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Question 1
Incorrect
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A 55-year-old woman presents to you for a follow-up blood pressure check. She has been evaluated by two other physicians in the past three months, with readings of 140/90 mmHg and 148/86 mmHg. Her current blood pressure is 142/84 mmHg. She has no familial history of hypertension, her BMI is 23, and she is a non-smoker. Based on the most recent NICE recommendations, what is the recommended course of action?
Your Answer: Advise on lifestyle changes and repeat in one year
Correct Answer: Check ECG and blood tests and see her again in a month with the results
Explanation:Understanding Hypertension Diagnosis and Management
Hypertension is a common condition that requires careful diagnosis and management. According to the 2019 NICE guidance on Hypertension (NG136), ambulatory or home blood pressure should be checked if a patient has a blood pressure equal to or greater than 140/90 mmHg. If the systolic reading is above 140 mmHg, it is considered a sign of hypertension.
The guidelines also state that lifestyle advice should be given to all patients, and drug treatment should be considered if there are signs of end organ damage or if the patient’s CVD risk is greater than 10% in 10 years. For patients under 40 years old, referral to a specialist should be considered.
It is important to note that NICE guidance is not the only source of information on hypertension diagnosis and management. While it is important to have an awareness of the latest guidance, it is also important to have a balanced view and consider other guidelines and consensus opinions.
In summary, understanding the diagnosis and management of hypertension is crucial for general practitioners. The 2019 NICE guidance on Hypertension provides important information on thresholds for diagnosis and management, but it is important to consider other sources of information as well.
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This question is part of the following fields:
- Cardiovascular Health
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Question 2
Correct
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Mary comes to see you for a medication review. She is a 65-year-old woman, with a past medical history of chronic kidney disease stage 3, hypertension and gout. Her current medication are amlodipine 10 mg daily and allopurinol 100 mg daily. Her blood pressure today is 151/93 mmHg. A recent urine dip was normal and her blood results are shown in the table below.
Na+ 137 mmol/L (135 - 145)
K+ 4.7 mmol/L (3.5 - 5.0)
Bicarbonate 27 mmol/L (22 - 29)
Urea 5.6 mmol/L (2.0 - 7.0)
Creatinine 130 µmol/L (55 - 120)
eGFR 55 ml/min/1.73m2 (>90)
What changes should you make to her medications?Your Answer: Continue current medications, add ramipril
Explanation:This patient is experiencing poorly controlled hypertension, despite being on the maximum dose of a calcium channel blocker. Additionally, he has established renal disease and his clinic blood pressure readings consistently exceed 140/90. To address this, it is recommended to add either an ACE inhibitor, an angiotensin 2 receptor blocker, or a thiazide-like diuretic to his current medication regimen. Simply relying on lifestyle modifications will not be sufficient to bring his blood pressure under control. Therefore, combination therapy with amlodipine should be continued.
Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.
Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.
Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.
The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.
If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.
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This question is part of the following fields:
- Cardiovascular Health
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Question 3
Correct
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A 25-year-old woman comes in seeking to switch from her current Microgynon 30 COC to another option due to experiencing mood swings. The decision is made to start her on Marvelon. What guidance should be provided regarding transitioning to a new COC?
Your Answer: Finish the current pill packet and the start the new COC without a pill free interval
Explanation:There is conflicting advice from the BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) regarding the omission of the pill free interval. The FSRH’s Clinical Effectiveness Unit has stated that the pill free interval doesn’t need to be skipped, while the BNF recommends skipping it if there are changes in progesterone. As there is no clear consensus, it is advisable to follow the BNF’s recommendation.
Special Situations for Combined Oral Contraceptive Pill
Concurrent Antibiotic Use:
In the UK, doctors have previously advised that taking antibiotics concurrently with the combined oral contraceptive pill may interfere with the enterohepatic circulation of oestrogen, making the pill ineffective. As a result, extra precautions were advised during antibiotic treatment and for seven days afterwards. However, this approach is not taken in the US or most of mainland Europe. In 2011, the Faculty of Sexual & Reproductive Healthcare updated their guidelines, abandoning the previous approach. The latest edition of the British National Formulary (BNF) has also been updated in line with this guidance. Precautions should still be taken with enzyme-inducing antibiotics such as rifampicin.Switching Combined Oral Contraceptive Pills:
The BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) appear to give contradictory advice on switching combined oral contraceptive pills. The Clinical Effectiveness Unit of the FSRH has stated in the Combined Oral Contraception guidelines that the pill-free interval doesn’t need to be omitted. However, the BNF advises missing the pill-free interval if the progesterone changes. Given the uncertainty, it is best to follow the BNF. -
This question is part of the following fields:
- Maternity And Reproductive Health
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Question 4
Incorrect
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A 25-year-old woman presents for follow-up. She has been experiencing recurrent genital warts for the last 3 years and has not seen improvement with topical podophyllum. She previously underwent cryotherapy but is hesitant to do it again due to discomfort. During the exam, numerous fleshy genital warts are observed around her introitus. What is the best course of action for treatment?
Your Answer: Oral aciclovir
Correct Answer: Topical imiquimod
Explanation:Understanding Genital Warts
Genital warts, also known as condylomata accuminata, are a common reason for visits to genitourinary clinics. These warts are caused by various types of the human papillomavirus (HPV), with types 6 and 11 being the most common. It is important to note that HPV, particularly types 16, 18, and 33, can increase the risk of cervical cancer.
The warts themselves are small, fleshy growths that are typically 2-5 mm in size and may be slightly pigmented. They can also cause itching or bleeding. Treatment options for genital warts include topical podophyllum or cryotherapy, depending on the location and type of lesion. Topical agents are generally used for multiple, non-keratinised warts, while solitary, keratinised warts respond better to cryotherapy. Imiquimod, a topical cream, is typically used as a second-line treatment. It is important to note that genital warts can be resistant to treatment, and recurrence is common. However, most anogenital HPV infections clear up on their own within 1-2 years without intervention.
