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Question 1
Incorrect
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You sample 100 patients' ages from your patient list and calculate the mean age to be 45 years old. This baseline data will be used before enrolling these patients on an exercise programme to measure the effect this has on age. The standard deviation of your data is 3. You wish to determine how accurate your estimate of the mean is likely to be.
What is the standard error of the mean?Your Answer: 13
Correct Answer: 0.5
Explanation:Understanding Confidence Interval and Standard Error of the Mean
The confidence interval is a widely used concept in medical statistics, but it can be confusing to understand. In simple terms, it is a range of values that is likely to contain the true effect of an intervention. The likelihood of the true effect lying within the confidence interval is determined by the confidence level, which is the specified probability of including the true value of the variable. For instance, a 95% confidence interval means that the range of values should contain the true effect of intervention 95% of the time.
To calculate the confidence interval, we use the standard error of the mean (SEM), which measures the spread expected for the mean of the observations. The SEM is calculated by dividing the standard deviation (SD) by the square root of the sample size (n). As the sample size increases, the SEM gets smaller, indicating a more accurate sample mean from the true population mean.
A 95% confidence interval is calculated by subtracting and adding 1.96 times the SEM from the mean value. However, if the sample size is small (n < 100), a 'Student's T critical value' look-up table should be used instead of 1.96. Similarly, if a different confidence level is required, such as 90%, the value used in the formula should be adjusted accordingly. In summary, the confidence interval is a range of values that is likely to contain the true effect of an intervention, and its calculation involves using the standard error of the mean. Understanding these concepts is crucial in interpreting statistical results in medical research.
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This question is part of the following fields:
- Evidence Based Practice, Research And Sharing Knowledge
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Question 2
Correct
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An 80-year-old man has been taking warfarin for atrial fibrillation for the past 3 months but is having difficulty controlling his INR levels. He wonders if his diet could be a contributing factor.
What is the one food that is most likely to affect his INR levels?Your Answer: Spinach
Explanation:Foods and Factors that Affect Warfarin and Vitamin K Levels
Warfarin is a medication used to prevent blood clots, but its effectiveness can be reduced by consuming foods high in vitamin K. These foods include liver, broccoli, cabbage, Brussels sprouts, green leafy vegetables (such as spinach, kale, and lettuce), peas, celery, and asparagus. It is important for patients to maintain a consistent intake of these foods to avoid fluctuations in vitamin K levels.
Contrary to popular belief, tomatoes have relatively low levels of vitamin K, although concentrated tomato paste contains higher levels. Alcohol consumption can also affect vitamin K levels, so patients should avoid heavy or binge drinking while taking warfarin.
Antibiotics can also impact warfarin effectiveness by killing off gut bacteria responsible for synthesizing vitamin K. Additionally, cranberry juice may inhibit warfarin metabolism, leading to an increase in INR levels.
Overall, patients taking warfarin should be mindful of their diet and avoid excessive consumption of vitamin K-rich foods, alcohol, and cranberry juice.
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This question is part of the following fields:
- Cardiovascular Health
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Question 3
Incorrect
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The wife of a middle-aged patient has called the clinic for guidance. Her husband has fallen down the stairs and suffered a head injury. You gather information about the fall and the patient's present state.
She owns a car, and their neighbor has offered to take him to the hospital if necessary.
As per NICE guidance CG176, which of the following details in the history would prompt you to recommend transfer to the hospital emergency department via the emergency ambulance service (i.e., 999 response):Your Answer: A vomiting episode since the injury
Correct Answer: The patient has difficulties with understanding
Explanation:NICE Guidance on prehospital Management of Head Injury
NICE has issued guidance on the management of head injury, including prehospital management for health professionals who may be giving advice about attending the emergency department and whether to travel by 999 ambulance. Patients should be transferred to the emergency department by emergency ambulance service if they have any of the following: unconsciousness or lack of full consciousness, any focal neurological deficit since the injury, any suspicion of a skull fracture or penetrating head injury, any seizure since the injury, a high-energy head injury, or the injured person or their carer is incapable of transporting the injured person safely to the hospital emergency department without the use of ambulance services. A focal neurological deficit is defined as a problem restricted to a particular part of the body or activity. It is important to identify patients who should attend the hospital emergency department, those who should be advised to transfer by the emergency ambulance service, and those who may simply need transfer by the ambulance service. Health professionals should be familiar with the definition of certain terms, such as focal neurological deficit.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 4
Correct
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A 67-year-old man with a lengthy COPD history calls for guidance. He has been experiencing increased shortness of breath for the past two days and has been using his inhalers more frequently. He is coughing up clear sputum and has no fever, chest pain, or haemoptysis. He is uncertain whether to take his 'rescue' medications. What is the best advice to give him?
Your Answer: Take a course of prednisolone
Explanation:NICE suggests including an antibiotic only when the sputum shows signs of being purulent.
The National Institute for Health and Care Excellence (NICE) updated its guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2018. The guidelines recommend general management strategies such as smoking cessation advice, annual influenza vaccination, and one-off pneumococcal vaccination. Pulmonary rehabilitation is also recommended for patients who view themselves as functionally disabled by COPD.
Bronchodilator therapy is the first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators. The next step is determined by whether the patient has asthmatic features or features suggesting steroid responsiveness. NICE suggests several criteria to determine this, including a previous diagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time, and substantial diurnal variation in peak expiratory flow.
If the patient doesn’t have asthmatic features or features suggesting steroid responsiveness, a long-acting beta2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) should be added. If the patient is already taking a short-acting muscarinic antagonist (SAMA), it should be discontinued and switched to a short-acting beta2-agonist (SABA). If the patient has asthmatic features or features suggesting steroid responsiveness, a LABA and inhaled corticosteroid (ICS) should be added. If the patient remains breathless or has exacerbations, triple therapy (LAMA + LABA + ICS) should be offered.
NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients who have optimised standard treatments and continue to have exacerbations. Mucolytics should be considered in patients with a chronic productive cough and continued if symptoms improve.
Cor pulmonale features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, and loud P2. Loop diuretics should be used for oedema, and long-term oxygen therapy should be considered. Smoking cessation, long-term oxygen therapy in eligible patients, and lung volume reduction surgery in selected patients may improve survival in patients with stable COPD. NICE doesn’t recommend the use of ACE-inhibitors, calcium channel blockers, or alpha blockers
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This question is part of the following fields:
- Respiratory Health
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Question 5
Incorrect
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A 27-year-old woman visits her doctor after missing her last two Microgynon 30 pills, which she has been taking for the past 4 years. She is currently 11 days into a new packet of pills and had not missed any prior to this. During intercourse with a new partner last night, the condom broke. What is the appropriate course of action?
Your Answer: No action needed
Correct Answer: Advise condom use for next 7 days
Explanation:The FSRH has updated its guidance on missed contraceptive pills. If a woman misses two or more pills, she should continue taking the rest of the pack as usual and use an additional form of contraception for the next seven days. Condoms should be used or sexual activity avoided until seven consecutive active pills have been taken. This advice may be overly cautious in the second and third weeks, but it serves as a backup in case more pills are missed. If the woman has a new partner, it is recommended to consider STI screening after a suitable period. For more information, refer to the FSRH guidelines.
The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their advice for women taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol. If one pill is missed at any time during the cycle, the woman should take the last pill, even if it means taking two pills in one day, and then continue taking pills daily, one each day. No additional contraceptive protection is needed. However, if two or more pills are missed, the woman should take the last pill, leave any earlier missed pills, and then continue taking pills daily, one each day. She should use condoms or abstain from sex until she has taken pills for seven days in a row. If pills are missed in week one, emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week one. If pills are missed in week two, after seven consecutive days of taking the COC, there is no need for emergency contraception. If pills are missed in week three, she should finish the pills in her current pack and start a new pack the next day, thus omitting the pill-free interval. Theoretically, women would be protected if they took the COC in a pattern of seven days on, seven days off.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 6
Correct
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A 35-year-old woman comes to the clinic with her worried partner. She has been exhibiting erratic behavior and mood swings since giving birth to their daughter 10 days ago. During the appointment, she seems restless and agitated.
According to her partner, she has been avoiding sleep due to her fear that something terrible might happen to their baby. The woman has a history of depression but has not taken her fluoxetine medication for the past 6 months due to concerns about potential complications.
What is the best course of action for managing this situation?Your Answer: Admit to hospital for urgent assessment
Explanation:The appropriate course of action for a woman exhibiting symptoms of agitation and paranoid delusions after giving birth is to admit her to the hospital for urgent assessment. This is likely a case of postpartum psychosis, which is different from postnatal depression. Prescribing medication to aid in sleep or reassuring the patient that her low mood will improve with time are not appropriate options in this case. Gradual titration of medication would also not manage her acute symptoms and ensure the safety of herself and her baby. Ideally, she should be admitted to a Mother & Baby Unit for proper care.
Understanding Postpartum Mental Health Problems
Postpartum mental health problems can range from mild ‘baby-blues’ to severe puerperal psychosis. To screen for depression, healthcare professionals may use the Edinburgh Postnatal Depression Scale, which is a 10-item questionnaire that indicates how the mother has felt over the previous week. A score of over 13 indicates a ‘depressive illness of varying severity’, and the questionnaire includes a question about self-harm. The sensitivity and specificity of this screening tool are over 90%.
‘Baby-blues’ are seen in around 60-70% of women and typically occur 3-7 days following birth. This condition is more common in primips, and mothers are characteristically anxious, tearful, and irritable. Postnatal depression affects around 10% of women, with most cases starting within a month and typically peaking at 3 months. The features of postnatal depression are similar to depression seen in other circumstances.
Puerperal psychosis affects approximately 0.2% of women and usually occurs within the first 2-3 weeks following birth. The features of this condition include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations). Reassurance and support are important for all these conditions, but admission to hospital is usually required for puerperal psychosis, ideally in a Mother & Baby Unit. Cognitive behavioural therapy may be beneficial, and certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe. While these medications are secreted in breast milk, they are not thought to be harmful to the infant. However, fluoxetine is best avoided due to its long half-life. There is around a 25-50% risk of recurrence following future pregnancies.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 7
Incorrect
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A 65-year-old gentleman presents for a medication review. He is currently on sildenafil for erectile dysfunction and has a longstanding history of stable angina. Which of the following medications should be avoided in this patient?
Your Answer: Isosorbide mononitrate
Correct Answer: Carvedilol
Explanation:Sildenafil: A Treatment for Impotence
Sildenafil is a well-established treatment for impotence that works by inhibiting phosphodiesterase type 5, which produces cavernous venodilation and erections in appropriately stimulated patients. It is important to note that sildenafil doesn’t increase sex drive or libido.
While sildenafil is not contraindicated in patients with ischaemic heart disease, it is contraindicated in subjects taking nitrates due to the potential for severe hypotension. Additionally, drugs like nicorandil are inadvisable due to the nitrate component.
Common side effects of sildenafil include flushing, which develops in the majority of patients, as well as nasal congestion and blue visual discolouration. It is important to discuss any potential risks and benefits of sildenafil with a healthcare provider before starting treatment.
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This question is part of the following fields:
- Improving Quality, Safety And Prescribing
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Question 8
Correct
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You are evaluating a study on the use of masks in public places to reduce viral upper respiratory tract infections among elderly individuals. The study found that the treatment group, who wore a mask, had fewer cases compared to the control group who did not wear a mask. The absolute risk in the control group was 0.5 whereas the absolute risk in the treatment group was 0.3.
