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Question 1
Incorrect
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A 47-year-old man is seen by his General Practitioner for his annual hypertension review. He agrees to be referred to the local smoking cessation service, as he is currently experiencing chest pain.
Which of the following medications will need to be monitored closely on cessation of smoking?Your Answer: Prednisolone
Correct Answer: Theophylline
Explanation:The Effect of Smoking Cessation on Asthma Medications
Smoking cessation can have a significant impact on the management of asthma and the use of certain medications. Here is a breakdown of how smoking cessation affects different asthma medications:
Theophylline: Smoking induces the hepatic enzyme CYP1A2, which plays a major role in metabolizing theophylline. Therefore, quitting smoking can lead to higher plasma levels of theophylline and potentially fatal arrhythmias. Patients need to have their plasma theophylline concentration levels monitored closely and may require a reduced dose after quitting smoking.
Budesonide/formoterol: Neither budesonide nor formoterol are metabolized by CYP1A2, so there is no need for close monitoring following smoking cessation. Asthma control should improve after quitting smoking, and the inhaler dose should be reviewed as part of stepwise management.
Montelukast: Montelukast is metabolized by the cytochrome P450 system but not CYP1A2, so smoking cessation does not affect its level.
Prednisolone: Prednisolone is metabolized by the cytochrome P450 system, but CYP1A2 is not involved. Therefore, smoking cessation does not affect its metabolism.
Salbutamol: Smoking cessation can improve asthma control, leading to less frequent use of salbutamol or other reliever inhalers. There is no need to monitor this closely as reducing the as-required use of this medication poses no risk.
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This question is part of the following fields:
- Haematology/Oncology
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Question 2
Correct
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A 27-year-old female patient presents to you for her cervical cancer screening and expresses interest in learning more about HPV (human papillomavirus). What is a true statement regarding HPV?
Your Answer: HPV 16 and 18 are most commonly associated with cervical cancer
Explanation:The most significant risk factor for cervical cancer is infection with the human papillomavirus (HPV), particularly types 16, 18, and 33. Among the approximately 15 types of HPV that are considered high-risk for cervical cancer, HPV 16 and 18 are responsible for about 70% of cases. HPV 6 and 11, on the other hand, are associated with the formation of genital warts.
Understanding Cervical Cancer: Risk Factors and Mechanism of HPV
Cervical cancer is a type of cancer that affects the cervix, which is the lower part of the uterus. It is most commonly diagnosed in women under the age of 45, with the highest incidence rates occurring in those aged 25-29. The cancer can be divided into two types: squamous cell cancer and adenocarcinoma. Symptoms may include abnormal vaginal bleeding, postcoital bleeding, intermenstrual bleeding, or postmenopausal bleeding, as well as vaginal discharge.
The most important factor in the development of cervical cancer is the human papillomavirus (HPV), particularly serotypes 16, 18, and 33. Other risk factors include smoking, human immunodeficiency virus, early first intercourse, many sexual partners, high parity, and lower socioeconomic status. While the association between combined oral contraceptive pill use and cervical cancer is sometimes debated, a large study published in the Lancet confirmed the link.
The mechanism by which HPV causes cervical cancer involves the production of oncogenes E6 and E7 by HPV 16 and 18, respectively. E6 inhibits the p53 tumour suppressor gene, while E7 inhibits the RB suppressor gene. Understanding the risk factors and mechanism of HPV in the development of cervical cancer is crucial for prevention and early detection. Regular cervical cancer screening is recommended for all women.
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This question is part of the following fields:
- Reproductive Medicine
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Question 3
Correct
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A 16-year-old male presents to the dermatology clinic for follow-up. He has a previous medical history of acne and is currently taking oral lymecycline. Despite treatment, there has been no improvement and upon examination, scarring is evident on his face. What is the most appropriate course of treatment?
Your Answer: Oral retinoin
Explanation:Referral for oral retinoin is recommended for patients with scarring.
Acne vulgaris is a common skin condition that typically affects adolescents, with the face, neck, and upper trunk being the most commonly affected areas. It is characterized by the obstruction of hair follicles with keratin plugs, leading to the formation of comedones, inflammation, and pustules. The severity of acne can be classified as mild, moderate, or severe, depending on the presence and extent of inflammatory lesions, papules, and pustules.
The management of acne vulgaris typically involves a step-up approach, starting with single topical therapy such as topical retinoids or benzoyl peroxide. If this is not effective, topical combination therapy may be used, which includes a topical antibiotic, benzoyl peroxide, and topical retinoid. Oral antibiotics such as tetracyclines may also be prescribed, but they should be avoided in pregnant or breastfeeding women and children under 12 years of age. Erythromycin may be used in pregnancy, while minocycline is now considered less appropriate due to the possibility of irreversible pigmentation. Oral antibiotics should be used for a maximum of three months and always co-prescribed with a topical retinoid or benzoyl peroxide to reduce the risk of antibiotic resistance.
Combined oral contraceptives (COCP) are an alternative to oral antibiotics in women, and Dianette (co-cyrindiol) may be used as it has anti-androgen properties. However, it has an increased risk of venous thromboembolism compared to other COCPs, so it should generally be used second-line and for only three months. Oral isotretinoin is a potent medication that should only be used under specialist supervision, and it is contraindicated in pregnancy. Finally, there is no evidence to support dietary modification in the management of acne vulgaris.
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This question is part of the following fields:
- Dermatology
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Question 4
Incorrect
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A 28-year-old female comes to the gastroenterology clinic for a follow-up on her Crohn's disease. She has been on budesonide for 3 months to induce remission and reports feeling well. She did not experience any acute episodes during treatment and her bowel habits are regular. The physician determines that she requires maintenance therapy. What is the most suitable medication to prescribe?
Your Answer: Mesalazine
Correct Answer: Azathioprine
Explanation:Bone marrow suppression, which can be fatal, is a potential risk associated with the use of azathioprine as a second-line treatment for Crohn’s disease. Budesonide, a corticosteroid medication primarily used for asthma prevention, may be considered as a second-line option for inducing remission in Crohn’s patients. Mesalazine, which acts locally on the colon’s mucous membrane and has various anti-inflammatory effects, is less effective than glucocorticoids but can be used as a second-line option to induce remission. Methotrexate, a folate derivative that inhibits enzymes responsible for nucleotide synthesis, is the second-line medication used to maintain remission in Crohn’s patients. However, in this case, there is no indication to use second-line management instead of first-line treatment.
