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Question 1
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A 4-week-old male infant is presented to the GP for his routine check-up. During the examination, the GP observes that one side of his scrotum appears larger than the other. Upon palpation, a soft and smooth swelling is detected below and anterior to the testis, which transilluminates. The mother of the baby reports that it has been like that since birth, and there are no signs of infection or redness. The baby appears comfortable and healthy.
What would be the most suitable course of action for managing the probable diagnosis?Your Answer: Reassurance, and surgical repair if it does not resolve within 1-2 years
Explanation:A congenital hydrocele is a common condition in newborn male babies, which usually resolves within a few months. Therefore, reassurance and observation are typically the only necessary management. However, if the hydrocele does not resolve, elective surgery is required when the child is between 1-2 years old to prevent complications such as an incarcerated hernia. Urgent surgical repair is not necessary unless there is a suspicion of testicular torsion or a strangulated hernia. Therapeutic aspiration is not a suitable option for this condition, except in elderly men with hydrocele who are not fit for surgery or in cases of very large hydroceles. Reassurance and surgical repair after 4-5 years is also incorrect, as surgery is usually considered at 1-2 years of age.
A hydrocele is a condition where fluid accumulates within the tunica vaginalis. There are two types of hydroceles: communicating and non-communicating. Communicating hydroceles occur when the processus vaginalis remains open, allowing peritoneal fluid to drain into the scrotum. This type of hydrocele is common in newborn males and usually resolves within a few months. Non-communicating hydroceles occur when there is excessive fluid production within the tunica vaginalis. Hydroceles can develop secondary to conditions such as epididymo-orchitis, testicular torsion, or testicular tumors.
The main feature of a hydrocele is a soft, non-tender swelling of the hemi-scrotum that is usually located anterior to and below the testicle. The swelling is confined to the scrotum and can be transilluminated with a pen torch. If the hydrocele is large, the testis may be difficult to palpate. Diagnosis can be made clinically, but ultrasound is necessary if there is any doubt about the diagnosis or if the underlying testis cannot be palpated.
Management of hydroceles depends on the severity of the presentation. Infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years. In adults, a conservative approach may be taken, but further investigation, such as an ultrasound, is usually warranted to exclude any underlying cause, such as a tumor.
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This question is part of the following fields:
- Surgery
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Question 2
Correct
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Megan, a 16-year-old girl, arrives at the emergency department after experiencing a seizure. During the examination, it is noted that she has a unilateral shoulder deformity and her shoulder is stuck in an internally rotated position. A shoulder x-ray has been requested.
What findings would you anticipate on Megan's shoulder x-ray?Your Answer: Posterior shoulder dislocation
Explanation:FOOSH is commonly associated with anterior shoulder dislocation, while seizures and electric shock are more likely to cause posterior shoulder dislocation.
When a person falls onto an outstretched hand, it can result in an anterior shoulder dislocation, which is characterized by a visible deformity in the affected shoulder. On the other hand, clavicular fracture is often observed in FOOSH cases, which can also cause deformity along the clavicle.
X-rays may not show a normal shoulder in cases where the patient presents with unilateral shoulder deformity.
In contrast, seizures and electric shock are more likely to cause posterior shoulder dislocation, which can also result in a visible deformity in the affected shoulder. While anterior instability and dislocations are still more common in seizures, a shoulder that is locked in an internally rotated position is highly suggestive of a posterior dislocation.
Shoulder dislocations happen when the humeral head becomes detached from the glenoid cavity of the scapula. This is the most common type of joint dislocation, with the shoulder accounting for around half of all major joint dislocations. In particular, anterior shoulder dislocations make up over 95% of cases.
There are many different techniques for reducing shoulders, but there is limited evidence to suggest that one is better than another. If the dislocation is recent, it may be possible to attempt reduction without any pain relief or sedation. However, some patients may require analgesia and/or sedation to ensure that the rotator cuff muscles are relaxed.
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This question is part of the following fields:
- Musculoskeletal
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Question 3
Incorrect
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A researcher is planning a study to evaluate the effectiveness of a new treatment for arthritis. What information is necessary to determine the appropriate sample size for the study?
