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Question 1
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A 28-year-old man presents with an acutely red right eye. He also has dull aching pain affecting the eye, and he is photosensitive, with light severely worsening the pain in the eye. There is no mucopurulent discharge and he has mild blurring of vision. The left eye is not affected. Other past history of note includes intermittent diarrhoea, which he says looked bloody on a couple of occasions, but he put this down to food poisoning. On examination, his blood pressure is 125/72 mmHg; he looks thin, with a body mass index of 19.
Investigations:
Investigation Result Normal value
Haemoglobin 119 g/l 135–175 g/l
White cell count (WCC) 8.1 × 109/l 4–11 × 109/l
Platelets 204 × 109/l 150–400 × 109/l
Erythrocyte sedimentation rate (ESR) 35 mm/h 0–10mm in the 1st hour
Sodium (Na+) 141 mmol/l 135–145 mmol/l
Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
Creatinine 130 μmol/l 50–120 µmol/l
Intraocular pressure: reduced in the affected eye, with numerous cells seen within the aqueous.
Which of the following is the most likely diagnosis?Your Answer: Anterior uveitis
Explanation:Differential Diagnosis for a Red, Painful Eye with Photophobia: Anterior Uveitis
Anterior uveitis is a possible diagnosis for a patient presenting with a red, painful eye and photophobia. The condition can be idiopathic or associated with systemic inflammatory diseases, such as ulcerative colitis. The presence of inflammatory cells in the aqueous is a hallmark of anterior uveitis. Treatment typically involves cyclopentolate for ocular pain relief and corticosteroids to reduce inflammation. Tapering of corticosteroid therapy is guided by the degree of clinical response.
Other potential diagnoses, such as conjunctivitis and herpetic ulcer, can be ruled out based on the absence of certain symptoms and risk factors. Acute glaucoma is also unlikely as intraocular pressures are low in anterior uveitis, whereas they would be expected to be raised in acute glaucoma. Anterior scleritis is another possibility, but it is less likely in this case as the examination findings do not mention intense redness of the anterior sclera.
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This question is part of the following fields:
- Ophthalmology
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Question 2
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A 28-year-old primigravida 1+0 arrives at 35 weeks gestation with a blood pressure reading of 165/120 mmHg and 3+ proteinuria on dipstick testing. She had a stable blood pressure of approximately 115/75mmHg before becoming pregnant, and her only medical history is well-managed asthma. Which of the following statements is correct regarding her treatment?
Your Answer: In induced labour, epidural anaesthesia should help reduce blood pressure
Explanation:1. The only effective treatment for pre-eclampsia is delivery, while IV magnesium sulphate is administered to prevent seizures in eclampsia.
2. Delivery on the same day is a viable option after 34 weeks.
3. Nifedipine is considered safe for breastfeeding mothers. (However, labetalol is the preferred antihypertensive medication, as beta-blockers should be avoided in patients with a history of asthma.)
4. Epidural anaesthesia can help lower blood pressure.
5. It is important to continue hypertension treatment during labour to manage blood pressure levels. Please refer to the NICE guideline on the diagnosis and management of hypertension in pregnancy for further information.Pre-eclampsia is a condition that occurs during pregnancy and is characterized by high blood pressure, proteinuria, and edema. It can lead to complications such as eclampsia, neurological issues, fetal growth problems, liver involvement, and cardiac failure. Severe pre-eclampsia is marked by hypertension, proteinuria, headache, visual disturbances, and other symptoms. Risk factors for pre-eclampsia include hypertension in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension, first pregnancy, and age over 40. Aspirin may be recommended for women with high or moderate risk factors. Treatment involves emergency assessment, admission for observation, and medication such as labetalol, nifedipine, or hydralazine. Delivery of the baby is the most important step in management, with timing depending on the individual case.
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This question is part of the following fields:
- Obstetrics
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Question 3
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A 20-year-old apprentice is referred by his general practitioner with a query of bacterial meningitis. A computed tomography (CT) scan of the brain was normal. The patient complains of ongoing headache, photophobia and fever. A lumbar puncture (LP) is to be performed.