Managing Crohn’s Disease: Guidelines and Treatment Options
Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract. To manage this condition, the National Institute for Health and Care Excellence (NICE) has published guidelines that provide recommendations for inducing and maintaining remission, as well as treating complications. One of the most important steps in managing Crohn’s disease is to advise patients to quit smoking, as this can worsen the condition. Additionally, some medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and the combined oral contraceptive pill, may increase the risk of relapse, although the evidence is not conclusive.
To induce remission, glucocorticoids are often used, either orally, topically, or intravenously. Budesonide is an alternative for some patients. Enteral feeding with an elemental diet may also be used, especially in young children or when there are concerns about the side effects of steroids. Second-line treatments for inducing remission include 5-ASA drugs like mesalazine, as well as azathioprine or mercaptopurine, which may be used in combination with other medications. Methotrexate is another option. Infliximab is useful for refractory disease and fistulating Crohn’s, and patients may continue on azathioprine or methotrexate.
To maintain remission, stopping smoking is a priority, and azathioprine or mercaptopurine is used first-line. TPMT activity should be assessed before starting these medications. Methotrexate is used second-line. Surgery may be necessary for around 80% of patients with Crohn’s disease, depending on the location and severity of the disease. Complications of Crohn’s disease include small bowel cancer, colorectal cancer, and osteoporosis. Perianal fistulae and abscesses require specific treatments, such as oral metronidazole, anti-TNF agents like infliximab, or a draining seton. By following these guidelines and treatment options, patients with Crohn’s disease can better manage their condition and improve their quality of life.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 5
Correct
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A mother brings in her 3-day-old female baby to the pediatrician's office. She noticed a small cyst on the roof of the baby's mouth. Upon examination, a small white cystic vesicle measuring approximately 2 mm in diameter is found on the hard palate near the midline. What is the probable diagnosis?
Your Answer: Epstein's pearl
Explanation:Epstein’s pearl, a type of congenital cyst found in the mouth, typically does not require any treatment. These cysts are commonly found on the hard palate, but can also be mistaken for a tooth eruption when located on the gums. They usually resolve on their own within a few weeks. Neonatal teeth, on the other hand, are rare and not typically found on the hard palate. Bohn’s nodules are mucous gland cysts that are usually located on the buccal or lingual aspects of the alveolar ridges, and rarely on the palate. A congenital ranula is a papule or nodule that is firm and translucent, and is typically found on the anterior floor of the mouth, lateral to the lingual frenulum.
Understanding Epstein’s Pearl
Epstein’s pearl is a type of cyst that is present in the mouth from birth. It is commonly found on the hard palate, but can also be seen on the gums, which may be mistaken for a tooth eruption. The good news is that no treatment is usually required as these cysts tend to disappear on their own within a few weeks.
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This question is part of the following fields:
- Paediatrics
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Question 6
Incorrect
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A 36-year-old entrepreneur arrives at Eye Casualty complaining of blurred vision in both eyes that started an hour ago. He reports seeing multiple wavy and shimmering lines in his peripheral vision that are gradually getting bigger. Upon examination with a slit lamp, the anterior chamber is clear and the fundus appears normal. What is the probable reason for his symptoms?
Your Answer: Posterior vitreous detachment
Correct Answer: Migraine with aura
Explanation:Migraine sufferers often experience visual symptoms before the onset of a headache, such as wavy or shimmering lines known as a scintillating scotoma. It is important to obtain a thorough medical history as the patient may not mention a history of headaches. A normal eye exam is crucial for proper diagnosis. The other conditions listed have associated exam findings, such as cells in the anterior chamber for uveitis, a pale disc and relative afferent pupillary defect for optic neuritis, and a Weiss ring appearance with occasional hemorrhage for posterior vitreous detachment.
Diagnostic Criteria for Migraine
Migraine is a neurological disorder that affects millions of people worldwide. The International Headache Society has established diagnostic criteria for migraine without aura, which includes at least five attacks lasting between 4-72 hours and having at least two of the following characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, and aggravation by routine physical activity. During the headache, there must be at least one of the following: nausea and/or vomiting, photophobia, and phonophobia. The headache cannot be attributed to another disorder.
Migraine with aura, which is seen in around 25% of migraine patients, tends to be easier to diagnose with a typical aura being progressive in nature and may occur hours prior to the headache. Typical aura include a transient hemianopic disturbance or a spreading scintillating scotoma (‘jagged crescent’). Sensory symptoms may also occur. NICE criteria suggest that migraines may be unilateral or bilateral and give more detail about typical auras, which may occur with or without headache and are fully reversible, develop over at least 5 minutes, and last 5-60 minutes. Atypical aura symptoms such as motor weakness, double vision, visual symptoms affecting only one eye, poor balance, and decreased level of consciousness may prompt further investigation or referral.
In summary, the diagnostic criteria for migraine without aura include specific characteristics of the headache and associated symptoms, while migraine with aura is characterized by typical aura symptoms that may occur prior to the headache. It is important to accurately diagnose migraine to provide appropriate treatment and management for those who suffer from this debilitating condition.
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This question is part of the following fields:
- Ophthalmology
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Question 7
Correct
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A 62-year-old woman comes to the Emergency Department with a worsening headache for one day. She noticed that the pain significantly worsened when she was brushing her hair. She also complains of pain in her jaw while talking.
Which of the following investigations is the gold standard test to confirm the suspected diagnosis of giant-cell arteritis (GCA) in this patient?Your Answer: Temporal artery biopsy
Explanation:Diagnostic Tests for Giant-Cell Arteritis
Giant-cell arteritis (GCA) is a medical emergency that requires prompt diagnosis and treatment to prevent irreversible vision loss. The gold-standard test for GCA is temporal artery biopsy, which should be performed as soon as the disease is suspected. However, treatment with corticosteroids should not be delayed until the biopsy results are available. Investigating antinuclear antibodies (ANA) is not useful, as they are usually negative in GCA. A CT scan of the brain is not typically performed for suspected GCA, but a CT angiography may be used to evaluate other large arteries. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are commonly elevated in GCA and are part of the initial evaluation. A full blood count with peripheral smear may show normocytic normochromic anemia with or without thrombocytosis. Early recognition and appropriate management of GCA are crucial to prevent serious complications.
