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Question 1
Incorrect
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A 57-year-old male presents to the emergency department with fever and diarrhoea. He has a medical history of systemic lupus erythematosus and received a renal transplant three years ago. He also has gout and dyspepsia and takes azathioprine, allopurinol, and omeprazole. He drinks 20 units of alcohol per week for the past ten years. His vital signs are as follows:
- Respiratory rate: 32/min
- Pulse: 133 bpm
- Temperature: 39.1ºC
- Blood pressure: 88/56 mmHg
- Oxygen saturation: 94% on room air
His blood test results show:
- Hb: 90 g/L (normal range for males: 135-180)
- Platelets: 85 * 109/L (normal range: 150 - 400)
- WBC: 1.3 * 109/L (normal range: 4.0 - 11.0)
- Neuts: 0.7 * 109/L (normal range: 2.0 - 7.0)
What drug interaction led to this patient's presentation?Your Answer: Omeprazole and allopurinol use
Correct Answer: Azathioprine and allopurinol use
Explanation:The combination of azathioprine and allopurinol use increases the risk of azathioprine toxicity, which can lead to neutropenic sepsis. Azathioprine is converted to its active form, 6-mercaptopurine, which causes immunosuppression, and allopurinol inhibits the enzyme responsible for metabolizing 6-mercaptopurine, leading to excessive myelosuppression. Chronic alcohol use and allopurinol use do not interact and will not affect a patient’s immune system. Azathioprine and chronic alcohol use also do not significantly increase a patient’s risk of myelosuppression as 6-mercaptopurine is not metabolized by the CYP family of enzymes. Similarly, omeprazole use does not significantly increase a patient’s risk of myelosuppression as 6-mercaptopurine is not metabolized via this route.
Allopurinol is a medication used to prevent gout by inhibiting xanthine oxidase. Traditionally, it was believed that urate-lowering therapy (ULT) should not be started until two weeks after an acute attack to avoid further attacks. However, the evidence supporting this is weak, and the British Society of Rheumatology (BSR) now recommends delaying ULT until inflammation has settled to make long-term drug decisions while the patient is not in pain. The initial dose of allopurinol is 100 mg once daily, with the dose titrated every few weeks to aim for a serum uric acid level of less than 300 µmol/l. Colchicine cover should be considered when starting allopurinol, and NSAIDs can be used if colchicine cannot be tolerated. ULT is recommended for patients with two or more attacks in 12 months, tophi, renal disease, uric acid renal stones, prophylaxis if on cytotoxics or diuretics, and Lesch-Nyhan syndrome.
The most significant adverse effects of allopurinol are dermatological, and patients should stop taking the medication immediately if they develop a rash. Severe cutaneous adverse reaction (SCAR), drug reaction with eosinophilia and systemic symptoms (DRESS), and Stevens-Johnson syndrome are potential risks. Certain ethnic groups, such as the Chinese, Korean, and Thai people, are at an increased risk of these dermatological reactions. Patients at high risk of severe cutaneous adverse reaction should be screened for the HLA-B *5801 allele. Allopurinol can interact with other medications, such as azathioprine, cyclophosphamide, and theophylline. Azathioprine is metabolized to the active compound 6-mercaptopurine, which is oxidized to 6-thiouric acid by xanthine oxidase. Allopurinol can lead to high levels of 6-mercaptopurine, so a much-reduced dose must be used if the combination cannot be avoided. Allopurinol also reduces renal clearance of cyclophosphamide, which may cause marrow toxicity. Additionally, allopurinol causes an increase in plasma concentration of theophylline by inhibiting its breakdown.
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This question is part of the following fields:
- Pharmacology
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Question 2
Correct
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The risk of developing schizophrenia if one monozygotic twin is affected is approximately:
Your Answer: 50%
Explanation:Understanding the Epidemiology of Schizophrenia
Schizophrenia is a psychotic disorder that affects a significant portion of the population. The strongest risk factor for developing this condition is having a family history of the disorder. Individuals with a parent who has schizophrenia have a relative risk of 7.5. Additionally, monozygotic twins have a 50% chance of developing schizophrenia, while siblings have a 10% chance. In contrast, individuals without relatives with schizophrenia have a 1% chance of developing the disorder.
Aside from family history, other factors can increase the risk of developing schizophrenia. Black Caribbean ethnicity has a relative risk of 5.4, while migration and living in an urban environment have relative risks of 2.9 and 2.4, respectively. Cannabis use also increases the risk of developing schizophrenia, with a relative risk of 1.4.
