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Question 1
Incorrect
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A 30-year-old woman visits her GP with a query regarding oral contraception. She gave birth to her fourth child 2 weeks ago and believes that her family is complete. After weighing the options, she has decided to begin taking the combined contraceptive pill. She has no significant medical history and only takes regular vitamin supplements without any allergies. She is not breastfeeding at the moment.
What is the earliest possible time for her to start taking her preferred contraceptive?Your Answer: Commence 16 weeks post-partum
Correct Answer: Commence 3 weeks post-partum
Explanation:Women need to start using contraception only 21 days after giving birth during the post-partum period. It is recommended that they begin taking the combined contraceptive pill three weeks after delivery. However, if they are breastfeeding, they should wait for six weeks before starting the pill.
After giving birth, women need to use contraception after 21 days. The progestogen-only pill (POP) can be started at any time postpartum, according to the FSRH. Additional contraception should be used for the first two days after day 21. A small amount of progestogen enters breast milk, but it is not harmful to the infant. On the other hand, the combined oral contraceptive pill (COCP) is absolutely contraindicated (UKMEC 4) if breastfeeding is less than six weeks post-partum. If breastfeeding is between six weeks and six months postpartum, it is a UKMEC 2. The COCP may reduce breast milk production in lactating mothers. It should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum. After day 21, additional contraception should be used for the first seven days. The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after four weeks.
The lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breastfeeding (no supplementary feeds), amenorrhoeic, and less than six months post-partum. It is important to note that an inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight, and small for gestational age babies.
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This question is part of the following fields:
- Reproductive Medicine
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Question 2
Incorrect
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A 14-year-old girl has been found to be regularly skipping school, frequently arguing with other students and has been caught smoking on several occasions. Her general practitioner suspects a diagnosis of conduct disorder. She has already been diagnosed with anxiety disorder. She is not currently on any medications.
Given the new suspected diagnosis of conduct disorder, what is the most appropriate initial management option for this patient?Your Answer: Referral to Child and Adolescent Mental Health Services (CAMHS) for another primary assessment by the team
Correct Answer: Refer for cognitive behavioural therapy
Explanation:Management of Conduct Disorder: Interventions and Referrals
Conduct disorder is a psychiatric condition characterized by persistent patterns of aggressive and antisocial behavior. The management of conduct disorder involves a combination of pharmacological and psychosocial interventions. Here are some of the key interventions and referrals for managing conduct disorder:
Cognitive Behavioral Therapy (CBT): CBT techniques are used as part of the psychosocial interventions for conduct disorder. These techniques are considered as part of the first-line management of conduct disorder.
Methylphenidate: Methylphenidate is a medication that is used in the treatment of ADHD, which is often a coexisting condition with conduct disorder. This medication should only be initiated and coordinated by a specialist in secondary care (such as CAMHS).
Antidepressant Medications: Antidepressant medications should not be the first line in the management of conduct disorder, particularly with no coexisting health conditions. If there were depressive symptoms, these medications could be considered but are generally avoided in this age group.
Psychosocial Interventions: Psychosocial interventions are important in the management of conduct disorder. These include child-focussed programmes, multimodal interventions and parent training programmes. These interventions would be considered first-line management for conduct disorder if there was not the co-existing complicating factor of ADHD.
Referral to Child and Adolescent Mental Health Services (CAMHS): Patients presenting with symptoms of conduct disorder with a significant complicating factor should be referred to CAMHS for specialist assessment. These factors include mental health problems, neurodevelopmental disorder, learning disability or difficulty, and substance misuse. However, if the patient has already been referred to CAMHS, re-referral would not be necessary.
Managing Conduct Disorder: Interventions and Referrals
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This question is part of the following fields:
- Psychiatry
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Question 3
Incorrect
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A 25-year-old man who is typically healthy presents with joint pain and swelling that has been ongoing for 2 weeks. During the examination, you observe a rash on his nose and detect 2+ protein in his urine upon dipping. What is the probable diagnosis?