What is the number needed to treat for elderly individuals in this study?Your Answer: 5
Explanation:The formula for calculating the number needed to treat is to divide one by the absolute risk reduction. The absolute risk reduction is determined by subtracting the absolute risk in the control group from the absolute risk in the treatment group. For example, if the absolute risk in the control group is 0.3 and the absolute risk in the treatment group is 0.5, the absolute risk reduction would be 0.2. Therefore, the number needed to treat would be one divided by 0.2, which equals five.
Numbers needed to treat (NNT) is a measure that determines how many patients need to receive a particular intervention to reduce the expected number of outcomes by one. To calculate NNT, you divide 1 by the absolute risk reduction (ARR) and round up to the nearest whole number. ARR can be calculated by finding the absolute difference between the control event rate (CER) and the experimental event rate (EER). There are two ways to calculate ARR, depending on whether the outcome of the study is desirable or undesirable. If the outcome is undesirable, then ARR equals CER minus EER. If the outcome is desirable, then ARR is equal to EER minus CER. It is important to note that ARR may also be referred to as absolute benefit increase.
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This question is part of the following fields:
- Evidence Based Practice, Research And Sharing Knowledge
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Question 9
Incorrect
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A 50-year-old man has been diagnosed with scabies after presenting with itchy lesions on his hands. As part of the treatment plan, it is important to advise him to apply permethrin 5% cream as directed. Additionally, he should be reminded to treat all members of his household and wash all bedding and clothes in hot water. What instructions should be given regarding the application of the cream?
Your Answer: From neck down + leave for 12 hours + repeat in 7 days
Correct Answer: All skin including scalp + leave for 12 hours + repeat in 7 days
Explanation:Scabies: Causes, Symptoms, and Treatment
Scabies is a skin condition caused by the mite Sarcoptes scabiei, which is spread through prolonged skin contact. It is most commonly seen in children and young adults. The mite burrows into the skin, laying its eggs in the outermost layer. The resulting intense itching is due to a delayed hypersensitivity reaction to the mites and eggs, which occurs about a month after infection. Symptoms include widespread itching, linear burrows on the fingers and wrists, and secondary features such as excoriation and infection.
The first-line treatment for scabies is permethrin 5%, followed by malathion 0.5% if necessary. Patients should be advised to avoid close physical contact until treatment is complete and to treat all household and close contacts, even if asymptomatic. Clothing, bedding, and towels should be laundered, ironed, or tumble-dried on the first day of treatment to kill off mites. The insecticide should be applied to all areas, including the face and scalp, and left on for 8-12 hours for permethrin or 24 hours for malathion before washing off. Treatment should be repeated after 7 days.
Crusted scabies, also known as Norwegian scabies, is a severe form of the condition seen in patients with suppressed immunity, particularly those with HIV. The skin is covered in hundreds of thousands of mites, and isolation is essential. Ivermectin is the treatment of choice.
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This question is part of the following fields:
- Dermatology
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Question 10
Correct
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A 52-year-old woman complains of infrequent periods, weight loss, tremor and sweating. She feels her symptoms gradually have worsened over several months. On examination she has a normal blood pressure and resting pulse of 100.
Select the following investigation that is the most appropriate in this patient.Your Answer: TSH and T4 levels
Explanation:The patient is displaying symptoms of thyrotoxicosis, which often includes menstrual irregularity or amenorrhoea. Conn syndrome, also known as primary hyperaldosteronism, is characterized by hypertension and hypokalaemia due to disturbances in aldosterone and renin levels. Phaeochromocytoma, on the other hand, is associated with elevated urinary catecholamines and typically presents with intermittent symptoms such as headache, sweating, tremor, palpitations, and paroxysmal hypertension. Pituitary failure, which may be caused by a pituitary adenoma or pituitary apoplexy, can result in hypothyroidism as part of panhypopituitarism and is best diagnosed with MRI scanning. While anaemia (full blood count and ferritin) can cause tachycardia, it is unlikely to cause tremor and weight loss.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 11
Incorrect
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A 55-year-old woman has recently been diagnosed with breast cancer and has tested positive for a BRCA1 mutation on genetic screening. Her mother and aunt both received treatment for breast cancer at a young age, indicating a strong family history of the disease.
The woman is worried that she may have passed the gene onto her son and daughter, and is also concerned that her sister may have inherited the gene.
During counselling, what is the most appropriate statement to make regarding the risk of her family members inheriting the BRCA1 gene?Your Answer: Both children have 25% chance of inheriting the gene while her sister has a 50% chance
Correct Answer: Both children and her sister have a 50% chance of inheriting the gene
Explanation:Breast Cancer Risk Factors
Breast cancer is a disease that affects many women worldwide. There are several factors that can increase a woman’s risk of developing breast cancer. One of the most significant predisposing factors is the presence of BRCA1 or BRCA2 genes, which can increase a woman’s lifetime risk of breast and ovarian cancer by 40%. Other factors include having a first-degree relative with premenopausal breast cancer, nulliparity, having a first pregnancy after the age of 30, early menarche, late menopause, combined hormone replacement therapy, combined oral contraceptive use, past breast cancer, not breastfeeding, ionizing radiation exposure, p53 gene mutations, and obesity. Additionally, previous surgery for benign disease may increase the risk of breast cancer due to the possibility of scar tissue hiding a lump. It is important for women to be aware of these risk factors and to discuss them with their healthcare provider.
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This question is part of the following fields:
- Genomic Medicine
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Question 12
Correct
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A 55-year-old woman presents with shortness of breath, haemoptysis, and pleuritic chest pain.
Her medical history includes a deep vein thrombosis affecting the right leg eight years ago. She is not on any current regular medication.