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This question is part of the following fields:
- Musculoskeletal
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Question 8
Incorrect
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A client is observed to have a missing triceps reflex. To which nerve root does this correspond?
Your Answer: C5-C6
Correct Answer: C7-C8
Explanation:Understanding Common Reflexes
Reflexes are automatic responses of the body to certain stimuli. These responses are controlled by the nervous system and do not require conscious thought. Common reflexes include the ankle reflex, knee reflex, biceps reflex, and triceps reflex. Each reflex is associated with a specific root in the spinal cord.
The ankle reflex is associated with the S1-S2 root, which is located in the lower part of the spinal cord. This reflex is elicited by tapping the Achilles tendon with a reflex hammer. The resulting contraction of the calf muscle indicates the integrity of the spinal cord and the peripheral nerves.
The knee reflex is associated with the L3-L4 root, which is located in the middle part of the spinal cord. This reflex is elicited by tapping the patellar tendon with a reflex hammer. The resulting contraction of the quadriceps muscle indicates the integrity of the spinal cord and the peripheral nerves.
The biceps reflex is associated with the C5-C6 root, which is located in the upper part of the spinal cord. This reflex is elicited by tapping the biceps tendon with a reflex hammer. The resulting contraction of the biceps muscle indicates the integrity of the spinal cord and the peripheral nerves.
The triceps reflex is associated with the C7-C8 root, which is located in the upper part of the spinal cord. This reflex is elicited by tapping the triceps tendon with a reflex hammer. The resulting contraction of the triceps muscle indicates the integrity of the spinal cord and the peripheral nerves.
Understanding these common reflexes can help healthcare professionals diagnose and treat various neurological conditions. By testing these reflexes, they can determine if there is any damage or dysfunction in the nervous system.
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This question is part of the following fields:
- Neurology
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Question 9
Correct
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A 35-year-old man presents to his General Practitioner with weight loss, dry eyes and palpitations. He reports feeling jittery and nervous for the past few weeks. Upon examination, a fine tremor, regular pulse of 105 bpm, exophthalmos and a moderate, smooth goitre are noted. The results of his thyroid function tests are as follows:
Investigation Result Normal Value
Thyroid-stimulating hormone (TSH) 0.03 mU/l 0.25–4.0 mU/l
Free T4 38.5 pmol/l 12.0–22.0 pmol/l
Free T3 11.8 pmol/l 3.1–6.8 pmol/l
Thyroid peroxidase (TPO) antibodies Positive
What is the most likely diagnosis?Your Answer: Graves' disease
Explanation:Differentiating Causes of Thyrotoxicosis: A Brief Overview
Thyrotoxicosis, or hyperthyroidism, can be caused by various conditions, including Graves’ disease, De Quervain’s thyroiditis, Hashimoto’s thyroiditis, hypothyroidism, and toxic multinodular goitre. Among these, Graves’ disease is the most common cause, characterized by autoimmune dysfunction and typical hyperthyroid symptoms. About a third of patients with Graves’ disease also develop eye signs, while pretibial myxoedema or clubbing of the fingers may occur rarely. De Quervain’s thyroiditis, on the other hand, is associated with transient hyperthyroidism following a viral infection and neck pain. Hashimoto’s thyroiditis, an autoimmune condition, causes hypothyroidism instead of hyperthyroidism. Hypothyroidism presents with weight gain, fatigue, constipation, dry skin, and depression, and is characterized by raised TSH and reduced T4 or T3. Finally, toxic multinodular goitre is the second most common cause of hyperthyroidism in the UK, presenting with a multinodular goitre and hyperthyroidism without Graves’ disease symptoms. However, in the case presented, the positive TPO antibodies and typical Graves’ disease symptoms make it the most likely diagnosis.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 10
Incorrect
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A 45-year-old man complains of pain and redness around his first metatarsophalangeal joint. Which medication is most likely responsible for this symptom?
Your Answer: Ciprofloxacin
Correct Answer: Furosemide
Explanation:Causes of Gout: Medications and Other Factors
Gout is a type of joint inflammation that occurs due to the accumulation of monosodium urate monohydrate crystals in the synovium. This condition is caused by chronic hyperuricemia, which is characterized by high levels of uric acid in the blood (above 0.45 mmol/l).
Several medications and other factors can contribute to the development of gout. Diuretics such as thiazides and furosemide, as well as immunosuppressant drugs like ciclosporin, can increase the risk of gout. Alcohol consumption, cytotoxic agents, and pyrazinamide are also known to be associated with gout.
In addition, low-dose aspirin has been found to increase the risk of gout attacks, according to a systematic review. However, this risk needs to be weighed against the cardiovascular benefits of aspirin. Patients who are prescribed allopurinol, a medication used to treat gout, are not at an increased risk of gout attacks when taking low-dose aspirin.
Overall, it is important to be aware of the potential causes of gout, including medications and lifestyle factors, in order to prevent and manage this condition effectively.
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This question is part of the following fields:
- Musculoskeletal
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Question 11
Incorrect
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A 30-year-old man presents with multiple, ring-shaped, papular rashes on his legs. He has recently noticed a red, raised intra-oral lesion.
What is the most likely diagnosis?Your Answer: Erythema multiforme
Correct Answer: Lichen planus
Explanation:Skin Conditions: Lichen Planus, Erythema Multiforme, Psoriasis, Ringworm, and Tinea Versicolor
Lichen Planus: A skin condition that affects cutaneous and mucosal surfaces, characterised by flat-topped plaques and papules with a purple hue and white striae. It can be treated with topical steroids and immunomodulators.
Erythema Multiforme: A skin condition characterised by targetoid lesions with a central depression, usually starting on the acral extensor surfaces and progressing to involve the trunk and back. It can be caused by medications, infections, or underlying conditions.
Psoriasis: An autoimmune chronic skin condition presenting with erythematous plaques and greyscale on the extensor surfaces of extremities. It is not associated with intra-oral mucosal lesions.