Which one of the following statements is correct with regard to performing an LP?Your Answer: A concurrent plasma glucose sample should be taken
Explanation:Guidelines for Lumbar Puncture in Patients with Suspected Meningitis
Lumbar puncture (LP) is a diagnostic procedure that involves the insertion of a needle into the spinal canal to obtain cerebrospinal fluid (CSF) for analysis. LP is an essential tool in the diagnosis of bacterial meningitis, but it should be performed with caution and only in appropriate patients. Here are some guidelines for LP in patients with suspected meningitis:
Concurrent plasma glucose sample should be taken to calculate the CSF: plasma glucose ratio, which is a key distinguishing feature of bacterial meningitis.
Normal CSF opening pressure ranges from 7-18 mmH2O.
Verbal consent for the procedure is sufficient, but written consent should be obtained from the patient if possible.
LP is typically performed in the left lateral position, but it may be performed in the sitting position or with imaging guidance if necessary.
Neuroimaging is required before an LP only in patients with a clinical suspicion of raised intracranial pressure, especially in immunocompromised patients.
Possible complications of LP include post-dural puncture headache, transient paraesthesiae, spinal haematoma or abscess, and tonsillar herniation. These should be discussed with the patient before the procedure.
LP should not be performed in patients with an acutely raised CSF pressure, as it may cause brainstem herniation.
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This question is part of the following fields:
- Neurology
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Question 4
Incorrect
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A 50-year-old woman presents with severe itching in the perineal region, accompanied by pain during urination and painful intercourse. During examination, you observe white, polygonal papules on the labia majora that merge into a patch that affects the labia minora. There is one area of fissuring that bleeds upon contact. The skin appears white, thin, and shiny, with mild scarring. There is no vaginal discharge, and no other skin lesions are present on the body. What is the most probable diagnosis?
Your Answer: Lichen planus
Correct Answer: Lichen sclerosus
Explanation:Common Genital Skin Conditions: Symptoms and Treatment Options
Lichen sclerosus, candidiasis, contact dermatitis, lichen planus, and psoriasis are some of the most common skin conditions that affect the genital area. Each condition has its own set of symptoms and treatment options.
Lichen Sclerosus: This chronic inflammatory condition can affect any part of the body but is most commonly found in the genital area. It presents with pruritus, skin irritation, hypopigmentation, and atrophy. Treatment involves topical steroids and good hygiene.
Candidiasis: This fungal infection is associated with pruritus, burning sensation, erythema, and oedema of the vestibule. The most common characteristic is a thick, curd-like, white vaginal discharge.
Contact Dermatitis: This condition is often caused by changes to shower gel or washing detergent. It presents with pruritus, erythematosus skin, excoriations, and skin breaks, leading to ulceration and superimposed infection. Chronic contact dermatitis can lead to lichenoid changes.
Lichen Planus: This condition presents with purple, red plaques usually on the labia, with central erosion and overlying lacy, white, striated patch. It can cause scarring and narrowing of the introitus and dyspareunia.
Psoriasis: This condition is rare in the genital area but can appear in the inguinal creases and the labia majora. It presents with erythematous plaques with minimal white scale and is associated with itching and excoriations.
It is important to seek medical attention if you suspect you have any of these conditions. Treatment options may include topical or oral medications, good hygiene practices, and lifestyle changes.
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This question is part of the following fields:
- Gynaecology
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Question 5
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A 35-year-old woman is 39 weeks pregnant with twins (dichorionic diamniotic). During labor, the midwife observes the umbilical cord protruding from the vagina. The emergency button is pressed, and the woman is rushed for an emergency C-section. What is the most probable cause of umbilical cord prolapse?
Your Answer: Artificial amniotomy
Explanation:The most probable reason for umbilical cord prolapse is artificial rupture of membranes. Factors such as cephalic presentation, nulliparity, and prolonged pregnancy decrease the chances of cord prolapse. Prostaglandins do not significantly affect the risk of cord prolapse.
Understanding Umbilical Cord Prolapse
Umbilical cord prolapse is a rare but serious complication that can occur during delivery. It happens when the umbilical cord descends ahead of the presenting part of the fetus, which can lead to compression or spasm of the cord. This can cause fetal hypoxia and potentially irreversible damage or death. Certain factors increase the risk of cord prolapse, such as prematurity, multiparity, polyhydramnios, twin pregnancy, cephalopelvic disproportion, and abnormal presentations like breech or transverse lie.
