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Question 1
Correct
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A 6-year-old girl is brought to see her GP by her mother. She is noted to be on the 4th centile for weight. Her mother notes that for the past few months her daughter has been tired and passes greasy foul-smelling stools three times a day. Blood tests reveal mild anaemia, positive serum IgA anti-endomysial antibody (EMA-IgA) and very elevated tissue transglutaminase (tTG) levels.
Which of the following is the most likely cause of her symptoms?
Select the SINGLE most likely cause from the list below. Select ONE option only.Your Answer: Coeliac disease
Explanation:Understanding Coeliac Disease: Symptoms, Diagnosis, and Treatment
Coeliac disease (CD) is a common autoimmune disorder that affects almost 1% of individuals in developed countries. It is triggered by gluten and related prolamins present in wheat, rye, and barley, and primarily affects the small intestine, leading to flattening of the small intestinal mucosa. CD can present in various ways, including typical GI symptoms, atypical symptoms, or no symptoms at all. Diagnosis is made through serology tests for specific autoimmune markers, and treatment involves a lifelong avoidance of gluten ingestion.
Other potential diagnoses, such as travellers’ diarrhoea, growth hormone deficiency, hypothyroidism, and severe combined immunodeficiency, have different clinical presentations and are not consistent with this patient’s symptoms. Understanding the symptoms, diagnosis, and treatment of CD is crucial for proper management and improved quality of life for affected individuals.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 2
Correct
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You assess a 10-month-old infant with parents of Jamaican descent. The parents have observed a minor bulge near the belly button. The child is healthy and falls on the 50th percentile. During the examination, you observe a small umbilical hernia that is less than 1 cm in size and can be reduced. What is the best course of action for this situation?
Your Answer: Reassure the parents that the vast majority resolve by the age of 4-5 years
Explanation:Abdominal wall hernias occur when an organ or the fascia of an organ protrudes through the wall of the cavity that normally contains it. Risk factors for developing these hernias include obesity, ascites, increasing age, and surgical wounds. Symptoms of abdominal wall hernias include a palpable lump, cough impulse, pain, obstruction (more common in femoral hernias), and strangulation (which can compromise the bowel blood supply and lead to infarction). There are several types of abdominal wall hernias, including inguinal hernias (which account for 75% of cases and are more common in men), femoral hernias (more common in women and have a high risk of obstruction and strangulation), umbilical hernias (symmetrical bulge under the umbilicus), paraumbilical hernias (asymmetrical bulge), epigastric hernias (lump in the midline between umbilicus and xiphisternum), incisional hernias (which may occur after abdominal surgery), Spigelian hernias (rare and seen in older patients), obturator hernias (more common in females and can cause bowel obstruction), and Richter hernias (a rare type of hernia that can present with strangulation without symptoms of obstruction). In children, congenital inguinal hernias and infantile umbilical hernias are the most common types, with surgical repair recommended for the former and most resolving on their own for the latter.
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This question is part of the following fields:
- Paediatrics
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Question 3
Incorrect
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A 35-year-old woman presents with a 7-day history of mucopurulent anal discharge, bloody stool and pain during defecation. She denies any recent travel and has not experienced any vomiting episodes.
Which of the following is the most probable diagnosis?
Your Answer: Crohn’s disease
Correct Answer: Gonorrhoea
Explanation:Sexually Transmitted Infections: Differential Diagnosis
Sexually transmitted infections (STIs) are a common cause of morbidity worldwide. When evaluating a patient with symptoms suggestive of an STI, it is important to consider a broad differential diagnosis. Here are some common STIs and their clinical presentations:
Gonorrhoea: This is a purulent infection of the mucous membranes caused by Neisseria gonorrhoeae. In men, symptoms include urethritis, acute epididymitis, and rectal infection. A diagnosis can be made by identifying typical Gram-negative intracellular diplococci after a Gram stain.
Crohn’s disease: This is an inflammatory bowel disease that presents with prolonged diarrhea, abdominal pain, anorexia, and weight loss. It is not consistent with a typical STI presentation.
Candidiasis: This is a fungal infection caused by yeasts from the genus Candida. It is associated with balanitis, presenting with penile pruritus and whitish patches on the penis.
Salmonella infection: This is often transmitted orally via contaminated food or beverages. Symptoms include a severe non-specific febrile illness, which can be confused with typhoid fever. There is nothing in this clinical scenario to suggest Salmonella infection.
Chancroid: This is a bacterial STI caused by Haemophilus ducreyi. It is characterised by painful necrotising genital ulcers and inguinal lymphadenopathy.
In summary, a thorough differential diagnosis is important when evaluating patients with symptoms suggestive of an STI.
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This question is part of the following fields:
- Infectious Diseases
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Question 4
Incorrect
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A 65-year-old man arrives at the emergency department with a dense left-sided hemiparesis that has been ongoing for 10 hours. A CT scan of the head reveals a hypodense area in the right middle cerebral artery territory, and he is admitted to the hyper-acute stroke unit for further treatment. He is given 300mg of aspirin. While in the hospital, an ECG shows an irregularly irregular rhythm with no p waves. The patient inquires about ways to decrease the risk of future strokes. What is the most appropriate course of action?
Your Answer: Lifelong aspirin and clopidogrel
Correct Answer: Start anticoagulation with a direct oral anticoagulant (DOAC) after 2 weeks
Explanation:Managing Atrial Fibrillation Post-Stroke
Atrial fibrillation is a significant risk factor for ischaemic stroke, making it crucial to identify and treat the condition in patients who have suffered a stroke or transient ischaemic attack (TIA). However, before starting any anticoagulation or antiplatelet therapy, it is important to rule out haemorrhage. For long-term stroke prevention, NICE Clinical Knowledge Summaries recommend warfarin or a direct thrombin or factor Xa inhibitor. The timing of when to start treatment depends on whether it is a TIA or stroke. In the case of a TIA, anticoagulation for AF should begin immediately after imaging has excluded haemorrhage. For acute stroke patients, anticoagulation therapy should be initiated after two weeks in the absence of haemorrhage. Antiplatelet therapy should be given during the intervening period. However, if imaging shows a very large cerebral infarction, the initiation of anticoagulation should be delayed.
Overall, managing atrial fibrillation post-stroke requires careful consideration of the patient’s individual circumstances and imaging results. By following these guidelines, healthcare professionals can help prevent future strokes and improve patient outcomes.
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This question is part of the following fields:
- Neurology
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Question 5
Incorrect
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A middle-aged man presents with a round, slowly enlarging erythema on his thigh. He also complains of joint discomfort and fatigue. Lyme disease is suspected.
Which of the following is the most appropriate laboratory test to confirm this diagnosis?
