering with intermittent cramping abdominal pain. He has had no recent foreign travel, and no other contacts have been unwell with similar symptoms. He has lost almost 6 kg in weight. He has no other past medical history of note.
Inflammatory bowel disease is high on the list of differentials.
Which one of the following is most commonly associated with Ulcerative colitis (UC)?Your Answer: Duodenal involvement
Correct Answer: Rectal involvement
Explanation:Differences between Ulcerative Colitis and Crohn’s Colitis
Ulcerative colitis (UC) and Crohn’s colitis are two types of inflammatory bowel disease (IBD) that affect the colon and rectum. However, there are several differences between the two conditions.
Rectal Involvement
UC usually originates in the rectum and progresses proximally, while Crohn’s colitis can affect any part of the gastrointestinal tract, including the duodenum.Transmural Inflammation
Crohn’s colitis involves transmural inflammation, while UC typically affects only the submucosa or mucosa.Anal Fistulae and Abscesses
Crohn’s colitis is more likely to cause anal fistulae and abscesses due to its transmural inflammation, while UC is less prone to these complications.Duodenal Involvement
UC usually affects only the colon, while Crohn’s colitis can involve the duodenum. As a result, colectomy is often curative in UC but not in Crohn’s disease.Symptoms and Severity
Both conditions can cause bloody diarrhea, weight loss, and abdominal pain. However, the severity of UC is measured by the number of bowel movements per day, abdominal pain and distension, signs of toxicity, blood loss and anemia, and colon dilation.Understanding the Differences between Ulcerative Colitis and Crohn’s Colitis
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This question is part of the following fields:
- Gastroenterology
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Question 3
Correct
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A 67-year-old man presents with nausea, vomiting, epigastric discomfort and weight loss over the last 2 months. On questioning, he describes postprandial fullness and loss of appetite. He denies any dysphagia, melaena or haematemesis. He has a long-standing history of heartburn. He has no other relevant past medical history. Investigations reveal iron deficiency anaemia. Endoscopy confirms gastric cancer.
What is a risk factor for gastric cancer in this 67-year-old man?Your Answer: Helicobacter pylori
Explanation:Risk Factors and Protective Measures for Gastric Cancer
Gastric cancer is a prevalent form of cancer worldwide, but its incidence is decreasing. Several factors are associated with an increased risk of developing gastric cancer, including pernicious anaemia, blood group A, smoking, and a diet high in nitrate and salt. However, a diet rich in citrus fruits and leafy green vegetables can decrease the risk. Helicobacter pylori infection is a significant risk factor, with a relative risk of 5.9. However, this bacterium is not a risk factor for cancer of the gastric cardia, which is increasing and associated with long-term gastro-oesophageal reflux disease, smoking, and obesity. Non-steroidal anti-inflammatory drugs (NSAIDs) may have a protective effect in preventing gastric cancer. Blood group B and a higher education/social class are protective factors. A diet rich in fresh fruits and vegetables is also likely to be protective.
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This question is part of the following fields:
- Gastroenterology
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Question 4
Incorrect
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A 38-year-old man arrives at the Emergency Department complaining of sudden central crushing chest pain while at a social gathering. He is sweating profusely and describes his pain as severe. He has no significant medical or family history but admits to snorting a considerable amount of cocaine at the party. An ECG reveals 4 mm ST elevation in the anterior leads, indicating acute coronary syndrome (ACS). What other interventions should be considered in managing this patient, in addition to standard ACS treatment?
Your Answer: IV labetalol
Correct Answer: IV lorazepam
Explanation:In the treatment of acute coronary syndrome (ACS) caused by cocaine use, it is recommended to administer IV benzodiazepines along with standard ACS protocols. This is because ACS in this context is often due to coronary artery vasospasm, which can be improved by benzodiazepines’ ability to reduce CNS sympathetic outflow and mitigate the toxic effects of cocaine. However, cautious dosing is necessary to avoid benzodiazepine toxicity. In cases of beta-blocker overdose with hemodynamic instability, IV glucagon is indicated. IV labetalol may be used for blood pressure control in hypertensive emergencies or aortic dissection, although its use in cocaine overdose is still generally avoided due to concerns about unopposed alpha-adrenergic activity.
Understanding Cocaine Toxicity
Cocaine is a popular recreational stimulant derived from the coca plant. However, its widespread use has resulted in an increase in cocaine toxicity cases. The drug works by blocking the uptake of dopamine, noradrenaline, and serotonin, leading to a variety of adverse effects.
Cardiovascular effects of cocaine include coronary artery spasm, tachycardia, bradycardia, hypertension, QRS widening, QT prolongation, and aortic dissection. Neurological effects may include seizures, mydriasis, hypertonia, and hyperreflexia. Psychiatric effects such as agitation, psychosis, and hallucinations may also occur. Other complications include ischaemic colitis, hyperthermia, metabolic acidosis, and rhabdomyolysis.
Managing cocaine toxicity involves using benzodiazepines as a first-line treatment for most cocaine-related problems. For chest pain, benzodiazepines and glyceryl trinitrate may be used, and primary percutaneous coronary intervention may be necessary if myocardial infarction develops. Hypertension can be treated with benzodiazepines and sodium nitroprusside. The use of beta-blockers in cocaine-induced cardiovascular problems is controversial, with some experts warning against it due to the risk of unopposed alpha-mediated coronary vasospasm.
In summary, cocaine toxicity can lead to a range of adverse effects, and managing it requires careful consideration of the patient’s symptoms and medical history.
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This question is part of the following fields:
- Pharmacology
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Question 5
Incorrect
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A 75-year-old woman is recuperating from an inguinal hernia surgery when she experiences a severe ischemic stroke. She is being treated on the rehabilitation ward. Nevertheless, she is still unable to eat securely, and multiple swallowing evaluations have revealed that she has a tendency to aspirate. What is the most suitable alternative for long-term feeding?
Your Answer: Long term nasogastric tube feeding
Correct Answer: PEG tube feeding
Explanation:Although PEG tubes are linked to a considerable amount of morbidity, they are the most suitable choice for a long-term solution. A feeding jejunostomy necessitates the use of general anesthesia. TPN is not a viable alternative. Long-term nasogastric feeding is typically inadequate.
Enteral feeding is a method of providing nutrition to patients who are malnourished or at risk of malnutrition and have a functional gastrointestinal tract. It involves administering food directly into the stomach through a tube, which can be placed either through the nose (nasogastric tube) or directly into the stomach (gastrostomy tube). The type of tube used depends on the patient’s condition and the presence of upper gastrointestinal dysfunction.