Your Answer: Dermatomyositis
Correct Answer: Systemic Lupus Erythematosus
Explanation:The symptoms exhibited by this individual are indicative of Systemic Lupus Erythematosus (SLE), as evidenced by the presence of the butterfly rash, joint pain, and proteinuria. In SLE, the impaired kidney function is responsible for the proteinuria. It is worth noting that SLE is more prevalent in females, with a ratio of 9:1 compared to males.
Understanding Systemic Lupus Erythematosus
Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects multiple systems in the body. It is more common in women and people of Afro-Caribbean origin, and typically presents in early adulthood. The general features of SLE include fatigue, fever, mouth ulcers, and lymphadenopathy.
SLE can also affect the skin, causing a malar (butterfly) rash that spares the nasolabial folds, discoid rash in sun-exposed areas, photosensitivity, Raynaud’s phenomenon, livedo reticularis, and non-scarring alopecia. Musculoskeletal symptoms include arthralgia and non-erosive arthritis.
Cardiovascular manifestations of SLE include pericarditis and myocarditis, while respiratory symptoms may include pleurisy and fibrosing alveolitis. Renal involvement can lead to proteinuria and glomerulonephritis, with diffuse proliferative glomerulonephritis being the most common type.
Finally, neuropsychiatric symptoms of SLE may include anxiety and depression, as well as more severe manifestations such as psychosis and seizures. Understanding the various features of SLE is important for early diagnosis and management of this complex autoimmune disorder.
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This question is part of the following fields:
- Musculoskeletal
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Question 4
Incorrect
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A 42-year-old woman visits her doctor with complaints of a persistent blocked nose and reduced sense of smell for the past few months. During examination, the doctor observes pale grey mucosal sacs in both nostrils. The patient has a history of allergies but is otherwise healthy. What is the most likely condition she is suffering from?
Your Answer: Simvastatin usage
Correct Answer: Aspirin usage
Explanation:Medical Conditions and Medication Usage: A Brief Overview
Aspirin Usage and Nasal Polyps
Nasal polyps, asthma, and rhinosinusitis are all symptoms of aspirin-exacerbated respiratory disease. This condition is caused by hypersensitivity to aspirin or other cyclooxygenase 1 inhibitors and typically develops in individuals aged 30-40 years. Treatment involves avoiding non-steroidal anti-inflammatory drugs, and in some cases, aspirin desensitization may be performed.COPD and Nasal Polyps
While nasal polyps can be associated with asthma, there is no known association with chronic obstructive pulmonary disease (COPD). Smokers with nosebleeds or unilateral nasal polyps should be referred for urgent ENT assessment to rule out malignancy.Infective Endocarditis and Nasal Polyps
Infective endocarditis occurs when bacteria enters the bloodstream, usually via poor dentition, an open wound, or mechanical device placed in the heart. There is no known association between nasal polyps and infective endocarditis.Paracetamol Usage and Nasal Polyps
Nasal polyps are associated with aspirin sensitivity, not sensitivity to paracetamol. According to the British National Formulary, the only side effect of oral paracetamol is thrombocytopenia, which is considered very rare.Simvastatin Usage and Nasal Polyps
Nasal polyps are not a recognized side effect of statins, which can cause muscle aches, headaches, diarrhea, and sleep disturbances.Understanding Medical Conditions and Medication Usage
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This question is part of the following fields:
- ENT
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Question 5
Incorrect
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A 35-year-old female patient complains of a malodorous vaginal discharge that appears white. She denies any associated dyspareunia or itch. The clinician suspects bacterial vaginosis. Which organism is most likely responsible for this presentation?
Your Answer: Trichomonas
Correct Answer: Gardnerella
Explanation:Bacterial vaginosis is a condition characterized by the excessive growth of mainly bacteria.
Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.
Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimes. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.
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This question is part of the following fields:
- Reproductive Medicine
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Question 6
Incorrect
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Can you analyze the post-bronchodilator spirometry findings of a 54-year-old female who has been experiencing gradual breathlessness?
