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Question 1
Incorrect
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A 4-year-old boy is brought to his pediatrician by his father. He has been experiencing a dry cough and runny nose for the past 7 days, along with a 6-day history of fevers up to 38.7ºC that have not responded to paracetamol and ibuprofen.
During the examination, the boy appears generally unwell and unhappy. His tongue is bright red, and there is a maculopapular rash on his trunk. Bilateral conjunctival injection is present, but there is no apparent discharge. Additionally, palpable submandibular lymphadenopathy is observed.
What investigation should be utilized to screen for long-term complications, given the probable diagnosis?Your Answer: ECG
Correct Answer: Echocardiogram
Explanation:An echocardiogram should be used to screen for coronary artery aneurysms, which are a complication of Kawasaki disease. To diagnose Kawasaki disease, a child must have a fever for at least 5 days and meet 4 out of 5 diagnostic criteria, including oropharyngeal changes, changes in the peripheries, bilateral non purulent conjunctivitis, polymorphic rash, and cervical lymphadenopathy. This disease is the most common cause of acquired cardiac disease in childhood, and it is important to exclude coronary artery aneurysms. Echocardiograms are a noninvasive and appropriate screening modality for this complication, as they do not expose the child to ionising radiation. Antistreptolysin O antibody titres, CT coronary angiogram, and ECG are not appropriate screening modalities for coronary artery aneurysms associated with Kawasaki disease.
Understanding Kawasaki Disease
Kawasaki disease is a rare type of vasculitis that primarily affects children. It is important to identify this disease early on as it can lead to serious complications, such as coronary artery aneurysms. The disease is characterized by a high-grade fever that lasts for more than five days and is resistant to antipyretics. Other symptoms include conjunctival injection, bright red, cracked lips, strawberry tongue, cervical lymphadenopathy, and red palms and soles that later peel.
Diagnosis of Kawasaki disease is based on clinical presentation as there is no specific diagnostic test available. Management of the disease involves high-dose aspirin, which is one of the few indications for aspirin use in children. Intravenous immunoglobulin is also used as a treatment option. Echocardiogram is the initial screening test for coronary artery aneurysms, rather than angiography.
Complications of Kawasaki disease can be serious, with coronary artery aneurysm being the most common. It is important to recognize the symptoms of Kawasaki disease early on and seek medical attention promptly to prevent potential complications.
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This question is part of the following fields:
- Paediatrics
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Question 2
Incorrect
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A 26-year-old male patient arrives at the Emergency department complaining of mild left testicular pain and dysuria that has been going on for six days. During the examination, the patient's scrotum is inflamed, and the epididymis is the most tender area. The patient has a temperature of 37.9°C, and the urine dipstick test came back negative. The cremasteric reflex is present.
What is the most appropriate management plan for the underlying cause of this patient's symptoms?Your Answer: Doxycycline 100 mg bd
Correct Answer: Doxycycline 100 mg bd for 10 days (or single dose 1g azithromycin) plus IM ceftriaxone
Explanation:Acute Epididymitis and its Treatment
Acute epididymitis is a condition characterized by the inflammation of the epididymis, which causes pain and swelling in the testicles over several days. It is most commonly caused by sexually transmitted infections such as Chlamydia trachomatis and Neisseria gonorrhoeae in patients under 35 years old. In contrast, urinary coliforms are the most common cause in children and men over 35 years old.
To treat acute epididymitis caused by Chlamydia trachomatis and Neisseria gonorrhoeae, a combination of antibiotics is required. A course of doxycycline or a single dose of azithromycin can cover chlamydia, while ceftriaxone can cover Neisseria, which can be resistant to other antibiotics. It is important to note that single agents do not cover both infections.
Symptomatic relief can be achieved through the use of anti-inflammatory drugs and scrotal support, but they do not treat the underlying cause. It is crucial to seek medical attention promptly to prevent complications and ensure proper treatment.
In summary, acute epididymitis is a painful condition that requires a combination of antibiotics to treat the underlying infection. Prompt medical attention and proper treatment are essential to prevent complications and achieve symptomatic relief.