To ensure safe and effective enteral feeding, healthcare professionals must check the placement of the tube using aspiration and pH tests. Gastric feeding is preferred, but if there is upper GI dysfunction, duodenal or jejunal tubes may be used. Patients in intensive care units (ICUs) should receive continuous feeding for 16-24 hours, and a motility agent may be used to aid gastric emptying. If this is ineffective, post-pyloric feeding or parenteral feeding may be considered.
Complications of enteral feeding include diarrhoea, aspiration, hyperglycaemia, and refeeding syndrome. Patients who are identified as malnourished or at risk of malnutrition should be considered for enteral feeding, especially if they have a BMI below 18.5 kg/m2, unintentional weight loss of more than 10% over 3-6 months, or a BMI below 20 kg/m2 and unintentional weight loss of more than 5% over 3-6 months. Surgical patients who are malnourished, have an unsafe swallow or inadequate oral intake, and have a functional GI tract may benefit from preoperative enteral feeding.
It is important to note that PEG tubes should not be removed until at least 2 weeks after insertion, and surgical patients due to have major abdominal surgery should be carefully evaluated before enteral feeding is initiated. Overall, enteral feeding is a valuable tool for providing nutrition to patients who are unable to eat normally, but it must be used with caution and under the guidance of a healthcare professional.
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This question is part of the following fields:
- Surgery
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Question 6
Incorrect
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A 42-year-old woman presented to the Emergency Department with a swollen and tender left leg. She had been diagnosed with a deep vein thrombosis (DVT) on her right leg 3 months ago and was prescribed warfarin, which has maintained her INR at 2.0–3.0. The Doppler scan confirmed a positive DVT on her left leg this time, and she has been referred to haematology for further investigations. What is the most appropriate plan for her anticoagulation?
Your Answer: Continue warfarin, aim INR target 3.0
Correct Answer: Continue warfarin, aim INR target 3.5
Explanation:Choosing the Right INR Target for Recurrent DVT: A Guide
When it comes to treating recurrent deep vein thrombosis (DVT), determining the appropriate international normalized ratio (INR) target is crucial. While a target of 2.5 (2.0-3.0) is recommended for first presentations of DVT, the target should be increased to 3.5 for recurrent cases. However, if the patient’s INR has been stable within the target range, there is no need to switch to low-molecular-weight heparin. Additionally, antiplatelet agents like clopidogrel have limited use in venous thromboembolism. By following these guidelines, healthcare providers can ensure that their patients receive the most effective treatment for recurrent DVT.
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This question is part of the following fields:
- Pharmacology
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Question 7
Incorrect
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A 65-year-old man visited the dermatology clinic in the summer with a rash on his forearms, shins, and face. Which medication is most likely to be linked with this photosensitive rash?
Your Answer: Clopidogrel
Correct Answer: Bendroflumethiazide
Explanation:Adverse Effects of Cardiology Drugs
Photosensitivity is a frequently observed negative reaction to certain cardiology drugs, such as amiodarone and thiazide diuretics. This means that patients taking these medications may experience an increased sensitivity to sunlight, resulting in skin rashes or other skin-related issues. Additionally, ACE inhibitors and A2RBs, which are commonly prescribed for cardiovascular conditions, have been known to cause rashes that may also be photosensitive. It is important for patients to be aware of these potential side effects and to take necessary precautions, such as wearing protective clothing and using sunscreen, when exposed to sunlight.
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This question is part of the following fields:
- Cardiology
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Question 8
Incorrect
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A 48-year-old woman is brought to the Emergency department by emergency ambulance following a deliberate overdose of an unknown drug.
She is accompanied by her husband who tells you that she has a long history of anxiety and depression and takes fluoxetine 20 mg od and lorazepam 2 mg bd.
On primary assessment, her airway is clear but she only groans when sternal rub is applied. Her chest is clear to auscultation but her respiratory rate is 6 ventilations per minute and oxygen saturations are 93% on air.
Heart sounds are normal with a rate of 80 bpm and blood pressure is 82/44 mmHg. ECG shows sinus rhythm. Capillary blood glucose is 6.3 mmol/L. Her GCS is 8/15 (E1, V2, M5) but her pupils are slowly reactive bilaterally and size 4. All limbs appear to move equally and there is no apparent injury. She smells of alcohol.
What is the first most appropriate step in the immediate management of this patient?Your Answer: Insert a nasogastric tube and administer 50 g activated charcoal
Correct Answer: Insert a nasopharyngeal airway and commence high flow oxygen
Explanation:The ABCDE approach is important for assessing acutely unwell patients. Protecting the airway is paramount in this case, as the patient’s level of consciousness threatens it. Oxygen and a nasopharyngeal airway are the first steps. Flumazenil and naloxone are not indicated, as the drug taken is unknown and opioid overdose is unlikely. Activated charcoal may not be effective if the time of ingestion is unknown. Prophylactic intubation is reasonable but not mandatory. Arterial blood gases can help determine ventilation, but supplemental oxygen and airway adjuncts are reasonable first steps.
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This question is part of the following fields:
- Emergency Medicine
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Question 9
Correct
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A 28-year-old primigravida woman is rushed for an emergency caesarean section due to fetal distress and hypoxia detected on cardiotocography. She is currently at 31 weeks gestation.
After delivery, the baby is admitted to the neonatal intensive care unit (NICU) and given oxygen to aid breathing difficulties.
Several weeks later, during an ophthalmological examination, the baby is found to have bilateral absent red reflex and retinal neovascularisation.
What is the probable diagnosis?Your Answer: Retinopathy of prematurity
Explanation:Risks Associated with Prematurity
Prematurity is a condition that poses several risks to the health of newborns. The risk of mortality increases with decreasing gestational age. Premature babies are at risk of developing respiratory distress syndrome, intraventricular haemorrhage, necrotizing enterocolitis, chronic lung disease, hypothermia, feeding problems, infection, jaundice, and retinopathy of prematurity. Retinopathy of prematurity is a significant cause of visual impairment in babies born before 32 weeks of gestation. The cause of this condition is not fully understood, but it is believed that over oxygenation during ventilation can lead to the proliferation of retinal blood vessels, resulting in neovascularization. Screening for retinopathy of prematurity is done in at-risk groups. Premature babies are also at risk of hearing problems.
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This question is part of the following fields:
- Obstetrics
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Question 10
Correct
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A 50-year-old male presents to the acute medical unit with severe jaundice and gross ascites. He has a history of alcohol abuse and was diagnosed with liver cirrhosis two years ago. He has been admitted to the hospital multiple times due to confusion and altered consciousness caused by his cirrhosis. What medications should be evaluated for preventing the recurrence of the aforementioned complication?