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This question is part of the following fields:
- Dermatology
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Question 5
Correct
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You are conducting the annual review for a 65-year-old man with type 2 diabetes. His glycaemic control is satisfactory with metformin therapy, and his latest HbA1c is 54 mmol/mol (7.1%). During his recent clinic visit, his blood pressure was measured at 152/90 mmHg. A 24-hour blood pressure monitor was subsequently requested, and the results indicate an average blood pressure of 142/88 mmHg. What would be the most appropriate course of action?
Your Answer: Start an ACE inhibitor
Explanation:Regardless of age, ACE inhibitors/A2RBs are the first-line treatment for hypertension in diabetic patients due to their renoprotective effect, even if the patient has stage 1 hypertension according to NICE guidelines. In contrast, for patients aged over 55 years without diabetes, a calcium channel blocker is the first-line treatment.
Blood Pressure Management in Diabetes Mellitus
Patients with diabetes mellitus have traditionally been managed with lower blood pressure targets to reduce their overall cardiovascular risk. However, a 2013 Cochrane review found that tighter blood pressure control did not significantly improve outcomes for patients with diabetes, except for a slightly reduced rate of stroke. As a result, NICE recommends a blood pressure target of < 140/90 mmHg for type 2 diabetics, the same as for patients without diabetes. For patients with type 1 diabetes, NICE recommends a blood pressure target of 135/85 mmHg unless they have albuminuria or two or more features of metabolic syndrome, in which case the target should be 130/80 mmHg. ACE inhibitors or angiotensin-II receptor antagonists (A2RBs) are the first-line antihypertensive regardless of age, as they have a renoprotective effect in diabetes. A2RBs are preferred for black African or African-Caribbean diabetic patients. However, autonomic neuropathy may result in more postural symptoms in patients taking antihypertensive therapy. It is important to note that the routine use of beta-blockers in uncomplicated hypertension should be avoided, especially when given in combination with thiazides, as they may cause insulin resistance, impair insulin secretion, and alter the autonomic response to hypoglycemia.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 6
Incorrect
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A 67-year-old man who has type II diabetes attends his general practice surgery for his annual review. He takes metformin and gliclazide.
On examination, his blood pressure (BP) is 130/80 mmHg. There are no signs of retinopathy. He feels well.
Investigations:
Investigation Result Normal values
Haemoglobin A1c (HbA1c) 53 mmol/mol < 43 mmol/mol
Estimated glomerular filtration rate (eGFR) 55 ml/min per 1.73 m2 > 90 ml/min per 1.73 m2
Albumin : creatinine ratio (ACR) 5.4 mg/mmol (up from 3.0 mg/mmol three months ago) < 1.0 mg/mmol
What is the most appropriate initial management option for this patient?Your Answer: Optimise his diabetic control and repeat the test in six months
Correct Answer: Start an angiotensin-converting enzyme (ACE) inhibitor
Explanation:Managing Chronic Kidney Disease in a Patient with Diabetes: Treatment Options
Chronic kidney disease (CKD) is a common complication of diabetes, and early management is crucial to slow progression. In a patient with diabetic nephropathy and stage 3a CKD, the following treatment options are available:
1. Start an angiotensin-converting enzyme (ACE) inhibitor: This is the most appropriate first-line treatment to reduce the risk of all-cause mortality in patients with diabetic kidney disease.
2. Refer him to a Nephrologist: Management of CKD requires specialized care to slow progression.
3. Optimise his diabetic control and repeat the test in six months: While important, diabetic control should not be the focus of immediate management in this patient.
4. Start a direct renin inhibitor: This treatment is not a priority as the patient’s blood pressure is already below the target.
5. Start a low-protein diet and repeat urinalysis in six months: Dietary protein restriction is not recommended in early-stage CKD, but high-protein intake should be avoided in stage 4 CKD under the guidance of a dietitian.
In conclusion, early management of CKD in patients with diabetes is crucial to slow progression and reduce the risk of mortality. Treatment options should be tailored to the individual patient’s needs and managed by a specialist.
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This question is part of the following fields:
- Kidney And Urology
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Question 7
Correct
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For which patients with a family history of breast cancer should a referral to secondary care be made for further assessment of their risk?
Your Answer: A 28-year-old woman whose 31-year-old brother has just been diagnosed with breast cancer
Explanation:Referral Criteria for Breast Cancer Screening
Breast cancer is a serious health concern that affects many individuals worldwide. To ensure early detection and prompt treatment, it is important to identify individuals who are at a higher risk of developing breast cancer. The following referral criteria have been established to identify individuals who should be referred to secondary care for breast cancer screening:
– One first degree female relative diagnosed with breast cancer under the age of 40 years
– One first degree male relative diagnosed with breast cancer at any age
– One first degree relative with bilateral breast cancer where the first primary was diagnosed under the age of 50 years
– Two first degree relatives, or one first degree and one second degree relative, diagnosed with breast cancer at any age
– One first degree or second degree relative diagnosed with breast cancer at any age and one first degree or second degree relative diagnosed with ovarian cancer at any age (one of these should be a first degree relative)
– Three first degree or second degree relatives diagnosed with breast cancer at any age.By identifying individuals who meet these criteria, healthcare providers can ensure that they receive appropriate screening and monitoring for breast cancer. Early detection and treatment can significantly improve outcomes and reduce the risk of complications associated with breast cancer.
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This question is part of the following fields:
- Genomic Medicine
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Question 8
Correct
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A 28-year-old female presents with dysuria and vaginal discharge which has deteriorated over the past week. She is in a steady relationship and uses the oral contraceptive pill. Her partner is asymptomatic.
She has a temperature of 37.5°C. Vaginal examination reveals tenderness with an inflamed cervix and a purulent discharge, culture of which reveals Gram negative diplococci.
