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Question 1
Incorrect
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A 25-year-old woman, who has never been pregnant, complains of chronic pain in her pelvis and sacrum during her menstrual cycle. Her temperature is 37.2 degrees Celsius. During the examination, there is tenderness in her posterior vaginal fornix and uterine motion tenderness. A pelvic ultrasound shows no abnormalities. What is the subsequent diagnostic test recommended?
Your Answer: Serial beta-hCG
Correct Answer: Laparoscopy
Explanation:When it comes to patients with suspected endometriosis, laparoscopy is considered the most reliable investigation method.
Understanding Endometriosis
Endometriosis is a common condition where endometrial tissue grows outside of the uterus. It affects around 10% of women of reproductive age and can cause chronic pelvic pain, painful periods, painful intercourse, and subfertility. Other symptoms may include urinary problems and painful bowel movements. Diagnosis is typically made through laparoscopy, and treatment options depend on the severity of symptoms.
First-line treatments for symptomatic relief include NSAIDs and/or paracetamol. If these do not help, hormonal treatments such as the combined oral contraceptive pill or progestogens may be tried. If symptoms persist or fertility is a priority, referral to secondary care may be necessary. Secondary treatments may include GnRH analogues or surgery. For women trying to conceive, laparoscopic excision or ablation of endometriosis plus adhesiolysis is recommended, as well as ovarian cystectomy for endometriomas.
It is important to note that there is poor correlation between laparoscopic findings and severity of symptoms, and that there is little role for investigation in primary care. If symptoms are significant, referral for a definitive diagnosis is recommended.
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This question is part of the following fields:
- Gynaecology
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Question 2
Incorrect
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A 13-year-old boy was hospitalized due to a two-week history of high-grade fever and bleeding gums. Upon examination of his peripheral blood, multiple blasts were observed, some of which displayed Auer rods. Which congenital condition is most strongly linked to this presentation?
Your Answer: Haemophilia
Correct Answer: Trisomy 21 (Down syndrome)
Explanation:Congenital syndromes associated with acute myeloblastic leukemia
Acute myeloblastic leukemia (AML) can be associated with various congenital syndromes, including severe congenital neutropenia (Kostmann syndrome), Bloom syndrome, Fanconi anemia, Diamond-Blackfan syndrome, neurofibromatosis type 1, and Li Fraumeni syndrome. However, Gardner syndrome, or familial colorectal polyposis, is not linked to AML. Trisomy 18 (Edward syndrome) is a chromosomal abnormality that has a poor prognosis but is not typically associated with AML. Klinefelter syndrome, a genetic disorder characterized by an extra X chromosome in males, may increase the risk of breast cancer and germ cell tumors, but the evidence for an association with AML is inconclusive. Haemophilia, a bleeding disorder caused by a deficiency in clotting factors, does not predispose to AML or mucosal bleeding.
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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 59-year-old man arrives at the emergency department complaining of severe epigastric pain that is radiating to his right upper quadrant and back. He has vomited three times since the pain started this morning and has never experienced this before. On examination, there is no abdominal distention or visible jaundice. His heart rate is 98/min, respiratory rate 18/min, blood pressure 108/66 mmHg, and temperature 37.9ºC. A new medication has recently been added to his regimen. What is the most probable cause of his presentation?
Your Answer:
Correct Answer: Mesalazine
Explanation:Mesalazine is a potential cause of drug-induced pancreatitis. This medication is commonly prescribed for Crohn’s disease, rheumatoid arthritis, and other conditions as an immunosuppressant. The patient’s symptoms, including epigastric pain radiating to the back, vomiting, low-grade fever, and lack of jaundice, suggest an acute presentation of pancreatitis induced by mesalazine. Although the exact mechanism is unclear, toxicity has been proposed as a possible explanation for mesalazine-induced pancreatitis. While hydroxychloroquine is used to treat systemic lupus erythematosus and rheumatoid arthritis, it is unlikely to cause pancreatitis and may even reduce the risk of this condition. Lithium, a mood stabilizer used to prevent bipolar disorder, has not been associated with pancreatitis. Similarly, metformin, a first-line medication for type 2 diabetes, has not been linked to pancreatitis.