Your Answer: Lactulose and rifaximin
Explanation:Lactulose and rifaximin are the recommended medications for secondary prophylaxis of hepatic encephalopathy. This condition is characterized by confusion, altered consciousness, asterixis, and triphasic slow waves on EEG, and is caused by excess absorption of ammonia and glutamine from bacterial breakdown of proteins in the gut. Lactulose promotes the excretion of ammonia and increases its metabolism by gut bacteria, while rifaximin modulates the gut flora to decrease ammonia production. Spironolactone and furosemide are not used for hepatic encephalopathy, but rather for managing ascites and edema in patients with hypoalbuminemia due to cirrhosis. Propranolol is also not used for prophylaxis against hepatic encephalopathy, but rather to lower portal pressure and prevent variceal bleeding.
Understanding Hepatic Encephalopathy
Hepatic encephalopathy is a condition that can occur in individuals with liver disease, regardless of the cause. The exact cause of this condition is not fully understood, but it is believed to be related to the absorption of excess ammonia and glutamine from the breakdown of proteins by bacteria in the gut. While hepatic encephalopathy is commonly associated with acute liver failure, it can also be seen in chronic liver disease. In fact, many patients with liver cirrhosis may experience mild cognitive impairment before the more recognizable symptoms of hepatic encephalopathy appear. It is also worth noting that transjugular intrahepatic portosystemic shunting (TIPSS) can trigger encephalopathy.
The symptoms of hepatic encephalopathy can range from irritability and confusion to incoherence and coma. The condition can be graded based on the severity of the symptoms, with Grade I being the mildest and Grade IV being the most severe. There are several factors that can precipitate hepatic encephalopathy, including infection, gastrointestinal bleeding, constipation, and certain medications.
The management of hepatic encephalopathy involves treating any underlying causes and using medications to alleviate symptoms. Lactulose is often the first-line treatment, as it promotes the excretion of ammonia and increases its metabolism by gut bacteria. Antibiotics such as rifaximin can also be used to modulate the gut flora and reduce ammonia production. In some cases, embolization of portosystemic shunts or liver transplantation may be necessary.
Overall, hepatic encephalopathy is a complex condition that requires careful management and monitoring. By understanding the causes, symptoms, and treatment options, healthcare providers can provide the best possible care for patients with this condition.
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This question is part of the following fields:
- Medicine
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Question 11
Incorrect
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You are requested to evaluate a 15-year-old Caucasian girl who has been feeling unwell for a few days. She has been experiencing intermittent fevers and chills and complains of extreme fatigue. Suddenly, half an hour before her admission to the hospital, she lost all vision in her left eye.
During the examination, the patient appears pale and unwell. Her vital signs are as follows: temperature 38.5°C, pulse 120/minute, regular, blood pressure 100/55 mmHg, and respiratory rate 22/minute. A pansystolic murmur is audible at the apex and lower left sternal border. Both lungs are clear.
The right pupil reacts normally to light, but there is no reaction from the left pupil, which remains fixed and dilated. The patient has complete loss of vision in the left eye, and the left fundus appears paler than the right, without papilloedema. The only additional finding on examination was a paronychia on her right thumb, and light pressure on the nail bed was very uncomfortable.
Investigations reveal the following results: Hb 109 g/L (115-165), WBC 14.1 ×109/L (4-11), Neutrophils 9.0 ×109/L (1.5-7), Lymphocytes 4.8 ×109/L (1.5-4), Monocytes 0.29 ×109/L (0-0.8), Eosinophils 0.01 ×109/L (0.04-0.4), and Platelets 550 ×109/L (150-400).
What is the most crucial investigation to determine the cause of her illness?Your Answer: MRI head with gadolinium contrast
Correct Answer: Blood cultures
Explanation:Complications of Chronic Paronychia
Chronic paronychia can lead to serious complications such as osteomyelitis and endocarditis. The most common causative organism for these complications is Staphylococcus aureus. Endocarditis can cause emboli, which are fragments of vegetation that can block or damage blood vessels in any part of the body. This can result in severe consequences such as blindness, stroke, or paralysis.
To properly assess and manage a patient with chronic paronychia and its complications, several investigations may be necessary. However, the most crucial immediate investigations are blood cultures and echocardiography. These tests can help identify the causative organism and determine the extent of damage to the heart valves. Early diagnosis and treatment are essential to prevent further complications and improve the patient’s prognosis.
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This question is part of the following fields:
- Neurology
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Question 12
Incorrect
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A 65-year-old lady with metastatic breast cancer is admitted to the hospice for ongoing care. She complains that, at night, strange men enter her room and move her belongings and that staff talk about her during the day. In addition, she sometimes sees a vision of her deceased sister in her room and this has caused her anxiety and distress.
Which of the following medications would be most appropriate to treat her symptoms?Your Answer: Diazepam
Correct Answer: Haloperidol
Explanation:Medications for Delirium and Hallucinations
Delirium is a common condition in elderly and unwell patients that can cause hallucinations and agitation. Haloperidol is the preferred treatment for these symptoms. It is an anti-psychotic medication that can effectively manage hallucinations and agitation associated with delirium.
Benzodiazepines like lorazepam and diazepam have anxiolytic and sedating effects but do not treat hallucinations. Midazolam can be used to treat anxiety and induce sedation but is not effective in treating hallucinations.
Hyoscine bromide is a medication used to treat respiratory secretions in patients with a weak cough and is not indicated for the treatment of delirium or hallucinations. It is important to actively diagnose and manage delirium in patients to provide appropriate treatment and improve outcomes.
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This question is part of the following fields:
- Palliative Care
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Question 13
Incorrect
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An 8-year-old boy arrives at the Emergency Department after falling on his outstretched hand. He is experiencing severe pain and cannot move his arm. An X-ray shows a fracture of the distal radius, along with dislocation of the distal radioulnar joint. The ulna appears to be intact. What is the most probable type of injury that this patient has suffered?
Your Answer: Colles fracture
Correct Answer: Galeazzi fracture-dislocation
Explanation:Common Fracture-Dislocations: Types and Characteristics
Fracture-dislocations are common injuries that occur due to falls or direct blows. Here are some of the most common types and their characteristics:
Galeazzi Fracture-Dislocation: This type of injury is most common in children and occurs when falling onto an outstretched hand with the elbow in flexion. It involves a radial shaft fracture with dorsal angulation, dislocation of the distal radioulnar joint, and radial shortening. Surgical fixation is required due to its instability.
Colles Fracture: This type of fracture occurs following a fall onto an outstretched hand and involves a fracture of the distal radius with dorsal angulation and impaction. There is no associated dislocation of the distal radioulnar joint.
Bankart Fracture: This type of fracture occurs as a complication of an anterior shoulder dislocation where the labrum and glenohumeral capsule/ligament are injured due to compression of the humeral head against the labrum. It is often seen with a Hill-Sachs lesion.