What is the probable diagnosis?Your Answer: Gonorrhoea
Explanation:Gonorrhea: Symptoms, Treatment, and Complications
Gonorrhea is a sexually transmitted infection caused by the Gram-negative diplococci Neisseria gonorrhoeae. It can affect both males and females, and they may be asymptomatic or have very few symptoms that can go unnoticed. However, some patients may experience cervicitis, a purulent discharge, and fever.
Due to problems with resistance, current treatment guidelines recommend a combination of IM ceftriaxone and azithromycin. Oral Cefixime may be offered if the injection is refused. It is important to treat gonorrhea promptly to prevent complications such as sepsis, arthritis, pharyngitis, and ophthalmia.
In conclusion, gonorrhea is a common sexually transmitted infection that can have serious consequences if left untreated. It is important to practice safe sex and get tested regularly to prevent the spread of the infection.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 9
Correct
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A 50-year-old man has a 25-year history of ulcerative colitis. He has had courses of prednisolone for exacerbations in the past but has never persisted with prophylactic medication. He has not had a hospital review for many years. He has now had a change in bowel habit for six months, with increasing diarrhoea.
Which of the following is the single most important management step for this patient?Your Answer: Urgent colonoscopy
Explanation:Management of a Patient with Subacute Change in Bowel Habit and Ulcerative Colitis
Patients with ulcerative colitis have an increased risk of developing colonic adenocarcinoma, which starts 8-10 years after the onset of the disease. Surveillance colonoscopy is recommended every 1-2 years to assess for dysplasia. In a patient with a long-standing disease and a new change in bowel habit, there should be a high index of suspicion for malignancy, especially if routine surveillance has been missed.
An abdominal plain X-ray may be useful in acute presentations of ulcerative colitis, but it is not the best choice for subacute changes in bowel habit. Oral mesalazine may reduce the risk of developing colorectal cancer, but it doesn’t address the red flags in this case.
Oral prednisolone may be prescribed to see if there is any resolution of symptoms, but the priority is an urgent colonoscopy to rule out a new diagnosis of colorectal cancer.
Stool microscopy and culture are unlikely to be helpful in this case, as there is no acute-onset diarrhea or recent foreign travel.
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This question is part of the following fields:
- Gastroenterology
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Question 10
Correct
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You assess a patient who has been on citalopram for the last three years to manage depression. He has been stable for the past two years, and you both decide to discontinue the antidepressant. What is the appropriate method to taper off citalopram?
Your Answer: Withdraw gradually over the next 4 weeks
Explanation:Gradual Reduction of SSRI Dose
When discontinuing the use of selective serotonin reuptake inhibitors (SSRIs), it is recommended to gradually reduce the dose over a period of four weeks. This allows the body to adjust to the decreasing levels of the medication and can help prevent withdrawal symptoms. However, this gradual reduction may not be necessary for fluoxetine, as it has a longer half-life compared to other SSRIs. The longer half-life means that the medication stays in the body for a longer period of time, allowing for a slower decrease in levels even after the medication is stopped. It is still important to consult with a healthcare provider before stopping any medication and to follow their instructions for discontinuation. Proper management of medication discontinuation can help ensure a safe and effective transition off of SSRIs.
Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for depression, with citalopram and fluoxetine being the preferred options. They should be used with caution in children and adolescents, and patients should be monitored for increased anxiety and agitation. Gastrointestinal symptoms are the most common side-effect, and there is an increased risk of gastrointestinal bleeding. Citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in certain patients. SSRIs have a higher propensity for drug interactions, and patients should be reviewed after 2 weeks of treatment. When stopping a SSRI, the dose should be gradually reduced over a 4 week period. Use of SSRIs during pregnancy should be weighed against the risks and benefits.
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This question is part of the following fields:
- Mental Health
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Question 11
Correct
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A 67-year-old man has a persistent tremor that only occurs when he extends his arm. His wife is worried that it may be a serious condition. Other than the tremor, there are no other neurological symptoms observed during examination.
What is the most probable diagnosis?Your Answer: Essential tremor
Explanation:Differentiating Tremors: Essential Tremor, Chorea, Intention Tremor, Parkinsonism, and Motor Neurone Disease
Tremors are involuntary movements that can be caused by various conditions. Essential tremor is a common type that is worsened by movement and relieved by rest. Patients may turn to alcohol to alleviate symptoms. It can be difficult to distinguish from other types of tremors, such as exaggerated physiological tremor or medication-induced tremor. Essential tremor typically affects the upper limbs, but can also involve the neck, face, and jaw muscles.
Chorea, on the other hand, is characterized by irregular, flowing movements that are not repetitive or rhythmic. Intention tremor is a feature of cerebellar ataxia, which is usually accompanied by other cerebellar signs like ataxia and dysarthria. Parkinsonism causes a resting tremor and cogwheel rigidity, which occurs even in a relaxed limb that is fully supported.
Motor neurone disease usually presents with fasciculations, which are involuntary muscle contractions and relaxations that are visible under the skin. It is important to differentiate between these different types of tremors to accurately diagnose and treat the underlying condition.
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This question is part of the following fields:
- Neurology
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Question 12
Incorrect
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A 56-year-old woman presents to your clinic with a complaint of frequent urine leakage. What is the initial method to evaluate urinary incontinence or overactive bladder in women?
Your Answer: Urodynamic studies
Correct Answer: Trial of therapy
Explanation:Importance of a Bladder Diary in Assessing Urinary Incontinence
A bladder diary is a crucial tool in the initial assessment of urinary incontinence or overactive bladder syndrome in women. It helps to identify patterns and triggers of urinary symptoms, which can aid in the diagnosis and treatment of the condition. Women should be encouraged to complete a minimum of three days of the diary to cover variations of their usual activities, including work and leisure time.
By keeping track of their urinary habits, women can provide their healthcare provider with valuable information about their symptoms, such as frequency, urgency, and leakage. This information can help the provider to determine the type and severity of the condition and develop an appropriate treatment plan. Therefore, it is essential for women to use a bladder diary when experiencing urinary incontinence or overactive bladder syndrome.