Select the SINGLE most appropriate laboratory test from the list below.Your Answer: Erythrocyte sedimentation rate
Correct Answer: Anti-Borrelia burgdorferi titre
Explanation:Diagnostic Tests for Lyme Disease: Understanding the Results
Lyme disease is a common illness caused by the spirochaete B. burgdorferi, transmitted to humans via tick bites. Serologic testing is the most frequently used diagnostic tool, but false positives and negatives are common. The enzyme immunoassay (EIA) or enzyme-linked immunosorbent assay (ELISA) is the first step, followed by a western blot if necessary. However, serologic results cannot distinguish active from inactive disease. Antinuclear antibodies and rheumatoid factor test results are negative in B. burgdorferi infection. The erythrocyte sedimentation rate is usually elevated but is not specific to detect infection. Culture of joint fluids can rule out gout and pseudogout, but detection of B. burgdorferi DNA in synovial fluid is not reliable. Blood cultures are impractical. Understanding the limitations of these tests is crucial for accurate diagnosis and treatment of Lyme disease.
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This question is part of the following fields:
- Infectious Diseases
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Question 6
Correct
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A 35-year-old woman presents to the Genitourinary Medicine Clinic with an 8-day history of dysuria and lower abdominal pain. She has had two sexual partners over the last three months and uses the combined oral contraceptive pill as contraception. She has noticed some spotting and post-coital bleeding since her last period and a foul-smelling vaginal discharge for the last few days. There is no past medical history of note and no known allergies.
On examination, she has lower abdominal tenderness but no guarding or palpable organomegaly. On examination, there is a thick yellow vaginal discharge and mildly tender palpable inguinal lymphadenopathy.
Given the likely diagnosis, what is the most appropriate management for this patient?
Select the SINGLE most appropriate management from the list below.
Select ONE option only.Your Answer: Doxycycline
Explanation:Treatment Options for Sexually Transmitted Diseases
Sexually transmitted diseases (STDs) can present with a variety of symptoms and signs. The most common STD is Chlamydia trachomatis, which can be asymptomatic or present with dysuria, abdominal pain, and vaginal discharge. Endocervical and high vaginal swabs should be taken, and a urinalysis and pregnancy test should be completed. The first-line treatment for C. trachomatis is doxycycline.
Ceftriaxone is indicated for Neisseria gonorrhoeae infections, which can present similarly to chlamydia with discharge and dysuria. However, the most likely diagnosis for this patient is C. trachomatis, making doxycycline the correct answer.
Benzylpenicillin is used in patients with suspected syphilis infection secondary to the spirochaete Treponema pallidum. Syphilis has primary, secondary, and tertiary stages with primary syphilis presenting as a painless chancre with local, non-tender lymphadenopathy prior to secondary disease with fever and a rash. This is not seen here, making syphilis a less likely diagnosis.
Metronidazole is the recommended treatment for bacterial vaginosis and Trichomonas vaginalis. However, it is not used in the treatment of C. trachomatis.
Trimethoprim would be the recommended treatment if this patient was diagnosed with a urinary-tract infection (UTI). While the history of lower abdominal pain and dysuria are suggestive of a UTI, a foul-smelling vaginal discharge points towards an alternative diagnosis.
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This question is part of the following fields:
- Infectious Diseases
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Question 7
Incorrect
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As a young medical practitioner in the emergency department, you encounter a patient who has been in a severe road accident. The patient has suffered significant head injuries and is now reliant on mechanical ventilation, with no signs of responsiveness. You and your senior colleagues suspect that the patient may have experienced brain death. What is the process for confirming this diagnosis?
Your Answer: By one doctor and one legal professional
Correct Answer: By a minimum of two doctors on separate occasions
Explanation:To minimize the risk of errors, brain death testing must be conducted by two experienced doctors on different occasions. The testing involves evaluating the patient’s history, pupil reactions, reflexes, pain response, and respiratory effort. Once brain death is confirmed, life support can be discontinued, and the patient may be considered for organ donation, which can take place before the withdrawal of life support.
Criteria and Testing for Brain Stem Death
Brain death occurs when the brain and brain stem cease to function, resulting in irreversible loss of consciousness and vital functions. To determine brain stem death, certain criteria must be met and specific tests must be performed. The patient must be in a deep coma of known cause, with reversible causes excluded and no sedation. Electrolyte levels must be normal.
The testing for brain stem death involves several assessments. The pupils must be fixed and unresponsive to changes in light intensity. The corneal reflex must be absent, and there should be no response to supraorbital pressure. The oculo-vestibular reflexes must be absent, which is tested by injecting ice-cold water into each ear. There should be no cough reflex to bronchial stimulation or gagging response to pharyngeal stimulation. Finally, there should be no observed respiratory effort in response to disconnection from the ventilator for at least five minutes, with adequate oxygenation ensured.
It is important that the testing is performed by two experienced doctors on two separate occasions, with at least one being a consultant. Neither doctor can be a member of the transplant team if organ donation is being considered. These criteria and tests are crucial in determining brain stem death and ensuring that the patient is beyond recovery.
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This question is part of the following fields:
- Neurology
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Question 8
Incorrect
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Which of the following statements about routine prenatal care is false?
Your Answer: All women are offered a HIV test
Correct Answer: The early ultrasound scan and nuchal scan should not be done at the same time
Explanation:Nowadays, numerous facilities combine the early ultrasound scan and nuchal scan into a single procedure.
NICE guidelines recommend 10 antenatal visits for first pregnancies and 7 for subsequent pregnancies if uncomplicated. The purpose of each visit is outlined, including booking visits, scans, screening for Down’s syndrome, routine care for blood pressure and urine, and discussions about labour and birth plans. Rhesus negative women are offered anti-D prophylaxis at 28 and 34 weeks. The guidelines also recommend discussing options for prolonged pregnancy at 41 weeks.
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This question is part of the following fields:
- Reproductive Medicine
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Question 9
Incorrect
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A 25-year-old female presents with a history of weight loss and diarrhoea. To investigate her symptoms, she undergoes a colonoscopy and a biopsy is taken. The biopsy report indicates the presence of pigment-laden macrophages suggestive of melanosis coli. What is the probable diagnosis?
Your Answer: Intestinal melanoma
Correct Answer: Laxative abuse
Explanation:Understanding Melanosis Coli
Melanosis coli is a condition that affects the pigmentation of the bowel wall. This disorder is characterized by the presence of pigment-laden macrophages, which can be observed through histology. The primary cause of melanosis coli is laxative abuse, particularly the use of anthraquinone compounds like senna.