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This question is part of the following fields:
- Surgery
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Question 3
Incorrect
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A new father who is 5 weeks post-partum comes in for a check-up. He has noticed a warm, red tender patch on his left breast just lateral to the areola. This has been worsening over the past four days and feeding is now painful. He saw the midwife yesterday who assisted with positioning but there has been no improvement. Upon examination, he has mastitis of the left breast without visible abscess. What is the best course of action for management?
Your Answer: Co-amoxiclav, continue Breastfeeding
Correct Answer: Flucloxacillin, continue Breastfeeding
Explanation:Breastfeeding Problems and Their Management
Breastfeeding is a natural process, but it can come with its own set of challenges. Some of the minor problems that breastfeeding mothers may encounter include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These issues can be managed by seeking advice on proper positioning, trying breast massage, and using appropriate medication.
Mastitis is a more serious problem that affects around 1 in 10 breastfeeding women. It is characterized by symptoms such as fever, nipple fissure, and persistent pain. Treatment involves the use of antibiotics, such as flucloxacillin, for 10-14 days. Breastfeeding or expressing milk should continue during treatment to prevent complications such as breast abscess.
Breast engorgement is another common problem that causes breast pain in breastfeeding women. It occurs in the first few days after birth and affects both breasts. Hand expression of milk can help relieve the discomfort of engorgement. Raynaud’s disease of the nipple is a less common problem that causes nipple pain and blanching. Treatment involves minimizing exposure to cold, using heat packs, and avoiding caffeine and smoking.
If a breastfed baby loses more than 10% of their birth weight in the first week of life, it may be a sign of poor weight gain. This should prompt consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight should continue until weight gain is satisfactory.
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This question is part of the following fields:
- Obstetrics
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Question 4
Incorrect
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A 58-year-old lady with multiple myeloma visits the Oncology Day Hospital for her monthly infusion of intravenous zoledronic acid. She reports experiencing neck pain and new weakness and paraesthesiae in her left hand and arm.
What is the most suitable initial approach for managing this woman?Your Answer: X-ray C-spine
Correct Answer: Urgent magnetic resonance imaging (MRI) whole spine
Explanation:Urgent Management for a Patient with Acute Neck Pain and Malignancy
Explanation:
When a patient with malignancy presents with acute neck pain and focal neurological deficits, urgent investigation is necessary. This is particularly important for patients with multiple myeloma, who are at risk for developing plasmacytomas, which can cause spinal cord compression or pathological fractures. In this case, an urgent magnetic resonance imaging (MRI) of the whole spine is needed to assess for spinal cord compression.
While blood cultures may be important in other situations, they would not affect the management of this patient. Instead, the focus should be on obtaining a diagnosis and definitive treatment. Plasmacytomas are radiosensitive, so urgent radiotherapy is indicated for treatment.
Although analgesia and pain assessment are necessary, they are not the top priority. Physiotherapy assessment for hand weakness may be beneficial, but it does not need to be done urgently. An X-ray of the cervical spine is not sensitive enough to detect all plasmacytomas, so an MRI of the whole spine is necessary to assess for multiple levels of disease.
In summary, urgent management for a patient with acute neck pain and malignancy includes an urgent MRI of the whole spine to assess for spinal cord compression, followed by urgent radiotherapy for treatment.
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This question is part of the following fields:
- Oncology
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Question 5
Incorrect
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Low molecular weight heparin has the most significant inhibitory impact on which of the following proteins involved in the coagulation cascade?
Your Answer: Thrombin
Correct Answer: Factor Xa
Explanation:Understanding Heparin and its Adverse Effects
Heparin is a type of anticoagulant that comes in two forms: unfractionated or standard heparin, and low molecular weight heparin (LMWH). Both types work by activating antithrombin III, but unfractionated heparin inhibits thrombin, factors Xa, IXa, XIa, and XIIa, while LMWH only increases the action of antithrombin III on factor Xa. However, heparin can cause adverse effects such as bleeding, thrombocytopenia, osteoporosis, and hyperkalemia.
Heparin-induced thrombocytopenia (HIT) is a condition where antibodies form against complexes of platelet factor 4 (PF4) and heparin, leading to platelet activation and a prothrombotic state. HIT usually develops after 5-10 days of treatment and is characterized by a greater than 50% reduction in platelets, thrombosis, and skin allergy. To address the need for ongoing anticoagulation, direct thrombin inhibitors like argatroban and danaparoid can be used.
