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  • Question 1 - A 30-year-old man observed a painless papule on the glans of his penis...

    Correct

    • A 30-year-old man observed a painless papule on the glans of his penis that turned into an ulcer within a few days. Upon examination, a solitary, circular, hardened ulcer is visible.
      What is the MOST PROBABLE diagnosis? Choose only ONE option.

      Your Answer: Syphilis

      Explanation:

      Primary Syphilis: The First Sign and Symptoms

      Primary syphilis is characterized by the appearance of a small, painless papule that quickly turns into an ulcer known as a chancre. This ulcer is typically solitary, round or oval, painless, and surrounded by a bright-red margin. Unlike other open syphilitic lesions, it is not usually infected with secondary bacteria. Treponema pallidum, the bacteria responsible for syphilis, can be detected in the serum from the sore, which can be easily obtained by slightly abrading the base. If left untreated, primary syphilis can progress to more severe stages of the disease. Therefore, it is important to seek medical attention if you suspect you may have syphilis.

    • This question is part of the following fields:

      • Infectious Disease And Travel Health
      14.5
      Seconds
  • Question 2 - A 42-year-old male has recently been diagnosed with prostate cancer and is considering...

    Incorrect

    • A 42-year-old male has recently been diagnosed with prostate cancer and is considering a new chemotherapeutic agent that is currently in a trial phase. However, there are concerns that the drug may increase the risk of developing thrombocytopenia. The patient wants to know his risk of developing thrombocytopenia if he decides to take this new drug.

      In a randomized study of age and sex-matched prostate cancer patients, 245 patients out of 800 patients who were taking the new agent did not develop thrombocytopenia. In the 1,500 patients who did not take the new agent, 1,100 developed thrombocytopenia.

      What is the relative risk of developing thrombocytopenia following treatment with this new chemotherapeutic agent?

      Your Answer: 2

      Correct Answer: 1.3

      Explanation:

      The relative risk is the ratio of the proportion of individuals who develop the disease in the exposed group compared to those who develop the disease in the non-exposed group. In this case, the exposed group consists of 1,026 individuals and the non-exposed group consists of 2,017 individuals. Out of the exposed group, 710 individuals developed the disease, while in the non-exposed group, 1,059 individuals developed the disease.

      The calculation for the relative risk is (710/1,026)/(1,059/2,017), which equals 1.3. This means that individuals who were exposed to the new agent have a 1.3 times higher chance of developing aplastic anaemia compared to those who were not exposed.

      It is important to note that if the calculation was done as the ratio of the proportion of individuals who develop the disease in the non-exposed group compared to those who develop the disease in the exposed group, the result would be the reciprocal of the relative risk. Additionally, calculating the odds ratio would provide a different measure of the association between exposure and disease outcome.

      Understanding Relative Risk in Clinical Trials

      Relative risk (RR) is a measure used in clinical trials to compare the risk of an event occurring in the experimental group to the risk in the control group. It is calculated by dividing the experimental event rate (EER) by the control event rate (CER). If the resulting ratio is greater than 1, it means that the event is more likely to occur in the experimental group than in the control group. Conversely, if the ratio is less than 1, the event is less likely to occur in the experimental group.

      To calculate the relative risk reduction (RRR) or relative risk increase (RRI), the absolute risk change is divided by the control event rate. This provides a percentage that indicates the magnitude of the difference between the two groups. Understanding relative risk is important in evaluating the effectiveness of interventions and treatments in clinical trials. By comparing the risk of an event in the experimental group to the control group, researchers can determine whether the intervention is beneficial or not.

    • This question is part of the following fields:

      • Evidence Based Practice, Research And Sharing Knowledge
      35.2
      Seconds
  • Question 3 - A 29-year-old woman had presented with occasional palpitations, sweating and restlessness. An ECG...

    Correct

    • A 29-year-old woman had presented with occasional palpitations, sweating and restlessness. An ECG had shown sinus tachycardia.

      Her blood tests had showed:

      Thyroid stimulating hormone (TSH) 0.2 mU/L (0.5-5.5)
      Free thyroxine (T4) 23 pmol/L (9.0 - 18)

      You had started her on a beta-blocker and referred her to secondary care for specialist treatment. However, the patient returns to you stating that her appointment is in 4 months' time and she cannot carry on with her symptoms for that long.

      What is the most appropriate course of action?

      Your Answer: Start carbimazole

      Explanation:

      This young female patient is likely suffering from Graves’ disease, causing hyperthyroidism and symptoms such as sweating, palpitations, and restlessness. A low TSH and high T4 confirm the diagnosis, along with positive TRAbs. While waiting for secondary care, starting carbimazole is the appropriate course of action to alleviate symptoms. Seeking senior or remote specialist advice can help with prescribing. Referring to the emergency department is unnecessary as the palpitations are occasional and the ECG shows sinus tachycardia. Starting amiodarone is not recommended as it can cause thyroid dysfunction and the ECG shows sinus tachycardia, not atrial fibrillation. Continuing to wait for secondary care review doesn’t address the patient’s symptoms and concerns.

      Management of Graves’ Disease

      Despite numerous trials, there is no clear consensus on the optimal management of Graves’ disease. Treatment options include anti-thyroid drugs (ATDs), radioiodine treatment, and surgery. In recent years, ATDs have become the most popular first-line therapy for Graves’ disease. This is particularly true for patients with significant symptoms of thyrotoxicosis or those at risk of hyperthyroid complications, such as elderly patients or those with cardiovascular disease.

      To control symptoms, propranolol is often used to block the adrenergic effects. NICE Clinical Knowledge Summaries recommend that patients with Graves’ disease be referred to secondary care for ongoing treatment. If symptoms are not controlled with propranolol, carbimazole should be considered in primary care.

      ATD therapy involves starting carbimazole at 40 mg and gradually reducing it to maintain euthyroidism. This treatment is typically continued for 12-18 months. The major complication of carbimazole therapy is agranulocytosis. An alternative regime, called block-and-replace, involves starting carbimazole at 40 mg and adding thyroxine when the patient is euthyroid. This treatment typically lasts for 6-9 months. Patients following an ATD titration regime have been shown to suffer fewer side-effects than those on a block-and-replace regime.

      Radioiodine treatment is often used in patients who relapse following ATD therapy or are resistant to primary ATD treatment. Contraindications include pregnancy (should be avoided for 4-6 months following treatment) and age < 16 years. Thyroid eye disease is a relative contraindication, as it may worsen the condition. The proportion of patients who become hypothyroid depends on the dose given, but as a rule, the majority of patients will require thyroxine supplementation after 5 years.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
      28.4
      Seconds
  • Question 4 - A 75-year-old man with a history of psoriasis complains of dyspnoea during physical...

    Correct

    • A 75-year-old man with a history of psoriasis complains of dyspnoea during physical activity. Upon examination, his respiratory rate is 24 breaths per minute, oxygen saturation is 94% on room air, heart rate is 90 beats per minute, and his chest reveals diffuse fine inspiratory crackles. Spirometry shows an FEV1/FVC ratio of 0.8. Which medication could be responsible for this clinical presentation?