In simpler terms, melanosis coli is a condition that causes changes in the color of the bowel wall due to the accumulation of pigments. This condition is often associated with the excessive use of laxatives, which can lead to the accumulation of pigment-laden macrophages in the bowel wall. These macrophages are responsible for the discoloration of the bowel wall, which can be observed through histology. It is important to note that melanosis coli is not a life-threatening condition, but it can be a sign of underlying health issues that need to be addressed.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 10
Incorrect
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A 63-year-old man presents with a complaint of neck and arm pain that has been ongoing for four months. He describes the pain as similar to 'electric shocks' and notes that it worsens when he turns his head. There is no history of trauma or any other apparent cause. The patient is in good health and not taking any medications. During the examination, it is noted that he has reduced sensation on the back of his thumb and middle finger. What is the probable underlying diagnosis?
Your Answer: T1 radiculopathy
Correct Answer: C6 radiculopathy
Explanation:Understanding Dermatomes: Major Landmarks and Mnemonics
Dermatomes are areas of skin that are innervated by a single spinal nerve. Understanding dermatomes is important in diagnosing and treating various neurological conditions. The major dermatome landmarks are listed with helpful mnemonics to remember them.
Starting from the top of the body, the C2 dermatome covers the posterior half of the skull, resembling a cap. Moving down to C3, it covers the area of a high turtleneck shirt. C4 covers the area of a low-collar shirt. The C5 dermatome runs along the ventral axial line of the upper limb, while C6 covers the thumb and index finger. To remember this, make a 6 with your left hand by touching the tip of the thumb and index finger together.
Moving down to C7, it covers the middle finger and palm of the hand. C8 covers the ring and little finger. The T4 dermatome covers the area of the nipples, while T5 covers the inframammary fold. T6 covers the xiphoid process, and T10 covers the umbilicus. To remember this, think of BellybuT-TEN.
The L1 dermatome covers the inguinal ligament, which can be remembered by thinking of L for ligament, 1 for 1nguinal. L4 covers the knee caps, and to remember this, think of being down on all fours. L5 covers the big toe and dorsum of the foot (except the lateral aspect), and can be remembered by thinking of it as the largest of the five toes. Finally, the S1 dermatome covers the lateral foot and small toe, while S2 and S3 cover the genitalia.
Understanding dermatomes and their landmarks can aid in diagnosing and treating various neurological conditions. The mnemonics provided can help in remembering these important landmarks.
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This question is part of the following fields:
- Neurology
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Question 11
Incorrect
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A 70-year-old male has been admitted to the cardiology ward following his presentation to the emergency department with palpitations and dyspnoea. After further investigations, he was diagnosed with atrial fibrillation and prescribed digoxin for rate control. What is the recommended frequency for routine drug monitoring in this case?
Your Answer: Every 2 weeks for the first 3 months
Correct Answer: No routine monitoring required
Explanation:Digoxin levels do not require regular monitoring, unless there is suspicion of toxicity. As this patient is commencing digoxin and has no signs of toxicity, routine monitoring is unnecessary. It is not necessary to measure digoxin levels every month until they have stabilized, nor is it appropriate to monitor the drug every 2 weeks for the first 3 months. Routine monitoring is also not required annually throughout the course of treatment.
Understanding Digoxin and Its Toxicity
Digoxin is a medication used for rate control in atrial fibrillation and for improving symptoms in heart failure patients. It works by decreasing conduction through the atrioventricular node and increasing the force of cardiac muscle contraction. However, it has a narrow therapeutic index and requires monitoring for toxicity.
Toxicity may occur even when the digoxin concentration is within the therapeutic range. Symptoms of toxicity include lethargy, nausea, vomiting, anorexia, confusion, yellow-green vision, arrhythmias, and gynaecomastia. Hypokalaemia is a classic precipitating factor, as it allows digoxin to more easily bind to the ATPase pump and increase its inhibitory effects. Other factors that may contribute to toxicity include increasing age, renal failure, myocardial ischaemia, electrolyte imbalances, hypoalbuminaemia, hypothermia, hypothyroidism, and certain medications such as amiodarone, quinidine, and verapamil.
Management of digoxin toxicity involves the use of Digibind, correction of arrhythmias, and monitoring of potassium levels. It is important to recognize the potential for toxicity and monitor patients accordingly to prevent adverse outcomes.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 12
Correct
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A 32-year-old man presents to the neurology clinic with primary generalised epilepsy and is currently taking sodium valproate. Despite being on a therapeutic dose, he is still experiencing seizures and has also noticed weight gain since starting the medication. He expresses a desire to discontinue the current drug and try an alternative. What would be the most suitable second-line treatment option?
Your Answer: Lamotrigine
Explanation:Before starting combination therapy, it is advisable to first try monotherapy with a different drug. When combining sodium valproate and lamotrigine, it is important to be cautious as it may lead to the development of severe skin rashes like Steven-Johnson’s syndrome.
Treatment for Epilepsy
Epilepsy is a neurological disorder that affects millions of people worldwide. The condition is characterized by recurrent seizures, which can be debilitating and life-threatening. Treatment for epilepsy typically involves the use of antiepileptic drugs (AEDs) to control seizures and improve quality of life.
According to NICE guidelines, AEDs should be started after the second epileptic seizure. However, if a patient has a neurological deficit, brain imaging shows a structural abnormality, the EEG shows unequivocal epileptic activity, or the patient or their family considers the risk of having a further seizure unacceptable, AEDs may be started after the first seizure. It is important to note that sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary due to the risk of neurodevelopmental delay in children.
The choice of AEDs depends on the type of epilepsy. For generalized tonic-clonic seizures, males are typically prescribed sodium valproate, while females are prescribed lamotrigine or levetiracetam. For focal seizures, lamotrigine or levetiracetam are the first-line treatments, with carbamazepine, oxcarbazepine, or zonisamide as second-line options. Ethosuximide is the first-line treatment for absence seizures, with sodium valproate or lamotrigine/levetiracetam as second-line options. For myoclonic seizures, males are prescribed sodium valproate, while females are prescribed levetiracetam. Finally, for tonic or atonic seizures, males are prescribed sodium valproate, while females are prescribed lamotrigine.
In summary, treatment for epilepsy involves the use of AEDs to control seizures and improve quality of life. The choice of AEDs depends on the type of epilepsy, and sodium valproate should be used with caution in women of childbearing age.
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This question is part of the following fields:
- Neurology
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Question 13
Incorrect
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A 50-year-old man comes to the clinic complaining of palpitations that started about 30 minutes ago. He mentions having a stressful day at work, but there doesn't seem to be any other obvious trigger. He denies experiencing any chest pain or difficulty breathing. Upon conducting an ECG, a regular tachycardia of 180 bpm with a QRS duration of 0.10s is observed. His blood pressure is 106/70 mmHg, and his oxygen saturation is 98% on room air. Despite performing the Valsalva manoeuvre, there is no effect on the rhythm. What is the most appropriate next step?
Your Answer: Re-attempt Valsava manoeuvre in 5 minutes
Correct Answer: Intravenous adenosine
Explanation:In cases of haemodynamically stable patients with SVT who do not respond to vagal manoeuvres, the recommended course of action is to administer adenosine.