Monteggia Fracture-Dislocation: This type of injury involves a fracture of the ulnar shaft and dislocation of the radial head. It typically occurs following a fall onto an outstretched hand.
Smith’s Fracture: This type of fracture occurs due to a fall onto a flexed wrist or a direct blow to the back of the wrist. It involves a fracture of the distal radius with volar, not dorsal, angulation of the distal fragments.
In summary, fracture-dislocations are common injuries that require prompt medical attention and appropriate treatment to ensure proper healing and prevent long-term complications.
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This question is part of the following fields:
- Trauma
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Question 14
Correct
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What is the mode of action of bisphosphonates in the management of osteoporosis?
Your Answer: Inhibition of osteoclast activity
Explanation:Bisphosphonates: The First Line Treatment for Osteoporosis
Bisphosphonates are the primary treatment for osteoporosis, a condition where there is an imbalance between bone formation and bone resorption. Osteoclasts are responsible for bone resorption, and bisphosphonates inhibit their activity. Peak bone mass is achieved between 25-35 years of age, after which bone mineral density gradually decreases every year. Women experience accelerated bone loss after menopause, and diseases that cause accelerated bone turnover can also increase bone loss. Bisphosphonates reduce the recruitment of osteoclasts, promote their apoptosis, and indirectly stimulate osteoblast activity. This overall slows bone turnover and loss of bone mineral density. Examples of bisphosphonates include alendronate, risedronate, disodium etidronate, and pamidronate, which is more commonly used to treat hypercalcaemia.
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This question is part of the following fields:
- Pharmacology
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Question 15
Incorrect
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A 56-year-old man with a long-standing history of type 2 diabetes mellitus and stage 3 chronic kidney disease presents with complaints of back pain that has been gradually worsening over the past few weeks. His GP has referred him for further evaluation. Upon examination, the patient is lying on his left side with his hips slightly flexed. Attempting to palpate his abdomen causes pain in his left hip and back. The patient experiences increased pain when asked to flex his hip against resistance or hyperextend his hip. His vital signs are as follows: temperature 38.3 ºC, heart rate 95/min, respiratory rate 20/min, and blood pressure 140/82 mmHg. His abdomen is soft and non-tender. What is the most appropriate initial management for this patient's condition?
Your Answer: IV antibiotics and urgent laparoscopy
Correct Answer: IV antibiotics and percutaneous drainage
Explanation:In cases of suspected iliopsoas abscess, antibiotics alone are unlikely to provide a cure. If there is a high clinical suspicion of a retrocaecal appendix, urgent laparoscopy and IV antibiotics may be necessary. However, this condition typically presents with acute pain in the right lower quadrant of the abdomen upon hip extension. Neoplastic spinal cord compression may require oral dexamethasone and an oncological review, as it initially presents with back pain and can progress to neurological deficits.
An iliopsoas abscess is a condition where pus accumulates in the iliopsoas compartment, which includes the iliacus and psoas muscles. There are two types of iliopsoas abscesses: primary and secondary. Primary abscesses occur due to the spread of bacteria through the bloodstream, with Staphylococcus aureus being the most common cause. Secondary abscesses are caused by underlying conditions such as Crohn’s disease, diverticulitis, colorectal cancer, UTIs, GU cancers, vertebral osteomyelitis, femoral catheterization, lithotripsy, endocarditis, and intravenous drug use. Secondary abscesses have a higher mortality rate compared to primary abscesses.
The clinical features of an iliopsoas abscess include fever, back/flank pain, limp, and weight loss. During a clinical examination, the patient is positioned supine with the knee flexed and the hip mildly externally rotated. Specific tests are performed to diagnose iliopsoas inflammation, such as placing a hand proximal to the patient’s ipsilateral knee and asking the patient to lift their thigh against the hand, which causes pain due to contraction of the psoas muscle. Another test involves lying the patient on the normal side and hyperextending the affected hip, which should elicit pain as the psoas muscle is stretched.
The investigation of choice for an iliopsoas abscess is a CT scan of the abdomen. Management involves antibiotics and percutaneous drainage, which is successful in around 90% of cases. Surgery is only indicated if percutaneous drainage fails or if there is another intra-abdominal pathology that requires surgery.
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This question is part of the following fields:
- Musculoskeletal
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Question 16
Correct
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A 38-year-old man presents with a one-month history of feeling a lump in his throat. The feeling comes and goes and has not progressed. He has no difficulty swallowing food or liquids; in fact, eating and drinking help to relieve the symptoms. He has not lost weight. He is a non-smoker. He was recently diagnosed with gastro-oesophageal reflux disease (GORD) and is taking a proton pump inhibitor. He also has chronic sinusitis, for which he takes a steroid nasal spray.
Examination is normal, without cervical lymphadenopathy.
What is the most likely diagnosis in this case?Your Answer: Globus pharyngeus
Explanation:Globus pharyngeus is a condition where patients feel a painless lump at the back of their throat. The cause of this condition is unknown, but it is often attributed to anxiety, pharyngeal spasm, reflux disease, or hiatus hernia. However, it is important to rule out more serious conditions such as thyroid disorders or cancer before diagnosing globus pharyngeus. An oesophageal ring is a benign structure at the lower end of the oesophagus that can cause swallowing difficulties. While not always symptomatic, patients may experience regurgitation and food obstruction. A diagnosis is confirmed through upper gastrointestinal endoscopy to rule out more serious causes such as oesophageal cancer. Achalasia is a disorder of the oesophagus where the lower oesophageal sphincter fails to relax, causing difficulty swallowing and regurgitation. A barium swallow and manometry can confirm the diagnosis. Eosinophilic oesophagitis is an allergic reaction that causes pain and heartburn upon swallowing, as well as vomiting and loss of appetite. Laryngeal squamous cell carcinoma is a type of head and neck cancer associated with smoking and other carcinogens. Symptoms include hoarseness, coughing, difficulty swallowing, and systemic signs of distant metastases. However, the patient in question had no warning signs or risk factors for this type of cancer.
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This question is part of the following fields:
- ENT
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Question 17
Incorrect
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A 28-year-old patient is admitted with vomiting and abdominal pain. She was noted to have marked buccal pigmentation.
Examination reveals dehydration, pulse 100 bpm, blood pressure (BP) 90/60 mmHg. Initial blood tests show: glucose 2.9 mmol/l, sodium (Na+) 126 mmol/l, potassium (K+) 4.9 mmol/l, urea 8.2 mmol/l, creatinine 117 µmol/l.
