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Question 1
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A 26-year-old man has been hit on the side of his head with a cricket bat. Upon initial examination, he has a Glasgow Coma Score (GCS) of 12 and shows some bruising at the point of impact. There are no indications of a basal skull fracture or any neurological impairments. He has not experienced vomiting or seizures. What would be the most suitable course of action?
Your Answer: Monitor the patient's status for deterioration before performing further tests
Correct Answer: Perform a CT head scan within 1 hour
Explanation:When it comes to detecting significant brain injuries in emergency situations, CT scans of the head are currently the preferred method of investigation. MRI scans are not typically used due to safety concerns, logistical challenges, and resource limitations. If a patient’s initial assessment in the emergency department reveals a Glasgow Coma Scale (GCS) score of less than 13, a CT head scan should be performed within one hour. The specific indications for an immediate CT head scan in this scenario can be found in the guidelines provided by NICE (2014) for the assessment and early management of head injuries.
NICE Guidelines for Investigating Head Injuries in Adults
Head injuries can be serious and require prompt medical attention. The National Institute for Health and Care Excellence (NICE) has provided clear guidelines for healthcare professionals to determine which adult patients need further investigation with a CT head scan. Patients who require immediate CT head scans include those with a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment, suspected open or depressed skull fractures, signs of basal skull fractures, post-traumatic seizures, focal neurological deficits, and more than one episode of vomiting.
For patients with any loss of consciousness or amnesia since the injury, a CT head scan within 8 hours is recommended for those who are 65 years or older, have a history of bleeding or clotting disorders, experienced a dangerous mechanism of injury, or have more than 30 minutes of retrograde amnesia of events immediately before the head injury. Additionally, patients on warfarin who have sustained a head injury without other indications for a CT head scan should also receive a scan within 8 hours of the injury.
It is important for healthcare professionals to follow these guidelines to ensure that patients receive appropriate and timely care for their head injuries. By identifying those who require further investigation, healthcare professionals can provide the necessary treatment and support to prevent further complications and improve patient outcomes.
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This question is part of the following fields:
- Surgery
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Question 2
Correct
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A 49-year-old woman visits her GP for a routine cervical smear. Later, she receives a phone call informing her that the smear was insufficient. She recalls having an inadequate smear more than ten years ago.
What is the correct course of action in this situation?Your Answer: Repeat smear in 3 months
Explanation:When a cervical cancer screening smear is inadequate, the recommended course of action is to repeat the smear within 3 months. It is not necessary to consider any previous inadequate smears from a decade ago. Therefore, repeating the smear in 1 month or 3 years is not appropriate. Referral for colposcopy or gynaecology is also not necessary at this stage, as it should only be considered if the second smear in 3 months’ time is also inadequate.
The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.
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This question is part of the following fields:
- Gynaecology
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Question 3
Incorrect
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A 6-week-old infant is experiencing projectile vomiting following feeds. The vomit is abundant but not bile-tinged and happens shortly after a feed. During examination, a small mass in the pylorus can be felt. What electrolyte abnormality is most likely to be observed in this baby?
Your Answer: Hypochloremic hypokalaemic metabolic acidosis
Correct Answer: Hypochloremic hypokalaemic metabolic alkalosis
Explanation:The infant is suffering from pyloric stenosis, which leads to a typical imbalance of electrolytes and acid-base known as hypochloremic, hypokalaemic metabolic alkalosis. The continuous vomiting results in a gradual loss of fluids that contain hydrochloric acid, causing the kidneys to retain hydrogen ions over potassium. If the illness is brief, there may not be any electrolyte abnormalities.
Understanding Pyloric Stenosis
Pyloric stenosis is a condition that usually occurs in infants between the second and fourth weeks of life. However, in rare cases, it may present later, up to four months. This condition is caused by the thickening of the circular muscles of the pylorus. Pyloric stenosis is more common in males, with an incidence of 4 per 1,000 live births. It is also more likely to affect first-borns and infants with a positive family history.