Understanding Supraventricular Tachycardia
Supraventricular tachycardia (SVT) is a type of tachycardia that originates above the ventricles. It is commonly associated with paroxysmal SVT, which is characterized by sudden onset of a narrow complex tachycardia, usually an atrioventricular nodal re-entry tachycardia (AVNRT). Other causes include atrioventricular re-entry tachycardias (AVRT) and junctional tachycardias.
When it comes to acute management, vagal maneuvers such as the Valsalva maneuver or carotid sinus massage can be used. Intravenous adenosine is also an option, with a rapid IV bolus of 6mg given initially, followed by 12mg and then 18mg if necessary. However, adenosine is contraindicated in asthmatics, and verapamil may be a better option for them. Electrical cardioversion is another option.
To prevent episodes of SVT, beta-blockers can be used. Radio-frequency ablation is also an option. It is important to work with a healthcare provider to determine the best course of treatment for each individual case.
Overall, understanding SVT and its management options can help individuals with this condition better manage their symptoms and improve their quality of life.
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This question is part of the following fields:
- Cardiovascular
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Question 14
Correct
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Which one of the following statements regarding migraines is accurate?
Your Answer: Typical aura include a spreading scintillating scotoma ('jagged crescent')
Explanation:Caution should be exercised when administering prokinetic agents like metoclopramide to children.
Diagnostic Criteria for Migraine
Migraine is a neurological disorder that affects millions of people worldwide. The International Headache Society has established diagnostic criteria for migraine without aura, which includes at least five attacks lasting between 4-72 hours and having at least two of the following characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, and aggravation by routine physical activity. During the headache, there must be at least one of the following: nausea and/or vomiting, photophobia, and phonophobia. The headache cannot be attributed to another disorder.
Migraine with aura, which is seen in around 25% of migraine patients, tends to be easier to diagnose with a typical aura being progressive in nature and may occur hours prior to the headache. Typical aura include a transient hemianopic disturbance or a spreading scintillating scotoma (‘jagged crescent’). Sensory symptoms may also occur. NICE criteria suggest that migraines may be unilateral or bilateral and give more detail about typical auras, which may occur with or without headache and are fully reversible, develop over at least 5 minutes, and last 5-60 minutes. Atypical aura symptoms such as motor weakness, double vision, visual symptoms affecting only one eye, poor balance, and decreased level of consciousness may prompt further investigation or referral.
In summary, the diagnostic criteria for migraine without aura include specific characteristics of the headache and associated symptoms, while migraine with aura is characterized by typical aura symptoms that may occur prior to the headache. It is important to accurately diagnose migraine to provide appropriate treatment and management for those who suffer from this debilitating condition.
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This question is part of the following fields:
- Neurology
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Question 15
Correct
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A 78-year-old man with known metastatic prostate cancer presents to his General Practitioner with generalised pain. He states that he has always had aches and pains from old age, but that this is different: he can feel the pain particularly in his back at night.
What is the most likely site to be involved in bone metastasis in this patient?Your Answer: Spine
Explanation:Common Sites of Metastatic Spread in Bone
Metastatic spread to the bone is a common occurrence in many types of cancer. The following are some of the most common sites of metastases in bone:
Spine: The spine is the most common site for bony metastases, with spread often found from a range of solid and haematological cancers, as well as infectious diseases such as tuberculosis.
Ribs: While breast cancer is known to spread to the ribs, this is not the case for many other cancers.
Pelvis: The pelvis is a prevalent site of metastatic spread occurring mostly from the prostate, breast, kidney, lung, and thyroid cancer.
Skull: Skull metastases are seen in 15-25% of all cancer patients and tend to include those from the breast, lungs, prostate, and thyroid, as well as melanoma.
Long bones: Localised bone pain is a red flag for metastatic spread to any of the long bones such as the femur and humerus. Breast, prostate, renal, thyroid, and lung cancers frequently metastasize to these areas.
Overall, understanding the common sites of metastatic spread in bone can help with early detection and treatment of cancer.
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This question is part of the following fields:
- Haematology/Oncology
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Question 16
Correct
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A 32-year-old woman has been referred by her General Practitioner (GP), as she is passing a substantial volume of urine. She complains that she is continuously thirsty.
Random plasma reveals the following:
Investigation Result Normal values
Sodium (Na+) 155 mmol
Osmolality 300 mOsmol/kg
Glucose 4.5 mmol
Urine analysis reveals the following:
Investigation Result
Osmolality 90 mOsmol/kg
Glucose 0.1 mmol/l
In healthy patients, the urine : plasma osmolality ratio is > 2.
A water deprivation test reveals the following:
After 6.5 hours of fluid deprivation, the patient’s weight had dropped by > 3%, and the serum osmolality was 310 mOsmol/kg. Urine osmolality at this stage was 210 mOsmol/kg. The patient was then given desmopressin intramuscularly (IM) and allowed to drink. The urine osmolality increased to 700 mOsmol/kg, and her plasma osmolality was 292 mOsmol/kg.
Which of the following is the most likely diagnosis?Your Answer: A pituitary tumour
Explanation:Diagnosing Cranial Diabetes Insipidus: A Pituitary Tumour as the Likely Cause
Cranial diabetes insipidus (DI) is a condition where the kidneys are unable to reabsorb free water, resulting in excessive water loss. The most likely cause of this condition is reduced antidiuretic hormone (ADH) secretion, which can be caused by a pituitary tumour. In this case, the patient’s low urine osmolality and reduced response to the water deprivation test confirm the presence of cranial DI.
Chronic renal disease and lithium therapy can also cause nephrogenic DI, but the patient’s response to desmopressin im excludes these as potential causes. Diabetes mellitus may cause polydipsia and polyuria, but it also presents with glycosuria and hyperglycaemia. Primary polydipsia, characterized by a compulsive desire to drink, can cause low urine osmolality, but the patient’s ability to concentrate urine to some extent excludes this as a likely cause.
In conclusion, a pituitary tumour is the most likely cause of the patient’s cranial DI, as confirmed by the water deprivation test and response to desmopressin im.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 17
Incorrect
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A 25-year-old woman has given birth to her first child. During delivery, the midwife had to perform McRoberts manoeuvre due to shoulder dystocia, but there were no other complications. After the placenta was delivered, the midwife discovered a perineal tear that involved the external anal sphincter (EAS) but did not extend to the internal anal sphincter (IAS) or rectal mucosa. What is the best course of action for management?
Your Answer: Allow a suitably trained midwife to suture the perineal tear on the ward
Correct Answer: Repair in theatre by a suitably trained clinician as it is a third degree tear
Explanation:The patient has suffered a third degree perineal tear that has extended beyond the perineal mucosa and muscle, involving the EAS but not the rectal mucosa. Therefore, it is classified as a third degree tear. The appropriate course of action is to repair the tear in theatre by a clinician who is suitably trained. Repairing the tear on the ward by a midwife is not an option as it is a third degree tear. Similarly, repairing it in theatre by a clinician trained for fourth degree tears is not necessary. It is important to note that first degree tears do not require repair, but in this case, as it is a third degree tear, not repairing it would not be appropriate as it may not heal properly.