Understanding the epidemiology of schizophrenia is crucial in identifying individuals who may be at risk of developing the disorder. By recognizing these risk factors, healthcare professionals can provide early interventions and support to prevent or manage the onset of schizophrenia.
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This question is part of the following fields:
- Psychiatry
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Question 3
Incorrect
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A 2-month-old baby is brought to the GP clinic by their parent for their first round of vaccinations. What vaccinations are recommended for this visit?
Your Answer: 6-1 vaccine' (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B), one dose of MMR (Measles, Mumps and Rubella vaccine) and one dose of Rotavirus vaccine
Correct Answer: 6-1 vaccine' (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B), one dose Men B (vaccine for group B meningococcal disease) and one dose of Rotavirus vaccine
Explanation:The recommended vaccination schedule includes the 6-in-1 vaccine for diphtheria, tetanus, whooping cough, polio, Hib, and hepatitis B, as well as one dose each of the MMR vaccine for measles, mumps, and rubella, and the Rotavirus vaccine.
The UK immunisation schedule recommends certain vaccines at different ages. At birth, the BCG vaccine is given if the baby is at risk of tuberculosis. At 2, 3, and 4 months, the ‘6-1 vaccine’ (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) and oral rotavirus vaccine are given, along with Men B and PCV at certain intervals. At 12-13 months, the Hib/Men C, MMR, and PCV vaccines are given, along with Men B. At 3-4 years, the ‘4-in-1 preschool booster’ (diphtheria, tetanus, whooping cough and polio) and MMR vaccines are given. At 12-13 years, the HPV vaccination is given, and at 13-18 years, the ‘3-in-1 teenage booster’ (tetanus, diphtheria and polio) and Men ACWY vaccines are given. Additionally, the flu vaccine is recommended annually for children aged 2-8 years.
It is important to note that the meningitis ACWY vaccine has replaced meningitis C for 13-18 year-olds due to an increased incidence of meningitis W disease in recent years. The ACWY vaccine will also be offered to new students (up to the age of 25 years) at university. GP practices will automatically send letters inviting 17-and 18-year-olds in school year 13 to have the Men ACWY vaccine. Students going to university or college for the first time as freshers, including overseas and mature students up to the age of 25, should contact their GP to have the Men ACWY vaccine, ideally before the start of the academic year.
It is worth noting that the Men C vaccine used to be given at 3 months but has now been discontinued. This is because the success of the Men C vaccination programme means there are almost no cases of Men C disease in babies or young children in the UK any longer. All children will continue to be offered the Hib/Men C vaccine at one year of age, and the Men ACWY vaccine at 14 years of age to provide protection across all age groups.
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This question is part of the following fields:
- Paediatrics
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Question 4
Correct
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A known case of chronic obstructive pulmonary disease (COPD) presents to the Emergency department, distressed and cyanosed. Arterial blood gases reveal pH 7.2 (7.36-7.44), PaO2 8.3 kPa (11.3-12.6 kPa), PaCO2 10 kPa (4.7-6.0 kPa). The patient, who is in his 60s, is given high concentration oxygen together with a salbutamol nebuliser and intravenous hydrocortisone. Despite these interventions, the patient's breathing effort worsens, although pulse oximetry showed SaO2 of 93%. What could be the reason for the patient's deterioration?
Your Answer: High concentration oxygen administration
Explanation:The Dangers of High Concentration Oxygen for COPD Patients
The patient’s acute exacerbation of COPD had led to hypoxia and hypercapnia. Due to the nature of his condition, his respiratory centre was only stimulated by hypoxia. As a result, when he was given high concentration oxygen, his respiratory effort decreased and his condition worsened. This is because the high concentration of oxygen deprived him of the hypoxic drive that was necessary to stimulate his respiratory centre. Therefore, it is important to be cautious when administering oxygen to COPD patients, as high concentrations can have dangerous consequences. Proper monitoring and management of oxygen levels can help prevent exacerbations and improve patient outcomes.
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This question is part of the following fields:
- Emergency Medicine
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Question 5
Incorrect
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A 22-year-old woman who is 26 weeks pregnant comes to the emergency department complaining of severe headache and epigastric pain that has been worsening for the past 48 hours. Upon examination, she has a heart rate of 110 beats/min, a respiratory rate of 21 /min, a temperature of 36.8ºC, mild pitting oedema of the ankles, and brisk tendon reflexes. As pre-eclampsia is the likely diagnosis, what is the most crucial sign to look for?