Ringworm: A fungal skin infection characterised by erythematous, scaly patches on the skin surface of the trunk, back, and extremities. It can lead to the formation of pustules or vesicles.
Tinea Versicolor: A fungal skin infection characterised by pale or dark, copper-coloured patches on the arms, neck, and trunk. It does not involve mucosal surfaces.
Understanding Different Skin Conditions
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This question is part of the following fields:
- Dermatology
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Question 12
Correct
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A 4-year-old boy is brought to the doctor's office because of a rash on his upper arm. During the examination, the doctor observes several raised lesions that are approximately 2 mm in diameter. Upon closer inspection, a central dimple is visible in most of the lesions. What is the probable diagnosis?
Your Answer: Molluscum contagiosum
Explanation:Understanding Molluscum Contagiosum
Molluscum contagiosum is a viral skin infection that is commonly seen in children, particularly those with atopic eczema. It is caused by the molluscum contagiosum virus and can be transmitted through direct contact or contaminated surfaces. The infection presents as pinkish or pearly white papules with a central umbilication, which can appear anywhere on the body except for the palms of the hands and soles of the feet. In children, lesions are commonly seen on the trunk and in flexures, while in adults, sexual contact may lead to lesions developing on the genitalia, pubis, thighs, and lower abdomen.
While molluscum contagiosum is a self-limiting condition that usually resolves within 18 months, it is important to avoid sharing towels, clothing, and baths with uninfected individuals to prevent transmission. Scratching the lesions should also be avoided, and treatment may be considered if the itch is problematic. However, treatment is not usually recommended, and if necessary, simple trauma or cryotherapy may be used. In some cases, referral may be necessary, such as for individuals who are HIV-positive with extensive lesions or those with eyelid-margin or ocular lesions and associated red eye.
Overall, understanding molluscum contagiosum and taking appropriate precautions can help prevent transmission and alleviate symptoms.
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This question is part of the following fields:
- Dermatology
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Question 13
Correct
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A 56-year-old woman collapses during a hypertension clinic. She is not breathing and a carotid pulse cannot be felt. What is the appropriate ratio of chest compressions to ventilation?
Your Answer: 30:02:00
Explanation:The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.
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This question is part of the following fields:
- Cardiovascular
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Question 14
Correct
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Among the following options, which condition is considered a restrictive lung disease/condition?
Your Answer: Severe scoliosis
Explanation:Different Types of Lung Diseases and their Spirometry Patterns
Scoliosis and Lung Function
Severe scoliosis can affect the respiratory muscles and the natural movements of the thoracic cage, leading to a restrictive pattern in pulmonary function tests. This can prevent the lungs from expanding correctly, compromising their function.Cystic Fibrosis and Lung Function
In early stage cystic fibrosis, the presence of inflammation and thick secretions in the airways can cause an obstructive pattern in spirometry tests. As damage to the lung tissue occurs, a restrictive component can also develop, resulting in a combined obstructive and restrictive pattern.Emphysema and Lung Function
Emphysema is a type of obstructive lung disease characterized by abnormal and irreversible enlargement of air spaces and alveolar wall destruction. This leads to airflow limitation and a spirometry pattern typical of obstructive lung disease.Asthma and Lung Function
Asthma is an inflammatory disorder of the airways that causes hyperresponsiveness and constriction of the airways in response to various stimuli. This leads to airflow limitation and a spirometry pattern typical of obstructive lung disease.Bronchiectasis and Lung Function
Bronchiectasis is characterized by abnormal and irreversible dilatation of the bronchial walls, leading to accumulation of secretions and recurrent inflammation of the airways. This produces an obstructive pattern in pulmonary function tests.In summary, different types of lung diseases can affect lung function in various ways, leading to different spirometry patterns. Understanding these patterns can help in the diagnosis and management of these conditions.
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This question is part of the following fields:
- Respiratory Medicine
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Question 15
Correct
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A mother brings her 8-year-old daughter to her General Practitioner, who is acutely unwell and has a high temperature, runny nose and inflamed eyes. The mother explains that her daughter has not had her vaccinations as she is worried about the long-term effects of the measles, mumps and rubella (MMR) jab.
Which of the following best reflects the current understanding of measles infection?Your Answer: It is more dangerous in overcrowded households
Explanation:Measles: Symptoms, Complications, and Prevention
Measles is a highly contagious viral infection that can lead to serious respiratory complications such as pneumonia, bronchiolitis, and bronchiectasis. While it does not cause recurrent pneumothoraces, severe infection from prolonged exposure to infected siblings in overcrowded households can be fatal.
Koplik’s spots, small red spots with bluish-white centers, are a characteristic late sign of measles infection that may appear on the mucous membranes of the mouth 1-2 days before the rash appears.
Contrary to popular belief, lifelong immunity is often established after natural infection with measles. This is also the mechanism by which the MMR vaccine prevents measles infection in later life.
Measles can also lead to corneal ulceration, especially in cases of vitamin A deficiency. High-dose oral vitamin A supplementation is recommended for all children with measles in developing countries to prevent this complication.
Overall, prevention through vaccination is the best way to avoid the serious complications of measles.
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This question is part of the following fields:
- Infectious Diseases
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Question 16
Correct
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Breast cancer is a disease that affects many women. What is true about breast cancer? Choose one statement from the options provided.
Your Answer: The cumulative risk of dying of breast cancer between 5 and 14 years after first diagnosis is improved 10-15% by tamoxifen with oestrogen-receptor-positive tumours.
Explanation:Breast cancer is the second most common cancer in women and the leading cause of cancer death among women worldwide. Tamoxifen is a drug that can be used to treat breast cancer that requires estrogen to grow. It works by either blocking estrogen receptors or blocking the production of estrogen. For women with estrogen receptor-positive breast cancer, continuing tamoxifen for 10 years instead of stopping at 5 years can further reduce the risk of recurrence and mortality. However, tamoxifen does not affect the risk of breast cancer recurrence. The risk of endometrial cancer is slightly increased with tamoxifen treatment. Screening modalities include breast self-examination, clinical breast examination, mammography, ultrasonography, and magnetic resonance imaging. Early detection is crucial in preventing breast cancer, and screening intervals may need to be shortened to prevent more deaths. Physical examination and biopsy are also important diagnostic approaches. Treatment for breast cancer typically involves surgery, radiation therapy, and adjuvant hormone or chemotherapy when necessary.