Which of the following is the most likely diagnosis?Your Answer: Insulinoma
Correct Answer: Addison’s disease
Explanation:Medical Conditions: Addison’s Disease and Other Differential Diagnoses
Addison’s Disease:
Addison’s disease, or primary hypoadrenalism, is a condition characterized by chronic adrenal insufficiency. The most common cause in the UK is autoimmune destruction of the adrenals, while worldwide tuberculosis is the most common cause. Other causes include long-term exogenous steroid use, cancer, or haemorrhage damage. Symptoms develop gradually, but patients can present in Addisonian crisis if there is a sudden deterioration in adrenal function or a physiological stress that the residual adrenal function is not capable of coping with. Treatment is with long-term replacement of corticosteroids and aldosterone. Treatment of a crisis requires intravenous glucocorticoids, as well as supportive measures and fluid resuscitation.Differential Diagnoses:
Peutz–Jeghers syndrome is an autosomal dominant condition characterized by perioral freckling and small bowel polyps. Insulinoma causes hypoglycaemia, but the other features are absent. Cushing syndrome is a result of excess corticosteroid, while Conn syndrome is also known as primary hyperaldosteronism. -
This question is part of the following fields:
- Endocrinology
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Question 18
Incorrect
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A 32-year-old patient is brought in by ambulance to Accident and Emergency. He is unresponsive, and therefore obtaining a medical history is not possible. He is breathing on his own, but his respiratory rate (RR) is low at 10 breaths per minute and his oxygen saturation is at 90% on room air. His arterial blood gas (ABG) reveals respiratory acidosis, and his pupils are constricted.
What would be the most suitable medication for initial management in this case?Your Answer: Adrenaline
Correct Answer: Naloxone
Explanation:Antidote Medications: Uses and Dosages
Naloxone:
Naloxone is a medication used to reverse the effects of opioid overdose. It works by blocking the opioid receptors in the brain, which can cause respiratory depression and reduced consciousness. It is administered in incremental doses every 3-5 minutes until the desired effect is achieved. However, full reversal may cause withdrawal symptoms and agitation.N-acetyl-L-cysteine (NAC):
NAC is an antidote medication used to treat paracetamol overdose. Paracetamol overdose can cause liver damage and acute liver failure. NAC is administered if the serum paracetamol levels fall to the treatment level on the nomogram or if the overdose is staggered.Flumazenil:
Flumazenil is a specific reversal agent for the sedative effects of benzodiazepines. It works by competing with benzodiazepines for the same receptors in the brain. However, it is not effective in treating pupillary constriction caused by benzodiazepine toxicity.Adrenaline:
Adrenaline is used in the treatment of cardiac arrest and anaphylaxis. It has no role in the treatment of opiate toxicity. The dosage of adrenaline varies depending on the indication, with a stronger concentration required for anaphylaxis compared to cardiac arrest.Atropine:
Atropine is a medication used to treat symptomatic bradycardia, where the patient’s slow heart rate is causing hemodynamic compromise. However, it can cause agitation in the hours following administration. -
This question is part of the following fields:
- Acute Medicine And Intensive Care
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Question 19
Correct
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A 68-year-old man was recently admitted to hospital with small bowel obstruction. A nasogastric (NG) tube was inserted, and he has been prescribed intravenous (IV) fluids. Three days later, he reports feeling short of breath, and on examination, he has widespread fine crackles and pitting sacral oedema. His notes show that he has been receiving 2 litres of fluid a day and that he weighs 50 kg. You treat him, and once his symptoms have resolved, you're-calculate his daily maintenance fluid requirements.
Which of the following options is the most suitable amount of daily fluid to give to the patient?Your Answer: 1000–1500 ml
Explanation:Calculating Fluid Requirements for a Patient with Fluid Overload
When determining a patient’s fluid requirements, it is important to consider their weight and any underlying medical conditions. For this particular patient, who weighs 48 kg, her maintenance fluid requirement is between 1200-1440 ml per day, calculated using 25-30 ml/kg/day.
However, this patient has developed fluid overload and pulmonary edema, likely due to receiving 2 liters of fluid per day. While this may have been necessary initially due to fluid loss from bowel obstruction, it is now important to step down to normal maintenance levels.
Giving the patient 1500-2000 ml of fluid per day would still be too much, as evidenced by examination findings of pitting sacral edema and widespread fine crackles. The maximum amount of fluid needed for maintenance therapy is 1440 ml per day.
It is crucial to monitor fluid intake and adjust as necessary to prevent further complications from fluid overload. Giving too much fluid, such as 2500-3500 ml per day, can be harmful for a patient with fluid overload and should be avoided.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 20
Incorrect
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A 35-year-old motorcyclist was brought to the Emergency Department after being in a road traffic accident and found alone on the road. Upon examination, he seems drowsy and is making grunting sounds, his pupils are equal and reactive to light, his eyes open to pain, and he withdraws his hand when the nurses attempt to insert a cannula. What is his Glasgow Coma Scale (GCS) score?
Your Answer: 5
Correct Answer: 8
Explanation:Understanding the Glasgow Coma Scale (GCS)
The Glasgow Coma Scale (GCS) is a tool used by clinicians to objectively measure a patient’s conscious state, particularly in cases of head injury. It provides a common language for healthcare professionals to discuss a patient’s condition. The GCS score is calculated based on the patient’s best eye, verbal, and motor responses, with a maximum score of 15/15 for a fully conscious and alert patient.
The calculation for the GCS score is as follows: for eyes, the score ranges from 1 to 4 depending on whether the patient’s eyes open spontaneously, in response to speech, in response to pain, or not at all. For verbal response, the score ranges from 1 to 5 depending on whether the patient is oriented, confused, uses inappropriate words or sounds, or has no verbal response. For motor response, the score ranges from 1 to 6 depending on whether the patient obeys commands, localizes pain, withdraws from pain, exhibits abnormal flexion or extension, or has no response.
If the GCS score is 8 or below, the patient will require airway protection as they will be unable to protect their own airway. This usually means intubation. Therefore, it is important for healthcare professionals to accurately calculate the GCS score and take appropriate action based on the score.
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This question is part of the following fields:
- Neurology
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Question 21
Incorrect
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A 52-year-old woman presents to her general practitioner (GP), complaining of bleeding gums every time she brushes her teeth. She reports that this is very concerning to her and has gotten to the point where she has stopped brushing her teeth.
Her past medical history is significant for hypertension, for which she takes lisinopril. She takes no anticoagulants or antiplatelet medication.
Her observations are as follows:
Temperature 37.1°C
Blood pressure 140/90 mmHg
Heart rate 68 bpm
Respiratory rate 16 breaths/min
Oxygen saturation (SpO2) 98% (room air)
Examination of the oral cavity reveals red, swollen gingiva, with bleeding easily provoked with a periodontal probe.