      Your Answer: Methotrexate

      Explanation:

      Methotrexate can lead to pulmonary fibrosis, while there is no evidence to suggest that terbinafine, paracetamol, montelukast, and tramadol have this side effect. The onset of pulmonary fibrosis due to low-dose methotrexate use can occur within weeks to months.

      Methotrexate is an antimetabolite that hinders the activity of dihydrofolate reductase, an enzyme that is crucial for the synthesis of purines and pyrimidines. It is a significant drug that can effectively control diseases, but its side-effects can be life-threatening. Therefore, careful prescribing and close monitoring are essential. Methotrexate is commonly used to treat inflammatory arthritis, especially rheumatoid arthritis, psoriasis, and acute lymphoblastic leukaemia. However, it can cause adverse effects such as mucositis, myelosuppression, pneumonitis, pulmonary fibrosis, and liver fibrosis.

      Women should avoid pregnancy for at least six months after stopping methotrexate treatment, and men using methotrexate should use effective contraception for at least six months after treatment. Prescribing methotrexate requires familiarity with guidelines relating to its use. It is taken weekly, and FBC, U&E, and LFTs need to be regularly monitored. Folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose. The starting dose of methotrexate is 7.5 mg weekly, and only one strength of methotrexate tablet should be prescribed.

      It is important to avoid prescribing trimethoprim or co-trimoxazole concurrently as it increases the risk of marrow aplasia. High-dose aspirin also increases the risk of methotrexate toxicity due to reduced excretion. In case of methotrexate toxicity, the treatment of choice is folinic acid. Overall, methotrexate is a potent drug that requires careful prescribing and monitoring to ensure its effectiveness and safety.

    • This question is part of the following fields:

      • Respiratory Health
      62.4
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  • Question 5 - A 65 year-old man comes to you with complaints of nasal blockage on...

    Correct

    • A 65 year-old man comes to you with complaints of nasal blockage on the right side for the past two months. He reports that it is now affecting his sleep. He denies any episodes of bleeding but has been experiencing postnasal drip. Upon examination, you observe a polyp on the right side and inflamed mucosa on both sides. What would be the most suitable course of action?

      Your Answer: Refer to ENT

      Explanation:

      A unilateral nasal polyp is a concerning symptom that requires immediate attention. While bilateral polyps are typically associated with rhinosinusitis, a unilateral polyp may indicate the presence of malignancy. Therefore, it is crucial to refer the patient to an ENT specialist for further evaluation.

      In cases where small bilateral nasal polyps are present, primary care treatment may involve saline nasal douching and intranasal steroids. However, if the polyps are causing significant obstruction, referral to an ENT specialist is necessary.

      Understanding Nasal Polyps

      Nasal polyps are a relatively uncommon condition affecting around 1% of adults in the UK. They are more commonly seen in men and are not typically found in children or the elderly. There are several associations with nasal polyps, including asthma (particularly late-onset asthma), aspirin sensitivity, infective sinusitis, cystic fibrosis, Kartagener’s syndrome, and Churg-Strauss syndrome. When asthma, aspirin sensitivity, and nasal polyposis occur together, it is known as Samter’s triad.

      The most common features of nasal polyps include nasal obstruction, rhinorrhoea, sneezing, and a poor sense of taste and smell. However, if a patient experiences unilateral symptoms or bleeding, further investigation is always necessary.

      If a patient is suspected of having nasal polyps, they should be referred to an ear, nose, and throat (ENT) specialist for a full examination. Treatment typically involves the use of topical corticosteroids, which can shrink polyp size in around 80% of patients. With proper management, most patients with nasal polyps can experience relief from their symptoms.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      14.4
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  • Question 6 - A 19-year-old sexually active female who is on the combined oral contraceptive pill...

    Incorrect

    • A 19-year-old sexually active female who is on the combined oral contraceptive pill presents with breakthrough bleeding between her periods.

      She has been on the same pill for almost three years and noticed breakthrough bleeding for the first time two months ago. She denies post-coital bleeding. On further questioning she has not missed any pills and has had no recent illnesses or medical problems.

      What is the most probable reason for her breakthrough bleeding?

      Your Answer: Normal finding

      Correct Answer: Chlamydia infection

      Explanation:

      Breakthrough Bleeding on Combined Oral Contraceptive

      In patients experiencing breakthrough bleeding while on the combined oral contraceptive, it is crucial to check their compliance and potential illness. However, if these factors are not the cause, breakthrough bleeding may indicate an alternative issue and prompt further investigation for gynaecological causes. This is especially true for patients who have been taking the pill for an extended period.

      To assess potential gynaecological causes, a pelvic examination and swabs are necessary. It is also important to ensure that the patient’s smear is up-to-date and to take one if overdue. While cervical cancer is rare in this age group, swabs should be taken to check for chlamydial cervicitis, the most common cause of breakthrough bleeding in young sexually active women.

      Additionally, it is crucial to consider the possibility of pregnancy and perform a pregnancy test. However, in cases where compliance and regular usage of the combined pill are confirmed, the likelihood of pregnancy is remote. Proper investigation and assessment can help identify the underlying cause of breakthrough bleeding and ensure appropriate treatment.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
      37.8
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  • Question 7 - Liam is a 6-year-old boy who has been brought to the emergency department...

    Correct

    • Liam is a 6-year-old boy who has been brought to the emergency department by his father. He experienced swelling of his lips and an itchy mouth after eating a peach. Liam is generally healthy, with only mild allergies to pollen and occasional skin irritation.

      During the examination, you observe that Liam's lips are swollen, and there are a few red bumps around his mouth. His chest sounds clear, and his vital signs are normal.

      What is the probable diagnosis?

      Your Answer: Oral allergy syndrome

      Explanation:

      The most common symptoms of oral allergy syndrome are itching and tingling of the lips, tongue, and mouth. This condition occurs when the body reacts to proteins in certain foods as if they were pollen due to cross-reacting allergens. While the reaction is localized, it can cause an itchy mouth or throat and sometimes hives. However, there is no evidence of anaphylaxis as there is no wheezing or hypotension.

      While contact dermatitis is a possibility, it typically presents with a rash rather than swelling of the lips and an itchy mouth. The presence of hay fever also makes a diagnosis of oral allergy syndrome more likely. Eczema, on the other hand, presents as dry and red skin rather than swelling and itching of the lips.

      Lastly, hand, foot, and mouth is a viral infection that causes a sore throat and high temperature. It can also cause ulcers in the mouth and blisters on the hands and feet.

      Understanding Oral Allergy Syndrome

      Oral allergy syndrome, also known as pollen-food allergy, is a type of hypersensitivity reaction that occurs when a person with a pollen allergy eats certain raw, plant-based foods. This reaction is caused by cross-reaction with a non-food allergen, most commonly birch pollen, where the protein in the food is similar but not identical in structure to the original allergen. As a result, OAS is strongly linked with pollen allergies and presents with seasonal variation. Symptoms of OAS typically include mild tingling or itching of the lips, tongue, and mouth.