On examination, her heart rate is 108 bpm, blood pressure is 104/68, respiratory rate is 24, oxygen saturations are 94% in room air and she is afebrile. She has no calf or leg swelling.
You suspect she might have a pulmonary embolism and there is nothing to find to suggest an alternative cause.
You calculate her two-level PE Wells score.
What is the most appropriate management plan?Your Answer: Admit as an emergency
Explanation:Calculating the Wells Score for Pulmonary Embolism
To determine the likelihood of a patient having a pulmonary embolism (PE), healthcare professionals use the Wells score. This score is calculated based on several factors, including clinical examination consistent with deep vein thrombosis, pulse rate, immobilization or recent surgery, past medical history, haemoptysis, cancer, and the likelihood of an alternative diagnosis.
If the two-level Wells score is more than 4 points, hospital admission should be arranged for an immediate computed tomography pulmonary angiogram. If the score is 4 or lower, a D-dimer blood test should be arranged. A negative result may indicate an alternative diagnosis, while a positive result should be managed the same way as a two-level Wells score of more than 4.
It is important to note that HASBLED and CHADS2VASC scoring are used in the management of patients with atrial fibrillation, not pulmonary embolism. By using the Wells score, healthcare professionals can quickly and accurately determine the likelihood of a patient having a PE and provide appropriate treatment.
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This question is part of the following fields:
- Respiratory Health
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Question 13
Incorrect
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You are seeing a 58-year-old woman who has been diagnosed with early invasive breast cancer which is oestrogen-receptor-positive. Her oncologist is treating her with anastrozole 1 mg daily. Which one of the following is the most common side effect of anastrozole?
Your Answer: Interstitial pneumonitis
Correct Answer: Bone fractures
Explanation:Anastrozole Side Effects According to BNF
The British National Formulary (BNF) is often used as a reference for setting questions in the AKT exam. One of the topics that may be tested is the side effects of medications. The BNF categorizes side effects based on their frequency, ranging from very common to very rare. Anastrozole is a medication used in the adjuvant treatment of oestrogen-receptor-positive early invasive breast cancer in postmenopausal women. However, it is contraindicated for premenopausal treatment. According to the BNF, bone fractures are common or very common side effects of Anastrozole. On the other hand, vasculitis and angioedema are very rare side effects. Notably, interstitial nephritis and interstitial pneumonitis are not listed as side effects.
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This question is part of the following fields:
- End Of Life
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Question 14
Incorrect
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A 35-year-old man is prescribed lithium for his bipolar disorder. What is the appropriate time interval before his plasma lithium should be checked for the first time?
Your Answer: 12–24 hours
Correct Answer: 7 days
Explanation:Monitoring Lithium Treatment: Guidelines and Recommendations
Before starting lithium treatment, it is important to conduct several tests, including ECG, thyroid function tests, renal function tests, and U&Es. After starting treatment, the plasma level should be checked after 7 days and then every 7 days until the required level is reached. The blood sample should be taken 12 hours after the dose has been taken. Once stable, the level should be checked every 3 months for the first year and 3-6 monthly depending on risk thereafter.
In addition to monitoring lithium levels, it is also important to regularly check thyroid function, calcium, eGFR, and U&Es every 6 months. Normal lithium levels vary between different laboratories but are generally about 0.6 – 1.0 mmol/l.
Lithium toxicity can occur at levels above the normal range and usually consists of gastrointestinal (anorexia, nausea, diarrhea) and central nervous system effects (muscle weakness, drowsiness, ataxia, coarse tremor, muscle twitching). Therefore, serum levels should also be taken during any intercurrent illness as this can increase toxicity.
Overall, monitoring lithium treatment is crucial for ensuring patient safety and optimizing treatment outcomes.
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This question is part of the following fields:
- Mental Health
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Question 15
Incorrect
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You are asked to see a 64-year-old woman known to have breast cancer.
Her family has become worried as yesterday she seemed to be behaving 'oddly'. They tell you that her behaviour has become inappropriate and that she has been walking around the house naked and been swearing a lot in conversation. Prior to yesterday she was her 'usual self'.
The family also report that she seems to be passing urine and opening her bowels as per usual and that she has been eating and drinking fine.
Examination reveals that the patient is alert and uncomplaining. Temperature is 37.1°C, blood pressure is 118/78 mmHg and pulse rate is 86 regular. Systems examination doesn't reveal anything acute aside from the patient swearing frequently and talking about inappropriate topics of conversation. Urine dipstick testing reveals 'trace' of blood and protein.
Which if the following investigations will confirm the underlying diagnosis?Your Answer: CT head
Correct Answer: Urine microscopy, culture and sensitivity
Explanation:Considerations for a Patient with Metastatic Cancer and Acute Change in Mental Status
A variety of factors need to be considered when a patient with metastatic cancer presents with an acute change in mental status. In this scenario, potential causes such as infection, hypercalcaemia, and brain metastases should be ruled out. It is also important to review the patient’s drug history to rule out any iatrogenic causes.
In this case, the patient’s observations, including temperature, pulse rate, and blood pressure, are normal, and there are no signs of infection. The urine dipstick test doesn’t reveal any significant abnormalities. The symptoms are also not consistent with hypercalcaemia.
However, the patient’s acute change in mental status with disinhibition requires urgent referral to the hospital and a CT head scan to look for frontal lobe metastases. A full ‘confusion’ screen would also be carried out to further investigate the underlying cause.
In summary, when a patient with metastatic cancer presents with an acute change in mental status, a thorough evaluation of potential causes is necessary to ensure appropriate management and treatment.
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This question is part of the following fields:
- End Of Life
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Question 16
Correct
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Which of the following is not a recognized feature of temporal arteritis in elderly patients?