Perineal tears are a common occurrence during childbirth, and the Royal College of Obstetricians and Gynaecologists (RCOG) has developed guidelines to classify them based on their severity. First-degree tears are superficial and do not require any repair, while second-degree tears involve the perineal muscle and require suturing by a midwife or clinician. Third-degree tears involve the anal sphincter complex and require repair in theatre by a trained clinician, with subcategories based on the extent of the tear. Fourth-degree tears involve the anal sphincter complex and rectal mucosa and also require repair in theatre by a trained clinician.
There are several risk factors for perineal tears, including being a first-time mother, having a large baby, experiencing a precipitant labour, and having a shoulder dystocia or forceps delivery. It is important for healthcare providers to be aware of these risk factors and to provide appropriate care and management during childbirth to minimize the risk of perineal tears. By following the RCOG guidelines and providing timely and effective treatment, healthcare providers can help ensure the best possible outcomes for both mother and baby.
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This question is part of the following fields:
- Reproductive Medicine
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Question 18
Correct
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The mother of a 8-year-old boy contacts the out-of-hours General Practitioner due to her concern about an itchy rash that has appeared on her child's body within the last hour. The boy had been diagnosed with bacterial tonsilitis earlier in the day. During examination, the doctor observes multiple raised red lesions on the boy's face and trunk with a central pallor. The boy does not have any breathing difficulties, lip or tongue swelling. What is the most probable diagnosis?
Your Answer: Acute urticaria
Explanation:Common Skin Reactions: Causes and Characteristics
Acute urticaria: This is a superficial swelling of the skin that results in a raised, red, itchy rash. Wheals are also often observed. It can appear anywhere on the body and develop quickly, usually following exposure to an allergen. Common triggers include viral infections, insect bites and stings, certain foods, and medications.
Erythema multiforme (EM): This is a hypersensitivity reaction that is usually triggered by a viral infection, with herpes simplex being the most common agent. The skin eruption associated with EM is typical of multiple ‘target lesions’ that comprise three concentric color zones and a dark/dusky center.
Acute angioedema: This is a skin reaction similar to urticaria, but it affects the deeper layers of the dermis and subcutaneous tissue. The mucous membranes are often affected, with the eyes or lips being the most common sites of swelling. Allergy is the most common cause of angioedema.
Erythema migrans: This is the most common skin manifestation of Lyme disease, which is a borrelia infection caused by infected ticks. Typically, the rash appears 7–14 days after the tick bite as a red papule or macule at the bite site. This then increases in size and is often described as a ‘bullseye’ lesion.
Stevens–Johnson syndrome: This is a rare, acute, severe, and potentially fatal skin reaction. It is the result of an unpredictable reaction to various medications, with antibiotics being the most common trigger. A flu-like prodromal illness is typically followed by the abrupt onset of a red rash. This rash spreads quickly all over the body and affects the mucous membranes before sheet-like skin and mucosal loss develops.
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This question is part of the following fields:
- Immunology/Allergy
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Question 19
Incorrect
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A 38-year-old male presents with left-sided dull chest pain that has been present for five days. He reports no associated shortness of breath, cough, collapse, or pleuritic nature of the chest pain. The patient had a recent sore throat and headache last week, which has since resolved. There is no family history of sudden cardiac death in a first-degree relative, and the patient has never smoked.
Upon examination, the patient's blood pressure is 125/89 mmHg, heart rate is 95/min, temperature is 37.3ºC, and oxygen saturations are 97% on room air. Pulsus paradoxus is not present. Blood results reveal Hb of 154 g/L, platelets of 425 * 109/L, WBC of 11.5 * 109/L, Na+ of 137 mmol/L, K+ of 4.6 mmol/L, urea of 6.4 mmol/L, creatinine of 100 µmol/L, CRP of 40 mg/L, and Troponin T of 13 ng/L. The ECG shows ST-segment elevation in lead I, II, III, aVL, V5, and V6, and PR segment elevation in aVR.
What is the most likely diagnosis for this patient?Your Answer: Myocardial infarction
Correct Answer: Pericarditis
Explanation:The ECG changes in this patient suggest pericarditis, given their young age, widespread ST-segment elevation, and normal troponin levels. While PR segment depression is typically seen in pericarditis, note that the PR segment may be elevated in aVR. Myocarditis would be a possible diagnosis if the troponin levels were elevated. Infective endocarditis is less likely due to the absence of fever and ECG changes consistent with pericarditis. Although cardiac tamponade is a potential complication of pericarditis, it is unlikely in this case as the patient’s blood pressure is normal and pulsus paradoxus is not present.
Understanding Acute Pericarditis
Acute pericarditis is a medical condition characterized by inflammation of the pericardial sac that lasts for less than 4-6 weeks. The condition can be caused by various factors such as viral infections, tuberculosis, uraemia, post-myocardial infarction, autoimmune pericarditis, radiotherapy, connective tissue disease, hypothyroidism, malignancy, and trauma. Symptoms of acute pericarditis include chest pain, non-productive cough, dyspnoea, and flu-like symptoms. Patients may also experience pericardial rub.
To diagnose acute pericarditis, doctors may perform an electrocardiogram (ECG) to check for changes in the heart’s electrical activity. Blood tests may also be conducted to check for inflammatory markers and troponin levels. Patients suspected of having acute pericarditis should undergo transthoracic echocardiography.
Treatment for acute pericarditis depends on the underlying cause. Patients with high-risk features such as fever or elevated troponin levels may need to be hospitalized. However, most patients with pericarditis secondary to viral infection can be managed as outpatients. Strenuous physical activity should be avoided until symptoms resolve and inflammatory markers normalize. A combination of nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine is typically used as first-line treatment for patients with acute idiopathic or viral pericarditis. The medication is usually tapered off over 1-2 weeks.
Overall, understanding acute pericarditis is important for prompt diagnosis and appropriate management of the condition.
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This question is part of the following fields:
- Cardiovascular
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Question 20
Incorrect
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A 56-year-old woman visits her GP complaining of pain and limited movement in her left shoulder joint for the past 4 weeks. She denies any history of injury and reports feeling generally healthy. Her medical history includes hypertension and hypothyroidism. During the examination, the patient experiences pain with all active and passive movements of the left shoulder, and there is significant restriction in external rotation. What is the probable diagnosis?