Your Answer: Expected median value
Correct Answer: Expected standard deviation
Explanation:Factors to Consider in Determining the Appropriate Size of a Clinical Trial
A clinical trial’s appropriate size is determined by several factors. One of these factors is the expected standard deviation, which can be obtained from the literature or a pilot study. For instance, the standard deviation of blood pressure within a population of patients with type 2 diabetes can be used to determine the expected standard deviation. Another factor is the minimum clinically-relevant difference, which can be challenging to establish, especially in a new field or where measurement could be difficult. For example, determining the minimum clinically-relevant difference for a drug that enhances quality of sleep can be challenging.
The standardised difference is used to combine these two factors. It is calculated by dividing the minimum clinically-relevant difference by the anticipated standard deviation. The result is then used to determine the total sample size by reading it off a nomogram or using a statistical software package.
When planning a study, it is essential to consider recruitment. The population must be chosen carefully, and thought should be given to whether it is appropriate to have a mixed gender population or if an age limit should be introduced. However, these issues do not directly impact the required sample size.
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This question is part of the following fields:
- Clinical Sciences
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Question 4
Incorrect
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A 24-year-old construction worker presents to the emergency department complaining of a foreign body sensation in his left eye. He reports experiencing pain and sensitivity to light on the left side. When asked about eye protection, he states that he wears it 99% of the time. Upon examination, you notice crusty, gold-colored lesions on his face. Using a slit lamp and fluorescein eye stain, you identify a dendritic ulcer in his left eye.
What is the probable diagnosis?Your Answer: Bacterial keratitis
Correct Answer: Herpes simplex keratitis
Explanation:A dendritic ulcer seen on fluorescein eye stain is indicative of herpes simplex keratitis, which is the likely diagnosis in this case. While mechanics may be at a higher risk for photokeratitis, it typically does not cause a foreign body sensation. While the other options are possible, the presence of a dendritic ulcer is a key diagnostic feature.
Understanding Herpes Simplex Keratitis
Herpes simplex keratitis is a condition that affects the cornea of the eye and is caused by the herpes simplex virus. The most common symptom of this condition is a dendritic corneal ulcer, which can cause a red, painful eye, photophobia, and epiphora. In some cases, visual acuity may also be decreased. Fluorescein staining may show an epithelial ulcer, which can help with diagnosis. One common treatment for this condition is topical acyclovir, which can help to reduce the severity of symptoms and prevent further damage to the cornea.
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This question is part of the following fields:
- Ophthalmology
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Question 5
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A 39-year-old man comes to his GP complaining of sudden headaches accompanied by sweating and palpitations. Upon examination, the patient appears anxious and has a pale complexion. His blood pressure measures 240/200 mmHg, and a 24-hour urine collection shows increased levels of catecholamines. What is the probable cause of this man's hypertension?
Your Answer: Phaeochromocytoma
Explanation:Differentiating Causes of Hypertension: A Brief Overview
Hypertension, or high blood pressure, is a common medical condition that affects millions of people worldwide. While there are many possible causes of hypertension, some are more common than others. In this article, we will discuss some of the most common causes of hypertension and how to differentiate them.
Phaeochromocytoma is a tumour of the adrenal gland that can cause hypertension, headache, sweating, and anxiety. It is often associated with the 10% rule, which states that 10% of cases are extramedullary, 10% are malignant, 10% are familial, and 10% are bilateral.
Conn syndrome, or primary aldosteronism, is characterized by hypertension, hypokalaemia, and metabolic alkalosis. The most common causes are aldosterone-producing adenomas and bilateral adrenal hyperplasia.
Renal artery stenosis (RAS) is a major cause of renovascular hypertension. However, it is not associated with elevated catecholamines or the symptoms described.
Polycystic kidney disease (PKD) is a genetic disorder that can cause hypertension due to progressive kidney enlargement. However, patients with PKD do not have elevated catecholamine levels.
Cushing syndrome is caused by prolonged hypercortisolism and can cause centripetal obesity, secondary hypertension, glucose intolerance, proximal myopathy, and hirsutism. Sweating, palpitations, and elevated catecholamines are not typical of hypercortisolism.
In conclusion, hypertension can have many different causes, and it is important to differentiate them to provide appropriate treatment. By understanding the characteristic features of each condition, healthcare professionals can make an accurate diagnosis and provide effective management.