      It is important to note that OAS is different from food allergies, which are caused by direct sensitivity to a protein present in food. Non-plant foods do not cause OAS because there are no cross-reactive allergens in pollen that would be structurally similar to meat. Food allergies may be caused by plant or non-plant foods and can lead to systemic symptoms such as vomiting and diarrhea, and even anaphylaxis.

      OAS is a clinical diagnosis, but further tests can be used to rule out other diagnoses and confirm the diagnosis when the history is unclear. Treatment for OAS involves avoiding the culprit foods and taking oral antihistamines if symptoms develop. In severe cases, an ambulance should be called, and intramuscular adrenaline may be required.

      In conclusion, understanding oral allergy syndrome is important for individuals with pollen allergies who may experience symptoms after eating certain raw, plant-based foods. By avoiding the culprit foods and seeking appropriate medical care when necessary, individuals with OAS can manage their symptoms effectively.

    • This question is part of the following fields:

      • Allergy And Immunology
      18.5
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  • Question 8 - You encounter a 35-year-old male patient with ulcerative colitis. His previous colonoscopies have...

    Incorrect

    • You encounter a 35-year-old male patient with ulcerative colitis. His previous colonoscopies have revealed widespread disease affecting his entire colon. He reports passing approximately 5 bloody stools per day for the past 3 days.

      Upon examination, his heart rate is 82 beats per minute, blood pressure is 129/62 mmHg, and temperature is 36.9ºC. His abdomen is soft and non-tender.

      What would be the most suitable course of action for this patient?

      Your Answer: Oral prednisolone

      Correct Answer: Rectal mesalazine and oral sulfasalazine

      Explanation:

      When a patient experiences a mild-moderate flare of ulcerative colitis that extends beyond the left-sided colon, it is recommended to add oral aminosalicylates to rectal aminosalicylates. This is because enemas can only reach a certain point and the addition of an oral medication ensures proper treatment. In this case, the patient’s colonoscopy showed extensive disease, making the use of an oral aminosalicylate necessary. Therefore, this is the correct option and using rectal mesalazine alone is not sufficient.

      Using oral steroids like prednisolone and dexamethasone as a first-line treatment is not recommended.

      Metronidazole is used to treat bacterial infections, but there is no indication of such an infection in this case.

      Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools per day, the amount of blood, and the presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Severe cases should be treated in a hospital setting with intravenous steroids or ciclosporin.

      To maintain remission, patients with proctitis and proctosigmoiditis may use topical aminosalicylate alone or in combination with an oral aminosalicylate. Those with left-sided and extensive ulcerative colitis may require a low maintenance dose of an oral aminosalicylate. Patients who have experienced severe relapses or multiple exacerbations may benefit from oral azathioprine or mercaptopurine. Methotrexate is not recommended for UC management, but probiotics may help prevent relapse in mild to moderate cases.

      In summary, the management of ulcerative colitis involves a combination of inducing and maintaining remission. Treatment options vary depending on the severity and location of the condition, with mild-to-moderate cases typically treated with topical aminosalicylate and severe cases requiring hospitalization and intravenous medication. Maintaining remission may involve using a combination of oral and topical medications or a low maintenance dose of an oral aminosalicylate. While methotrexate is not recommended, probiotics may be helpful in preventing relapse in mild to moderate cases.

    • This question is part of the following fields:

      • Gastroenterology
      34
      Seconds
  • Question 9 - A 6-year-old boy is brought to see you by his mother due to...

    Correct

    • A 6-year-old boy is brought to see you by his mother due to concerns about his hearing. The school has raised concerns about his lack of attention in class and his speech and language development. The mother reports that at home, she has noticed her son sitting close to the television and frequently having to repeat herself when speaking to him.

      Upon reviewing the medical records, it is noted that the child has had recurrent episodes of acute otitis media affecting both ears over the past 18 months. He was last seen by a colleague at the practice three months ago and was treated for right-sided acute otitis media with a course of oral amoxicillin.

      On examination, the child appears to be in good health, but both tympanic membranes are intact and have a grey color with absent light reflexes.

      What is the most appropriate initial management strategy for this child?

      Your Answer: Refer for specialist assessment

      Explanation:

      Management of Otitis Media with Effusion (Glue Ear)

      Eighty percent of children under 10-years-old will have experienced at least one episode of otitis media with effusion (OME), commonly known as glue ear. This condition is characterized by relapsing and remitting episodes that can last for 6-10 weeks, with bimodal peaks at 2 and 5 years of age. The main concern with glue ear is the associated conductive hearing impairment, which can have significant repercussions for a child’s education and speech and language development.

      In cases where symptoms persist, specialist referral to audiometry or ENT for hearing assessment is indicated, probably leading to the need for ENT intervention (grommet insertion) based on the clinical picture (developmental issues are present and the problems are persistent). It is worth noting that antibiotics, topical and systemic steroids, decongestants, mucolytics, and antihistamines are not recommended in the routine management of OME.

      The National Institute for Health and Care Excellence (NICE) guidelines recommend a period of watchful waiting for three months, with two pure-tone audiograms three months apart, to confirm and quantify the hearing loss. Audiometry is important to ensure there is not a more significant hearing deficit. Ultimately, surgical treatment in the form of ventilation tube (grommet) insertion is effective in managing OME.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 10 - A 68-year-old woman presents with a two month history of mild nausea and...

    Incorrect

    • A 68-year-old woman presents with a two month history of mild nausea and upper abdominal discomfort after eating. You suspect gallstones so arrange an ultrasound scan of the abdomen along with a full blood count and liver function tests. Her BMI is 36.

      The ultrasound scan doesn't show any stones in the Gallbladder and her liver function tests are normal. Her haemoglobin level is 95 g/L with a microcytic picture. When it was checked 18 months ago her haemoglobin level was 120 g/L. She has no history of vaginal bleeding or melaena. Her BMI is now 32.

      What is the most appropriate management?

      Your Answer: Refer urgently for upper GI endoscopy

      Correct Answer: Arrange a routine barium meal and swallow

      Explanation:

      Urgent Referral for Upper GI Endoscopy in a Woman with Recent Onset Anemia and Weight Loss

      This woman, aged over 55, has recently developed anemia and has also experienced weight loss. According to the latest NICE guidelines, urgent referral for upper GI endoscopy is necessary in such cases. Routine referrals for CT scan and barium meal are not appropriate. Treating with iron without referral is not recommended as it may delay diagnosis.

      The loss of blood from the gastrointestinal tract is a common cause of anemia, and the symptoms experienced by this woman suggest an upper GI cause. Therefore, it is important to refer her for an upper GI endoscopy as soon as possible to identify the underlying cause of her symptoms and provide appropriate treatment. Proper diagnosis and treatment can help prevent further complications and improve the woman’s overall health and well-being.

    • This question is part of the following fields:

      • Gastroenterology
      49.3
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  • Question 11 - As the duty doctor at a GP practice, you encounter a 26-year-old woman...