Acute pancreatitis is a condition that is mainly caused by gallstones and alcohol in the UK. A popular mnemonic to remember the causes is GET SMASHED, which stands for gallstones, ethanol, trauma, steroids, mumps, autoimmune diseases, scorpion venom, hypertriglyceridaemia, hyperchylomicronaemia, hypercalcaemia, hypothermia, ERCP, and certain drugs. CT scans of patients with acute pancreatitis show diffuse parenchymal enlargement with oedema and indistinct margins. It is important to note that pancreatitis is seven times more common in patients taking mesalazine than sulfasalazine.
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This question is part of the following fields:
- Surgery
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Question 4
Incorrect
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A 65-year-old woman comes to her GP complaining of frequent falls and unsteadiness on her feet for the past 2 days. During the examination, the GP observes weakness and loss of sensation in the muscles of her right lower limb, while her upper limbs and face show no sensory deficit or weakness. The GP refers her to the nearest stroke unit for further evaluation and treatment. A CT scan confirms a thromboembolic cerebrovascular accident.
Which vessel is the most probable culprit?Your Answer:
Correct Answer: The left anterior cerebral artery distal to the anterior communicating branch
Explanation:Identifying the Correct Artery in a Case of Peripheral Weakness
In cases of peripheral weakness, identifying the correct artery involved is crucial for proper diagnosis and treatment. In this case, the weakness is on the right side, with involvement of the lower limb but not the upper limb or face. This suggests a problem with the left anterior cerebral artery distal to the anterior communicating branch, which supplies the medial aspect of the frontal and parietal lobes, including the primary motor and sensory cortices for the lower limb and distal trunk.
Other potential arteries that could be involved include the left middle cerebral artery, which would present with right-sided upper limb and facial weakness, as well as speech and auditory comprehension difficulties. The right anterior cerebral artery distal to the anterior communicating branch is unlikely, as it would be associated with left-sided weakness and sensory loss in the lower limb. The right posterior cerebral artery proximal occlusion would result in visual field defects and contralateral weakness in both upper and lower limbs, as well as contralateral loss of sensation, which does not match the current presentation. The left posterior cerebral artery is also unlikely, as the upper limb is spared and there are no visual symptoms.
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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 67-year-old woman was admitted 3 days ago with small bowel obstruction. A nasogastric (NG) tube was inserted, and she began 2 litres of intravenous (IV) fluids daily. She reports feeling short of breath and, on examination has widespread fine crackles on auscultation of her chest and pitting sacral oedema. Her notes show that she weighs 48 kg. You're-calculate her daily fluid intake.
What is her required daily fluid intake?Your Answer:
Correct Answer: 1000–1500 ml
Explanation:Calculating Maintenance Fluids for a Patient in Fluid Overload
When a patient is in fluid overload and experiencing pulmonary edema, it is important to carefully calculate their maintenance fluid requirements to avoid worsening their condition. The recommended calculation is 25-30 ml/kg/day. For a patient weighing 48 kg, this equates to a fluid requirement of 1200-1440 ml per day.
If the patient is currently receiving 2 liters of fluid per day, it is likely that this was necessary initially to replace fluid loss. However, once this has been achieved, it is important to step down to normal maintenance levels to avoid exacerbating the fluid overload. Giving 1500-2000 ml or more would only worsen the patient’s condition.
Therefore, it is important to carefully monitor a patient’s fluid intake and adjust as necessary to maintain a safe balance and prevent complications.