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This question is part of the following fields:
- Kidney And Urology
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Question 13
Incorrect
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One of the nurses at your hospital sustains a needlestick injury while administering medication to a patient.
What is the single, most appropriate, immediate management?Your Answer: Administer prophylactic hepatitis B immunoglobulin regardless of vaccine status
Correct Answer: Wash the wound with soap under running water
Explanation:First Line Management of Needlestick Injuries
First line management of needlestick injuries involves immediate washing of the affected area under running water. It is important to report all incidents to the occupational health department and undergo a careful risk assessment. If the donor is known to be hepatitis B positive and the victim is non-immune, HBIG is given. However, antiretroviral therapy is only given after counselling if the donor is known to be HIV positive and the exposure is deemed high risk. By following these guidelines, the risk of infection can be minimized and appropriate treatment can be administered.
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This question is part of the following fields:
- Leadership And Management
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Question 14
Correct
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You are seeing a 65-year-old patient that you have known for the past 3 months who has disabling rheumatoid arthritis. At the end of the consultation, she hands you a box of chocolates. What is the most appropriate response?
Your Answer: Accept the gift and thank the patient for her kindness
Explanation:When a patient expresses their gratitude by giving you a box of chocolates, it is important to exercise good judgement in how you respond. While it may not be necessary to formally register the gift, it is important to consider the appropriateness of accepting it, especially if it is a large or expensive gift.
Rather than asking the patient to donate an equivalent amount to charity, which may come across as insensitive or inappropriate, it may be more appropriate to simply express your appreciation for the gesture and thank them for their kindness.
Declining the gift outright may be seen as impolite or ungrateful, so it is important to consider the patient’s feelings and intentions when deciding how to respond. Similarly, it is never appropriate to scold or reprimand a patient for offering a gift, as this can damage the therapeutic relationship and undermine trust.
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This question is part of the following fields:
- Consulting In General Practice
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Question 15
Incorrect
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A 25-year-old woman who has had type 1 diabetes since childhood is now 20 weeks pregnant.
She has had problems with her blood sugar control in the last few months and has had three hypoglycaemic episodes (hypos) in the late afternoon over the last month. Each time she had to have glucagon injections given either by her husband or paramedics.
She wants to know if she can continue driving.
What is the DVLA guidance regarding driving in patients on insulin who have hypoglycaemic attacks?Your Answer: Cannot drive for 12 months if any hypos occur
Correct Answer: Can drive if up to three hypos requiring help from another person in the last 12 months
Explanation:Criteria for Patient Recognition of Hypoglycaemia Warning Symptoms
The following criteria must be met for a patient to recognise the warning symptoms of hypoglycaemia:
– The patient must not have had more than one episode of hypoglycaemia requiring the assistance of another person within the preceding 12 months.
It is important for patients to be able to recognise the warning symptoms of hypoglycaemia, as this can help prevent severe episodes that require assistance from others. By meeting this criteria, patients can ensure that they are able to manage their blood sugar levels effectively and avoid potentially dangerous situations.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 16
Incorrect
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Which of the following antibiotics is most likely to cause pseudomembranous colitis?
Your Answer: Erythromycin
Correct Answer: Cefaclor
Explanation:C.difficile is strongly associated with cephalosporins, in addition to clindamycin.
Clostridioides difficile is a type of bacteria that is commonly found in hospitals. It produces a toxin that can damage the intestines and cause a condition called pseudomembranous colitis. This bacteria usually develops when the normal gut flora is disrupted by broad-spectrum antibiotics, with second and third generation cephalosporins being the leading cause. Other risk factors include the use of proton pump inhibitors. Symptoms of C. difficile infection include diarrhea, abdominal pain, and a raised white blood cell count. The severity of the infection can be determined using the Public Health England severity scale.
To diagnose C. difficile infection, a stool sample is tested for the presence of the C. difficile toxin. Treatment involves reviewing current antibiotic therapy and stopping antibiotics if possible. For a first episode of infection, oral vancomycin is the first-line therapy for 10 days, followed by oral fidaxomicin as second-line therapy and oral vancomycin with or without IV metronidazole as third-line therapy. Recurrent infections may require different treatment options, such as oral fidaxomicin within 12 weeks of symptom resolution or oral vancomycin or fidaxomicin after 12 weeks of symptom resolution. In life-threatening cases, oral vancomycin and IV metronidazole may be used, and surgery may be considered with specialist advice. Other therapies, such as bezlotoxumab and fecal microbiota transplant, may also be considered for preventing recurrences in certain cases.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 17
Correct
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A 28-year-old woman is seen at home 12 weeks after a successful first pregnancy. She is tearful, has lost her appetite and is very anxious about her infant’s health. There are no features of delirium. She has a history of illicit drug use but denies current use. Her older brother has depression. There are no features to suggest infection and there are no focal neurological signs.
Select from the list the single most likely diagnosis.Your Answer: postpartum depression
Explanation:Understanding Postpartum Mental Health: Depression, Psychosis, and Maternity Blues
Postpartum mental health can be a challenging experience for new mothers. Within the first year of pregnancy, postpartum depression can occur, which is similar to major depression at other times of life. However, postpartum psychosis is a severe mental illness that usually occurs suddenly within the first two weeks after delivery and is often associated with confusion and disorientation. While delusions of something being wrong with the baby are relatively common in postpartum psychosis, depression is also associated with anxiety about the baby.
On the other hand, maternity blues is relatively common and occurs within a few days of delivery. It consists of irritability and tearfulness without features of a major depressive episode. It is essential to understand the differences between these conditions to provide appropriate support and treatment for new mothers.
It is worth noting that there is no mention of schizophrenia in this woman’s history or any suggestion of current illicit drug use. By understanding the different types of postpartum mental health conditions, we can better support new mothers and ensure they receive the care they need.