Standard heparin is administered intravenously and has a short duration of action, while LMWH is administered subcutaneously and has a longer duration of action. Standard heparin is useful in situations where there is a high risk of bleeding as anticoagulation can be terminated rapidly, while LMWH is now standard in the management of venous thromboembolism treatment and prophylaxis and acute coronary syndromes. Monitoring for standard heparin is done through activated partial thromboplastin time (APTT), while LMWH does not require routine monitoring. Heparin overdose may be reversed by protamine sulfate, although this only partially reverses the effect of LMWH.
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This question is part of the following fields:
- Pharmacology
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Question 6
Incorrect
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A 28-year-old man, diagnosed with ulcerative colitis (UC) 18 months ago, presents with 2-day history of progressively worsening abdominal pain and bloody diarrhoea. He is currently passing motion 11 times per day.
On examination, there is generalised abdominal tenderness and distension. He is pyrexial, with a temperature of 39 °C; his pulse is 124 bpm.
Investigations:
Investigation Result Normal value
Haemoglobin (Hb) 90 g/l 135–175 g/l
White cell count (WCC) 15 × 109/l 4–11 × 109/l
Erect chest X-ray Normal
Plain abdominal X-ray 12-cm dilation of the transverse colon
He also has a raised C-reactive protein (CRP).
What would be the most appropriate initial management of this patient?Your Answer: IV hydrocortisone, LMWH, IV fluids, IV infliximab
Correct Answer: Intravenous (IV) hydrocortisone, low-molecular-weight heparin (LMWH), IV fluids, reassess response after 72 hours
Explanation:Management of Toxic Megacolon in Ulcerative Colitis: Medical and Surgical Options
Toxic megacolon (TM) is a rare but life-threatening complication of ulcerative colitis (UC) characterized by severe colon dilation and systemic toxicity. The initial management of TM involves aggressive medical therapy with intravenous (IV) hydrocortisone, low-molecular-weight heparin (LMWH), and IV fluids to restore hemodynamic stability. Oral mesalazine is indicated for mild to moderate UC or for maintenance of remission. If the patient fails to respond to medical management after 72 hours, urgent surgery, usually subtotal colectomy with end ileostomy, should be considered.
Infliximab and vedolizumab are second-line management options for severe active UC in patients who fail to respond to intensive IV steroid treatment. However, their role in the setting of TM is unclear. LMWH is required for UC patients due to their high risk of venous thromboembolism.
Prompt recognition and management of TM is crucial to prevent mortality. A multidisciplinary approach involving gastroenterologists, surgeons, and critical care specialists is recommended for optimal patient outcomes.
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This question is part of the following fields:
- Gastroenterology
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Question 7
Correct
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A mother brings her 12-year-old boy into the Emergency Department. She is concerned as he has started to limp over the last few days and is in pain. There is no history of trauma; he has no temperature and is otherwise well. You notice he is overweight for his age.
Which is the most likely diagnosis?Your Answer: Slipped femoral epiphysis
Explanation:Pediatric Hip Conditions: Slipped Femoral Epiphysis, Perthes’ Disease, Septic Arthritis, and Juvenile Idiopathic Arthritis
Hip conditions in children can present with a variety of symptoms and causes. One common condition is slipped femoral epiphysis, which typically affects boys aged 10-16 who are overweight. Symptoms include a painful limp, limited internal rotation, and displacement of the femoral head on X-ray. Treatment involves surgical fixation.
Another condition is Perthes’ disease, which is avascular necrosis of the femoral head and typically affects younger children aged 4-10, more commonly in boys. Symptoms include an intermittent limp and limited joint movement. Treatment can be medical or surgical, but surgery may result in limb shortening and a permanent limp.
Septic arthritis presents with an acutely painful, inflamed, and swollen joint, often with fever. It is more common in patients with underlying joint disease or a history of trauma. Musculoskeletal back pain is unlikely in this scenario.
Juvenile idiopathic arthritis is an autoimmune inflammatory joint disease seen in children under 16. It presents with joint swelling, morning pain, limping, lethargy, reduced activity, and poor appetite, and is associated with anterior uveitis and spiking fevers. However, it is unlikely in this scenario due to the chronicity of symptoms and the child’s overall health.
In conclusion, pediatric hip conditions can have various causes and symptoms, and proper diagnosis and treatment are crucial for optimal outcomes.