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This question is part of the following fields:
- Clinical Biochemistry
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Question 6
Incorrect
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A 21-year-old student presents to his GP a few days after returning from a regeneration project working with a fishing community in South America. His main complaint is of an itchy, erythematosus rash predominantly affecting both feet. He has no past medical history of note. On examination he has erythematosus, edematous papules and vesicles affecting both feet. There are serpiginous erythematosus trails which track 2-3 cm from each lesion. Investigations:
Investigation Result Normal value
Haemoglobin 138 g/l 135–175 g/l
White cell count (WCC) 8.0 × 109/l
(slight peripheral blood eosinophilia) 4–11 × 109/l
Platelets 245 × 109/l 150–400 × 109/l
Sodium (Na+) 140 mmol/l 135–145 mmol/l
Potassium (K+) 4.8 mmol/l 3.5–5.0 mmol/l
Creatinine 79 μmol/l 50–120 µmol/l
Chest X-ray Normal lung fields
Which of the following diagnoses fits best with this clinical scenario?Your Answer:
Correct Answer: Cutaneous larva migrans
Explanation:Cutaneous Larva Migrans and Other Skin Conditions: A Differential Diagnosis
Cutaneous larva migrans is a common skin condition caused by the migration of nematode larvae through the skin. It is typically found in warm sandy soils and can be diagnosed based on the history and appearance of serpiginous lesions. Treatment involves the use of thiobendazole. Other skin conditions, such as impetigo, tinea pedis, and photoallergic dermatitis, have different causes and presentations and are less likely to be the correct diagnosis. Larva currens, caused by Strongyloides stercoralis, is another condition that can cause itching and skin eruptions, but it is typically associated with an intestinal infection and recurrent episodes. A differential diagnosis is important to ensure proper treatment and management of these skin conditions.
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This question is part of the following fields:
- Dermatology
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Question 7
Incorrect
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A 12-year-old girl is diagnosed with rheumatic fever after presenting with a 3-day history of fever and polyarthralgia. The patient’s mother is concerned about any potential lasting damage to the heart.
What is the most common cardiac sequelae of rheumatic fever?Your Answer:
Correct Answer: Mitral stenosis
Explanation:Rheumatic Fever and its Effects on Cardiac Valves
Rheumatic fever is a condition caused by group A β-haemolytic streptococcal infection. To diagnose it, the revised Duckett-Jones criteria are used, which require evidence of streptococcal infection and the presence of certain criteria. While all four cardiac valves may be damaged as a result of rheumatic fever, the mitral valve is the most commonly affected, with major criteria including carditis, subcutaneous nodule, migratory polyarthritis, erythema marginatum, and Sydenham’s chorea. Minor criteria include arthralgia, fever, raised CRP or ESR, raised WCC, heart block, and previous rheumatic fever. Mitral stenosis is the most common result of rheumatic fever, but it is becoming less frequently seen in clinical practice. Pulmonary regurgitation, aortic sclerosis, and tricuspid regurgitation are also possible effects, but they are less common than mitral valve damage. Ventricular septal defect is not commonly associated with rheumatic fever.
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This question is part of the following fields:
- Cardiology
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Question 8
Incorrect
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A 9-month old infant is brought to the pediatrician by his parents. They report that he has had a runny nose and mild fever for the past week. Today, they noticed that he appeared paler than usual, has been increasingly lethargic, and seems to be struggling to breathe.
During the examination, the infant exhibits normal coloring, but there is moderate intercostal recession and nasal flaring. He only responds to chest rubbing after 5 seconds. His pulse rate is 140 beats per minute, respiratory rate is 40 breaths per minute, oxygen saturation is 94% on room air, and temperature is 37.9 ºC.
What is the most concerning aspect of this presentation as a sign of a serious illness?Your Answer:
Correct Answer: Intercostal recession
Explanation:An amber flag (intermediate risk) on the traffic light system indicates that the patient is on room air. For infants aged 12 months or older, a respiratory rate of over 40 breaths per minute would also be considered an amber flag, but not for a 6-12-month-old in this particular case.
The NICE Feverish illness in children guidelines were introduced in 2007 and updated in 2013. These guidelines use a ‘traffic light’ system to assess the risk of children under 5 years old presenting with a fever. It is important to note that these guidelines only apply until a clinical diagnosis of the underlying condition has been made. When assessing a febrile child, their temperature, heart rate, respiratory rate, and capillary refill time should be recorded. Signs of dehydration should also be looked for. Measuring temperature should be done with an electronic thermometer in the axilla if the child is under 4 weeks old or with an electronic/chemical dot thermometer in the axilla or an infrared tympanic thermometer.