Your Answer: Inflammatory arthritis
Correct Answer: Adhesive capsulitis
Explanation:The impairment of external rotation, both on active and passive movement, is a classic feature of adhesive capsulitis. This condition is the most likely diagnosis, as the patient’s symptoms of restricted active and passive external rotation have only been present for the last 4 weeks. Osteoarthritis, on the other hand, tends to present with a more chronic pain history. Adhesive capsulitis is often associated with endocrine conditions such as diabetes and thyroid disease, and has three distinct phases: painful, stiff, and recovery. Physiotherapy is the mainstay of treatment, but early intra-articular steroid injection may be considered if conservative measures are not effective. Biceps tendonitis typically presents with anterior shoulder pain and point tenderness over the biceps tendon on examination. Inflammatory arthritis is unlikely as there are no other joint involvements, morning stiffness, or systemic symptoms, and the history and examination are consistent with adhesive capsulitis. While osteoarthritis may be considered in the differential diagnosis, the duration of symptoms and classic examination findings suggest adhesive capsulitis as the most likely diagnosis.
Understanding Adhesive Capsulitis (Frozen Shoulder)
Adhesive capsulitis, commonly known as frozen shoulder, is a prevalent cause of shoulder pain that primarily affects middle-aged women. The exact cause of this condition is not yet fully understood. However, studies have shown that up to 20% of diabetics may experience an episode of frozen shoulder. Symptoms typically develop over several days, with external rotation being more affected than internal rotation or abduction. Both active and passive movement are affected, and patients usually experience a painful freezing phase, an adhesive phase, and a recovery phase. In some cases, the condition may affect both shoulders, which occurs in up to 20% of patients. The episode typically lasts between 6 months and 2 years.
Diagnosis of adhesive capsulitis is usually clinical, although imaging may be necessary for atypical or persistent symptoms. Unfortunately, no single intervention has been proven to improve the outcome in the long-term. However, there are several treatment options available, including nonsteroidal anti-inflammatory drugs (NSAIDs), physiotherapy, oral corticosteroids, and intra-articular corticosteroids.
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This question is part of the following fields:
- Musculoskeletal
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Question 21
Incorrect
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Neuropathic pain typically does not improve with opioids. Nevertheless, if conventional treatments have been ineffective, which opioid should be considered for initiation in elderly patients?
Your Answer: Buprenorphine
Correct Answer: Tramadol
Explanation:Understanding Neuropathic Pain and its Management
Neuropathic pain is a type of pain that occurs due to damage or disruption of the nervous system. It is a complex condition that is often difficult to treat and does not respond well to standard painkillers. Examples of neuropathic pain include diabetic neuropathy, post-herpetic neuralgia, trigeminal neuralgia, and prolapsed intervertebral disc.
To manage neuropathic pain, the National Institute for Health and Care Excellence (NICE) updated their guidance in 2013. The first-line treatment options include amitriptyline, duloxetine, gabapentin, or pregabalin. If the first-line drug treatment does not work, patients may try one of the other three drugs. Unlike standard painkillers, drugs for neuropathic pain are typically used as monotherapy, meaning that if they do not work, patients should switch to a different drug rather than adding another one.
Tramadol may be used as rescue therapy for exacerbations of neuropathic pain, while topical capsaicin may be used for localized neuropathic pain, such as post-herpetic neuralgia. Pain management clinics may also be useful for patients with resistant problems. However, it is important to note that for some specific conditions, such as trigeminal neuralgia, the guidance may vary, and carbamazepine may be used as a first-line treatment. Overall, understanding neuropathic pain and its management is crucial for improving the quality of life for patients suffering from this condition.
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This question is part of the following fields:
- Neurology
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Question 22
Incorrect
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A 72-year-old man presents to the cardiology clinic with symptomatic aortic stenosis. Despite his overall good health, he is eager for intervention. What intervention is most likely to be recommended for him?
Your Answer: Aortic bypass graft
Correct Answer: Bioprosthetic aortic valve replacement
Explanation:Mechanical valves are typically preferred for younger patients as they have a longer lifespan compared to other types of prosthetic heart valves.
Prosthetic Heart Valves: Options for Replacement
Prosthetic heart valves are commonly used to replace damaged aortic and mitral valves. There are two main options for replacement: biological (bioprosthetic) or mechanical. Biological valves are usually sourced from bovine or porcine origins and are commonly used in older patients. However, they have a major disadvantage of structural deterioration and calcification over time. On the other hand, mechanical valves have a low failure rate but require long-term anticoagulation due to the increased risk of thrombosis. Warfarin is still the preferred anticoagulant for patients with mechanical heart valves, and the target INR varies depending on the valve type. Aspirin is only given in addition if there is an additional indication, such as ischaemic heart disease. Following the 2008 NICE guidelines, antibiotics are no longer recommended for common procedures such as dental work for prophylaxis of endocarditis.
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This question is part of the following fields:
- Cardiovascular
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Question 23
Correct
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A 6-year-old girl is brought to the clinic by her mother due to complaints of itching around her vulva and anus for the past 3 days. Upon examination, the area appears red and the skin on her vulva is broken from excessive scratching. Her mother has been applying sudocrem but it has not provided relief. There are no other individuals at home with similar symptoms. Based on the probable diagnosis, what is the most suitable course of action?
Your Answer: Prescribe a single dose of mebendazole for the household and give hygiene advice
Explanation:The recommended first line treatment for threadworm is mebendazole. In this case, as the patient is showing symptoms of threadworm, it is important to treat all members of the household with a single dose of mebendazole and provide hygiene advice. While a ‘Scotch tape test’ can be used to confirm the presence of eggs or worms, treatment is often based on symptoms. It is not appropriate to only treat the daughter and provide hygiene advice, as other members of the household may also be infected. Additionally, prescribing 7 days of mebendazole for the daughter alone is incorrect, as a single dose is recommended and a second dose should be taken 14 days later. Piperazine is only recommended for children under 2 years old, so it is not appropriate to prescribe 14 days of piperazine for the daughter in this case.
Threadworm Infestation in Children
Threadworm infestation, caused by Enterobius vermicularis or pinworms, is a common occurrence among children in the UK. The infestation happens when eggs present in the environment are ingested. In most cases, threadworm infestation is asymptomatic, but some possible symptoms include perianal itching, especially at night, and vulval symptoms in girls. Diagnosis can be made by applying Sellotape to the perianal area and sending it to the laboratory for microscopy to see the eggs. However, most patients are treated empirically, and this approach is supported in the CKS guidelines.
The CKS recommends a combination of anthelmintic with hygiene measures for all members of the household. Mebendazole is the first-line treatment for children over six months old, and a single dose is given unless the infestation persists. It is essential to treat all members of the household to prevent re-infection. Proper hygiene measures, such as washing hands regularly, keeping fingernails short, and washing clothes and bedding at high temperatures, can also help prevent the spread of threadworm infestation.