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This question is part of the following fields:
- Endocrinology
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Question 6
Incorrect
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A patient with severe sepsis, who is suffering from a urinary tract infection, is found to have a multi-drug resistant Escherichia coli. What is the probable mechanism of resistance?
Your Answer: Drug impermeability
Correct Answer: Extended spectrum beta-lactamase (ESBL) production
Explanation:ESBL-Producing E. coli and Treatment Options
Some strains of E. coli bacteria have the ability to produce an enzyme called extended-spectrum beta-lactamase (ESBL), which can render certain antibiotics ineffective. Specifically, ESBL can inactivate second and third generation cephalosporins, which are commonly used to treat bacterial infections. In such cases, the most effective class of drugs for treating these infections are the carbapenems. It is important to note that carbapenems should be used judiciously and only when necessary, as overuse can lead to the development of carbapenem-resistant bacteria. Therefore, it is crucial to properly identify and diagnose ESBL-producing E. coli infections to ensure appropriate treatment and prevent the spread of antibiotic resistance.
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This question is part of the following fields:
- Clinical Sciences
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Question 7
Incorrect
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You are a FY2 doctor working in a district general hospital in Scotland. You have recently detained your 19-year old patient who was admitted a flare up of ulcerative colitis. He was demanding to go home because he is hearing voices that are telling him that everyone in the hospital is going to kill him. He tells you that his mother is the instigator and needs to be punished for her actions. You do note that he is delirious secondary to sepsis. You have contacted a psychiatrist, who has told you that she will be there within the next 6 hours. The patient is sitting peacefully in bed, making no attempts to leave, but appears to be responding to auditory hallucinations and talking about harming his mother.
You wish to give the patient a sedative. Can you do this?Your Answer: Yes, as long as it approved by the psychiatrist
Correct Answer: Yes, but the patient must consent
Explanation:Administering Medication to Patients with Emergency Detention Certificates: Consent and Approval Requirements
When a patient is placed under an emergency detention certificate, the purpose is to assess whether they require medical treatment for a mental disorder. However, administering medication to these patients requires careful consideration of consent and approval requirements.
Firstly, it is important to note that patients should not be given treatment without their consent unless they fall under the Adults with Incapacity (Scotland) Act 2000, or treatment is needed urgently to save their life or prevent serious deterioration. If the patient does not fall under the Adults with Incapacity Act and there is no urgent need for treatment, medication cannot be given without the patient’s express consent.
Even if medication is urgently needed, it cannot be administered against the patient’s will until they have been formally assessed and placed on a short-term detention certificate. Additionally, medication cannot be offered without the patient’s consent, even if it is urgently needed.
It is also important to note that a psychiatrist’s approval is not required to offer medication to these patients. However, the patient’s spouse or family member cannot provide consent on their behalf.
In summary, administering medication to patients with emergency detention certificates requires their express consent, unless there is an urgent need for treatment to save their life or prevent serious deterioration. A psychiatrist’s approval is not required, but consent cannot be given by a patient’s family member.
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This question is part of the following fields:
- Ethics And Legal
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Question 8
Incorrect
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You review a patient on the ward on day two of admission. He is a 16-year-old without medical history; however, his family history reveals that his mother has type II diabetes. The 16-year-old originally presented with a Glasgow Coma Scale (GCS) score of 3/15. The paramedics recorded that the glucose monitor at the scene read ‘LO’ and he was given intravenous dextrose and intramuscular glucagon. On arrival to the Emergency Department, blood glucose was 2.1 and his treatment was continued. He is now euglycaemic off treatment. Blood tests were taken at the time and they have just returned. These tests reveal that:
Serum insulin – raised
C-peptide – raised
What is the most likely cause of this patient’s presentation?Your Answer: Starvation
Correct Answer: Gliclazide overdose
Explanation:Understanding Gliclazide Overdose: Clinical Features and Differential Diagnosis
Gliclazide is an anti-diabetic drug that belongs to the sulfonylurea group. It works by binding to the sulfonylurea receptors on the pancreatic beta cells, causing the release of insulin and C-peptide. In cases of gliclazide overdose, we expect to see high levels of insulin and C-peptide, which can lead to hypoglycaemia, dizziness, sweating, tremors, seizures, and loss of consciousness.