FEV1/FVC ratio: 0.60
FEV1 percentage predicted: 60%
What would be the suitable conclusion based on these outcomes?Your Answer: Poor technique - repeat spirometry
Correct Answer: COPD (stage 2 - moderate)
Explanation:Investigating and Diagnosing COPD
COPD is a condition that should be considered in patients over 35 years of age who are smokers or ex-smokers and have symptoms such as chronic cough, exertional breathlessness, or regular sputum production. To confirm a diagnosis of COPD, several investigations are recommended. These include post-bronchodilator spirometry to demonstrate airflow obstruction, a chest x-ray to exclude lung cancer and identify hyperinflation, bullae, or flat hemidiaphragm, a full blood count to exclude secondary polycythaemia, and a calculation of body mass index (BMI).
The severity of COPD is categorized based on the post-bronchodilator FEV1/FVC ratio. If the ratio is less than 70%, the patient is diagnosed with COPD. The severity of the condition is then determined based on the FEV1 value. Stage 1 is considered mild, and symptoms should be present to diagnose COPD in these patients. Stage 2 is moderate, Stage 3 is severe, and Stage 4 is very severe.
It is important to note that measuring peak expiratory flow is of limited value in COPD, as it may underestimate the degree of airflow obstruction. The grading system for COPD severity has changed following the 2010 NICE guidelines. If the FEV1 is greater than 80% predicted but the post-bronchodilator FEV1/FVC is less than 0.7, the patient is classified as Stage 1 – mild.
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This question is part of the following fields:
- Respiratory Medicine
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Question 7
Incorrect
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A patient with a history of depression at the age of 50 presents for review. What indicates an elevated risk of suicide?
Your Answer: Female sex
Correct Answer: History of arm cutting
Explanation:Arm cutting may be seen as attention-seeking or a way to release pain, but studies indicate that it increases the risk of suicide for those with a history of deliberate self harm. Employment is a protective factor.
Suicide Risk Factors and Protective Factors
Suicide risk assessment is a common practice in psychiatric care, with patients being stratified into high, medium, or low risk categories. However, there is a lack of evidence on the positive predictive value of individual risk factors. A review in the BMJ concluded that such assessments may not be useful in guiding decision-making, as 50% of suicides occur in patients deemed low risk. Nevertheless, certain factors have been associated with an increased risk of suicide, including male sex, history of deliberate self-harm, alcohol or drug misuse, mental illness, depression, schizophrenia, chronic disease, advancing age, unemployment or social isolation, and being unmarried, divorced, or widowed.
If a patient has attempted suicide, there are additional risk factors to consider, such as efforts to avoid discovery, planning, leaving a written note, final acts such as sorting out finances, and using a violent method. On the other hand, there are protective factors that can reduce the risk of suicide, such as family support, having children at home, and religious belief. It is important to consider both risk and protective factors when assessing suicide risk and developing a treatment plan.
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This question is part of the following fields:
- Psychiatry
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Question 8
Incorrect
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A 28-year-old woman comes to your clinic for a check-up. She is currently 16 weeks pregnant and has had no complications so far. During her visit, she mentions that her 4-year-old son was recently diagnosed with chickenpox. The patient is concerned about the potential impact on her pregnancy as she cannot recall if she had chickenpox as a child. What would be the appropriate course of action for this patient?
Your Answer: Prescribe varicella-zoster immunoglobulin (VZIG)
Correct Answer: Arrange a blood test for varicella antibodies and await the result
Explanation:In cases where a pregnant woman is exposed to chickenpox and her immunity status is uncertain, it is recommended to conduct a blood test to check for varicella antibodies. If she is found to be not immune and is over 20 weeks pregnant, either VZIG or aciclovir can be given. However, VZIG is the only option for those under 20 weeks pregnant and not immune. It is important to note that VZIG is effective up to 10 days post-exposure, so there is no need to administer it immediately after the blood test. Prescribing medication without confirming the patient’s immunity status is not recommended. Similarly, reassuring the patient and sending her away without following proper prophylaxis protocol is not appropriate. It is also important to note that the varicella-zoster vaccine is not currently part of the UK’s vaccination schedule and does not play a role in the management of pregnant women.