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This question is part of the following fields:
- Paediatrics
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Question 24
Incorrect
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A 28-year-old female presents to the GP office with a complaint of unusual vaginal discharge. The discharge is described as frothy and green-yellow in color. She is sexually active and does not use any form of birth control. Her most recent sexual encounter was with a new partner two weeks ago. During speculum examination, a strawberry cervix is observed. She is in good health and not taking any medications. A pregnancy test came back negative. What is the recommended course of action for the most probable diagnosis?
Your Answer: Oral doxycycline
Correct Answer: Oral metronidazole
Explanation:The recommended treatment for the patient’s likely diagnosis of trichomoniasis is oral metronidazole, either as a 7-day course of 200mg or a one-time dose of 2g. Intramuscular ceftriaxone, benzathine benzylpenicillin, and oral doxycycline are not indicated for the treatment of trichomoniasis. Oral azithromycin is also not effective for this condition.
Understanding Trichomonas vaginalis and its Comparison to Bacterial Vaginosis
Trichomonas vaginalis is a type of protozoan parasite that is highly motile and flagellated. It is known to cause trichomoniasis, which is a sexually transmitted infection. The infection is characterized by symptoms such as offensive, yellow/green, frothy vaginal discharge, vulvovaginitis, and strawberry cervix. The pH level is usually above 4.5, and in men, it may cause urethritis.
To diagnose trichomoniasis, a wet mount microscopy is conducted to observe the motile trophozoites. The treatment for trichomoniasis involves oral metronidazole for 5-7 days, although a one-off dose of 2g metronidazole may also be used.
When compared to bacterial vaginosis, trichomoniasis has distinct differences. Bacterial vaginosis is caused by an overgrowth of bacteria in the vagina, while trichomoniasis is caused by a protozoan parasite. The symptoms of bacterial vaginosis include a thin, grayish-white vaginal discharge with a fishy odor, and a pH level above 4.5. Unlike trichomoniasis, bacterial vaginosis is not considered a sexually transmitted infection.
In conclusion, understanding the differences between trichomoniasis and bacterial vaginosis is crucial in diagnosing and treating these conditions effectively. Proper diagnosis and treatment can help prevent complications and improve overall health and well-being.
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This question is part of the following fields:
- Reproductive Medicine
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Question 25
Incorrect
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A 45-year-old woman with multiple sclerosis comes in for evaluation. She reports experiencing worsening issues with painful spasms in her leg muscles. What is the initial treatment option that should be considered?
Your Answer: Referral for relaxation therapy
Correct Answer: Baclofen
Explanation:The recommended initial treatments for spasticity in multiple sclerosis are baclofen and gabapentin.
Multiple sclerosis is a condition that cannot be cured, but its treatment aims to reduce the frequency and duration of relapses. In the case of an acute relapse, high-dose steroids may be administered for five days to shorten its length. However, it is important to note that steroids do not affect the degree of recovery. Disease-modifying drugs are used to reduce the risk of relapse in patients with MS. These drugs are typically indicated for patients with relapsing-remitting disease or secondary progressive disease who have had two relapses in the past two years and are able to walk a certain distance unaided. Natalizumab, ocrelizumab, fingolimod, beta-interferon, and glatiramer acetate are some of the drugs used to reduce the risk of relapse in MS.
Fatigue is a common problem in MS patients, and amantadine is recommended by NICE after excluding other potential causes such as anaemia, thyroid problems, or depression. Mindfulness training and CBT are other options for managing fatigue. Spasticity is another issue that can be addressed with first-line drugs such as baclofen and gabapentin, as well as physiotherapy. Cannabis and botox are currently being evaluated for their effectiveness in managing spasticity. Bladder dysfunction is also a common problem in MS patients, and anticholinergics may worsen symptoms in some patients. Ultrasound is recommended to assess bladder emptying, and intermittent self-catheterisation may be necessary if there is significant residual volume. Gabapentin is the first-line treatment for oscillopsia, which is a condition where visual fields appear to oscillate.
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This question is part of the following fields:
- Neurology
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Question 26
Incorrect
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A 35-year-old woman is pregnant with her first child. She is offered screening for chromosomal abnormalities and an ultrasound assessment.
She decides to proceed with testing, which assesses nuchal thickness, pregnancy-associated plasma protein-A (PAPP-A), free beta-human chorionic gonadotrophin (β-hCG) and crown-rump length. She is told the pregnancy is a high risk for Down syndrome, and she and her partner are offered an amniocentesis.
Which one of the following statements regarding amniocentesis is correct?Your Answer: It cannot be carried out after week 15
Correct Answer: It is associated with an increased risk of fetal limb defects
Explanation:A 32-year-old woman visits the general surgery practice with a 2-year history of occasional abdominal discomfort, bloating and change in bowel habit, which alternates between loose stools and constipation. She reports that these episodes are most intense during her work-related stress and after consuming spicy food. There is no history of weight loss or presence of blood or mucus in the stool. Physical examination, including digital rectal examination, is unremarkable. Bloods, including full blood count, liver function test, thyroid function test and coeliac screen are all normal.
Which of the following is the most likely diagnosis? -
This question is part of the following fields:
- Genetics
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Question 27
Correct
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A 64-year-old woman presents to her GP complaining of worsening dyspnea. Upon taking a detailed medical history and conducting a thorough physical examination, the GP orders an outpatient chest CT scan. The results reveal lung fibrosis as the likely cause of the patient's symptoms. The patient has a medical history of gout and rheumatoid arthritis. Which medication prescribed to the patient is most likely responsible for causing lung fibrosis?
Your Answer: Sulfasalazine
Explanation:Drugs that can lead to lung fibrosis
Lung fibrosis is a condition where the lung tissue becomes scarred and thickened, making it difficult for the lungs to function properly. There are several drugs that can cause lung fibrosis as a side effect. These drugs include amiodarone, which is used to treat heart rhythm problems, cytotoxic agents such as busulphan and bleomycin, which are used to treat cancer, and anti-rheumatoid drugs like methotrexate and sulfasalazine. Nitrofurantoin, an antibiotic used to treat urinary tract infections, and ergot-derived dopamine receptor agonists like bromocriptine, cabergoline, and pergolide, which are used to treat Parkinson’s disease, can also cause lung fibrosis. It is important to be aware of the potential side effects of these drugs and to discuss any concerns with a healthcare provider. Proper monitoring and management can help prevent or minimize the risk of lung fibrosis.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 28
Incorrect
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A 25-year-old man presents to the clinic with persistent beliefs that his coworkers are plotting against him and trying to sabotage his work, despite reassurance and evidence to the contrary. He has had multiple heated arguments with his colleagues and after each one, he becomes aggressive and blames them for his outbursts. He sometimes feels like he cannot function without them, but also sometimes feels that they are out to get him. He has a history of a recent suicide attempt and has difficulties trusting his family as he feels they are part of the conspiracy. What is the most likely diagnosis?