When presented with a patient experiencing hypoglycaemia, it is important to consider the differential diagnosis. Starvation is unlikely to cause severe hypoglycaemia and is typically associated with anaemia and vitamin deficiencies. Insulin overdose, on the other hand, would result in low C-peptide levels and high insulin levels. Metformin overdose, which inhibits gluconeogenesis in the liver, does not typically cause hypoglycaemia but can lead to metabolic acidosis and non-specific symptoms such as nausea, vomiting, abdominal pain, lethargy, and hyperventilation.
Undiagnosed type 1 diabetes mellitus, which is characterized by hyperglycaemia and a deficiency in insulin production, would result in low insulin and C-peptide levels. In cases where a patient’s family member has type 2 diabetes and hypoglycaemic agents are available at home, intentional gliclazide overdose should be considered as a possible cause of hypoglycaemia. Understanding the clinical features and differential diagnosis of gliclazide overdose is crucial in providing appropriate treatment and management for patients.
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This question is part of the following fields:
- Pharmacology
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Question 9
Incorrect
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A 54-year-old woman presents to the rheumatology clinic with severe Raynaud's phenomenon and finger arthralgia. Upon examination, you observe tight and shiny skin on her fingers, as well as several telangiectasia on her upper torso and face. She is also awaiting a gastroscopy for heartburn investigation. Which antibody is the most specific for the underlying condition?
Your Answer: Anti-Scl-70 antibodies
Correct Answer: Anti-centromere antibodies
Explanation:The most specific test for limited cutaneous systemic sclerosis among patients with systemic sclerosis is the anti-centromere antibodies.
Understanding Systemic Sclerosis
Systemic sclerosis is a condition that affects the skin and other connective tissues, but its cause is unknown. It is more common in females, with three patterns of the disease. Limited cutaneous systemic sclerosis is characterised by Raynaud’s as the first sign, affecting the face and distal limbs, and associated with anti-centromere antibodies. CREST syndrome is a subtype of limited systemic sclerosis that includes Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, and Telangiectasia. Diffuse cutaneous systemic sclerosis affects the trunk and proximal limbs, associated with scl-70 antibodies, and has a poor prognosis. Respiratory involvement is the most common cause of death, with interstitial lung disease and pulmonary arterial hypertension being the primary complications. Renal disease and hypertension are also possible complications, and patients with renal disease should be started on an ACE inhibitor. Scleroderma without internal organ involvement is characterised by tightening and fibrosis of the skin, manifesting as plaques or linear. Antibodies such as ANA, RF, anti-scl-70, and anti-centromere are associated with different types of systemic sclerosis.
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This question is part of the following fields:
- Musculoskeletal
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Question 10
Correct
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A 10-year-old child is brought to the general practitioner by his mother. He complains of loss of sensation over the dorsal aspect of his right forearm and hand for the last few days. His mother also states that he cannot extend his fingers and wrist after she pulled her son’s right hand gently while crossing a street 4 days ago. He had pain in his right elbow at that time but did not see a doctor immediately. On examination, there is loss of sensation and muscle weakness over the extensor surface of his right forearm and hand.
Which of the following nerves is most likely to be injured in this patient?Your Answer: Radial nerve
Explanation:Common Nerve Injuries and their Effects on Movement and Sensation
Radial nerve: Nursemaid’s elbow is a common injury in children that can cause damage to the deep branch of the radial nerve. This can result in wrist drop due to paralysis of the extensors of the forearm and hand.
Long thoracic nerve: The long thoracic nerve supplies the serratus anterior muscle, which is used in all reaching and pushing movements. Injury to this nerve causes winging of the scapula.
Musculocutaneous nerve: Injury to the musculocutaneous nerve causes a loss of elbow flexion, weakness in supination, and sensation loss on the lateral aspect of the forearm.
Axillary nerve: The axillary nerve supplies the deltoid muscle and teres minor. Injury to this nerve presents with flattening of the deltoid muscle after injury, loss of lateral rotation, abduction of the affected shoulder due to deltoid muscle weakness, and loss of sensation over the lateral aspect of the arm.
Middle subscapular nerve: The middle subscapular nerve supplies the latissimus dorsi, which adducts and extends the humerus.
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This question is part of the following fields:
- Neurology
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