Your Answer: Oedema
Correct Answer: Brisk tendon reflexes
Explanation:Brisk reflexes are a specific clinical sign commonly linked to pre-eclampsia, unlike the other answers which are more general.
Pre-eclampsia is a condition that occurs during pregnancy and is characterized by high blood pressure, proteinuria, and edema. It can lead to complications such as eclampsia, neurological issues, fetal growth problems, liver involvement, and cardiac failure. Severe pre-eclampsia is marked by hypertension, proteinuria, headache, visual disturbances, and other symptoms. Risk factors for pre-eclampsia include hypertension in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension, first pregnancy, and age over 40. Aspirin may be recommended for women with high or moderate risk factors. Treatment involves emergency assessment, admission for observation, and medication such as labetalol, nifedipine, or hydralazine. Delivery of the baby is the most important step in management, with timing depending on the individual case.
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This question is part of the following fields:
- Obstetrics
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Question 6
Incorrect
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An 80-year-old woman comes in with postmenopausal bleeding that has been occurring for the past 5 months. After an endometrial biopsy, she is diagnosed with well-differentiated adenocarcinoma (stage II) and there is no indication of metastatic disease. What is the most suitable course of treatment?
Your Answer: Transcervical endometrial resection
Correct Answer: Total abdominal hysterectomy with bilateral salpingo-oophorectomy
Explanation:Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Postmenopausal bleeding is the most common symptom of endometrial cancer, which is usually slight and intermittent initially before becoming more heavy. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.
When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness (< 4 mm). Hysteroscopy with endometrial biopsy is also commonly used for investigation. The management of localized disease involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may have postoperative radiotherapy. progesterone therapy is sometimes used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.
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This question is part of the following fields:
- Gynaecology
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Question 7
Incorrect
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A 25-year-old woman comes to the clinic with a neck nodule that she has observed for the past month. Upon examination, a non-painful 3.5 cm nodule is found on the right side of her neck, located deep to the lower half of the right sternocleidomastoid. The nodule moves upwards when she swallows, and no other masses are palpable in her neck. What is the nature of this mass?
Your Answer: Branchial cyst
Correct Answer: Thyroid nodule
Explanation:Thyroid Nodule and its Investigation
A thyroid nodule is suspected in this patient due to the movement observed during swallowing. The possible causes of a thyroid nodule include colloid cyst, adenoma, and carcinoma. To investigate this lesion, the most appropriate method would be fine needle aspiration. This procedure involves inserting a thin needle into the nodule to collect a sample of cells for examination under a microscope. Fine needle aspiration is a minimally invasive and safe procedure that can provide valuable information about the nature of the thyroid nodule. It can help determine whether the nodule is benign or malignant, and guide further management and treatment options. Therefore, if a thyroid nodule is suspected, fine needle aspiration should be considered as the first step in the diagnostic process.
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This question is part of the following fields:
- Endocrinology
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Question 8
Incorrect
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A 70-year-old man visits his doctor with complaints of fatigue and lower back pain. Upon conducting a thorough examination and taking a complete medical history, the physician orders blood tests. The results are as follows:
- Hemoglobin (Hb): 101 g/L (normal range for males: 135-180; females: 115-160)
- Platelets: 138 * 109/L (normal range: 150-400)
- White blood cells (WBC): 4.9 * 109/L (normal range: 4.0-11.0)
- Sodium (Na+): 132 mmol/L (normal range: 135-145)
- Potassium (K+): 3.7 mmol/L (normal range: 3.5-5.0)
- Bicarbonate: 27 mmol/L (normal range: 22-29)
- Urea: 8.4 mmol/L (normal range: 2.0-7.0)
- Creatinine: 142 µmol/L (normal range: 55-120)
- Calcium: 3.2 mmol/L (normal range: 2.1-2.6)
- Phosphate: 1.4 mmol/L (normal range: 0.8-1.4)
- Magnesium: 1.0 mmol/L (normal range: 0.7-1.0)
What is the recommended first-line imaging for this patient?Your Answer: Brain and spinal cord MRI
Correct Answer: Whole body MRI
Explanation:Understanding Multiple Myeloma: Features and Investigations
Multiple myeloma is a type of blood cancer that occurs due to genetic mutations in plasma cells. It is commonly diagnosed in individuals over the age of 70. The disease is characterized by the acronym CRABBI, which stands for Calcium, Renal, Anaemia, Bleeding, Bones, and Infection. Patients with multiple myeloma may experience hypercalcemia, renal damage, anaemia, bleeding, bone pain, and increased susceptibility to infections. Other symptoms may include amyloidosis, carpal tunnel syndrome, neuropathy, and hyperviscosity.