Which of the following is the next best step?Your Answer: Vitamin K
Correct Answer: Referral to a neurologist
Explanation:Medical Recommendations for Gingival Overgrowth
Gingival overgrowth is a condition where the gum tissues grow excessively, leading to the formation of pockets that can harbor bacteria and cause inflammation. This condition can be caused by certain medications like phenytoin, calcium channel blockers, and ciclosporin. Here are some medical recommendations for managing gingival overgrowth:
Referral to a Neurologist: If the patient is taking antiepileptic medication, a neurologist should review the medication to determine if it is causing the gingival overgrowth.
Avoid Brushing Teeth: Although brushing can exacerbate bleeding, not brushing can lead to poor oral hygiene. The cause of the gingival overgrowth needs to be addressed.
Epstein–Barr Virus Testing: Patients with oral hairy leukoplakia may benefit from Epstein–Barr virus testing.
Pregnancy Test: A pregnancy test is not indicated in patients with gingival overgrowth unless medication is not the likely cause.
Vitamin K: Vitamin K is indicated for patients who require warfarin reversal for supratherapeutic international normalized ratios (INRs). It is not necessary for patients who are clinically stable and not actively bleeding.
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This question is part of the following fields:
- Neurology
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Question 22
Incorrect
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A 72-year-old male is brought to the emergency department by his daughter. His daughter reports that 3 days ago, he fell down the stairs and hit his head. Initially, he seemed fine and did not want to go to the hospital. However, his daughter is now concerned as he has been acting confused on and off, which is unusual for him.
The patient has a medical history of atrial fibrillation, which is managed with warfarin. He also has well-controlled high blood pressure and diabetes. He does not consume alcohol.
The patient is unresponsive and unable to provide a history. During the neurological examination, there is no weakness in the face or limbs.
What is the most likely diagnosis based on this information?Your Answer: Extradural haematoma
Correct Answer: Subdural haematoma
Explanation:The patient’s age, history of trauma, and fluctuating confusion and decreased consciousness suggest that she may have a subdural haematoma, especially since she is taking warfarin which increases the risk of intracranial bleeds. Diffuse axonal injury is another possibility, but this type of brain injury is usually caused by shearing forces from rapid acceleration-deceleration, such as in road traffic accidents. Extradural haematomas are more common in younger people and typically occur as a result of acceleration-deceleration trauma or a blow to the side of the head. Although intracerebral haemorrhage is a possibility due to the patient’s risk factors, such as atrial fibrillation, anticoagulant use, hypertension, and older age, this condition usually presents with stroke symptoms such as facial weakness, arm/leg weakness, and slurred speech, which the patient does not have. Subarachnoid haemorrhages, on the other hand, usually present with a sudden-onset ‘thunderclap’ headache in the occipital area.
Types of Traumatic Brain Injury
Traumatic brain injury can result in primary and secondary brain injury. Primary brain injury can be focal or diffuse. Diffuse axonal injury occurs due to mechanical shearing, which causes disruption and tearing of axons. intracranial haematomas can be extradural, subdural, or intracerebral, while contusions may occur adjacent to or contralateral to the side of impact. Secondary brain injury occurs when cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury. The normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia. The Cushings reflex often occurs late and is usually a pre-terminal event.
Extradural haematoma is bleeding into the space between the dura mater and the skull. It often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of epidural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Subdural haematoma is bleeding into the outermost meningeal layer. It most commonly occurs around the frontal and parietal lobes. Risk factors include old age, alcoholism, and anticoagulation. Subarachnoid haemorrhage classically causes a sudden occipital headache. It usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury. Intracerebral haematoma is a collection of blood within the substance of the brain. Causes/risk factors include hypertension, vascular lesion, cerebral amyloid angiopathy, trauma, brain tumour, or infarct. Patients will present similarly to an ischaemic stroke or with a decrease in consciousness. CT imaging will show a hyperdensity within the substance of the brain. Treatment is often conservative under the care of stroke physicians, but large clots in patients with impaired consciousness may warrant surgical evacuation.
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This question is part of the following fields:
- Surgery
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Question 23
Incorrect
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A 67-year-old man presents to the emergency department with a 3-hour history of right-sided loin to groin pain. He has never experienced pain like this before and regular analgesia has not relieved his symptoms. His past medical history includes hypertension for which he takes amlodipine and indapamide.
His observations are as follows:
Temperature 35.8ºC
Heart rate 105 bpm
Blood pressure 100/60 mmHg
Respiratory rate 22 breaths/min
Saturations 96% on air
On examination, he is clammy to touch. His chest is clear and heart sounds are normal. There is generalised abdominal tenderness and central guarding. Bowel sounds are present.
What is the most appropriate next step in the management of this patient?Your Answer: Urinalysis
Correct Answer: Urgent vascular review
Explanation:Immediate vascular review for emergency surgical repair is necessary for patients suspected of having a ruptured AAA. This is particularly important for men aged above 50 years who may present with symptoms similar to renal colic, such as loin to groin pain. In this case, the patient is displaying signs of shock, including tachycardia and hypotension, which further support the diagnosis of a ruptured AAA. Blood cultures are not necessary at this stage as the patient’s symptoms are more likely due to haemorrhagic shock than sepsis. Similarly, urinalysis is not useful in managing a ruptured AAA. Although a CT KUB is commonly used to detect ureteric calculi and renal pathology in patients with loin to groin pain, the presence of shock in an older man with a history of hypertension suggests a ruptured AAA as the more likely diagnosis.
Ruptured Abdominal Aortic Aneurysm: Symptoms and Management
A ruptured abdominal aortic aneurysm (AAA) can present in two ways: as a sudden collapse or as persistent severe central abdominal pain with developing shock. The mortality rate for a ruptured AAA is almost 80%, making it a medical emergency. Symptoms of a ruptured AAA include severe, central abdominal pain that radiates to the back and a pulsatile, expansile mass in the abdomen. Patients may also experience shock, which is characterized by hypotension and tachycardia, or they may have collapsed.
Immediate vascular review is necessary for patients with a suspected ruptured AAA, with emergency surgical repair being the primary management option. In haemodynamically unstable patients, the diagnosis is clinical, and they are not stable enough for a CT scan to confirm the diagnosis. These patients should be taken straight to theatre. For frail patients with multiple comorbidities, a ruptured AAA may represent a terminal event, and consideration should be given to a palliative approach.
Patients who are haemodynamically stable may undergo a CT angiogram to confirm the diagnosis and assess the suitability of endovascular repair. In summary, a ruptured AAA is a medical emergency that requires immediate attention and management to improve the patient’s chances of survival.
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This question is part of the following fields:
- Surgery
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Question 24
Correct
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A 26-year-old female patient arrives at the emergency department complaining of constant pain in the left iliac fossa and nausea that started a day ago. She reports vomiting once but denies any other symptoms. The patient has a menstrual cycle of 28 days, and her last period began 5 days ago. She is sexually active and has consistently used condoms for contraception. There is no vaginal bleeding. What is the probable diagnosis?