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This question is part of the following fields:
- Reproductive Medicine
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Question 17
Correct
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A 60-year-old man had a left mastectomy three years ago for breast cancer. He has now presented with a 4-month history of progressive ataxia and dysarthria. On examination, there is gaze-evoked nystagmus, dysarthria, upper limb ataxia and gait ataxia. Power, tone, reflexes and sensation are normal. Plantar response is flexor bilaterally. Computerised tomography (CT) and magnetic resonance imaging (MRI) of the brain and cerebrospinal fluid (CSF) microscopy are normal.
Which one of the following is the most likely cause of his ataxia?Your Answer: Paraneoplastic cerebellum syndrome
Explanation:Differential diagnosis for a patient with subacute cerebellar dysfunction and normal imaging
Paraneoplastic cerebellum syndrome, multiple sclerosis, cerebellar metastasis, malignant meningitis, and Wernicke’s encephalopathy are among the possible diagnoses for a patient presenting with subacute onset of cerebellar signs and normal imaging.
Paraneoplastic cerebellum syndrome is a rare immune-mediated complication of many cancers, which may be diagnosed before the underlying tumour. Symptoms develop rapidly and include dizziness, nausea, vertigo, nystagmus, ataxia, oscillopsia, dysarthria, tremor, dysphagia, and blurry vision. MRI may be normal, but CSF may show raised protein and anti-neuronal antibodies.
Multiple sclerosis is more common in women and usually presents with transient episodes of visual change or limb weakness/paraesthesiae, as well as bladder and cerebellar dysfunction. MRI may visualise plaques of demyelination, and CSF shows oligoclonal bands.
Cerebellar metastasis could occur in breast cancer, but it would be visualised on MRI.
Malignant meningitis occurs when cancer spreads to the meninges and presents with confusion, headaches, and weakness. Imaging and CSF would be abnormal.
Wernicke’s encephalopathy is due to thiamine deficiency, typically seen in alcoholics, and presents with acute confusional state, ophthalmoplegia, and gait ataxia. Dysarthria is not usually a feature. Thiamine deficiency is not suggested by this patient’s history.
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This question is part of the following fields:
- Neurology
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Question 18
Incorrect
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A 75-year-old man is brought to the emergency department by ambulance after being found unresponsive in his home. His medical records show that he had recently been prescribed doxycycline for an unknown reason. Upon assessment, he is breathing rapidly with a respiratory rate of 40 breaths/min and has bibasal crackles. His heart rate is 96 beats/min and his blood pressure is 82/44 mmHg. His blood glucose is 4.1mmol/L, his temperature 38.9ºC and his Glasgow Coma Scale (GCS) is 9 (E3M4V2). He is given a fluid bolus and an arterial blood gas (ABG) on 4L/min of oxygen is taken, revealing an abnormal pH. What is the most likely cause of the abnormal pH?
Your Answer: Carbon dioxide retention
Correct Answer: Lactic acidosis
Explanation:Understanding Metabolic Acidosis and Anion Gap
Metabolic acidosis is a condition that occurs when the body produces too much acid or when the kidneys are not able to remove enough acid from the body. It is commonly classified according to the anion gap, which can be calculated by subtracting the sum of chloride and bicarbonate levels from the sum of sodium and potassium levels. The normal range for anion gap is 10-18 mmol/L. If a question supplies the chloride level, it may be a clue that the anion gap should be calculated.
There are two types of metabolic acidosis based on anion gap levels. Normal anion gap or hyperchloraemic metabolic acidosis is caused by gastrointestinal bicarbonate loss, prolonged diarrhea, ureterosigmoidostomy, fistula, renal tubular acidosis, drugs, ammonium chloride injection, and Addison’s disease. On the other hand, raised anion gap is caused by lactate, ketones, urate, acid poisoning, and other factors.
Metabolic acidosis secondary to high lactate levels may be subdivided into two types: lactic acidosis type A and lactic acidosis type B. Lactic acidosis type A is caused by sepsis, shock, hypoxia, and burns, while lactic acidosis type B is caused by metformin. Understanding the different types of metabolic acidosis and anion gap levels can help in diagnosing and treating the condition.
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This question is part of the following fields:
- Respiratory Medicine
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Question 19
Correct
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A 72-year-old man who smokes visits your GP clinic and inquires about potential complications associated with surgical resection of his malignant parotid gland tumour. What is the classic complication linked to parotid gland surgery?
Your Answer: Lower motor neurone facial palsy
Explanation:A lower motor neurone facial palsy can be caused by parotid pathology.
After exiting the stylomastoid foramen, the facial nerve passes through the parotid gland and divides into five branches: temporal, zygomatic, buccal, marginal mandibular, and cervical. If there is any pathology within the parotid gland, it can lead to a lower motor neurone facial palsy. Additionally, surgery to the parotid gland can also result in this complication.
Facial Nerve Palsy: Causes and Path
Facial nerve palsy is a condition that affects the facial nerve, which supplies the muscles of facial expression, digastric muscle, and glandular structures. It can be caused by various factors, including sarcoidosis, Guillain-Barre syndrome, Lyme disease, acoustic neuromas, and Bell’s palsy. Bilateral facial nerve palsy is less common and can be caused by the same factors as unilateral palsy, but it can also be a result of neurofibromatosis type 2.
The facial nerve has two paths: the subarachnoid path and the facial canal path. The subarachnoid path originates from the pons and passes through the petrous temporal bone into the internal auditory meatus with the vestibulocochlear nerve. The facial canal path passes superior to the vestibule of the inner ear and contains the geniculate ganglion at the medial aspect of the middle ear. It has three branches: the greater petrosal nerve, the nerve to stapedius, and the chorda tympani. The facial nerve then passes through the stylomastoid foramen and gives rise to the posterior auricular nerve and a branch to the posterior belly of the digastric and stylohyoid muscle.