Your Answer: Elevated creatine kinase
Explanation:Temporal arteritis doesn’t cause an increase in creatine kinase levels.
Temporal arteritis is a type of large vessel vasculitis that often occurs in patients over the age of 60 and is commonly associated with polymyalgia rheumatica. This condition is characterized by changes in the affected artery that skip certain sections while damaging others. Symptoms of temporal arteritis include headache, jaw claudication, and visual disturbances, with anterior ischemic optic neuropathy being the most common ocular complication. A tender, palpable temporal artery is also often present, and around 50% of patients may experience symptoms of PMR, such as muscle aches and morning stiffness.
To diagnose temporal arteritis, doctors will typically look for elevated inflammatory markers, such as an ESR greater than 50 mm/hr or elevated CRP levels. A temporal artery biopsy may also be performed to confirm the diagnosis, with skip lesions often being present. Treatment for temporal arteritis involves urgent high-dose glucocorticoids, which should be given as soon as the diagnosis is suspected and before the temporal artery biopsy. If there is no visual loss, high-dose prednisolone is typically used, while IV methylprednisolone is usually given if there is evolving visual loss. Patients with visual symptoms should be seen by an ophthalmologist on the same day, as visual damage is often irreversible. Other treatments may include bone protection with bisphosphonates and low-dose aspirin, although the evidence supporting the latter is weak.
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This question is part of the following fields:
- Neurodevelopmental Disorders, Intellectual And Social Disability
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Question 17
Correct
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A 60-year-old man has recently been discharged from hospital with a new diagnosis of heart failure with reduced ejection fraction. His symptoms of breathlessness and ankle swelling have now resolved and he has been commenced on ramipril, bisoprolol and furosemide. He also has type 2 diabetes, for which he is already taking metformin and gliclazide. His renal function is normal and his serum potassium is 4.9 mmol/L.
What ongoing care interventions should be included for this patient?Your Answer: Annual influenza vaccination
Explanation:An annual influenza vaccine should be offered as part of the comprehensive lifestyle approach to managing heart failure.
Individuals diagnosed with heart failure with reduced ejection fraction should receive an annual influenza vaccine and a one-time pneumococcal vaccination.
Typically, only those with asplenia, splenic dysfunction, or chronic kidney disease require pneumococcal revaccination every five years.
Following a myocardial infarction, patients are typically advised to abstain from sexual activity for four weeks, rather than heart failure.
While patients should limit their salt intake to no more than 6 g per day, they should not replace it with potassium-containing salt substitutes due to the risk of hyperkalemia when used concurrently with ACE inhibitors.
For group 1 entitlement (cars, motorcycles), driving may continue as long as there are no symptoms that could distract the driver’s attention, and there is no need to notify the DVLA.
Chronic heart failure can be managed through drug therapy, as outlined in the updated guidelines issued by NICE in 2018. While loop diuretics are useful in managing fluid overload, they do not reduce mortality in the long term. The first-line treatment for all patients is an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Aldosterone antagonists are the standard second-line treatment, but both ACE inhibitors and aldosterone antagonists can cause hyperkalaemia, so potassium levels should be monitored. SGLT-2 inhibitors are increasingly being used to manage heart failure with a reduced ejection fraction, as they reduce glucose reabsorption and increase urinary glucose excretion. Third-line treatment options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, and cardiac resynchronisation therapy. Other treatments include annual influenza and one-off pneumococcal vaccines.
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This question is part of the following fields:
- Cardiovascular Health
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Question 18
Correct
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A 25-year-old nanny, Sarah, cares for 5 different children during the week. What is a concerning sign to look out for in one of her charges?
Your Answer: Sarah aged 10 months preferentially uses her right hand to pick up toys
Explanation:Red flags in child development serve as warning signs that can indicate a possible developmental delay. The following table outlines some common red flags to look out for:
Age Red Flags
Birth-3 months Consistent clenching of fists before 3 months of age, rolling over before 3 months
4-6 months Lack of smiling by 10 weeks, failure to reach for objects by 5 months
6-12 months Persistence of primitive reflexes after 6 months
12-24 months Demonstrating hand dominance before 12 months may be a red flag for hemiparesis, inability to walk independently by 18 months, and difficulty using a spoon, which typically develops between 12-15 months.Common Developmental Problems and Their Causes
Developmental problems can manifest in various ways, including referral points, fine motor skill problems, gross motor problems, and speech and language problems. Referral points may include a lack of smiling at 10 weeks, inability to sit unsupported at 12 months, and inability to walk at 18 months. Fine motor skill problems may be indicated by abnormal hand preference before 12 months, which could be a sign of cerebral palsy. Gross motor problems are often caused by a variant of normal, cerebral palsy, or neuromuscular disorders like Duchenne muscular dystrophy. Speech and language problems should always be checked for hearing issues, but other causes may include environmental deprivation and general developmental delay. It is important to identify and address these developmental problems early on to ensure the best possible outcomes for the child’s future.
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This question is part of the following fields:
- Children And Young People
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Question 19
Correct
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A 31-year-old woman attends with her partner. Unfortunately the couple suffered a cot death. They would like to try for another child and would like to discuss some of the features of cot death with you. Both smoke heavily.
Which one of the following is true with respect to the risk of cot death in future offspring?Your Answer: Risk is reduced if parents give up smoking
Explanation:Sudden Unexpected Death in Infancy (SUDI)
Sudden unexpected death in infancy (SUDI), commonly known as cot death, is a condition where infants die without any apparent cause found in their history, clinical examination, or post mortem investigations. This condition is most common in infants under six months of age, with the peak incidence occurring in the second month. SUDI is the leading cause of death in this age group, and premature and low birth weight babies, as well as twins, are at higher risk.