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This question is part of the following fields:
- Mental Health
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Question 18
Correct
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A 42-year-old man states he has special powers that allow him to know what other people are thinking. He also believes he is related to the Royal family. He has been overactive, elated in mood and not sleeping.
Select from the list the term that best describes his delusions.Your Answer: Grandiose delusions
Explanation:Understanding Delusions: Types and Associated Mental Illnesses
Delusions are false beliefs that persist despite evidence to the contrary and are not accepted by others in the person’s culture or subculture. There are various types of delusions, each associated with different mental illnesses.
Grandiose delusions are beliefs of exaggerated importance and are often seen in mania. Nihilistic delusions involve a persistent denial of the existence of things or everything, including oneself, and are common in schizophrenia. Delusions of guilt are found in depressive illnesses, while delusions of reference are seen in schizophrenia and mania.
Persecutory delusions involve the belief that the person or someone close to them is being mistreated or spied on, and are common in schizophrenia, depression, and organic mental states. Understanding the different types of delusions and their associated mental illnesses can aid in diagnosis and treatment.
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This question is part of the following fields:
- Mental Health
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Question 19
Incorrect
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A 65-year-old woman presents to an early morning duty appointment with complaints of increasing fatigue, abdominal pain, vomiting, and excessive thirst over the past week. She has a history of well-controlled hypertension with amlodipine and takes atorvastatin. She recently started a six-week course of high-dose colecalciferol, prescribed by another GP, but has only taken one dose so far. On examination, she appears fatigued and drowsy, but her observations are unremarkable. Urgent blood tests are ordered, and the results show a Hb of 124 g/L, platelets of 224 * 109/L, WBC of 6.4 * 109/L, Na+ of 141 mmol/L, K+ of 4.0 mmol/L, urea of 6.9 mmol/L, creatinine of 100 µmol/L, calcium of 3.7 mmol/L, phosphate of 1.1 mmol/L, magnesium of 1.0 mmol/L, and TSH of 3.24 mU/L. Looking back at her blood results from the previous week, her calcium was 2.56 mmol/L, phosphate was 1.2 mmol/L, magnesium was 0.8 mmol/L, and vitamin D was 7 nmol/L. Based on these findings, she is admitted directly under the acute medical team for further management. What is the most likely underlying diagnosis?
Your Answer:
Correct Answer: Primary hyperparathyroidism
Explanation:If a patient with coexistent hyperparathyroidism undergoes rapid vitamin D replacement, it can lead to toxicity. In the case of this woman, she requires urgent admission under the medical team due to severe hypercalcaemia. The cause is likely vitamin D toxicity and unidentified primary hyperparathyroidism. Previous blood tests indicate a severe vitamin D deficiency, but her calcium level is at the higher end of normal, suggesting an overactive parathyroid gland that was masked by the low vitamin D. Testing for parathyroid hormone prior to administering vitamin D could have clarified this. It is advisable to seek advice from endocrinology before rapid vitamin D replacement if the baseline corrected calcium is >2.5. While multiple myeloma can cause hypercalcaemia, it doesn’t occur as rapidly. Paget’s disease causes an increased ALP with a normal calcium level, and thyrotoxicosis due to Graves disease can cause hypercalcaemia due to increased bone turnover, but a suppressed TSH would be expected.
Vitamin D supplementation has been a topic of interest for several years, and recent releases have provided some clarity on the matter. The Chief Medical Officer’s 2012 letter and the National Osteoporosis Society’s 2013 UK Vitamin D guideline recommend that certain groups take vitamin D supplements. These groups include pregnant and breastfeeding women, children aged 6 months to 5 years, adults over 65 years, and individuals who are not exposed to much sun, such as housebound patients.
Testing for vitamin D deficiency is not necessary for most people. The NOS guidelines suggest that testing may be appropriate for patients with bone diseases that may be improved with vitamin D treatment, such as osteomalacia or Paget’s disease, and for patients with musculoskeletal symptoms that could be attributed to vitamin D deficiency, such as bone pain. However, patients with osteoporosis should always be given calcium/vitamin D supplements, and individuals at higher risk of vitamin D deficiency should be treated regardless of testing. Overall, vitamin D supplementation is recommended for certain groups, while testing for deficiency is only necessary in specific situations.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 20
Incorrect
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A 55-year-old man presents to the emergency department with burns on the extensor aspects of his lower legs. He accidentally spilled hot water on himself while wearing shorts. Upon examination, he has pale, pink skin with small blisters forming. The burns are classified as superficial dermal burns. Using a chart, you calculate the TBSA of the burns. What is the minimum TBSA that would require immediate referral to the plastic surgeons?
Your Answer:
Correct Answer: 3%
Explanation:First Aid and Management of Burns
Burns can be caused by heat, electricity, or chemicals. Immediate first aid involves removing the person from the source of the burn and irrigating the affected area with cool water. The extent of the burn can be assessed using Wallace’s Rule of Nines or the Lund and Browder chart. The depth of the burn can be determined by its appearance, with full-thickness burns being the most severe. Referral to secondary care is necessary for deep dermal and full-thickness burns, as well as burns involving certain areas of the body or suspicion of non-accidental injury.
Severe burns can lead to tissue loss, fluid loss, and a catabolic response. Intravenous fluids and analgesia are necessary for resuscitation and pain relief. Smoke inhalation can result in airway edema, and early intubation may be necessary. Circumferential burns may require escharotomy to relieve compartment syndrome and improve ventilation. Conservative management is appropriate for superficial burns, while more complex burns may require excision and skin grafting. There is no evidence to support the use of antimicrobial prophylaxis or topical antibiotics in burn patients.
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This question is part of the following fields:
- Dermatology
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Question 21
Incorrect
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You see a 20-year-old male patient who is worried about his erections. He has been experiencing problems for the past 8 months. He is generally healthy with no medical history. He doesn't use any illegal drugs and is a non-smoker. He drinks occasionally on weekends. He lives with his parents and has recently started dating a girl from his university.