Chickenpox exposure in pregnancy can pose risks to both the mother and fetus, including fetal varicella syndrome. Post-exposure prophylaxis (PEP) with varicella-zoster immunoglobulin (VZIG) or antivirals should be given to non-immune pregnant women, with timing dependent on gestational age. If a pregnant woman develops chickenpox, specialist advice should be sought and oral aciclovir may be given if she is ≥ 20 weeks and presents within 24 hours of onset of the rash.
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This question is part of the following fields:
- Reproductive Medicine
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Question 9
Correct
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A 55-year-old man arrives at the emergency department with complaints of abdominal pain, nausea, and vomiting. His urine and serum tests reveal elevated ketone levels, and his serum glucose level is 3 mmol/L. An ABG is conducted, and the results are as follows:
pH 7.24
PaO2 14.7 kPa
PCO2 3.5 kPa
HCO3 13 mEq/L
What is the most probable cause of these findings?Your Answer: Alcoholic ketoacidosis
Explanation:If a patient is experiencing metabolic ketoacidosis with normal or low glucose levels, alcohol consumption should be considered as a possible cause. This condition is characterized by partial respiratory compensation. While diabetic ketoacidosis could also be a potential cause, a serum glucose level of 3mmol/L makes it less likely. Therefore, the patient is more likely to be suffering from alcoholic ketoacidosis. It is important to note that a hyperosmolar hyperglycemic state would present with high serum glucose levels and normal ketone levels, while a diabetic hypoglycemic episode would not typically result in elevated ketone levels or metabolic acidosis.
Alcoholic ketoacidosis is a type of ketoacidosis that occurs in individuals who consume large amounts of alcohol regularly. This condition is not related to diabetes and is characterized by normal blood sugar levels. Alcoholics often suffer from malnutrition due to their irregular eating habits and may vomit the food they consume, leading to starvation. When the body becomes malnourished, it starts breaking down body fat, which produces ketones and leads to ketoacidosis.
The typical symptoms of alcoholic ketoacidosis include metabolic acidosis, elevated anion gap, elevated serum ketone levels, and normal or low glucose concentration. The most effective treatment for this condition is an infusion of saline and thiamine. Thiamine is essential to prevent the development of Wernicke encephalopathy or Korsakoff psychosis. Therefore, it is crucial to provide timely and appropriate treatment to individuals suffering from alcoholic ketoacidosis to prevent further complications.
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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 50-year-old woman, who is currently four weeks into a course of postoperative radiotherapy for locally advanced cervical carcinoma, is admitted with abdominal pain and diarrhoea.
Which of the following is the most likely cause of the clinical picture?Your Answer: Complication of surgery
Correct Answer: Radiation enteritis
Explanation:Understanding Radiation Enteritis and Other Possible Causes of Bowel Symptoms
Radiation enteritis is a condition that occurs when the bowel becomes inflamed due to radiation therapy. It can manifest as ileitis, colitis, or proctitis, and can be acute or chronic. Acute radiation enteritis typically occurs during therapy and presents with symptoms such as anorexia, diarrhoea, and abdominal pain. Chronic radiation enteritis, on the other hand, can develop months or years after treatment and may cause weight loss, steatorrhoea, and small bowel obstruction.
While radiation enteritis is a likely cause of bowel symptoms in patients who have undergone radiation therapy, other conditions should also be considered. Bowel obstruction, for example, can cause nausea, vomiting, and bloating, but does not typically cause diarrhoea. Local malignant infiltration to the bowel may present with obstruction, while bowel perforation is a medical emergency that causes peritonitis and sepsis.
In summary, understanding the possible causes of bowel symptoms is important in determining the appropriate treatment for patients. While radiation enteritis is a common consequence of radiation therapy, other conditions such as bowel obstruction, local malignant infiltration, and bowel perforation should also be considered.