The most common symptom of pyloric stenosis is projectile vomiting, which usually occurs about 30 minutes after a feed. Other symptoms may include constipation, dehydration, and a palpable mass in the upper abdomen. Prolonged vomiting can lead to hypochloraemic, hypokalaemic alkalosis, which can be life-threatening.
Diagnosis of pyloric stenosis is typically made using ultrasound. Management of this condition involves a surgical procedure called Ramstedt pyloromyotomy. This procedure involves making a small incision in the pylorus to relieve the obstruction and allow for normal passage of food. With prompt diagnosis and treatment, infants with pyloric stenosis can make a full recovery.
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This question is part of the following fields:
- Paediatrics
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Question 4
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A 6-year-old girl is referred to the paediatric clinic for failure to thrive. She has failed to maintain her weight and suffers from diarrhoea and frequent respiratory tract infections. A sweat test is performed and the chloride content of the sweat is 68 mmol/l.
Which of the following modes of inheritance fits best with this condition?Your Answer: Autosomal recessive
Explanation:Genetic Inheritance Patterns and Abnormalities
Genetic inheritance patterns play a crucial role in the development of various diseases and abnormalities. Autosomal recessive inheritance is seen in conditions like cystic fibrosis, where mutations in the CFTR gene cause defective chloride transport and excessive viscous mucous secretions. Diagnosis is made through the sweat test, which measures chloride levels. Autosomal dominant inheritance is seen in conditions like Marfan syndrome and familial hypercholesterolaemia. Sex-linked inheritance is seen in conditions like Duchenne muscular dystrophy and haemophilia. Chromosomal non-disjunction occurs when homologous chromosomes fail to separate during meiosis, leading to aneuploidy zygotes like in Down syndrome. Chromosomal translocation occurs when non-homologous chromosomes exchange parts, leading to fusion chromosomes like in chronic myelogenous leukaemia. Understanding these inheritance patterns and abnormalities is crucial in the diagnosis and management of various genetic conditions.
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This question is part of the following fields:
- Genetics
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Question 5
Correct
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Which one of the following statements regarding the reporting of medication related adverse events using the Yellow Card scheme is accurate?
Your Answer: Diarrhoea occuring after starting a black triangle medicine should be reported
Explanation:The Yellow Card Scheme for Reporting Adverse Reactions to Medications
The Yellow Card scheme is a widely recognized method for reporting adverse reactions to medications. It is managed by the Medicines and Healthcare products Regulatory Agency (MHRA). The scheme is designed to encourage healthcare professionals and patients to report any suspected adverse drug reactions, including those related to new medicines, off-label use of medicines, and herbal remedies.
The MHRA recommends that all suspected adverse drug reactions for new medicines, identified by the black triangle symbol, should be reported. Additionally, all suspected adverse drug reactions occurring in children, even if a medicine has been used off-label, should be reported. Serious suspected adverse drug reactions for established vaccines and medicines, including unlicensed medicines, should also be reported.
Yellow Cards can be found at the back of the British National Formulary (BNF) or completed online through the Yellow Card website. It is important to note that any suspected reactions, not just confirmed ones, should be reported. Patients can also report adverse events through the scheme.
Once Yellow Cards are submitted, the MHRA collates and assesses the information. The agency may consult with the Commission on Human Medicines (CHM), an independent scientific advisory body on medicines safety, to further evaluate the reported adverse reactions. Reactions that are fatal, life-threatening, disabling or incapacitating, result in or prolong hospitalization, or are medically significant are considered serious.
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This question is part of the following fields:
- Pharmacology
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Question 6
Incorrect
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An 80-year-old man visits his General Practitioner (GP) with a growth on the left side of his cheek. The growth has been present for around six months, and it is not causing any discomfort. Upon examination, it is a raised pearly papule with central telangiectasia and a rolled edge. The GP suspects it to be a basal cell carcinoma, measuring approximately 8 mm in diameter.