The risk stratification table includes green for low risk, amber for intermediate risk, and red for high risk. The table includes categories such as color, activity, respiratory, circulation and hydration, and other symptoms. If a child is categorized as green, they can be managed at home with appropriate care advice. If they are categorized as amber, parents should be provided with a safety net or referred to a pediatric specialist for further assessment. If a child is categorized as red, they should be urgently referred to a pediatric specialist. It is important to note that oral antibiotics should not be prescribed to children with fever without an apparent source, and a chest x-ray does not need to be routinely performed if a pneumonia is suspected but the child is not going to be referred to the hospital.
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This question is part of the following fields:
- Paediatrics
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Question 9
Incorrect
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A glazier in his 40s slipped and cut his wrist on a piece of glass a few months ago. He did not seek medical advice at the time.
What signs of ulnar nerve damage would you expect to find on examination?Your Answer:
Correct Answer: Wasting of the interossei
Explanation:Lesion of the Ulnar Nerve at the Wrist
A lesion of the ulnar nerve at the wrist does not result in sensory loss as the dorsal cutaneous branch of the ulnar nerve remains unaffected. Additionally, the flexor carpi ulnaris muscle is also spared, which means that wrist flexion is not affected. However, wasting and weakness are limited to the interossei and adductor pollicis muscle, while the hypothenar muscles are usually spared.
It is important to note that sensory loss of the lateral part of the hand occurs in a median nerve injury, while sensory loss of the dorsal surface of the thumb occurs in a radial nerve injury. Furthermore, weakness of wrist flexion occurs when the ulnar or median nerve is damaged, but not at the wrist. these distinctions can aid in the diagnosis and treatment of nerve injuries.
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This question is part of the following fields:
- Clinical Sciences
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Question 10
Incorrect
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A 68-year-old woman presents to eye casualty with a painful, red eye and blurred vision. She reports that the pain started suddenly this morning. On examination, there is swelling of the eyelid and a small hypopyon is present. Her vision is blurry in the affected eye and she can only see moving fingers at a distance of one meter. Fundoscopy reveals periphlebitis. The patient has no significant medical history except for cataract surgery performed 3 days ago. What is the probable diagnosis?
Your Answer:
Correct Answer: Endophthalmitis
Explanation:Endophthalmitis is a rare but serious complication of cataract surgery that requires urgent treatment. This patient is experiencing a painful and red eye after undergoing cataract surgery, which is a common symptom of endophthalmitis. The condition occurs when microbial organisms are introduced into the eye during surgery, either from the patient’s normal flora or contaminated instruments. Symptoms include retinal periphlebitis, pain, redness, ocular discharge, and worsening vision. Treatment involves prompt administration of intravitreal or systemic antibiotics. Blepharitis, infective conjunctivitis, and keratitis are other ocular conditions that do not fit the symptoms presented by this patient.
Understanding Cataracts: Causes, Symptoms, and Management
A cataract is a common eye condition that affects the lens of the eye, causing it to become cloudy and reducing the amount of light that reaches the retina. This can lead to blurred or reduced vision, making it difficult to see clearly. Cataracts are more common in women and tend to increase in incidence with age. While the normal ageing process is the most common cause, other factors such as smoking, alcohol consumption, trauma, diabetes, and long-term corticosteroid use can also contribute to the development of cataracts.
Symptoms of cataracts include reduced vision, faded colour vision, glare, and halos around lights. A defect in the red reflex is also a sign of cataracts. Diagnosis is typically made through ophthalmoscopy and slit-lamp examination, which can reveal the presence of a visible cataract.
In the early stages, age-related cataracts can be managed conservatively with stronger glasses or contact lenses and brighter lighting. However, surgery is the only effective treatment for cataracts and involves removing the cloudy lens and replacing it with an artificial one. Referral for surgery should be based on the presence of visual impairment, impact on quality of life, and patient choice. Complications following surgery can include posterior capsule opacification, retinal detachment, posterior capsule rupture, and endophthalmitis.
Overall, cataracts are a common and treatable eye condition that can significantly impact a person’s vision. Understanding the causes, symptoms, and management options can help individuals make informed decisions about their eye health.
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This question is part of the following fields:
- Ophthalmology
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