Which of the following history findings would indicate a psychogenic cause rather than an organic cause for his erectile dysfunction?Your Answer:
Correct Answer: The presence of self stimulated or morning erections
Explanation:Erectile dysfunction (ED) is the inability to achieve and maintain an erection sufficient for satisfactory sexual performance. It can be caused by organic, psychogenic, or mixed factors, as well as certain medications.
Symptoms that suggest a psychogenic cause of ED include a sudden onset, early loss of erection, self-stimulated or morning erections, premature ejaculation or inability to ejaculate, relationship problems or changes, major life events, and psychological issues.
Symptoms that suggest an organic cause of ED include a gradual onset, normal ejaculation, normal libido (except in hypogonadal men), a history of medical risk factors (such as cardiovascular, endocrine, or neurological conditions), pelvic or scrotal trauma, radiotherapy or surgery, current use of medications known to cause ED, smoking, high alcohol consumption, or use of recreational or bodybuilding drugs.
Erectile dysfunction (ED) is a condition where a man is unable to achieve or maintain an erection that is sufficient for sexual performance. It is not a disease but a symptom that can be caused by organic, psychogenic, or mixed factors. It is important to differentiate between the causes of ED, with factors such as a gradual onset of symptoms and lack of tumescence favoring an organic cause, while sudden onset of symptoms and decreased libido favoring a psychogenic cause. Risk factors for ED include cardiovascular disease, alcohol use, and certain medications.
To assess for ED, it is recommended to measure lipid and fasting glucose serum levels to calculate cardiovascular risk. Free testosterone should also be measured in the morning, and if low or borderline, further assessment may be needed. PDE-5 inhibitors, such as sildenafil, are the first-line treatment for ED and should be prescribed to all patients regardless of the cause. Vacuum erection devices can be used as an alternative for those who cannot or will not take PDE-5 inhibitors. Referral to urology may be appropriate for young men who have always had difficulty achieving an erection, and those who cycle for more than three hours per week should be advised to stop.
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This question is part of the following fields:
- Mental Health
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Question 22
Incorrect
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A 35-year-old man comes to see you about his depression. He lost his job six months ago and has been living on savings. He lives with his two sons who are both in school. He divorced six years ago and neither he nor his children have seen his ex-wife since. He says that he has been ignoring bills and is now running out of money, relying on food banks to feed his family. His landlord has issued an ultimatum after failing to pay rent.
He says that his sister is in receipt of Universal Credit (UC), but he doesn't know anything about it. You have advised him to contact the Benefits Agency, but in the meantime, what can you say about Universal Credit in this man's case?Your Answer:
Correct Answer: He will receive extra allowance if he has a health condition which prevents him from working
Explanation:Understanding Universal Credit
Universal Credit (UC) is a monthly payment that replaces six income-related benefits, including Income-based Jobseeker’s Allowance, Income-related Employment and Support Allowance, Income Support, Child Tax Credit, Working Tax Credit, and Housing Benefit. It is available to people in and out of work. If someone is currently receiving any of these six benefits, they do not need to take any action unless there is a change in their circumstances or the Department for Work and Pensions (DWP) contacts them about moving to Universal Credit.
A person’s monthly Universal Credit payment consists of a standard allowance and any additional amounts that apply to them, such as having children, a disability or health condition that prevents them from working, or needing help paying their rent. If a patient claims UC on health grounds, they may ask for a fit note. In cases where a patient is working but has restricted ability to work, they may request medical evidence of their health condition.
The patient will be referred to CHDA for a Work Capability Assessment, similar to ESA. Medical evidence, such as fit notes, is required until the DWP makes a decision on their claim. No further fit notes are necessary unless the patient wishes to appeal the decision. If the patient’s appeal is unsuccessful and it is determined that they are fit for work, further fit notes should only be issued if their condition significantly worsens or they develop a new condition.
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This question is part of the following fields:
- Consulting In General Practice
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Question 23
Incorrect
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You are evaluating a 67-year-old patient during his chronic kidney disease follow-up. He has been undergoing haemodialysis for the past 6 years. What is the leading cause of mortality for this patient?
Your Answer:
Correct Answer: Ischaemic heart disease
Explanation:Causes of Chronic Kidney Disease
Chronic kidney disease is a condition that affects the kidneys and can lead to kidney failure if left untreated. There are several common causes of chronic kidney disease, including diabetic nephropathy, chronic glomerulonephritis, chronic pyelonephritis, hypertension, and adult polycystic kidney disease. Diabetic nephropathy is a complication of diabetes that affects the kidneys, while chronic glomerulonephritis is a condition that causes inflammation in the kidneys. Chronic pyelonephritis is a type of kidney infection that can lead to scarring and damage to the kidneys. Hypertension, or high blood pressure, can also cause damage to the kidneys over time. Finally, adult polycystic kidney disease is an inherited condition that causes cysts to form in the kidneys, leading to kidney damage and eventually kidney failure. It is important to identify the underlying cause of chronic kidney disease in order to properly manage and treat the condition.
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This question is part of the following fields:
- Kidney And Urology
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Question 24
Incorrect
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A 58-year-old woman comes to her General Practitioner with complaints of diarrhoea without any associated bleeding. She has also experienced weight loss and has abdominal pain with malaise and fever. During the examination, she has oral ulcers, sore red eyes and tender nodules on her shins. There is tenderness in the right iliac fossa and a vague right iliac fossa mass. What is the most probable diagnosis?