    Correct

    • As the duty doctor at a GP practice, you encounter a 26-year-old woman who is on the desogestrel progesterone only contraceptive pill (POP). She has been suffering from a vomiting bug and has missed taking her pill for four days. However, she is now feeling better and has taken two of her POPs this afternoon. She plans to continue taking them daily from now on. Her last sexual encounter was seven days ago. What guidance should you provide regarding extra contraception?

      Your Answer: Additional contraception is needed for 48 hours

      Explanation:

      If a patient misses a progesterone only pill by over 12 hours or a desogestrel pill by over 36 hours, they should take the missed pill as soon as they remember. Only one pill should be taken, even if multiple pills have been missed. The next pill should be taken at the usual time, which may result in taking two pills in one day. To ensure effectiveness, additional contraceptive precautions such as condoms or abstaining from sex should be taken for 48 hours after restarting the pill. Emergency contraception may be necessary if unprotected sex occurred after the missed pill and within 48 hours of restarting it. The desogestrel pill has the advantage of a longer window for taking it, reducing the likelihood of missed pills.

      The progestogen only pill (POP) has simpler rules for missed pills compared to the combined oral contraceptive pill. It is important to not confuse the two. For traditional POPs such as Micronor, Noriday, Norgeston, and Femulen, as well as Cerazette (desogestrel), if a pill is less than 3 hours late, no action is required and pill taking can continue as normal. However, if a pill is more than 3 hours late (i.e. more than 27 hours since the last pill was taken), action is needed. If a pill is less than 12 hours late, no action is required. But if a pill is more than 12 hours late (i.e. more than 36 hours since the last pill was taken), action is needed.

      If action is needed, the missed pill should be taken as soon as possible. If more than one pill has been missed, only one pill should be taken. The next pill should be taken at the usual time, which may mean taking two pills in one day. Pill taking should continue with the rest of the pack. Extra precautions, such as using condoms, should be taken until pill taking has been re-established for 48 hours.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
      174.1
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  • Question 12 - You examine a femoral X-ray of a 14-year-old girl that you ordered yesterday....

    Correct

    • You examine a femoral X-ray of a 14-year-old girl that you ordered yesterday. She complained of persistent bone pain in her distal femur for the past month. The X-ray reveals destruction of the medullary and cortical bone in the distal femur. What is the recommended follow-up for this X-ray?

      Your Answer: Ensure patient is seen by a specialist within 48 hours

      Explanation:

      An urgent referral is required for specialist assessment of children and young people who have an X-ray indicating bone sarcoma, with a timeframe of less than 48 hours. This is particularly important for a child who presents with symptoms suggestive of osteosarcoma, as bony destruction is a typical finding. According to NICE guidelines, suspected cancer in children should be referred urgently within 48 hours, rather than the 2-week pathway for adults. Medications such as vitamin D, calcium, and alendronate are used to treat osteoporosis, which is not likely to be the primary cause of the child’s X-ray. If required, specialists may request a bone marrow biopsy, which cannot be performed at the GP surgery.

      Sarcomas: Types, Features, and Assessment

      Sarcomas are malignant tumors that originate from mesenchymal cells. They can either be bone or soft tissue in origin. Bone sarcomas include osteosarcoma, Ewing’s sarcoma, and chondrosarcoma, while soft tissue sarcomas are a more diverse group that includes liposarcoma, rhabdomyosarcoma, leiomyosarcoma, and synovial sarcomas. Malignant fibrous histiocytoma is a sarcoma that can arise in both soft tissue and bone.

      Certain features of a mass or swelling should raise suspicion for a sarcoma, such as a large (>5cm) soft tissue mass, deep tissue or intramuscular location, rapid growth, and a painful lump. Imaging of suspicious masses should utilize a combination of MRI, CT, and USS. Blind biopsy should not be performed prior to imaging, and where required, should be done in such a way that the biopsy tract can be subsequently included in any resection.

      Ewing’s sarcoma is more common in males, with an incidence of 0.3/1,000,000 and onset typically between 10 and 20 years of age. Osteosarcoma is more common in males, with an incidence of 5/1,000,000 and peak age 15-30. Liposarcoma is rare, with an incidence of approximately 2.5/1,000,000, and typically affects an older age group (>40 years of age). Malignant fibrous histiocytoma is the most common sarcoma in adults and is usually treated with surgical resection and adjuvant radiotherapy.

      In summary, sarcomas are a diverse group of malignant tumors that can arise from bone or soft tissue. Certain features of a mass or swelling should raise suspicion for a sarcoma, and imaging should utilize a combination of MRI, CT, and USS. Treatment options vary depending on the type and location of the sarcoma.

    • This question is part of the following fields:

      • Musculoskeletal Health
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  • Question 13 - A 50-year-old woman visits her GP clinic with concerns about her susceptibility to...

    Correct

    • A 50-year-old woman visits her GP clinic with concerns about her susceptibility to ovarian cancer, given the recent media coverage. What factor is most closely linked to the development of ovarian cancer?

      Your Answer: Early menarche

      Explanation:

      The hormonal factors are responsible for the risk of ovarian cancer. Women who experience ovulation without suppression are at a higher risk. Therefore, early menarche and late menopause, which increase ovulation, are considered risk factors for ovarian cancer. On the other hand, hormone replacement therapy (HRT) and obesity, not low body weight, are also risk factors.

      Pregnancy, which suppresses ovulation, is a protective factor against ovarian cancer. Similarly, the use of combined oral contraceptives is also considered protective.

      The media often highlights vague symptoms such as bloating as potential signs of ovarian cancer. However, it is important to reassure patients and conduct a thorough history and examination to identify any risk factors.

      Understanding Ovarian Cancer: Risk Factors, Symptoms, and Management

      Ovarian cancer is a type of cancer that affects women, with the peak age of incidence being 60 years. It is the fifth most common malignancy in females and carries a poor prognosis due to late diagnosis. Around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas. Interestingly, recent studies suggest that the distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancers.

      There are several risk factors associated with ovarian cancer, including a family history of mutations of the BRCA1 or the BRCA2 gene, early menarche, late menopause, and nulliparity. Clinical features of ovarian cancer are notoriously vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms, early satiety, and diarrhea.

      To diagnose ovarian cancer, a CA125 test is usually done initially. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 should not be used for screening for ovarian cancer in asymptomatic women. Diagnosis is difficult and usually involves diagnostic laparotomy.

      Management of ovarian cancer usually involves a combination of surgery and platinum-based chemotherapy. The prognosis for ovarian cancer is poor, with 80% of women having advanced disease at presentation and the all stage 5-year survival being 46%. It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. However, recent evidence suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies.

    • This question is part of the following fields:

      • Gynaecology And Breast
      65.1
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  • Question 14 - You see a child who you are investigating for coeliac disease. Their serology...

    Incorrect

    • You see a child who you are investigating for coeliac disease. Their serology test result is positive.

      What would be the next step in your management?