Your Answer: Ovarian torsion
Explanation:The most probable diagnosis for this patient is ovarian torsion, which is common in women of reproductive age. Symptoms include pain in the iliac fossa that can spread to the loin, groin, or back, as well as nausea and vomiting. An adnexal mass may be present on examination, which is often caused by an ovarian cyst or neoplasm that has disrupted the ovary’s normal position and caused torsion. In some cases, a low-grade fever may also be present if ovarian necrosis has occurred.
It is important to rule out ectopic pregnancy as a differential diagnosis, which can be done with a pregnancy test regardless of reported contraception. Vaginal bleeding may help differentiate between the two conditions. However, since the patient’s menstrual period started 7 days ago and she uses condoms for contraception, ectopic pregnancy is less likely than ovarian torsion.
Appendicitis is also a possible cause of this presentation, but it typically presents with diffuse abdominal pain that later localizes to the right iliac fossa. In appendicitis, pain can be reproduced in the right iliac fossa by palpating the left iliac fossa (Rovsing’s sign), but left iliac fossa pain would not be the presenting symptom.
Mittelschmerz, which is mild pain in the right iliac fossa, could also be a possible cause, but it would not be associated with nausea and vomiting.
Causes of Pelvic Pain in Women
Pelvic pain is a common complaint among women, with primary dysmenorrhoea being the most frequent cause. Mittelschmerz, or pain during ovulation, may also occur. However, there are other conditions that can cause pelvic pain, which can be acute or chronic in nature.
Acute pelvic pain can be caused by conditions such as ectopic pregnancy, urinary tract infection, appendicitis, pelvic inflammatory disease, and ovarian torsion. Ectopic pregnancy is characterized by lower abdominal pain and vaginal bleeding in women with a history of 6-8 weeks of amenorrhoea. Urinary tract infection may cause dysuria and frequency, while appendicitis may present with pain in the central abdomen before localizing to the right iliac fossa. Pelvic inflammatory disease may cause pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria, and menstrual irregularities. Ovarian torsion, on the other hand, may cause sudden onset unilateral lower abdominal pain, nausea, vomiting, and a tender adnexal mass on examination.
Chronic pelvic pain, on the other hand, may be caused by conditions such as endometriosis, irritable bowel syndrome, ovarian cysts, and urogenital prolapse. Endometriosis is characterized by chronic pelvic pain, dysmenorrhoea, deep dyspareunia, and subfertility. Irritable bowel syndrome is a common condition that presents with abdominal pain, bloating, and change in bowel habit. Ovarian cysts may cause a dull ache that is intermittent or only occurs during intercourse, while urogenital prolapse may cause a sensation of pressure, heaviness, and urinary symptoms such as incontinence, frequency, and urgency.
In summary, pelvic pain in women can be caused by various conditions, both acute and chronic. It is important to seek medical attention if the pain is severe or persistent, or if there are other concerning symptoms present.
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This question is part of the following fields:
- Gynaecology
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Question 25
Incorrect
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A 35-year-old man comes to you seeking advice. He had a splenectomy ten years ago after a cycling accident and has been in good health since. However, a friend recently told him that he should be receiving treatment for his splenectomy. He is currently not taking any medication.
What would you recommend to him?Your Answer: No treatment
Correct Answer: Pneumococcal vaccination
Explanation:Asplenic Patients and the Importance of Vaccination
Asplenic patients are individuals who have had their spleen removed, leaving them at risk of overwhelming bacterial infections, particularly from pneumococcus and meningococcus. To prevent such infections, it is recommended that these patients receive the Pneumovax vaccine two weeks before surgery or immediately after emergency surgery. This vaccine should be repeated every five years. Additionally, influenzae vaccination is also recommended to prevent super added bacterial infections.
While oral penicillin is recommended for children, its long-term use in adults is a topic of debate. However, current guidance suggests that splenectomized patients should receive both antibiotic prophylaxis and appropriate immunization. It is crucial to take these preventative measures to protect asplenic patients from potentially life-threatening infections.
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This question is part of the following fields:
- Haematology
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Question 26
Incorrect
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A 68-year-old man visits his GP with concerns about unusual symptoms in his eyes. He reports experiencing flashes of light in his eyes for a few days and has also noticed dark specks floating around in his vision. He denies any discomfort. The patient is nearsighted and wears glasses, but has no significant medical history. Upon examination, his visual acuity and fields are normal. What is the probable cause of his symptoms?
Your Answer: Migraine
Correct Answer: Posterior vitreous detachment
Explanation:The most likely cause of the patient’s flashers and floaters is posterior vitreous detachment, which is a common age-related condition that occurs when the vitreous membrane separates from the retina. This condition does not cause pain or vision loss, but highly myopic patients are at increased risk. It is important to refer the patient to an ophthalmologist within 24 hours to rule out retinal tears or detachment.
Migraine is an unlikely cause as there is no headache described. Optic neuritis is also unlikely as there is no pain or history of previous disease. While retinal detachment may be a complication of PVD, it is not as common as PVD itself and would present with sudden visual loss and a veil covering the visual field. A retinal tear may also occur without progressing to detachment and would require intervention from an ophthalmologist.
Understanding Posterior Vitreous Detachment
Posterior vitreous detachment is a condition where the vitreous membrane separates from the retina due to natural changes in the vitreous fluid of the eye with ageing. This is a common condition that does not cause any pain or loss of vision. However, it is important to rule out retinal tears or detachment as they may result in permanent loss of vision. Posterior vitreous detachment occurs in over 75% of people over the age of 65 and is more common in females. Highly myopic patients are also at increased risk of developing this condition earlier in life.
Symptoms of posterior vitreous detachment include the sudden appearance of floaters, flashes of light in vision, blurred vision, and cobweb across vision. If there is an associated retinal tear or detachment, the patient will require surgery to fix this. All patients with suspected vitreous detachment should be examined by an ophthalmologist within 24 hours to rule out retinal tears or detachment.
The management of posterior vitreous detachment alone does not require any treatment as symptoms gradually improve over a period of around 6 months. However, it is important to monitor the condition and seek medical attention if any new symptoms arise. The appearance of a dark curtain descending down vision indicates retinal detachment and requires immediate medical attention. Overall, understanding posterior vitreous detachment and its associated risks is important for maintaining good eye health.
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This question is part of the following fields:
- Ophthalmology
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Question 27
Incorrect
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A 19-year-old woman presents with sudden onset lower abdominal pain and nausea. Upon examination, she is stable and has a temperature of 37.8 °C. There is tenderness in the right iliac fossa. Urinalysis reveals the presence of red blood cells (RBC) and white blood cells (WBC), but no nitrites. What is the most suitable subsequent test?