Boys are more susceptible to SUDI than girls, and infants born to young mothers, in low socio-economic class, and households with smokers are also at higher risk. Smoking is a dose-related risk factor. A minor preceding illness in the previous day or so is often reported before the occurrence of SUDI.
Sleeping on their fronts is another factor that increases the risk of SUDI, which is why the back to sleep campaign has significantly reduced the incidence of SUDI. Co-sleeping with parents, especially in families with a history of drug or alcohol misuse, is also a risk factor for SUDI.
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This question is part of the following fields:
- Population Health
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Question 20
Incorrect
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You come across a pair of patients who are both under your care and are interested in starting a family. They are worried because their niece has Fragile X syndrome (FXS). They require additional details about it and would like a recommendation to a geneticist.
What is the characteristic linked with Fragile X syndrome?Your Answer: Decreased muscle tone
Correct Answer: Macroorchidism
Explanation:Macroorchidism is a common feature of Fragile X syndrome, which also presents with delayed developmental milestones and learning difficulties (typically with an IQ less than 70). Physical characteristics include a high forehead, facial asymmetry, a large jaw, and long ears. Diagnosis is often made by age 3 due to developmental delays. Life-threatening cardiovascular issues and full lips are not associated with FXS, but are seen in William’s syndrome. Down’s syndrome is characterized by decreased muscle tone and hypothyroidism.
Fragile X Syndrome: A Genetic Disorder
Fragile X syndrome is a genetic disorder caused by a trinucleotide repeat. It affects males more severely than females, with symptoms including learning difficulties, large low set ears, a long thin face, high arched palate, macroorchidism, hypotonia, and a higher likelihood of autism. Mitral valve prolapse is also common in males with this syndrome. Females who have one fragile chromosome and one normal X chromosome may have a range of symptoms from normal to mild.
Diagnosis of fragile X syndrome can be made antenatally through chorionic villus sampling or amniocentesis. Analysis of the number of CGG repeats using restriction endonuclease digestion and Southern blot analysis is also used to diagnose this disorder. Proper diagnosis and management can help individuals with fragile X syndrome lead fulfilling lives.
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This question is part of the following fields:
- Children And Young People
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Question 21
Incorrect
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Samantha is an 80-year-old woman with chronic kidney disease and hypertension who has scheduled an appointment with you for a medication review. She is currently on ramipril 2.5mg once daily and amlodipine 5mg once daily. Her recent blood and urine tests are as follows:
Na+ 138 mmol/L (135 - 145)
K+ 4.6 mmol/L (3.5 - 5.0)
Urea 8.2 mmol/L (2.0 - 7.0)
Creatinine 135 µmol/L (55 - 120)
eGFR 39 ml/min/1.73m²
Urine albumin:creatinine ratio = 73 mg/mmol.
Based on the above results, what is the target blood pressure for Samantha according to NICE guidelines?Your Answer: <140/90 mmHg
Correct Answer:
Explanation:For patients with chronic kidney disease, hypertension, and a urinary albumin:creatinine ratio (ACR) of 70 or more, it is recommended to aim for a lower blood pressure target of <130/80 mmHg. This approach can provide advantages such as reducing the risk of cardiovascular complications and slowing the progression of the disease. However, if the patient’s ACR is less than 70 mg/mmol, the blood pressure target can be slightly higher at <140/90 mmHg. For individuals under 80 years old, the recommended target for home blood pressure readings is <135/85 mmHg. Chronic kidney disease (CKD) patients often require more than two drugs to manage hypertension. The first-line treatment is ACE inhibitors, which are especially effective in proteinuric renal disease like diabetic nephropathy. However, these drugs can reduce filtration pressure, leading to a slight decrease in glomerular filtration pressure (GFR) and an increase in creatinine. NICE guidelines state that a decrease in eGFR of up to 25% or a rise in creatinine of up to 30% is acceptable, but any increase should prompt careful monitoring and exclusion of other causes. If the rise is greater than this, it may indicate underlying renovascular disease. Furosemide is a useful Antihypertensive drug for CKD patients, particularly when the GFR falls below 45 ml/min*. It also helps to lower serum potassium levels. However, high doses are usually required, and if the patient is at risk of dehydration (e.g. due to gastroenteritis), the drug should be temporarily stopped. The NKF K/DOQI guidelines suggest a lower cut-off of less than 30 ml/min.
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This question is part of the following fields:
- Kidney And Urology
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Question 22
Correct
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Which of the following patients is most likely to develop nasal polyps?
Your Answer: A 40-year-old man
Explanation:Male adults are the most commonly affected by nasal polyps.
Understanding Nasal Polyps
Nasal polyps are a relatively uncommon condition affecting around 1% of adults in the UK. They are more commonly seen in men and are not typically found in children or the elderly. There are several associations with nasal polyps, including asthma (particularly late-onset asthma), aspirin sensitivity, infective sinusitis, cystic fibrosis, Kartagener’s syndrome, and Churg-Strauss syndrome. When asthma, aspirin sensitivity, and nasal polyposis occur together, it is known as Samter’s triad.
The most common features of nasal polyps include nasal obstruction, rhinorrhoea, sneezing, and a poor sense of taste and smell. However, if a patient experiences unilateral symptoms or bleeding, further investigation is always necessary.