What is the best course of action for management?Your Answer: 5-fluorouracil cream
Correct Answer: Refer the patient routinely to Dermatology
Explanation:Management of Basal Cell Carcinoma: Referral and Treatment Options
Basal cell carcinomas (BCCs) are slow-growing skin cancers that require prompt referral to a dermatologist for assessment and management. While not urgent, referral should be routine to ensure timely treatment and prevent further growth and potential complications. Treatment options may include surgical excision, curettage and cautery, radiotherapy, or cryotherapy, depending on the size and location of the lesion.
5-fluorouracil cream and diclofenac topical gel are not recommended for the treatment of BCCs but may be used for pre-malignant lesions such as solar keratoses. Referral to oncology for radiotherapy may be considered, but dermatology should be consulted first to explore less invasive treatment options.
A watch-and-wait approach is not recommended for suspected BCCs, as delaying referral can lead to more extensive treatments and potential complications. All lesions suspected of malignancy should be referred to a specialist for further assessment and definitive treatment.
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This question is part of the following fields:
- Dermatology
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Question 7
Correct
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A 35-year-old woman complains of lower abdominal pain during her 8th week of pregnancy. A transvaginal ultrasound reveals the presence of a simple ovarian cyst alongside an 8-week intrauterine pregnancy. What is the best course of action for managing the cyst?
Your Answer: Reassure patient that this is normal and leave the cyst alone
Explanation:During the initial stages of pregnancy, ovarian cysts are typically physiological and referred to as corpus luteum. These cysts typically disappear during the second trimester. It is crucial to provide reassurance in such situations as expecting mothers are likely to experience high levels of anxiety. It is important to avoid anxiety during pregnancy to prevent any negative consequences for both the mother and the developing fetus.
Understanding the Different Types of Ovarian Cysts
Ovarian cysts are a common occurrence in women, and they can be classified into different types. The most common type of ovarian cyst is the physiological cyst, which includes follicular cysts and corpus luteum cysts. Follicular cysts occur when the dominant follicle fails to rupture or when a non-dominant follicle fails to undergo atresia. These cysts usually regress after a few menstrual cycles. Corpus luteum cysts, on the other hand, occur when the corpus luteum fails to break down and disappear after the menstrual cycle. These cysts may fill with blood or fluid and are more likely to cause intraperitoneal bleeding than follicular cysts.
Another type of ovarian cyst is the benign germ cell tumour, which includes dermoid cysts. Dermoid cysts are also known as mature cystic teratomas and are usually lined with epithelial tissue. They may contain skin appendages, hair, and teeth. Dermoid cysts are the most common benign ovarian tumour in women under the age of 30, and they are usually asymptomatic. However, torsion is more likely to occur with dermoid cysts than with other ovarian tumours.
Lastly, there are benign epithelial tumours, which arise from the ovarian surface epithelium. The most common benign epithelial tumour is the serous cystadenoma, which bears a resemblance to the most common type of ovarian cancer (serous carcinoma). Serous cystadenomas are bilateral in around 20% of cases. The second most common benign epithelial tumour is the mucinous cystadenoma, which is typically large and may become massive. If it ruptures, it may cause pseudomyxoma peritonei.
In conclusion, understanding the different types of ovarian cysts is important for proper diagnosis and treatment. Complex ovarian cysts should be biopsied to exclude malignancy, while benign cysts may require monitoring or surgical removal depending on their size and symptoms.
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This question is part of the following fields:
- Obstetrics
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Question 8
Incorrect
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A 65-year-old moderately obese man is brought to the Emergency Department with complaints of severe chest pain and shortness of breath. Upon physical examination, a pericardial tamponade is suspected and confirmed by an electrocardiogram (ECG) showing total electrical alternans and an echocardiogram revealing pericardial effusion. Which jugular vein is typically the most reliable indicator of central venous pressure (CVP)?