Around half of all cord prolapses occur when the membranes are artificially ruptured. Diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally or visible beyond the introitus. Cord prolapse is an obstetric emergency that requires immediate management. The presenting part of the fetus may be pushed back into the uterus to avoid compression, and the cord should be kept warm and moist to prevent vasospasm. The patient may be asked to go on all fours or assume the left lateral position until preparations for an immediate caesarian section have been carried out. Tocolytics may be used to reduce uterine contractions, and retrofilling the bladder with saline can help elevate the presenting part. Although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery may be possible if the cervix is fully dilated and the head is low.
In conclusion, umbilical cord prolapse is a rare but serious complication that requires prompt recognition and management. Understanding the risk factors and appropriate interventions can help reduce the incidence of fetal mortality associated with this condition.
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This question is part of the following fields:
- Obstetrics
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Question 6
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A 65-year-old man presents to the Emergency Department after several episodes of vomiting bright red blood. He has presented to the same hospital in the past for spontaneous bacterial peritonitis, alcohol intoxication and peptic ulcer disease (PUD). The gastroenterology team review the patient and perform an urgent gastroscopy, which reveals several oesophageal varices.
Which of the following medications should be prescribed to this patient to reduce his chance of future variceal bleeding?Your Answer: Propranolol
Explanation:Medications for Alcoholic Liver Disease and Variceal Bleeding Prophylaxis
Secondary prophylaxis for variceal haemorrhage in patients with alcoholic liver disease involves the use of non-specific beta-blockers like nadolol and propranolol. These medications reduce portal inflow and prevent further episodes of variceal bleeding. However, it is important to initiate treatment at the lowest possible dose and monitor for complications such as bradycardia.
Omeprazole, a proton pump inhibitor commonly used for reflux and PUD, is not indicated for the management of variceal bleeding. Erythromycin, a macrolide antibiotic with prokinetic properties, has no role in secondary prophylaxis for variceal bleeding.
Atenolol, a cardioselective beta-blocker, is not the preferred choice for patients with oesophageal varices as it has limited effect on peripheral tissues. Instead, a non-selective beta-blocker is more appropriate.
H2 antagonists like ranitidine and cimetidine can be used as alternatives to proton pump inhibitors in some patients with reflux and PUD.
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This question is part of the following fields:
- Gastroenterology
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Question 7
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A 4-year-old child was admitted with a high fever, cervical lymph node enlargement, conjunctival congestion, redness of lips and palms, and desquamation of fingertips. Upon examination, erythema of the oral cavity was observed. Blood tests showed a hemoglobin level of 110 g/l and a platelet count of 450,000. The symptoms resolved after two weeks, but during the third week, the child unexpectedly passed away. An autopsy revealed vasculitis of the coronary arteries and aneurysm formation. What is the most likely diagnosis?
Your Answer: Kawasaki’s disease
Explanation:Understanding Kawasaki’s Disease and Differential Diagnosis
Kawasaki disease, also known as mucocutaneous lymph node syndrome, is a multisystem disease that primarily affects children under the age of 5. It is characterized by fever, cervical adenitis, and changes in the skin and mucous membranes. While generally benign and self-limited, it can lead to coronary artery aneurysms in 25% of cases and has a case-fatality rate of 0.5-2.8%. Treatment with high-dose intravenous globulin and aspirin has been shown to be effective in reducing the prevalence of coronary artery abnormalities.
When considering a differential diagnosis, it is important to distinguish Kawasaki disease from other conditions with similar symptoms. Scarlet fever, rheumatic fever, diphtheria, and Marfan syndrome can all present with fever and cardiovascular involvement, but each has distinct clinical features and underlying pathophysiologic mechanisms. Careful evaluation and diagnosis are essential for appropriate treatment and management.
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This question is part of the following fields:
- Paediatrics
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Question 8
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A 78-year-old man experiences a sensation of something ‘giving way’ in his right arm while lifting a heavy bag of garden waste. The arm is visibly bruised, and upon flexing the elbow, a lump appears in the middle of the anterior aspect of the arm. The diagnosis is a rupture of the tendon of the long head of the biceps brachii. Where does this tendon typically attach to a bony point?
Your Answer: Supraglenoid tubercle of the scapula
Explanation:The supraglenoid tubercle of the scapula is where the tendon of the long head of the biceps brachii attaches within the shoulder joint capsule. The lesser tuberosity of the humerus is where the subscapularis muscle inserts, while the crest of the lesser tuberosity is where the latissimus dorsi and teres major muscles attach. The coracoid process of the scapula is where the short head of the biceps brachii, coracobrachialis, and pectoralis minor muscles attach. The greater tuberosity of the humerus is where the supraspinatus, infraspinatus, and teres minor muscles insert. Lastly, the long head of the triceps brachii attaches to the infraglenoid tubercle of the scapula. These attachments and insertions are important for understanding the anatomy and function of the shoulder and arm muscles.