      Your Answer: Refer to gastroenterology

      Correct Answer: No intervention

      Explanation:

      Diagnosis of Coeliac Disease

      Patients who are suspected of having coeliac disease and have positive serology test results should be referred to a gastroenterologist for further investigation. The gastroenterologist will perform an endoscopy and intestinal biopsy to confirm or exclude the diagnosis of coeliac disease. It is important for patients to continue eating gluten-containing foods until the biopsy is performed to ensure accurate results.

      While dietary advice may be helpful if coeliac disease is confirmed, it is more appropriate to first seek a referral to a gastroenterologist. There is no need to repeat the serology test if it is positive. For more information on how to interpret coeliac serology results, refer to the link provided below. Proper diagnosis and management of coeliac disease can greatly improve a patient’s quality of life.

    • This question is part of the following fields:

      • Gastroenterology
      30.9
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  • Question 15 - One option needs to be selected from the following tumour types that are...

    Incorrect

    • One option needs to be selected from the following tumour types that are NOT hormone responsive.

      Your Answer: Thyroid

      Correct Answer: Renal cell

      Explanation:

      Hormonal Therapy for Metastatic Cancer: A Review of Treatment Options

      Hormonal therapy has been used in the treatment of various types of metastatic cancer, but its effectiveness varies depending on the cancer type. In renal cell cancer, hormonal therapy has not shown promising results. However, medroxyprogesterone acetate may be used to treat cancer-related anorexia or loss of appetite.

      For metastatic/locally advanced carcinoma of the prostate, testosterone ablation with orchidectomy or anti-androgens can produce a clinical remission in the majority of cases.

      In breast cancer, anti-oestrogen therapy with tamoxifen can be effective for oestrogen-receptor positive tumours, which make up 60% of breast tumours.

      In metastatic endometrial cancer, progestogens may be effective in 30% of cases.

      For high-risk thyroid cancer, thyroxine can be used to suppress thyroid-stimulating hormone.

      Overall, hormonal therapy can be a useful treatment option for certain types of metastatic cancer, but it is important to consider the specific cancer type and individual patient factors when determining the most appropriate treatment plan.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
      30.5
      Seconds
  • Question 16 - A 50-year-old woman presents with menorrhagia and is found to have a haemoglobin...

    Incorrect

    • A 50-year-old woman presents with menorrhagia and is found to have a haemoglobin level of 80 g/l, microcytosis and a serum ferritin of 10 μg/l. The menorrhagia has been treated by the insertion of the Mirena® intrauterine system. She has commenced ferrous sulphate 200 mg once daily. She has a further blood count performed after three weeks.
      What is the expected increase in haemoglobin level after three weeks of iron treatment?

      Your Answer: Too early to see a significant rise

      Correct Answer: 20 g/l

      Explanation:

      Management of Iron Deficiency Anemia

      Iron deficiency anemia is a common condition that can be effectively managed with oral iron supplementation. The haemoglobin concentration should rise by about 20 g/l over 3-4 weeks if there is a response. It is important to check the full blood count at 2-4 months to ensure that the haemoglobin level has returned to normal. Treatment should be continued for a further three months to replenish the iron stores once the haemoglobin is in the reference range.

      Epithelial tissue changes such as atrophic glossitis and koilonychia may improve, but the response is often slow. If there is an inadequate response to oral iron, it is important to assess compliance and whether the iron treatment is tolerated. Malabsorption or other complicating factors such as another source of blood loss are also possible and should be considered. Effective management of iron deficiency anemia requires careful monitoring and evaluation to ensure optimal outcomes.

    • This question is part of the following fields:

      • Haematology
      78.5
      Seconds
  • Question 17 - A 36-year-old woman presents with malaise, joint pain and swelling, Raynaud's phenomenon, Sjögren...

    Incorrect

    • A 36-year-old woman presents with malaise, joint pain and swelling, Raynaud's phenomenon, Sjögren syndrome, muscle pain and sclerodactyly. Her immunology results show a positive ANA and high titre of anti-nRNP, but no antibodies to Ro (SSA), La (SSB), Jo-1 (RNA synthetase), PM-1 (nucleolar protein), double-stranded DNA, SCL-70 (topoisomerase) and centromere. What is the most likely diagnosis?

      Your Answer: Systemic lupus erythematosus (SLE)

      Correct Answer: Mixed connective tissue disorder

      Explanation:

      Understanding Autoimmune Disorders: Differentiating Between Mixed Connective Tissue Disorder and Other Conditions

      Autoimmune disorders can be difficult to diagnose due to their overlapping symptoms and shared antibodies. One such disorder is mixed connective tissue disorder, which presents with undifferentiated connective tissue disorder and anti-nRNP antibodies along with Raynaud’s phenomenon. However, it is important to differentiate this disorder from others with similar features.

      Polymyositis and/or dermatomyositis, for example, are associated with anti-Jo-1 and anti-PM-1 antibodies. Sjögren syndrome, on the other hand, is commonly associated with SSA and SSB antibodies, which can also be seen in systemic lupus erythematosus (SLE). Systemic sclerosis and/or CREST may present with anti-centromere or topoisomerase antibodies.

      Therefore, a thorough understanding of the specific antibodies associated with each autoimmune disorder is crucial in accurately diagnosing and treating patients.

    • This question is part of the following fields:

      • Musculoskeletal Health
      37.4
      Seconds
  • Question 18 - A 65 year-old man visits your clinic following a blood test that revealed...

    Incorrect

    • A 65 year-old man visits your clinic following a blood test that revealed an elevated prostate specific antigen (PSA) level. He inquires if this indicates the presence of cancer. Can you provide an estimate of the proportion of men with an elevated PSA who have prostate cancer?

      Your Answer: 1-Feb

      Correct Answer: 1-Mar

      Explanation:

      The PSA blood test is used to screen for prostate cancer, but it lacks specificity as only one-third of patients with elevated levels are actually diagnosed with the disease. Therefore, it is crucial to inform patients about this before they undergo the test.

      PSA Testing for Prostate Cancer

      Prostate specific antigen (PSA) is an enzyme produced by the prostate gland, and it is used as a tumour marker for prostate cancer. However, there is still much debate about its usefulness as a screening tool. The NHS Prostate Cancer Risk Management Programme (PCRMP) has published guidelines on how to handle requests for PSA testing in asymptomatic men. The National Screening Committee has decided not to introduce a prostate cancer screening programme yet, but rather allow men to make an informed choice.

      The PCRMP has recommended age-adjusted upper limits for PSA, while NICE Clinical Knowledge Summaries suggest a lower threshold for referral. However, PSA levels may also be raised by other conditions such as benign prostatic hyperplasia, prostatitis, urinary tract infection, ejaculation, vigorous exercise, urinary retention, and instrumentation of the urinary tract.

      PSA testing has poor specificity and sensitivity, and various methods are used to try and add greater meaning to a PSA level, including age-adjusted upper limits and monitoring change in PSA level with time. It is important to note that digital rectal examination may or may not cause a rise in PSA levels, which is a matter of debate.