Your Answer: Schizotypal personality disorder
Correct Answer: Borderline personality disorder
Explanation:The young man in question is likely suffering from borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD). This condition is characterized by unstable relationships, alternating between idealization and devaluation of others, recurrent self-harm, unstable self-image and self-esteem, suicidal behavior, difficulty controlling anger, and efforts to avoid abandonment. All of these traits are present in this patient, making BPD the most likely diagnosis.
Narcissistic personality disorder is not a likely diagnosis for this patient, as it is characterized by a grandiose sense of self-importance, lack of empathy, and a sense of entitlement. These traits are not present in this patient, and his periods of devaluing her partner are temporary and not pervasive.
Dependent personality disorder is also an unlikely diagnosis, as this condition is characterized by a pervasive need for others to make decisions for the patient and constant reassurance. While the patient has felt that he cannot live without his partner in the past, his labile mood and alternating view of his partner make this diagnosis less likely.
Paranoid personality disorder is also an unlikely diagnosis, as patients with this condition tend to be reluctant to confide in others and have an unforgiving attitude when insulted or questioned. The patient in question does not exhibit these traits, and his difficulty with trusting friends is likely due to his belief that he is undeserving of them.
Personality disorders are a set of personality traits that are maladaptive and interfere with normal functioning in life. It is estimated that around 1 in 20 people have a personality disorder, which are typically categorized into three clusters: Cluster A, which includes Odd or Eccentric disorders such as Paranoid, Schizoid, and Schizotypal; Cluster B, which includes Dramatic, Emotional, or Erratic disorders such as Antisocial, Borderline (Emotionally Unstable), Histrionic, and Narcissistic; and Cluster C, which includes Anxious and Fearful disorders such as Obsessive-Compulsive, Avoidant, and Dependent.
Paranoid individuals exhibit hypersensitivity and an unforgiving attitude when insulted, a reluctance to confide in others, and a preoccupation with conspirational beliefs and hidden meanings. Schizoid individuals show indifference to praise and criticism, a preference for solitary activities, and emotional coldness. Schizotypal individuals exhibit odd beliefs and magical thinking, unusual perceptual disturbances, and inappropriate affect. Antisocial individuals fail to conform to social norms, deceive others, and exhibit impulsiveness, irritability, and aggressiveness. Borderline individuals exhibit unstable interpersonal relationships, impulsivity, and affective instability. Histrionic individuals exhibit inappropriate sexual seductiveness, a need to be the center of attention, and self-dramatization. Narcissistic individuals exhibit a grandiose sense of self-importance, lack of empathy, and excessive need for admiration. Obsessive-compulsive individuals are occupied with details, rules, and organization to the point of hampering completion of tasks. Avoidant individuals avoid interpersonal contact due to fears of criticism or rejection, while dependent individuals have difficulty making decisions without excessive reassurance from others.
Personality disorders are difficult to treat, but a number of approaches have been shown to help patients, including psychological therapies such as dialectical behavior therapy and treatment of any coexisting psychiatric conditions.
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This question is part of the following fields:
- Psychiatry
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Question 29
Incorrect
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You assess a 50-year-old woman who has developed a dependence on temazepam, which was initially prescribed as a sleep aid. She expresses a desire to overcome her addiction to temazepam and seeks assistance. Her current dosage is 20 mg per day. What would be the most suitable approach?
Your Answer: Switch to the equivalent zopiclone dose then slowly withdraw over the next 2 months
Correct Answer: Switch to the equivalent diazepam dose then slowly withdraw over the next 2 months
Explanation:Benzodiazepines are drugs that enhance the effect of the neurotransmitter GABA, which inhibits brain activity. They are used for various purposes, including sedation, anxiety relief, muscle relaxation, and seizure prevention. However, patients can develop a tolerance and dependence on these drugs, so they should only be prescribed for a short period of time. When withdrawing from benzodiazepines, it is important to do so gradually to avoid withdrawal symptoms, which can include insomnia, anxiety, and seizures. Barbiturates are another type of drug that affect GABA, but they work differently than benzodiazepines by increasing the duration of chloride channel opening.
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This question is part of the following fields:
- Psychiatry
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Question 30
Correct
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A 25-year-old student presents to his General Practitioner with symptoms of a flu-like illness. He reports not having eaten for the past 48 hours. During examination, mild jaundice is observed, but no other significant physical findings are noted. The patient's total serum bilirubin level is elevated at 60 μmol/l (reference range < 20 μmol/l), while the other liver function tests (LFTs) are normal. Full blood count (FBC), urea and electrolytes, and haptoglobins are within normal limits. What is the most likely diagnosis for this clinical presentation?
Your Answer: Gilbert syndrome
Explanation:Differential Diagnosis: Jaundice and Abdominal Symptoms
Gilbert Syndrome:
Gilbert syndrome is an inherited condition that can manifest as jaundice on clinical examination. Patients may also experience non-specific symptoms such as abdominal cramps, fatigue, and malaise. Fasting, febrile illness, alcohol, or exercise can exacerbate jaundice in patients with Gilbert syndrome. Diagnosis is based on a thorough history and physical examination, as well as blood tests that show unconjugated hyperbilirubinaemia.Haemolytic Anaemia:
Haemolysis is the premature destruction of erythrocytes, which can lead to anaemia if bone marrow activity cannot compensate for erythrocyte loss. Mild haemolysis can be asymptomatic, while severe haemolysis can cause life-threatening symptoms such as angina and cardiopulmonary decompensation. Changes in lactate dehydrogenase and serum haptoglobin levels are the most sensitive general tests for haemolytic anaemia.Hepatitis A:
Hepatitis A is a viral infection that results almost exclusively from ingestion, typically through faecal-oral transmission. Symptoms include fatigue, anorexia, nausea, and vomiting. LFT abnormalities are common, and diagnosis is based on serologic testing for immunoglobulin M (IgM) antibody to HAV.Hepatitis B:
Hepatitis B is a viral infection that is transmitted haematogenously and sexually. Symptoms include fatigue, anorexia, nausea, and vomiting. LFT abnormalities are common, and diagnosis is based on serologic testing for hepatitis B surface antigen (HBsAg).Cholecystitis:
Cholecystitis is inflammation of the gall bladder that occurs most commonly because of an obstruction of the cystic duct by gallstones arising from the gall bladder. Symptoms include upper abdominal pain, nausea, vomiting, and fever. Signs of peritoneal irritation may also be present.Conclusion:
In summary, the differential diagnosis of jaundice and abdominal symptoms includes Gilbert syndrome, haemolytic anaemia, hepatitis A, hepatitis B, and cholecystitis. Diagnosis is based on a thorough history and physical examination, as well as blood tests and serologic testing as appropriate. Treatment -
This question is part of the following fields:
- Gastroenterology/Nutrition
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