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This question is part of the following fields:
- Orthopaedics
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Question 9
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You are asked to see a 33-year-old G1P0 woman who is 39 weeks pregnant. She has had an uncomplicated pregnancy so far. The obstetrician has recommended induction of labour and she has agreed. What medication would be administered for this purpose?
Your Answer: Oxytocin
Explanation:The medication used for induction of labour is oxytocin, which has a synthetic version called Syntocinon. It can also be used in the active management of the third stage of labour by causing the uterus to contract. Ergometrine is an alternative medication used to reduce blood loss in the third stage of labour, but it is not used for induction of labour. Magnesium sulphate is used in women with pre-eclampsia or as a neuroprotective agent in premature birth, but it is not indicated for this patient who is at full term and has had no pregnancy issues. Mifepristone is a prostaglandin analogue used for termination of pregnancy and not for induction of labour.
Drugs Used in Obstetrics and Gynaecology
Syntocinon is a synthetic form of oxytocin that is utilized in the active management of the third stage of labour. It works by stimulating the contraction of the uterus, which reduces the risk of postpartum haemorrhage. Additionally, it is used to induce labour. Ergometrine, on the other hand, is an ergot alkaloid that can be used as an alternative to oxytocin in the active management of the third stage of labour. It works by constricting the vascular smooth muscle of the uterus, which can decrease blood loss. Its mechanism of action involves stimulating alpha-adrenergic, dopaminergic, and serotonergic receptors. However, it can cause coronary artery spasm as an adverse effect.
Mifepristone is another drug used in obstetrics and gynaecology. It is used in combination with misoprostol to terminate pregnancies. Misoprostol is a prostaglandin analog that causes uterine contractions. Mifepristone’s mechanism of action involves being a competitive progesterone receptor antagonist. However, it can cause menorrhagia as an adverse effect.
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This question is part of the following fields:
- Pharmacology
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Question 10
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A 28-year-old woman presents to the breast clinic with a lump in her right breast that she has noticed for the past 4 weeks. She denies any pain, discharge, or skin changes. The patient is concerned about the lump as she has recently started a new relationship and her partner has also noticed it. On examination, a mobile, smooth, firm breast lump measuring 3.5 cm is palpated. Ultrasound confirms a fibroadenoma. What is the best course of action for this patient?
Your Answer: Surgical excision
Explanation:Surgical excision is the recommended treatment for fibroadenomas larger than 3 cm in size. This is because such masses can cause cosmetic concerns and discomfort, especially if they continue to grow. Given the patient’s expressed anxiety about the mass, surgical excision should be offered as a treatment option. Anastrozole, which is used to treat hormone-receptor-positive breast cancer in postmenopausal women, is not appropriate in this case as the patient has a benign breast lesion, and there is no information about hormone receptor status or menopausal status. Tamoxifen, which has been shown to reduce benign breast lump development in some pre-menopausal women, is not a primary treatment for fibroadenomas. Ultrasound-guided monochloroacetic acid injection is also not a suitable treatment option as it is used for plantar wart management and not for breast cryotherapy. While some centers may offer ultrasound-guided cryotherapy for fibroadenomas smaller than 4 cm, surgical excision is the more common treatment.
Understanding Breast Fibroadenoma
Breast fibroadenoma is a type of breast mass that develops from a whole lobule. It is characterized by a mobile, firm, and smooth lump in the breast, which is often referred to as a breast mouse. Fibroadenoma accounts for about 12% of all breast masses and is more common in women under the age of 30.
Fortunately, fibroadenomas are usually benign and do not increase the risk of developing breast cancer. In fact, over a two-year period, up to 30% of fibroadenomas may even get smaller on their own. However, if the lump is larger than 3 cm, surgical excision is typically recommended.
In summary, breast fibroadenoma is a common type of breast mass that is usually benign and does not increase the risk of breast cancer. While it may cause concern for some women, it is important to remember that most fibroadenomas do not require treatment and may even resolve on their own.
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This question is part of the following fields:
- Surgery
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