Your Answer: Ultrasound of the abdomen and pelvis
Correct Answer: Pregnancy test (beta-human chorionic gonadotrophin (β-hCG))
Explanation:Diagnostic Tests for Abdominal Pain in Women of Childbearing Age
Abdominal pain in women of childbearing age requires a thorough diagnostic workup to rule out gynaecological emergencies such as ectopic pregnancy. The following diagnostic tests should be considered:
1. Pregnancy test (beta-human chorionic gonadotrophin (β-hCG)): This test should be the first step in the diagnostic workup to rule out ectopic pregnancy. A positive result requires urgent referral to the gynaecological team.
2. Full blood count: This test may indicate an ongoing infective process or other pathology, but a pregnancy test should be done first to rule out ectopic pregnancy.
3. Ultrasound of the abdomen and pelvis: Imaging may be useful in determining the cause of the pain, but a pregnancy test should be done first before considering imaging studies.
4. Urine culture and sensitivity: This test may be useful if a urinary tract infection and possible pyelonephritis are considered, but an ectopic pregnancy has to be ruled out first.
5. Erect chest X-ray: This test can show free air under the diaphragm, indicating a ruptured viscus and a surgical emergency. However, a pregnancy test should be done first to rule out ectopic pregnancy.
In conclusion, a thorough diagnostic workup is necessary to determine the cause of abdominal pain in women of childbearing age, with a pregnancy test being the first step to rule out gynaecological emergencies.
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This question is part of the following fields:
- Gynaecology
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Question 28
Correct
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A patient has passed away at home. The physician is aware that the patient had been suffering from liver cirrhosis, but it has been a while since the physician last saw the patient. The physician is worried about the statutory period for writing on the medical certificate of the cause of death. What is the duration of this statutory period?
Your Answer: 28 days
Explanation:Updated Guidance on Death Certification in England and Wales
The guidance on death certification in England and Wales was recently updated in March 2022. One significant change was the extension of the period of time for seeing a patient before death from 14 days to 28 days. While this may be an important learning point for doctors, it may not necessarily appear in the RCGP exam as candidates will be tested on guidance that applies to all parts of the UK, including Scotland. However, it is still useful information for doctors working in England and Wales to be aware of. The UK government has provided guidance for doctors completing medical certificates of cause of death in England and Wales, which can be accessed for further information.
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This question is part of the following fields:
- Miscellaneous
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Question 29
Incorrect
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A concerned mother visits her GP to discuss her 8-week-old baby. She is worried as he is not feeding well, his urine has a musty smell and he has very dry skin all over his trunk, which is not responding to regular emollients. On examination, the baby’s weight has dropped from the 25th to the 9th centile, he has a mild tremor and his trunk is covered in an eczema-like rash. Her older son has an inborn error of metabolism and she is concerned this baby may also be affected.
Which of the following is a disorder of amino acid metabolism?Your Answer: Lesch–Nyhan syndrome
Correct Answer: Phenylketonuria (PKU)
Explanation:Inherited Metabolic Disorders: Types and Symptoms
Inherited metabolic disorders are genetic conditions that affect the body’s ability to process certain nutrients. Here are some common types and their symptoms:
Phenylketonuria (PKU): This autosomal recessive condition affects amino acid metabolism. It causes a deficiency of the enzyme phenylalanine hydroxylase, which can lead to behavioural problems, seizures, and learning disability. PKU is screened for with the newborn heel prick test.
G6PD deficiency: This X-linked recessive condition predisposes those affected to develop haemolysis. It does not affect amino acid metabolism. Patients are usually asymptomatic unless they have a haemolytic crisis triggered by an infection or certain medications.
Lesch–Nyhan syndrome: This X-linked condition affects uric acid metabolism and causes hyperuricaemia. It does not affect amino acid metabolism. Affected males have severe developmental delay, behavioural and cognitive dysfunction, and marked involuntary movements. They also develop recurrent self-mutilation habits.
Medium chain acyl-CoA dehydrogenase deficiency (MCADD): This autosomal recessive condition affects fatty acid oxidation. It does not affect amino acid metabolism. Babies with MCADD usually present with lethargy, poor feeding, and vomiting. It is screened for with the newborn heel prick test.
Porphyria: This is a deficiency of enzymes that affect haem synthesis. It can lead to acute porphyria (abdominal pain, psychiatric symptoms, breathing problems) or cutaneous porphyria.
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This question is part of the following fields:
- Paediatrics
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Question 30
Incorrect
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A 35-year-old male patient visits his GP complaining of a rash and fever that have been present for three days. He has a maculopapular rash on his trunk and palms, along with palpable lymph nodes in his groin and axilla. Additionally, he has mouth ulcers and flat white wart-like lesions around his anus. What is the recommended treatment for this patient?
Your Answer: Antiretroviral therapy
Correct Answer: Intramuscular benzathine penicillin
Explanation:The first-line treatment for syphilis is intramuscular benzathine penicillin, which is the correct management for the most likely diagnosis based on the patient’s symptoms of rash, lymphadenopathy, buccal ulcers, and condylomata, indicating secondary syphilis. The presence of a palmar rash is highly indicative of syphilis, although HIV should also be tested for as it can coexist with syphilis and present with similar symptoms. Cryotherapy is a treatment option for genital warts, but the flat white appearance of the wart-like lesions described here suggests they are more likely to be condylomata lata. The suggestion of no specific treatment except hydration and rest is incorrect, as this would only be appropriate for self-limiting viral illnesses such as Epstein-Barr virus, which is a potential differential diagnosis but less likely given the characteristic rash and history of the patient.
Management of Syphilis
Syphilis can be effectively managed with intramuscular benzathine penicillin as the first-line treatment. In cases where penicillin cannot be used, doxycycline may be used as an alternative. After treatment, nontreponemal titres such as rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) should be monitored to assess the response. A fourfold decline in titres is often considered an adequate response to treatment.
It is important to note that the Jarisch-Herxheimer reaction may occur following treatment. This reaction is characterized by fever, rash, and tachycardia after the first dose of antibiotic. Unlike anaphylaxis, there is no wheezing or hypotension. The reaction is thought to be due to the release of endotoxins following bacterial death and typically occurs within a few hours of treatment. However, no treatment is needed other than antipyretics if required.
In summary, the management of syphilis involves the use of intramuscular benzathine penicillin or doxycycline as an alternative. Nontreponemal titres should be monitored after treatment, and the Jarisch-Herxheimer reaction may occur but does not require treatment unless symptomatic.
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This question is part of the following fields:
- Medicine
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