If a patient is suspected of having nasal polyps, they should be referred to an ear, nose, and throat (ENT) specialist for a full examination. Treatment typically involves the use of topical corticosteroids, which can shrink polyp size in around 80% of patients. With proper management, most patients with nasal polyps can experience relief from their symptoms.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 23
Correct
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A 56-year-old woman who has had two Colle's fractures in the past two years undergoes a DEXA scan:
T-score
L2-4 -1.4
Femoral neck -2.7
What is the result of the scan?Your Answer: Osteopaenia in vertebrae, osteoporosis in femoral neck
Explanation:Understanding DEXA Scan Results for Osteoporosis
When it comes to diagnosing osteoporosis, a DEXA scan is often used to measure bone density. The results of this scan are given in the form of a T score, which compares the patient’s bone mass to that of a young reference population. A T score of -1.0 or higher is considered normal, while a score between -1.0 and -2.5 indicates osteopaenia, or low bone mass. A T score below -2.5 is classified as osteoporosis, which means the patient has a significantly increased risk of fractures. It’s important to note that the Z score, which takes into account age, gender, and ethnicity, can also be used to interpret DEXA scan results. By understanding these scores, patients can work with their healthcare providers to develop a plan for managing and treating osteoporosis.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 24
Correct
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A 60-year-old man has evidence of sun damage on his bald scalp including several actinic keratoses.
Select from the list the single most correct statement regarding actinic keratoses.Your Answer: Induration under the surface keratin suggests malignant change
Explanation:Understanding Actinic Keratoses: Causes, Symptoms, and Treatment Options
Actinic keratoses (AK) or solar keratoses are skin lesions caused by prolonged exposure to ultraviolet light. This condition is commonly seen in fair-skinned individuals who have spent a lot of time in the sun. While AK is similar to Bowen’s disease, which is a type of skin cancer, most solitary lesions do not progress to malignancy. However, patients with more than 10 AKs have a 10 to 15% risk of developing skin cancer, making it a significant concern.
AKs typically start as small rough spots that are more easily felt than seen. Over time, they enlarge and become red and scaly. Lesions with pronounced hyperkeratosis, increased erythema, or induration, ulceration, and lesions that recur after treatment or are unresponsive to treatment should be suspected of malignant change.
For mild AKs, no therapy or emollients are necessary. However, curettage or excision, cryotherapy, and photodynamic therapy are the most effective treatments. 5-fluorouracil cream can clear AKs, but it produces a painful inflammatory response. Diclofenac gel has moderate efficacy but has fewer side effects than other topical preparations and is used for mild AKs.
In conclusion, understanding the causes, symptoms, and treatment options for AKs is crucial for early detection and prevention of skin cancer. Regular skin checks and sun protection measures are essential for individuals at risk of developing AKs.
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This question is part of the following fields:
- Dermatology
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Question 25
Incorrect
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A 42-year-old woman with a medical history of asthma, Down syndrome, and hypothyroidism is seeking information about necessary tests and treatment. What is the typical presentation of thyroid disease in individuals with Down syndrome?
Your Answer: Screening tests are recommended every three years
Correct Answer: Using clinical features for diagnosis of hypothyroidism is unreliable
Explanation:Misconceptions and Clarifications about Hypothyroidism in Down Syndrome
There are several misconceptions about hypothyroidism in individuals with Down syndrome. One common misconception is that clinical features alone can be used to diagnose hypothyroidism. However, this is unreliable as symptoms can be caused by other conditions. Biochemical markers are essential for accurate diagnosis and treatment.
Another misconception is that borderline blood abnormalities with a free T4 level less than 10 are an indication for treatment. However, treatment should only be started if hypothyroidism is confirmed with biochemical markers and not based on borderline results.
It is also important to note that screening tests for thyroid disease in individuals with Down syndrome are recommended every 1-2 years, not every three years as in the general population. This is because thyroid disease is more common in individuals with Down syndrome, with hypothyroidism being the most common.
Additionally, while individuals with Down syndrome are at an increased risk for both hypo- and hyperthyroidism, hypothyroidism is much more common. Contrary to another misconception, the risk of thyroid disease in individuals with Down syndrome actually increases with age, rather than diminishing.
Overall, it is important to have accurate information about hypothyroidism in individuals with Down syndrome to ensure proper diagnosis and treatment.
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This question is part of the following fields:
- Neurodevelopmental Disorders, Intellectual And Social Disability
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Question 26
Correct
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Sadia is a 32-year-old woman who has come with complaints of cyclical breast pain. What would be the initial recommended course of action?
Your Answer: A supportive bra
Explanation:The initial approach to treating cyclical mastalgia involves a supportive bra and basic pain relief measures like paracetamol, ibuprofen, or topical NSAIDs. Codeine is not the preferred first-line option. The evidence is inadequate to suggest reducing caffeine intake or using the progestogen-only pill. A systematic review revealed that evening primrose oil is not superior to placebo.
Cyclical mastalgia is a common cause of breast pain in younger females. It varies in intensity according to the phase of the menstrual cycle and is not usually associated with point tenderness of the chest wall. The underlying cause is difficult to identify, but focal lesions such as cysts may be treated to provide symptomatic relief. Women should be advised to wear a supportive bra and conservative treatments such as standard oral and topical analgesia may be used. Flaxseed oil and evening primrose oil are sometimes used, but neither are recommended by NICE Clinical Knowledge Summaries. If the pain persists after 3 months and affects the quality of life or sleep, referral should be considered. Hormonal agents such as bromocriptine and danazol may be more effective, but many women discontinue these therapies due to adverse effects.
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This question is part of the following fields:
- Gynaecology And Breast
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Question 27
Correct
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A 16-year-old-girl comes to the clinic with complaints of not having started her periods yet. During the examination, it is observed that she has a high-arched palate, underdeveloped external genitalia, and no breast development. Her height is 151cm, which is at the 2nd centile for her age and gender.
What condition is the most probable diagnosis?Your Answer: Turner's syndrome
Explanation:Turner’s syndrome is the likely diagnosis for a patient with short stature and primary amenorrhoea. Hypothyroidism may also cause these symptoms, but the presence of a high-arched palate makes it less likely. While gonadal dysgenesis (46, XX) can cause primary amenorrhoea, it doesn’t typically present with the characteristic dysmorphic features seen in Turner’s syndrome.