    • This question is part of the following fields:

      • Kidney And Urology
      12.7
      Seconds
  • Question 19 - A trial is conducted to evaluate the effectiveness of a new screening test...

    Incorrect

    • A trial is conducted to evaluate the effectiveness of a new screening test for detecting early signs of heart disease in a group of patients. The contingency table below shows the results of the trial:

      Heart disease present Heart disease absent
      Test positive 120 15
      Test negative 10 255

      What is the positive predictive value of the new screening test (rounded to 2 decimal places)?

      Your Answer: 0.96

      Correct Answer: 0.98

      Explanation:

      To calculate the negative predictive value (NPV) of a test, the formula is NPV = true negative / (true negative + false negative). This represents the chance that a patient doesn’t have the condition if the test is negative. For example, if 225 patients test negative for colon cancer and do not have the condition (true negative), while 5 patients test negative but do have colon cancer (false negative), the NPV would be calculated as follows: NPV = 225 / (225 + 5) = 0.98. It is important to use the correct formula to avoid incorrect results. The positive predictive value (PPV) is calculated using the formula PPV = true positives / (true positives + false positives), which represents the chance that a patient has the condition if the test is positive.

      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.

    • This question is part of the following fields:

      • Evidence Based Practice, Research And Sharing Knowledge
      14.3
      Seconds
  • Question 20 - A 62-year-old lady comes to see you after a routine assessment by her...

    Correct

    • A 62-year-old lady comes to see you after a routine assessment by her optician. She has had no visual problems prior to the assessment. The assessment revealed early nuclear sclerotic cataracts bilaterally. Her corrected visual acuity today is 6/5 in the right eye and 6/5 in the left eye.

      What is the most appropriate action to take?

      Your Answer: No action is required

      Explanation:

      Understanding Cataracts and Driving Requirements

      It is common for individuals to develop nuclear sclerotic cataracts as they age. However, there is no need for referral unless there is a visual impairment that affects the patient’s lifestyle. If a person has a visual acuity of 6/5, it means they can read at a distance of six meters what a person with normal vision can read at five meters. Therefore, if a patient has excellent vision, they are unlikely to benefit from new glasses.

      There is no indication for a person to stop driving if they meet the minimum eyesight standard for driving, which is a visual acuity of at least 6/12 measured on the Snellen scale. To drive legally, a person must also be able to read a car number plate made after 1 September 2001 from a distance of 20 meters, with glasses or contact lenses if necessary.

      It is important to note that YAG laser capsulotomy is a procedure carried out for posterior capsular opacification, which can develop after cataract extraction. This procedure is not necessary for a patient with nuclear sclerotic cataracts and would not benefit them.

    • This question is part of the following fields:

      • Eyes And Vision
      55.7
      Seconds
  • Question 21 - A 45-year-old male with type 1 diabetes has been diagnosed with microalbuminuria during...

    Incorrect

    • A 45-year-old male with type 1 diabetes has been diagnosed with microalbuminuria during his yearly check-up. He is aware of other patients with type 1 diabetes who have developed renal failure and required dialysis a few years after being diagnosed with nephropathy. When examining his vascular risk profile, which parameter is most likely to decrease the risk of future renal failure?

      Your Answer: BP <145 systolic

      Correct Answer:

      Explanation:

      Managing Nephropathy Progression

      Tight control of blood pressure and glucose levels is crucial in managing the progression of nephropathy. The recommended target for systolic blood pressure is 130 or less, while the HbA1c target should be less than 53 mmol/mol. Although BMI, diastolic blood pressure, and cholesterol are relevant factors, they are less significant compared to blood pressure and glucose control.

      Among all antihypertensives, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) have the strongest evidence for reducing nephropathy progression. Therefore, it is important to prioritize these medications in the management of nephropathy. Proper management of blood pressure and glucose levels, along with the use of ACE inhibitors and ARBs, can significantly slow down the progression of nephropathy.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
      21.2
      Seconds
  • Question 22 - A 55-year-old man visits his GP for a check-up and reveals that he...

    Correct

    • A 55-year-old man visits his GP for a check-up and reveals that he consumes over 60 units of alcohol per week. The GP conducts an assessment to ascertain if the patient has alcohol dependence syndrome.
      If the diagnosis is accurate, what is the most probable indication?
      Choose ONE answer.

      Your Answer: Withdrawal symptoms

      Explanation:

      Understanding Alcohol Dependence Syndrome: Symptoms and Behaviors

      Alcohol dependence syndrome is a serious condition that can have a significant impact on an individual’s life. Withdrawal symptoms are a common occurrence when someone tries to stop drinking, including feeling sick, trembling, sweating, and craving for alcohol. In some cases, convulsions and delirium tremens may occur. It is not uncommon for an individual to find it difficult to stop drinking due to these symptoms.

      Alcohol dependence syndrome can also have a negative impact on an individual’s family and career. The individual may find it difficult to function in both roles due to exhaustion and decreased sleep quality. Additionally, tolerance to alcohol tends to increase rather than decrease, requiring larger quantities to achieve the same effect.

      Reinstatement after a period of abstinence, commonly referred to as falling off the wagon, is a significant and common problem in addictive behavior. However, preferential drinking of spirits over beer is not necessarily an indication of alcohol dependence syndrome. It is important to understand the symptoms and behaviors associated with alcohol dependence syndrome to seek appropriate treatment and support.

    • This question is part of the following fields:

      • Smoking, Alcohol And Substance Misuse
      58.9
      Seconds
  • Question 23 - A 65-year-old man presents with haematuria. Investigations confirm the presence of a bladder...

    Correct

    • A 65-year-old man presents with haematuria. Investigations confirm the presence of a bladder carcinoma.
      In his occupational history, select the single substance exposure which would be a significant risk factor for his current diagnosis.

      Your Answer: Aromatic amines

      Explanation:

      Occupational and Environmental Carcinogens: A Brief Overview

      Exposure to certain chemicals and substances in the workplace and environment can increase the risk of developing cancer. Bladder carcinoma, for example, is linked to exposure to aromatic amines found in various industries such as dyes, paints, and textiles. Smoking is also a major contributor to bladder cancer. Asbestos, commonly found in construction materials, increases the risk of lung cancer and mesothelioma. Vinyl chloride, used in plastic production and tobacco smoke, is associated with liver cancer, brain cancer, lung cancer, lymphoma, and leukemia. Arsenic exposure predisposes individuals to skin cancer, while nickel exposure increases the risk of squamous-cell carcinomas in the lung and nasal cavity. It is important for individuals to be aware of potential carcinogens in their workplace and environment to take necessary precautions and reduce their risk of developing cancer.

    • This question is part of the following fields:

      • Kidney And Urology
      12.1
      Seconds
  • Question 24 - A 45-year-old woman with Addison's disease is admitted to the Emergency Department with...

    Incorrect

    • A 45-year-old woman with Addison's disease is admitted to the Emergency Department with gastroenteritis. As she is being admitted to the medical ward, what steps should be taken regarding her steroid replacement?