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This question is part of the following fields:
- Paediatrics
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Question 8
Incorrect
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Which condition is commonly associated with neonatal cyanosis?
Your Answer: Ventricular septal defect (VSD)
Correct Answer: Total anomalous pulmonary venous drainage
Explanation:Total Anomalous Pulmonary Venous Connection
Total anomalous pulmonary venous connection (TAPVC) is a condition that causes cyanosis in newborns. It is characterized by an abnormality in blood flow where all four pulmonary veins drain into systemic veins or the right atrium, with or without pulmonary venous obstruction. This results in the mixing of systemic and pulmonary venous blood in the right atrium.
In contrast, conditions such as patent ductus arteriosus (PDA), atrial septal defect (ASD), and ventricular septal defect (VSD) are left to right shunts. Tricuspid atresia is another condition that is typically associated with cyanosis, but mitral regurgitation is not.
It is important to understand the differences between these conditions and their effects on blood flow in order to properly diagnose and treat them. Further reading on TAPVC can be found on Medscape.
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This question is part of the following fields:
- Paediatrics
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Question 9
Correct
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A 35-year-old female presents in the emergency department. She is concerned that her waters broke earlier today and reports a sudden 'gush' that soaked her pants. She is currently 28 weeks pregnant and has had an uneventful pregnancy thus far. What is the initial investigation that should be conducted?
Your Answer: Speculum examination
Explanation:To evaluate a patient with suspected premature rupture of membranes, a thorough medical history should be obtained, including the number of pregnancies. A sterile speculum examination is necessary to check for the accumulation of amniotic fluid in the posterior vaginal vault. Digital examination should be avoided to prevent infection. Serum beta-HCG is not recommended, and the patient should have had previous ultrasound scans and have confirmed her pregnancy by this stage. Ultrasound is the appropriate diagnostic tool if there is no evidence of amniotic fluid pooling in the posterior vaginal vault.
Preterm prelabour rupture of the membranes (PPROM) is a condition that occurs in approximately 2% of pregnancies, but it is responsible for around 40% of preterm deliveries. This condition can lead to various complications, including prematurity, infection, and pulmonary hypoplasia in the fetus, as well as chorioamnionitis in the mother. To confirm PPROM, a sterile speculum examination should be performed to check for pooling of amniotic fluid in the posterior vaginal vault. However, digital examination should be avoided due to the risk of infection. If pooling of fluid is not observed, testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) or insulin-like growth factor binding protein-1 is recommended. Ultrasound may also be useful to show oligohydramnios.
The management of PPROM involves admission and regular observations to ensure that chorioamnionitis is not developing. Oral erythromycin should be given for ten days, and antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome. Delivery should be considered at 34 weeks of gestation, but there is a trade-off between an increased risk of maternal chorioamnionitis and a decreased risk of respiratory distress syndrome as the pregnancy progresses. PPROM is a serious condition that requires prompt diagnosis and management to minimize the risk of complications for both the mother and the fetus.
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This question is part of the following fields:
- Obstetrics
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Question 10
Correct
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A 65-year-old retiree visits his GP as he is becoming increasingly breathless and tired whilst walking. He has always enjoyed walking and usually walks 3 times a week. Over the past year he has noted that he can no longer manage the same distance that he used to be able to without getting breathless and needing to stop. He wonders if this is a normal part of ageing or if there could be an underlying medical problem.
Which of the following are consistent with normal ageing with respect to the cardiovascular system?Your Answer: Reduced VO2 max
Explanation:Ageing and Cardiovascular Health: Understanding the Normal and Abnormal Changes
As we age, our organs may still function normally at rest, but they may struggle to respond adequately to stressors such as exercise or illness. One of the key indicators of cardiovascular health is VO2 max, which measures the maximum rate of oxygen consumption during exercise. In normal ageing, VO2 max may decrease along with muscle strength, making intense exertion more difficult. However, significantly reduced VO2 max, left ventricular ejection fraction (LVEF), or stroke volume are not consistent with normal ageing. Additionally, hypotension or hypertension are not typical changes associated with ageing. Understanding these normal and abnormal changes can help us better monitor and manage our cardiovascular health as we age.
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This question is part of the following fields:
- Cardiology
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