Understanding Turner’s Syndrome
Turner’s syndrome is a genetic condition that affects approximately 1 in 2,500 females. It is caused by the absence of one sex chromosome (X) or a deletion of the short arm of one of the X chromosomes. This condition is identified as 45,XO or 45,X.
The features of Turner’s syndrome include short stature, a shield chest with widely spaced nipples, a webbed neck, a bicuspid aortic valve (present in 15% of cases), coarctation of the aorta (present in 5-10% of cases), primary amenorrhea, cystic hygroma (often diagnosed prenatally), a high-arched palate, a short fourth metacarpal, multiple pigmented naevi, lymphoedema in neonates (especially in the feet), and elevated gonadotrophin levels. Hypothyroidism is also more common in individuals with Turner’s syndrome, as well as an increased incidence of autoimmune diseases such as autoimmune thyroiditis and Crohn’s disease.
In summary, Turner’s syndrome is a chromosomal disorder that affects females and is characterized by various physical features and health conditions. Early diagnosis and management can help individuals with Turner’s syndrome lead healthy and fulfilling lives.
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This question is part of the following fields:
- Children And Young People
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Question 28
Correct
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You receive the result of a routine mid-stream urine test taken on a 84-year-old woman in a nursing home. The result shows a pure growth of Escherichia coli with full sensitivity but levels of white cells and red blood cells are within the normal range. You telephone the nursing home and are told that she is well in herself but that they routinely send urine specimens on all patients.
Select the single most appropriate management option in this patient.Your Answer: No action required
Explanation:Asymptomatic Bacteriuria in Elderly and Pregnant Women
Asymptomatic bacteriuria is a common condition in elderly and pregnant women. In healthy patients, a pure growth with normal white and red cells doesn’t require treatment unless an invasive urological procedure is planned. However, in pregnant women, it should be treated as it is associated with low birth weight and premature delivery. There is no evidence of long-term harm or benefit from medication in patients with a normal renal tract. It is important to be cautious in apparently asymptomatic men who may have chronic prostatitis.
Public Health England advises against sending urine for culture in asymptomatic elderly individuals with positive dipsticks. Urine should only be sent for culture if there are two or more signs of infection, such as dysuria, fever > 38 °C, or new incontinence. Asymptomatic bacteriuria in the elderly should not be treated as it is very common, and treating it doesn’t reduce mortality or prevent symptomatic episodes. In fact, treating it can increase side effects and antibiotic resistance.
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This question is part of the following fields:
- Kidney And Urology
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Question 29
Incorrect
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A new blood test is developed to detect pulmonary embolisms (PEs) in elderly patients with covid-19. A study compares its performance with the current gold standard for diagnosis, CT pulmonary angiogram (CTPA) scanning. A total of 250 elderly patients with covid-19 undergo CTPA scanning. Amongst those, 50 patients are identified as having PEs on CTPA scans and are subsequently tested using the new blood test. Of these, 40 have a positive test, and 10 have a negative test. Of the 200 covid-19 patients who did not have a PE demonstrated on CTPA scanning, 180 have a negative blood test, and 20 have a positive blood test. What is the sensitivity of the new test based on the given results?
Your Answer: 50%
Correct Answer: 80%
Explanation:To determine the sensitivity of the new blood test for detecting pulmonary embolisms (PEs), we need to calculate the proportion of true positive results among all actual positive cases identified by the CTPA scans.
Definitions
- Sensitivity: The probability that the test correctly identifies patients with the disease (true positives) among all patients who actually have the disease.
Sensitivity=True Positives/(True Positives+False Negatives)
Data from the Study
- Total patients with PE on CTPA (True Condition Positive): 50 patients
- True Positives (TP): Patients with PE who tested positive on the blood test: 40
- False Negatives (FN): Patients with PE who tested negative on the blood test: 10
Calculation of Sensitivity
Using the formula for sensitivity:
Sensitivity=True Positives/(True Positives+False Negatives)
Sensitivity=40/(40+10)
Sensitivity=40/50
Sensitivity=0.8
Sensitivity=0.8×100=80%
Conclusion
The sensitivity of the new blood test for detecting pulmonary embolisms in elderly patients with covid-19 is 80%. This means that the test correctly identifies 80% of patients who have a pulmonary embolism, according to the CTPA results.
- Sensitivity: The probability that the test correctly identifies patients with the disease (true positives) among all patients who actually have the disease.
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This question is part of the following fields:
- Evidence Based Practice, Research And Sharing Knowledge
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Question 30
Correct
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A 59-year-old woman has been treated for six months for reflux oesophagitis. She also has a history of hypertension, Raynaud syndrome and telangiectasia. Autoimmune screening reveals a positive antinuclear antibody test and positive extractable nuclear antibody to Scl-70 (anti-topoisomerase-1). Renal function testing reveals a creatinine of 215 µmol/l (50–120 µmol/l).
What is the most probable reason for this patient's kidney dysfunction? Choose ONE option only.Your Answer: Systemic sclerosis
Explanation:The patient is likely suffering from systemic sclerosis, a connective tissue disease that affects multiple systems in the body. Symptoms such as oesophageal dysmotility, telangiectasia, Raynaud’s phenomenon, and renal dysfunction are all indicative of this condition. Treatment can be challenging, especially if there is associated pulmonary fibrosis, hypertension, and cardiac fibrosis. Renal involvement in systemic sclerosis carries a poor prognosis, and renal failure is a common outcome. The presence of positive anti-SCL-70 antibodies strongly supports a diagnosis of systemic sclerosis. Other conditions such as membranous glomerulonephritis, rheumatoid arthritis, systemic lupus erythematosus, and granulomatosis with polyangiitis are less likely to be the cause of the patient’s symptoms.
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This question is part of the following fields:
- Musculoskeletal Health
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