It is important to differentiate between lower motor neuron and upper motor neuron lesions in facial nerve palsy. An upper motor neuron lesion spares the upper face, while a lower motor neuron lesion affects all facial muscles. Multiple sclerosis and diabetes mellitus can also cause an upper motor neuron palsy. Understanding the causes and path of facial nerve palsy can aid in its diagnosis and treatment.
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This question is part of the following fields:
- ENT
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Question 20
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A 28-year-old Afro-Caribbean woman presents with a 3-month history of a non-productive cough, dyspnoea and pleuritic chest pain, especially when climbing stairs. She reports intermittent fevers of up to 39°C and a 3.5-kg weight loss. She complains of wrist and ankle pain that has interfered with her work. She smokes two packets of cigarettes per day. Her full blood count is normal and serum ANA is negative. On examination there are red nodules over her lower legs.
Which of the following is the most likely diagnosis?Your Answer: Sarcoidosis
Explanation:Sarcoidosis is a condition where non-caseating granulomata develop in at least two organs, causing systemic inflammation. It is most common in African-Caribbean women and often affects the lungs, causing symptoms such as dry cough, dyspnea, and weight loss. Erythema nodosum is also frequently seen in patients with sarcoidosis. Histoplasmosis, Goodpasture’s syndrome, adenocarcinoma of the lung, and systemic lupus erythematosus are all possible differential diagnoses, but the absence of specific features makes sarcoidosis more likely in this case.
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This question is part of the following fields:
- Respiratory Medicine
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Question 21
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A 45-year-old man visits his GP with a lump on the side of his head. During the examination, the GP suspects that the lump may be a basal cell carcinoma. What characteristic is most indicative of this diagnosis?
Your Answer: Telangiectasia
Explanation:Understanding Basal Cell Carcinomas: Symptoms and Diagnosis
Basal cell carcinomas are the most common type of non-melanocytic skin carcinoma, typically found in sun-exposed areas of the skin such as the face and neck. They can be familial and associated with certain syndromes. Symptoms of basal cell carcinomas include a slow-growing, skin-colored, pearly nodule with surface telangiectasia, an ulcerated lesion with rolled edges, and crusted edges. Pigmentation is not a predominant feature, but bleeding may occur. Size is not a specific feature of malignancy, but sudden changes in size should be referred to a dermatologist for further assessment and investigation. Diagnosis is confirmed with a biopsy, and treatment involves excision with a clear margin. Recurrence is possible, but basal cell carcinomas rarely metastasize.
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This question is part of the following fields:
- Dermatology
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Question 22
Correct
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At what age should individuals be offered human papillomavirus vaccination for the first time?
Your Answer: Girls and boys aged 12-13 years
Explanation:Starting September 2019, boys in school Year 8 who are 12-13 years old will also be provided with the HPV vaccine, which is currently administered in two doses. Girls receive the second dose within 6-24 months after the first, depending on local guidelines.
The human papillomavirus (HPV) is a known carcinogen that infects the skin and mucous membranes. There are numerous strains of HPV, with the most significant being 6 & 11, which cause genital warts, and 16 & 18, which are linked to various cancers, particularly cervical cancer. HPV infection is responsible for over 99.7% of cervical cancers, and testing for HPV is now a crucial part of cervical cancer screening. Other cancers linked to HPV include anal, vulval, vaginal, mouth, and throat cancers. While there are other risk factors for cervical cancer, such as smoking and contraceptive pill use, HPV is a significant contributor.
In 2008, the UK introduced a vaccination for HPV, initially using Cervarix, which protected against HPV 16 & 18 but not 6 & 11. This decision was criticized due to the significant disease burden caused by genital warts. In 2012, Gardasil replaced Cervarix as the vaccine used, protecting against HPV 6, 11, 16 & 18. Initially given only to girls, boys were also offered the vaccine from September 2019. All 12- and 13-year-olds in school Year 8 are offered the HPV vaccine, which is typically given in school. Parents are informed that their daughter may receive the vaccine against their wishes. The vaccine is given in two doses, with the second dose administered between 6-24 months after the first, depending on local policy. Men who have sex with men under the age of 45 should also be offered the HPV vaccine to protect against anal, throat, and penile cancers. Injection site reactions are common with HPV vaccines.
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This question is part of the following fields:
- Reproductive Medicine
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Question 23
Incorrect
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A 40-year-old male visits his GP complaining of pain in his foot and lower limb that worsens at night. He reports that the pain alleviates when he dangles his leg over the bed's edge. Upon further inquiry, he mentions experiencing 'pins and needles' in his fingers, which feel cold. The patient has no medical history but is a heavy smoker, consuming 25 cigarettes per day. What is the probable diagnosis based on the given information?
Your Answer: Peripheral vascular disease
Correct Answer: Buerger's disease
Explanation:Buerger’s disease (thromboangiitis obliterans) is the likely diagnosis for a young male smoker experiencing symptoms similar to limb ischaemia. This non-atherosclerotic vasculitis primarily affects medium-sized arteries and is most common in young male smokers. Symptoms include cold sensation or paraesthesia in the limbs or fingers, rest pain, and possible ulceration or gangrene. Granulomatosis with polyangiitis and peripheral vascular disease are important differentials to consider, but unlikely in this case. Sickle cell anaemia and vitamin B12 deficiency are also less likely explanations for the symptoms.
Understanding Buerger’s Disease
Buerger’s disease, also known as thromboangiitis obliterans, is a type of vasculitis that affects the small and medium-sized blood vessels. This condition is strongly linked to smoking and can cause a range of symptoms, including extremity ischemia, intermittent claudication, ischaemic ulcers, superficial thrombophlebitis, and Raynaud’s phenomenon.
Individuals with Buerger’s disease may experience reduced blood flow to their limbs, which can lead to pain, numbness, and tingling sensations. This can make it difficult to walk or perform other activities, and may even result in the development of ulcers or sores on the skin.
Superficial thrombophlebitis, or inflammation of the veins close to the surface of the skin, is another common symptom of Buerger’s disease. This can cause redness, swelling, and tenderness in the affected area.
Raynaud’s phenomenon, which is characterized by the narrowing of blood vessels in the fingers and toes, is also associated with Buerger’s disease. This can cause the affected areas to turn white or blue and feel cold and numb.