Your Answer:
Correct Answer: Crohn's disease
Explanation:Possible Diagnoses for a Patient with Gastrointestinal Symptoms and Other Complications
Crohn’s Disease, Appendicular Abscess, Ileocaecal Tuberculosis, Ovarian Cyst, and Ulcerative Colitis are possible diagnoses for a patient presenting with gastrointestinal symptoms and other complications. In women over 60 years of age, Crohn’s disease may even be the most likely diagnosis. This condition can cause episcleritis, uveitis, erythema nodosum, pyoderma gangrenosum, vasculitis, gallstones, kidney stones, or abnormal liver function tests. The predominantly right-sided symptoms suggest terminal ileitis, which is more common in Crohn’s disease than ulcerative colitis. Fever can occur in Crohn’s disease due to the inflammatory process, ranging from high fever during acute flare-ups to persistent low-grade fever. Appendicular abscess is a complication of acute appendicitis, causing a palpable mass in the right iliac fossa and fever. Ileocaecal tuberculosis can present with a palpable mass in the right lower quadrant and complications of obstruction, perforation, or malabsorption, especially in the presence of stricture. A large ovarian cyst may be palpable on abdominal examination, but it is unlikely to cause oral ulcers, sore eyes, or erythema nodosum. Ulcerative colitis, which has similar clinical features to Crohn’s disease, is usually diagnosed from the biopsy result following a sigmoidoscopy or colonoscopy. However, rectal bleeding is more common in ulcerative colitis, while fever is more common in Crohn’s disease. A right lower quadrant mass may be seen in Crohn’s disease but not in ulcerative colitis unless complicated by bowel cancer.
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This question is part of the following fields:
- Gastroenterology
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Question 25
Incorrect
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You are conducting a medication review for Mrs Jones, a 75-year-old woman. You observe that she has been on alendronate for the past 4 years following a FRAX score that indicated a risk of fracture. She has not experienced any fractures before. Her other medications consist of ramipril, amlodipine, atorvastatin, and allopurinol. She reports no adverse effects from her medications.
What is the best course of action concerning her bisphosphonate treatment?Your Answer:
Correct Answer: Arrange a repeat DEXA scan and reassess need to continue alendronate
Explanation:According to the National Osteoporosis Guideline Group and NICE guidelines, individuals with osteoporosis who are undergoing treatment with alendronate should have their 10 year fracture risk evaluated again after 5 years. After this point, it may be appropriate to discontinue treatment, although this decision should be made on a case-by-case basis. Patients who are over 75, have a history of hip or vertebral fracture, have experienced any low trauma fracture while on treatment, or are still taking steroid therapy should continue with their treatment.
Osteoporosis is a condition that weakens bones, making them more prone to fractures. The National Institute for Health and Care Excellence (NICE) has updated its guidelines on the management of osteoporosis in postmenopausal women. Treatment is recommended for women who have confirmed osteoporosis following fragility fractures. Vitamin D and calcium supplements should be offered to all women unless they have adequate intake. Alendronate is the first-line treatment, but if patients cannot tolerate it, risedronate or etidronate may be given. Strontium ranelate and raloxifene are recommended if bisphosphonates cannot be taken. Treatment criteria for patients not taking alendronate are complex and based on age, T-score, and risk factors. Bisphosphonates have been shown to reduce the risk of fractures, while vitamin D and calcium supplements have a poor evidence base. Raloxifene, strontium ranelate, and denosumab are other treatment options, but they have potential side effects and should only be prescribed by specialists. Hormone replacement therapy is no longer recommended for osteoporosis prevention due to concerns about increased rates of cardiovascular disease and breast cancer. Hip protectors and falls risk assessments may also be considered in the management of high-risk patients.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 26
Incorrect
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A 51-year-old teacher comes to her General Practitioner complaining of tiredness and fatigue that has been persisting for 10 months. She is unable to perform even minimal activities due to extreme fatigue and has been absent from work. She reports experiencing difficulty swallowing, frequent headaches, and sore throats with myalgia. She has been researching chronic fatigue syndrome (CFS) and believes her symptoms are consistent with this condition.
What is the most pressing investigation to conduct next?Your Answer:
Correct Answer: Oesophago-gastro-duodenoscopy (OGD)
Explanation:Investigations for Chronic Fatigue Syndrome: When to Consider Urgent Investigation
Chronic fatigue syndrome (CFS) is a diagnosis of exclusion, requiring the presence of unexplained chronic fatigue for more than six months, along with other symptoms such as impaired memory or concentration, sore throats, myalgia, arthralgia, headaches, unrefreshing sleep, and post-exertion malaise. However, certain symptoms may indicate the need for urgent investigation to rule out underlying organic or psychiatric problems.
Dysphagia, or difficulty swallowing, is a red flag symptom that may indicate an underlying oesophageal cancer and should be investigated urgently with an oesophago-gastro-duodenoscopy (OGD) under the 2-week wait rule. Thyroid function tests should also be carried out to rule out hypothyroidism, which can present similarly to CFS, but the presence of dysphagia is atypical and prompts urgent investigation for underlying malignancy.
Myalgia, or muscle pain, is a commonly reported symptom of CFS, but it can also be a feature of rhabdomyolysis, which would cause high creatine kinase levels. However, this is a rarer diagnosis and would usually be associated with a history of trauma or long lie causing muscle damage.
Headache and chronic pain are recognised associations of CFS, although they are not exclusive. A magnetic resonance imaging (MRI) brain is not usually indicated unless there are neurological signs or signs that may indicate raised intracranial pressure.
Flu-like symptoms, including sore throat, tender glands, nausea, chills, or muscle aches, are often reported as a feature of CFS. However, Group A streptococcus can cause an acute sore throat rather than the recurrent symptoms described in this patient, so swabbing should be considered if there is diagnostic uncertainty or if there is a history of immunocompromise putting the patient at increased risk of complications.
In summary, while CFS is a diagnosis of exclusion, certain symptoms such as dysphagia may indicate the need for urgent investigation to rule out underlying organic or psychiatric problems.