      Your Answer: Double hydrocortisone dose, double fludrocortisone dose

      Correct Answer: Double hydrocortisone dose, same fludrocortisone dose

      Explanation:

      When a patient with Addison’s disease experiences an intercurrent illness, it is recommended to increase their glucocorticoid dosage by two-fold. However, the dose of fludrocortisone should remain the same as usual, as it is not as crucial during times of illness. This is because individuals with Addison’s have limited or no natural steroid production, and the body typically responds to stress by increasing cortisol production.

      Addison’s disease is a condition that requires patients to undergo glucocorticoid and mineralocorticoid replacement therapy. This treatment involves taking a combination of hydrocortisone and fludrocortisone. Hydrocortisone is usually given in 2 or 3 divided doses, with patients requiring 20-30 mg per day, mostly in the first half of the day. Fludrocortisone is also included in the treatment regimen. Patient education is crucial in managing Addison’s disease. Patients should be reminded not to miss glucocorticoid doses, and they may consider wearing MedicAlert bracelets and steroid cards. Additionally, patients should be provided with hydrocortisone for injection with needles and syringes to treat an adrenal crisis. It is also important to discuss how to adjust the glucocorticoid dose during an intercurrent illness.

      During an intercurrent illness, the glucocorticoid dose should be doubled, while the fludrocortisone dose remains the same. The Addison’s Clinical Advisory Panel has produced guidelines that detail specific scenarios for managing intercurrent illness. These guidelines can be found on the CKS link for more information. Proper management of Addison’s disease is essential to ensure that patients receive the appropriate treatment and care they need to manage their condition effectively.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
      12.1
      Seconds
  • Question 25 - A 29-year-old man contacts his GP seeking advice for his seasonal allergic rhinitis....

    Correct

    • A 29-year-old man contacts his GP seeking advice for his seasonal allergic rhinitis. He has been managing his symptoms with intranasal decongestants, but lately, he has noticed that they are only partially effective. He experiences a runny nose and occasional sneezing, but there are no red flag symptoms such as unilateral obstruction or cacosmia. He has already taken the maximum dose of over-the-counter decongestants and is wondering if the GP can prescribe a higher dose.

      Your Answer: Stop the intranasal decongestant

      Explanation:

      Prolonged use of intranasal decongestants like oxymetazoline should be avoided due to the development of tachyphylaxis, where increasing doses are needed to achieve the same effect. Additionally, stopping the medication can lead to rebound symptoms known as rhinitis medicamentosa. Therefore, it is best to encourage patients to discontinue the decongestant rather than prescribing a higher dose. Oral decongestants like pseudoephedrine are not commonly prescribed due to limited evidence supporting their effectiveness. For patients with allergic rhinitis, short-term use of oral corticosteroids may be recommended for severe symptoms, but intranasal corticosteroids and antihistamines are more practical options. Patients should also be advised on self-help strategies like allergen avoidance. Referral to an ENT specialist is not necessary for most cases of allergic rhinitis, except for those with red flags, suspected structural abnormalities, diagnostic uncertainty, or persisting symptoms despite optimal primary care management.

      Understanding Allergic Rhinitis

      Allergic rhinitis is a condition that causes inflammation in the nose due to sensitivity to allergens such as dust mites, grass, tree, and weed pollens. It can be classified into seasonal, perennial, or occupational, depending on the timing and cause of symptoms. Seasonal rhinitis, which occurs due to pollens, is commonly known as hay fever. Symptoms of allergic rhinitis include sneezing, bilateral nasal obstruction, clear nasal discharge, post-nasal drip, and nasal pruritus.

      The management of allergic rhinitis involves allergen avoidance and medication. For mild-to-moderate intermittent or mild persistent symptoms, oral or intranasal antihistamines may be prescribed. For moderate-to-severe persistent symptoms or if initial drug treatment is ineffective, intranasal corticosteroids may be recommended. In some cases, a short course of oral corticosteroids may be necessary to cover important life events. Topical nasal decongestants, such as oxymetazoline, may also be used for short periods, but prolonged use can lead to tachyphylaxis and rebound hypertrophy of the nasal mucosa (rhinitis medicamentosa) upon withdrawal.

      In summary, allergic rhinitis is a common condition that can cause discomfort and affect daily life. Understanding the different types of allergic rhinitis and its symptoms can help in managing the condition effectively. It is important to consult a healthcare professional for proper diagnosis and treatment.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      39.8
      Seconds
  • Question 26 - You are visiting a local nursing home to see a new resident who...

    Correct

    • You are visiting a local nursing home to see a new resident who is complaining of an itchy rash when you get an urgent call to see a 78-year-old lady who has collapsed in the dining room.

      The relief staff at the home tell you that she is a diabetic and has had a stroke some years ago, but they do not know much else about her.

      On examination, she is lying in the recovery position on the floor and her BP is 115/70 mmHg, pulse 95 she is bathed in sweat and is unresponsive. She has adequate air entry on auscultation of the chest and there is no danger in the immediate vicinity. Trained nursing staff are at hand to help you with her management and take any further action.

      What would be your first action in this situation?

      Your Answer: Check her finger prick glucose

      Explanation:

      Managing Hypoglycaemia in Nursing Homes

      Hypoglycaemia is a common occurrence in nursing homes and can lead to significant neurological impairment if not managed promptly. When a patient is suspected of having hypoglycaemia, the first step is to check their finger prick glucose level. This should be done after ensuring their airway, breathing, and circulation are stable.

      Early intervention with a glucagon injection can prevent further complications. It is important to note that nursing home ‘strokes’ are a common cause of admissions to emergency departments. Therefore, prompt management of hypoglycaemia can potentially avoid such admissions.

      If the patient is unconscious, they should be placed in the recovery position until medical help arrives. By following these steps, nursing home staff can effectively manage hypoglycaemia and prevent further complications.

    • This question is part of the following fields:

      • Older Adults
      22.9
      Seconds
  • Question 27 - A 61-year-old gentleman presents to the emergency department with a persistent cough that...

    Correct

    • A 61-year-old gentleman presents to the emergency department with a persistent cough that has been troubling him for the last six months. His wife has brought him in as he has coughed up small amounts of blood on several occasions and has lost about a stone in weight over the last few months. He is a heavy smoker of 40 cigarettes a day for the last 40 years and has developed noisy breathing over the last few days. He also complains of a persistent headache and feeling a little dizzy. On examination, he has a soft stridor at rest and dilated veins on his chest wall. His oxygen saturations are 98% in room air, blood pressure is 128/88 mmHg, and pulse rate is 90 regular. He is alert, oriented, and afebrile with clear chest sounds on auscultation. What is the most appropriate management plan?

      Your Answer: Admit as a medical emergency

      Explanation:

      Superior Vena Caval Obstruction (SVCO)

      Superior Vena Caval Obstruction (SVCO) is a condition where there is an obstruction of blood flow in the superior vena cava. This can be caused by extraluminal compression or thrombosis within the vein. The most common cause of SVCO is malignancy, particularly lung cancer and lymphoma. Benign causes include intrathoracic goitre and granulomatous conditions such as sarcoidosis.