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This question is part of the following fields:
- Neurology
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Question 24
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You are conducting the eight-week baby check on a healthy infant who was born at term. As part of health promotion, you are discussing ways to minimize the risk of Sudden Infant Death Syndrome (SIDS) with the mother. She is already aware of the significance of placing the baby on its back while sleeping and does not smoke. What is the most crucial additional risk factor for SIDS?
Your Answer: Sleeping in the same bed as the baby
Explanation:Studies have indicated that bed sharing is the most prominent risk factor for SIDS, followed by prone sleeping, parental smoking, hyperthermia and head covering, and prematurity.
Understanding Sudden Infant Death Syndrome
Sudden infant death syndrome (SIDS) is the leading cause of death in infants during their first year of life, with the highest incidence occurring at three months of age. There are several major risk factors associated with SIDS, including placing the baby to sleep on their stomach, parental smoking, prematurity, bed sharing, and hyperthermia or head covering. These risk factors are additive, meaning that the more risk factors present, the higher the likelihood of SIDS. Other risk factors include male sex, multiple births, lower social classes, maternal drug use, and an increased incidence during winter.
However, there are also protective factors that can reduce the risk of SIDS. Breastfeeding, room sharing (but not bed sharing), and the use of pacifiers have been shown to be protective. In the event of a SIDS occurrence, it is important to screen siblings for potential sepsis and inborn errors of metabolism.
Overall, understanding the risk factors and protective factors associated with SIDS can help parents and caregivers take steps to reduce the likelihood of this tragic event. By following safe sleep practices and promoting healthy habits, we can work towards reducing the incidence of SIDS.
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This question is part of the following fields:
- Paediatrics
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Question 25
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A 28-year-old woman visits her GP because she is worried about her ability to conceive. She has experienced three miscarriages in the past five years and has also had an unprovoked deep vein thrombosis. The GP orders various blood tests and suspects that one of them may show a positive result for a potential cause of her issues.
Which of the following antibody tests is the most likely to be positive? Choose only ONE option.Your Answer: Anti-phospholipid antibodies
Explanation:Autoimmune Antibodies and Their Associated Conditions
Autoimmune disorders are conditions in which the immune system mistakenly attacks the body’s own tissues. One way to diagnose autoimmune disorders is by testing for specific antibodies that are associated with certain conditions. Here are some common autoimmune antibodies and the conditions they are associated with:
1. Anti-phospholipid antibodies: These antibodies are linked to anti-phospholipid syndrome (APS), also known as Hughes’ syndrome. APS can cause blood clots and pregnancy-related complications.
2. Anti-endomysial antibodies: These antibodies are associated with coeliac disease, an autoimmune disorder that affects the small intestine.
3. Anti-histone antibodies: These antibodies are linked to drug-induced systemic lupus erythematosus (SLE), another autoimmune disorder.
4. Anti-mitochondrial antibodies: These antibodies are associated with primary biliary cholangitis, autoimmune hepatitis, and idiopathic cirrhosis, all of which affect the liver.
5. Anti-nuclear antibodies: These antibodies are associated with several autoimmune disorders, including SLE, autoimmune hepatitis, Sjögren’s syndrome, systemic sclerosis, and rheumatoid arthritis.
Testing for these antibodies can help diagnose autoimmune disorders and guide treatment.
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This question is part of the following fields:
- Haematology/Oncology
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Question 26
Correct
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A 67-year-old woman is brought to the Emergency Department after being found near-unconscious by her husband. Her husband indicates that she has a long-term joint disorder for which she has been taking oral steroids for many years. She has recently been suffering from depression and has had poor compliance with medications.
On examination, she is responsive to pain. Her pulse is 130 beats per minute, and her blood pressure is 90/60 mmHg. She is afebrile.
Basic blood investigations reveal the following:
Investigation Patient Normal value
Haemoglobin (Hb) 121 g/l 135–175 g/l
White cell count (WCC) 6.1 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 233 × 109/l 150–400 × 109/l
Sodium (Na+) 129 mmol/l 135–145 mmol/l
Potassium (K+) 6.0 mmol/l 3.5–5.0 mmol/l
Creatinine (Cr) 93 μmol/l 50–120 µmol/l
Glucose 2.7 mmol/l < 11.1 mmol/l (random)
What is the most likely diagnosis?Your Answer: Addisonian crisis
Explanation:Differential Diagnosis: Addisonian Crisis and Other Conditions
Addisonian Crisis: A Brief Overview
Addison’s disease, or adrenal insufficiency, is a condition that results from the destruction of the adrenal cortex, leading to a deficiency in glucocorticoid and mineralocorticoid hormones. The majority of cases in the UK are due to autoimmune disease, while tuberculosis is the most common cause worldwide. Patients with Addison’s disease may present with vague symptoms such as anorexia, weight loss, and gastrointestinal upset, as well as hyperpigmentation of the skin. Basic investigations may reveal hyponatremia, hyperkalemia, and hypoglycemia. A short ACTH stimulation test is used to confirm the diagnosis. Emergency treatment involves IV or IM hydrocortisone and fluids, while long-term treatment is based on oral cortisol and mineralocorticoid replacement.
Differential Diagnosis
Insulin Overdose: While hypoglycemia is a common feature of insulin overdose, the clinical information provided suggests that the low glucose level is due to the loss of the anti-insulin effect of cortisol, which is a hallmark of Addison’s disease.
Meningococcal Septicaemia: Although hypotension and tachycardia may be present in meningococcal septicaemia, the other features described do not support this diagnosis.
Paracetamol Overdose: Paracetamol overdose can cause liver toxicity, but the clinical features described are not typical of this condition and are more suggestive of an Addisonian crisis.
Salicylate Overdose: Salicylate overdose can cause a range of symptoms, including nausea, vomiting, and abdominal pain, but the clinical features described do not support this diagnosis.
Conclusion
Based on the information provided, an Addisonian crisis is the most likely diagnosis. However, further investigations may be necessary to rule out other conditions. Prompt recognition and treatment of an Addisonian crisis are essential to prevent life-threatening complications.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 27
Correct
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A 7-year-old girl is brought to surgery by her father. For the past 3 months she has been complaining of pain in her shins and ankles at night-time. Her symptoms are bilateral and she is otherwise healthy. There is no significant family history. Upon clinical examination, no abnormalities are found. What is the probable diagnosis?