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This question is part of the following fields:
- Neurology
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Question 27
Incorrect
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A 32-year-old man visits his General Practitioner to discuss his recent diagnosis of Crohn's disease. He presented eight months ago with weight loss and a change in bowel habit, and was referred to the Gastroenterology Department. The diagnosis was confirmed and he was successfully treated as an inpatient. At the time, he declined maintenance therapy but has since become very worried about this decision and would like to start the treatment. What is the most suitable agent to maintain remission in this patient?
Your Answer:
Correct Answer: Azathioprine
Explanation:Medications for Maintaining Remission in Crohn’s Disease
Crohn’s disease is a chronic inflammatory condition that affects the digestive tract. While some patients may choose not to take medication to maintain remission, others may opt for drug therapy. The two main options are azathioprine and mercaptopurine, but it is important to measure thiopurine methyltransferase (TPMT) activity before using these drugs. Sulfasalazine is effective in maintaining remission for ulcerative colitis but has limited efficacy for Crohn’s disease. Methotrexate may be considered if other drugs fail or are not tolerated. Metronidazole is used for perianal disease but not for maintaining remission. Conventional corticosteroids like prednisolone or budesonide should not be used for long-term maintenance due to the risks associated with prolonged steroid use. Preventative treatment may be particularly appropriate for those with adverse prognostic factors such as early age of onset, perianal disease, corticosteroid use at presentation, and severe illness at presentation.
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This question is part of the following fields:
- Gastroenterology
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Question 28
Incorrect
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A study is conducted to evaluate the efficacy of the faecal immunochemical test as a screening tool for bowel cancer in individuals over the age of 50. The study involves 1000 patients, and 100 of them test positive for the test. Out of these 100 patients, 60 are diagnosed with bowel cancer through colonoscopy. On the other hand, 10 patients who tested negative for the test were later found to have bowel cancer.
What is the nearest whole number likelihood ratio for a positive test result?Your Answer:
Correct Answer: 20
Explanation:The likelihood ratio for a positive test result is 20. This is calculated by dividing the sensitivity (85.7%) by 1 minus the specificity (4.3%).
Precision refers to the consistency of a test in producing the same results when repeated multiple times. It is an important aspect of test reliability and can impact the accuracy of the results. In order to assess precision, multiple tests are performed on the same sample and the results are compared. A test with high precision will produce similar results each time it is performed, while a test with low precision will produce inconsistent results. It is important to consider precision when interpreting test results and making clinical decisions.
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This question is part of the following fields:
- Evidence Based Practice, Research And Sharing Knowledge
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Question 29
Incorrect
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A 68-year-old man presents for follow-up of his atrial fibrillation. He recently underwent catheter ablation for atrial fibrillation and it was successful.
The patient has a medical history of hypertension and type 2 diabetes. His most recent blood pressure reading was 150/92 mmHg.
What is the optimal approach for managing his anticoagulation?Your Answer:
Correct Answer: Continue anticoagulation long-term
Explanation:Patients who have undergone catheter ablation for atrial fibrillation must continue with long-term anticoagulation based on their CHA2DS2-VASc score. According to the guidelines of the American College of Cardiology, the decision to discontinue anticoagulation after two months of catheter ablation should be based on the patient’s stroke risk profile, not on the outcome of the procedure. There is no published evidence that it is safe to stop anticoagulation after ablation if the CHA2DS2-Vasc score is equal to or greater than 1. Therefore, in the given scenario, since the CHA2DS2-VASc score indicates moderate to high risk (3 points), anticoagulation should be continued.
Although monitoring heart rhythm is crucial due to the risk of recurrence, anticoagulation should still be continued even if the patient remains in sinus rhythm. Blood pressure readings do not provide any indication to stop anticoagulation.
Atrial fibrillation (AF) is a heart condition that requires prompt management. The management of AF depends on the patient’s haemodynamic stability and the duration of the AF. For haemodynamically unstable patients, electrical cardioversion is recommended. For haemodynamically stable patients, rate control is the first-line treatment strategy, except in certain cases. Medications such as beta-blockers, calcium channel blockers, and digoxin are commonly used to control the heart rate. Rhythm control is another treatment option that involves the use of medications such as beta-blockers, dronedarone, and amiodarone. Catheter ablation is recommended for patients who have not responded to or wish to avoid antiarrhythmic medication. The procedure involves the use of radiofrequency or cryotherapy to ablate the faulty electrical pathways that cause AF. Anticoagulation is necessary before and during the procedure to reduce the risk of stroke. The success rate of catheter ablation varies, with around 50% of patients experiencing an early recurrence of AF within three months. However, after three years, around 55% of patients who have undergone a single procedure remain in sinus rhythm.
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This question is part of the following fields:
- Cardiovascular Health
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Question 30
Incorrect
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A study is being planned to investigate the association between environmental exposure to pesticides and the incidence of cancer in elderly individuals. The researchers have limited funding for the study and need to keep the length and cost of the trial to a minimum.
What is the most appropriate study design?Your Answer:
Correct Answer: Case-control study
Explanation:Different Study Designs and Their Suitability for Investigating Pesticide Exposure and Cancer Risk
When investigating the potential link between pesticide exposure and cancer risk, various study designs can be used. A case-control study involves comparing the history of pesticide exposure in a group of cancer patients (cases) with that in a group of individuals without cancer (controls). This design is useful for answering the study question without the need for a long and expensive follow-up.
A cohort study, on the other hand, involves following up on an entire population over time, measuring exposure to pesticides and observing the incidence of cancer. While this design can provide valuable information, it is likely to be time-consuming and costly.
A case series involves studying a group of cancer patients with a history of pesticide exposure, but this design provides a low level of evidence.
A cross-sectional survey involves looking at data from a population at a specific point in time, providing information on the prevalence of a condition but not the incidence.
Finally, a randomized controlled trial, which is considered the gold standard study design, is not suitable for investigating the link between pesticide exposure and cancer risk as it would be neither practical nor ethical to expose subjects to pesticides.
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This question is part of the following fields:
- Population Health
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