To diagnose multiple myeloma, doctors may perform a variety of tests, including blood tests, protein electrophoresis, bone marrow aspiration, and imaging studies. Blood tests may reveal anaemia, elevated levels of M protein in the blood or urine, and renal failure. Protein electrophoresis can detect raised concentrations of monoclonal IgA/IgG proteins in the serum or urine. Bone marrow aspiration confirms the diagnosis if the number of plasma cells is significantly raised. Imaging studies, such as whole-body MRI or X-rays, can detect osteolytic lesions or the characteristic raindrop skull pattern.
The diagnostic criteria for multiple myeloma require one major and one minor criteria or three minor criteria in an individual who has signs or symptoms of the disease. Major criteria include plasmacytoma, 30% plasma cells in a bone marrow sample, and elevated levels of M protein in the blood or urine. Minor criteria include 10% to 30% plasma cells in a bone marrow sample, minor elevations in the level of M protein in the blood or urine, osteolytic lesions, and low levels of antibodies not produced by the cancer cells in the blood.
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This question is part of the following fields:
- Medicine
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Question 9
Incorrect
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A 48-year-old male presents to the urology clinic with complaints of impotence. He has a history of hypertension and reports the absence of morning erections. Upon further inquiry, the patient describes experiencing pain in his buttocks that intensifies with movement. Physical examination reveals muscle atrophy, while the penis and scrotum appear normal. What is the probable diagnosis?
Your Answer: S3-S4 cord lesion
Correct Answer: Leriche syndrome
Explanation:Leriche syndrome is a condition that typically affects men and is characterized by three main symptoms: claudication (painful cramping) in the buttocks and thighs, muscle wasting in the legs, and impotence caused by nerve paralysis in the L1 region. This condition is caused by atherosclerosis, which leads to blockages in the abdominal aorta and/or iliac arteries. Treatment involves addressing underlying risk factors such as high cholesterol and smoking cessation. Diagnosis is typically made through angiography.
Understanding Leriche Syndrome
Leriche syndrome is a condition that affects the iliac vessels, causing atheromatous disease that can compromise blood flow to the pelvic viscera. This can result in symptoms such as buttock claudication and impotence. To diagnose the condition, angiography is often used to identify any iliac occlusions. Treatment typically involves endovascular angioplasty and stent insertion to address the occlusions and improve blood flow.
In summary, Leriche syndrome is a condition that can have significant impacts on a patient’s quality of life. By understanding the symptoms and diagnostic and treatment options available, healthcare providers can help patients manage this condition effectively.
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This question is part of the following fields:
- Musculoskeletal
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Question 10
Correct
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You assess a 6-year-old girl with cerebral palsy who is experiencing persistent spasticity in her legs resulting in contractures and pain. After discussing with her mother, you discover that she is receiving regular physiotherapy, utilizing appropriate orthoses, and has previously attempted oral diazepam. What treatment option could be presented to potentially enhance her symptoms?
Your Answer: Baclofen
Explanation:Understanding Cerebral Palsy
Cerebral palsy is a condition that affects movement and posture due to damage to the motor pathways in the developing brain. It is the most common cause of major motor impairment and affects 2 in 1,000 live births. The causes of cerebral palsy can be antenatal, intrapartum, or postnatal. Antenatal causes include cerebral malformation and congenital infections such as rubella, toxoplasmosis, and CMV. Intrapartum causes include birth asphyxia or trauma, while postnatal causes include intraventricular hemorrhage, meningitis, and head trauma.
Children with cerebral palsy may exhibit abnormal tone in early infancy, delayed motor milestones, abnormal gait, and feeding difficulties. They may also have associated non-motor problems such as learning difficulties, epilepsy, squints, and hearing impairment. Cerebral palsy can be classified into spastic, dyskinetic, ataxic, or mixed types.
Managing cerebral palsy requires a multidisciplinary approach. Treatments for spasticity include oral diazepam, oral and intrathecal baclofen, botulinum toxin type A, orthopedic surgery, and selective dorsal rhizotomy. Anticonvulsants and analgesia may also be required. Understanding cerebral palsy and its management is crucial in providing appropriate care and support for individuals with this condition.
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This question is part of the following fields:
- Paediatrics
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