Your Answer: Growing pains
Explanation:Understanding Growing Pains in Children
Growing pains are a common complaint among children aged 3-12 years. These pains are often attributed to ‘benign idiopathic nocturnal limb pains of childhood’ in rheumatology, as they are not necessarily related to growth. Boys and girls are equally affected by growing pains, which are characterized by intermittent pain in the legs with no obvious cause.
One of the key features of growing pains is that they are never present at the start of the day after the child has woken up. Additionally, there is no limp or limitation of physical activity, and the child is systemically well with normal physical examination and motor milestones. Symptoms may worsen after a day of vigorous activity.
Overall, growing pains are a benign condition that can be managed with reassurance and simple measures such as massage or heat application. However, it is important to rule out other potential causes of leg pain in children, especially if there are any worrying features present.
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This question is part of the following fields:
- Paediatrics
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Question 28
Incorrect
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A 67-year-old woman presents to the breast clinic with an abnormal mammogram and a small fixed lump in her right breast. What type of breast cancer is most frequently encountered?
Your Answer: Invasive lobular carcinoma
Correct Answer: Invasive ductal carcinoma (no special type)
Explanation:The most prevalent form of breast cancer is invasive ductal carcinoma, without any distinctive features.
Breast Cancer: Understanding Types and Classification
Breast cancer can be classified based on the type of tissue it originates from, namely duct or lobular tissue. Ductal carcinoma and lobular carcinoma are the two main types of breast cancer, which can further be classified as either carcinoma-in-situ or invasive. Invasive ductal carcinoma, also known as No Special Type, is the most common type of breast cancer. Lobular carcinoma and other rare types of breast cancer are classified as Special Type.
Apart from the common types, there are several rarer types of breast cancer, including medullary breast cancer, mucinous breast cancer, tubular breast cancer, adenoid cystic carcinoma of the breast, metaplastic breast cancer, lymphoma of the breast, basal type breast cancer, phyllodes or cystosarcoma phyllodes, and papillary breast cancer. Paget’s disease of the nipple is another type of breast cancer that is associated with an underlying mass lesion. Inflammatory breast cancer is a rare type of breast cancer that results in an inflamed appearance of the breast due to cancerous cells blocking the lymph drainage.
Understanding the different types and classifications of breast cancer is crucial for accurate diagnosis and treatment. It is important to note that some types of breast cancer may be associated with underlying lesions seen in the common types, rather than being completely separate subtypes.
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This question is part of the following fields:
- Haematology/Oncology
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Question 29
Correct
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An 80-year-old man complains of lower back pain and right hip pain. Upon conducting blood tests, the following results were obtained:
Calcium 2.20 mmol/l
Phosphate 0.8 mmol/l
ALP 890 u/L
What is the probable diagnosis?Your Answer: Paget's disease
Explanation:Understanding Paget’s Disease of the Bone
Paget’s disease of the bone is a condition characterized by increased and uncontrolled bone turnover. It is believed to be caused by excessive osteoclastic resorption followed by increased osteoblastic activity. Although it is a common condition, affecting 5% of the UK population, only 1 in 20 patients experience symptoms. The most commonly affected areas are the skull, spine/pelvis, and long bones of the lower extremities. Predisposing factors include increasing age, male sex, northern latitude, and family history.
Symptoms of Paget’s disease include bone pain, particularly in the pelvis, lumbar spine, and femur. The stereotypical presentation is an older male with bone pain and an isolated raised alkaline phosphatase (ALP). Classical, untreated features include bowing of the tibia and bossing of the skull. Diagnosis is made through blood tests, which show raised ALP, and x-rays, which reveal osteolysis in early disease and mixed lytic/sclerotic lesions later.
Treatment is indicated for patients experiencing bone pain, skull or long bone deformity, fracture, or periarticular Paget’s. Bisphosphonates, either oral risedronate or IV zoledronate, are the preferred treatment. Calcitonin is less commonly used now. Complications of Paget’s disease include deafness, bone sarcoma (1% if affected for > 10 years), fractures, skull thickening, and high-output cardiac failure.
Overall, understanding Paget’s disease of the bone is important for early diagnosis and management of symptoms and complications.
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This question is part of the following fields:
- Musculoskeletal
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Question 30
Correct
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A 52-year-old woman presents to her general practitioner (GP) with symptoms of a urinary tract infection. There is a history of multiple attendances and a previous neurology referral for migraine. She admits to taking multiple painkillers for her headaches. Blood pressure is 160/90 mmHg. Urinalysis reveals haematuria, and the GP commences her on a 2-week course of nitrofurantoin. She returns, still complaining of symptoms, at which point the presence of a normochromic normocytic anaemia is noted, along with a serum creatinine level of 230 μmol/l (reference range 44–97 μmol/l).
What diagnosis fits best with this clinical picture?Your Answer: Analgesic nephropathy
Explanation:Possible Diagnosis for a Patient with Excessive Analgesic Consumption
Excessive consumption of analgesic medications such as aspirin and paracetamol can lead to kidney injury, a condition known as analgesic nephropathy. This is caused by decreased blood flow to the kidney, rapid consumption of antioxidants, and subsequent oxidative damage to the kidney, resulting in renal papillary necrosis and chronic interstitial nephritis. The kidney injury may lead to progressive chronic kidney disease, abnormal urinalysis results, hypertension, and normochromic normocytic anaemia.
Other possible diagnoses for renal damage include reflux nephropathy, acute nephritis, renal failure secondary to sepsis, and hypertensive renal disease. Reflux nephropathy is characterized by renal damage due to the backflow of urine from the bladder towards the kidneys, while acute nephritis is caused by infections or drug-associated hypersensitivity. Renal failure secondary to sepsis is associated with systemic inflammatory response syndrome, and hypertensive renal disease is defined by the coexistence of renal arterial vascular disease and hypertension.
In the given clinical scenario, the most likely diagnosis is analgesic nephropathy due to the patient’s history of excessive analgesic consumption. However, other diagnoses cannot be ruled out without further evaluation.
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This question is part of the following fields:
- Renal Medicine/Urology
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