      The typical features of SVCO include facial/upper body oedema, facial plethora, venous distention, and increased shortness of breath. Other symptoms may include dizziness, syncopal attacks, and headache due to pressure effect. Prompt recognition of SVCO on clinical grounds and immediate referral for specialist assessment is crucial. If there is any stridor or laryngeal oedema, SVCO is considered a medical emergency.

      Management of SVCO involves treatment with steroids and radiotherapy. Chemotherapy and stent insertion may also be indicated. It is important to address the underlying cause of SVCO to prevent further complications.

    • This question is part of the following fields:

      • Urgent And Unscheduled Care
      65.7
      Seconds
  • Question 28 - A 35-year-old woman presents with complaints of a dull ache and numbness in...

    Correct

    • A 35-year-old woman presents with complaints of a dull ache and numbness in her right hand. She reports that her symptoms are more severe at night and she has to hang her arm out of bed and shake it to get relief. On examination, forced flexion of the wrist and pressure over the proximal wrist crease with thumbs reproduces the paraesthesia in her thumb, index finger, and middle finger. What is the most appropriate initial management strategy?

      Your Answer: Local corticosteroid injection

      Explanation:

      Treatment Options for Carpal Tunnel Syndrome

      Carpal tunnel syndrome is a condition that affects many people, and it can be quite debilitating. However, there are several treatment options available to help manage the symptoms. It is important to note that anti-inflammatories may exacerbate symptoms, and there is no significant evidence behind using a diuretic or amitriptyline as a treatment option. Instead, treatment options include avoiding precipitating causes, simple advice about minimizing activities that trigger symptoms, nocturnal wrist splintage, and corticosteroid injection. Referral for nerve conduction studies is appropriate in some cases where there is diagnostic doubt, but if there is a clear clinical diagnosis, further investigation is not needed, and treatment can be initiated. Corticosteroid injection is a first-line treatment option and can be performed based on a clinical diagnosis in primary care by an adequately trained and competent clinician. Surgery, which would not be an appropriate initial management, would clearly need referral to secondary care. By understanding these treatment options, individuals with carpal tunnel syndrome can work with their healthcare provider to find the best approach for managing their symptoms.

    • This question is part of the following fields:

      • Musculoskeletal Health
      11.6
      Seconds
  • Question 29 - A 51-year-old woman presents to her General Practitioner with polyuria. She has a...

    Correct

    • A 51-year-old woman presents to her General Practitioner with polyuria. She has a history of multiple attendances and a previous neurology referral for headache.
      On examination, her blood pressure is 150/90 mmHg. Dipstick urinalysis reveals haematuria. She commences a three-day course of trimethoprim. She returns, still complaining of symptoms, at which point the presence of normochromic normocytic anaemia is noted, along with a serum creatinine of 220 µmol/l (normal range: 50–120 µmol/l). A urine culture result shows no growth.
      What diagnosis is most likely to explain her reduced renal function?

      Your Answer: Analgesic nephropathy

      Explanation:

      Possible Causes of Renal Dysfunction in a Patient with Chronic Headache

      One possible cause of renal dysfunction in a patient with chronic headache is analgesic nephropathy. This condition is characterized by polyuria, haematuria, deteriorating renal function, hypertension, and anaemia, which can result from long-term use of over-the-counter analgesics. Another possible cause is acute glomerulonephritis, which can present with asymptomatic proteinuria, haematuria, or nephrotic or nephritic syndrome. However, the patient’s history is more suggestive of analgesic nephropathy. Renal failure secondary to sepsis is unlikely, as the patient has no symptoms of sepsis and the urine culture is negative. Hypertensive renal disease usually presents with asymptomatic microalbuminuria and deteriorating renal function in patients with a long history of hypertension, which doesn’t fit with the clinic history given above. Reflux nephropathy, which commonly occurs in children due to a posterior urethral valve or in adults due to bladder outlet obstruction, is not suggested by the above history.

    • This question is part of the following fields:

      • Kidney And Urology
      24.8
      Seconds
  • Question 30 - A 57-year-old woman presents with persistent abdominal bloating, lower abdominal pain, and early...

    Incorrect

    • A 57-year-old woman presents with persistent abdominal bloating, lower abdominal pain, and early satiety for the past 6-9 months. She reports feeling more tired than usual and experiencing slight urinary urgency and frequency. She denies any rectal bleeding or vaginal discharge. Her last period was at the age of 52, and she has had no vaginal bleeding since then. On her previous visits, she was treated for a presumed urine infection and prescribed omeprazole, but neither intervention was effective. She has also tried an over-the-counter antispasmodic and a gluten-free diet with no improvement. Clinical examination reveals no concerning findings. What is the most appropriate next step in managing her symptoms in primary care?

      Your Answer: Perform a pelvic examination and blood test for CA125

      Correct Answer: Trial a selective serotonin reuptake inhibitor (SSRI)

      Explanation:

      Detecting Ovarian Cancer: Symptoms and Testing

      The symptoms of ovarian cancer can be vague, making it difficult to detect in its early stages. Patients may present with persistent bloating, abdominal or pelvic pain, and difficulty eating. Women over the age of 50 who experience these symptoms more than 12 times a month or for more than a month should be offered CA125 testing. If the CA125 level is 35 IU/mL or greater, an urgent ultrasound scan of the pelvis should be arranged.

      It is important to note that symptoms of ovarian cancer can overlap with less serious conditions, such as irritable bowel syndrome (IBS). However, IBS rarely arises for the first time in women over 50, so persistent symptoms should be investigated further.

      Patients who suspect they may have Coeliac disease should be tested before starting a gluten-free diet. The tTG antibody test will produce a negative result if the patient is not consuming gluten, so a daily gluten-containing diet should be followed for at least 6 weeks prior to testing. By being aware of these symptoms and testing options, healthcare professionals can help detect ovarian cancer early and improve patient outcomes.

    • This question is part of the following fields:

      • Gynaecology And Breast
      101.8
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Infectious Disease And Travel Health (1/1) 100%
Evidence Based Practice, Research And Sharing Knowledge (0/2) 0%
Metabolic Problems And Endocrinology (1/4) 25%
Respiratory Health (1/1) 100%
Ear, Nose And Throat, Speech And Hearing (2/2) 100%
Maternity And Reproductive Health (1/2) 50%
Allergy And Immunology (1/1) 100%
Gastroenterology (0/3) 0%
Children And Young People (1/1) 100%
Musculoskeletal Health (2/3) 67%
Gynaecology And Breast (1/2) 50%
Haematology (0/1) 0%
Kidney And Urology (2/3) 67%
Eyes And Vision (1/1) 100%
Smoking, Alcohol And Substance Misuse (1/1) 100%
Older Adults (1/1) 100%
Urgent And Unscheduled Care (1/1) 100%
Passmed