Your Answer: Left internal
Correct Answer: Right internal
Explanation:The Best Vein for Measuring Central Venous Pressure
Pericardial tamponade can lead to compression of the heart by the pericardium, resulting in decreased intracardiac diastolic pressure and reduced blood flow to the right atrium. This can cause distension of the jugular veins, making the right internal jugular vein the best vein for measuring central venous pressure (CVP). Unlike the right external vein, which joins the right internal vein at an oblique angle, the right internal vein has a straight continuation with the right brachiocephalic vein and the superior vena cava, making CVP measurement more accurate. On the other hand, the left internal jugular vein makes an oblique union with the left brachiocephalic vein and the external jugular veins, making it a less reliable indicator of CVP. Similarly, the left external vein also joins the left internal vein at an oblique angle, making CVP reading less reliable.
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This question is part of the following fields:
- Cardiology
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Question 9
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These results were obtained from a 43-year-old female. Her serum levels showed an elevated level of aldosterone and a low level of renin. Specifically, her Na+ level was 154 mmol/l (135–145 mmol/l) and her K+ level was 3.7 mmol/l (3.5–5 mmol/l). What condition are these results consistent with?
Your Answer: Conn’s syndrome
Explanation:Electrolyte Imbalances in Various Conditions and Treatments
Conn’s Syndrome and Hyperaldosteronism
Conn’s syndrome is a type of primary hyperaldosteronism caused by the overproduction of aldosterone in the adrenal glands due to an adrenal adenoma. This results in elevated levels of aldosterone, causing water retention and increased excretion of potassium. Renin levels are low in this condition due to the raised sodium and plasma volume. Patients with Conn’s syndrome are typically hypertensive, but it is important to note that some patients may have normal potassium levels.Addison’s Disease and Adrenal Gland Failure
Addison’s disease is caused by adrenal gland failure, resulting in a deficiency of glucocorticoids and mineralocorticoids. This leads to sodium loss and potassium retention.Renal Artery Stenosis and Secondary Hyperaldosteronism
Patients with renal artery stenosis may also exhibit elevated sodium and low potassium levels. However, in this case, renin levels are elevated due to reduced renal perfusion, leading to secondary hyperaldosteronism.Bartter Syndrome and Congenital Salt-Wasting
Bartter syndrome is a congenital condition that causes salt-wasting due to a defective channel in the loop of Henle. This results in sodium and chloride leakage, leading to hypokalemia and metabolic alkalosis. Renin and aldosterone production are increased in response to sodium and volume depletion.Furosemide Treatment and Loop Diuretics
Furosemide is a loop diuretic that promotes sodium and chloride excretion, leading to potassium loss. Patients undergoing furosemide treatment may exhibit hyponatremia and hypokalemia. -
This question is part of the following fields:
- Endocrinology
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Question 10
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A 35-year-old woman presents with increasing early-morning bilateral knee pain and stiffness and generalised fatigue. On examination, she is noted to have flat erythema over the malar eminences with sparing of the nasolabial folds. Multiple painless oral ulcers are also noted. Examination of the knee joints reveals tenderness and suprapatellar effusions bilaterally.
Which of these is most specific for the underlying condition?Your Answer: Anti-double-stranded DNA (dsDNA) antibody
Explanation:Systemic lupus erythaematosus (SLE) is an autoimmune disease where the body produces autoantibodies against various antigens, leading to the formation of immune complexes that can deposit in different parts of the body, such as the kidneys. Symptoms of SLE include fatigue, joint pain, rash, and fever. Diagnosis of SLE requires the presence of at least four out of eleven criteria, including malar rash, discoid rash, photosensitivity, oral or nasopharyngeal ulceration, arthritis, serositis, renal disorder, CNS disorders, haematological disorders, positive immunology, and positive ANA. Anti-double-stranded DNA (dsDNA) antibody is highly specific for SLE but only positive in 60% of patients. Other antibodies, such as anti-La antibodies, rheumatoid factor IgG, ANCA, and Scl70, are raised in other autoimmune diseases such as Sjögren’s syndrome, rheumatoid arthritis, and various vasculitides.
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This question is part of the following fields:
- Rheumatology
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