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This question is part of the following fields:
- Haematology/Oncology
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Question 11
Incorrect
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A 45-year-old female patient complains of painful erythematous lesions on her shins. Which of the following is not commonly associated with this presentation?
Your Answer: Sarcoidosis
Correct Answer: Syphilis
Explanation:Erythema nodosum caused by syphilis is uncommon.
Understanding Erythema Nodosum
Erythema nodosum is a condition characterized by inflammation of the subcutaneous fat, resulting in tender, erythematous, nodular lesions. These lesions typically occur over the shins but may also appear on other parts of the body such as the forearms and thighs. The condition usually resolves within six weeks, and the lesions heal without scarring.
There are several possible causes of erythema nodosum, including infections such as streptococci, tuberculosis, and brucellosis. Systemic diseases like sarcoidosis, inflammatory bowel disease, and Behcet’s can also lead to the condition. In some cases, erythema nodosum may be associated with malignancy or lymphoma. Certain drugs like penicillins, sulphonamides, and the combined oral contraceptive pill, as well as pregnancy, can also trigger the condition.
Overall, understanding the causes and symptoms of erythema nodosum is important for prompt diagnosis and treatment.
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This question is part of the following fields:
- Dermatology
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Question 12
Incorrect
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You are conducting a neurological examination on a thirty-five-year-old patient who presents with recent onset of blurred vision, speech disturbance, pronounced reflexes, and upward plantars upon attempting the Babinski reflex. The patient denies any history of headache and fundoscopy reveals normal findings. What is the probable diagnosis?
Your Answer: Cerebral venous thrombosis
Correct Answer: Multiple sclerosis
Explanation:The presence of Babinski sign suggests the presence of a condition affecting the upper motor neurons. When the sole of the foot is stimulated with a blunt object, an atypical reflex is observed where the toes move upwards.
When ankle jerks are absent and extensor plantars are present, it is usually due to a lesion that affects both the upper and lower motor neurons. This can be caused by various conditions such as subacute combined degeneration of the cord, motor neuron disease, Friedreich’s ataxia, syringomyelia, taboparesis (syphilis), or a lesion in the conus medullaris. These conditions can lead to a loss of reflexes in the ankle and a specific type of reflex in the foot that indicates damage to both the upper and lower motor neurons. It is important to identify the underlying cause of these symptoms in order to provide appropriate treatment and management.
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This question is part of the following fields:
- Neurology
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Question 13
Incorrect
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A 28-year-old law student visits his primary care physician complaining of ear pain. He suspects that this is related to the same issue causing dryness in his scalp and beard, as well as eczema-like patches in his nasolabial folds. He has been using non-prescription topical treatments to manage these symptoms but seeks guidance for his earache. What is the probable diagnosis that connects all of this patient's symptoms?
Your Answer: Irritant dermatitis
Correct Answer: Seborrhoeic dermatitis
Explanation:Seborrhoeic dermatitis can lead to common complications such as otitis externa and blepharitis. The patient is experiencing eczema-like plaques and dry skin in areas rich in sebum, which he has been treating with over-the-counter antifungal shampoos. However, his complaint of earache may be due to otitis externa, which is associated with seborrhoeic dermatitis. A full ear examination should be performed to rule out other diagnoses. Contact dermatitis is unlikely to present in this distribution and would not cause otalgia. Eczema herpeticum is a severe primary infection by herpes-simplex-virus 1 or 2, commonly seen in children with atopic eczema. Guttate psoriasis commonly affects children after Streptococcal upper respiratory tract infection and will clear over the course of ,3 months without treatment. Irritant dermatitis is unlikely to cause such focal areas of irritation.
Understanding Seborrhoeic Dermatitis in Adults
Seborrhoeic dermatitis is a chronic skin condition that affects around 2% of the general population. It is caused by an inflammatory reaction related to the overgrowth of a fungus called Malassezia furfur, which is a normal inhabitant of the skin. The condition is characterized by eczematous lesions that appear on the sebum-rich areas of the body, such as the scalp, periorbital, auricular, and nasolabial folds. It can also lead to the development of otitis externa and blepharitis.
Seborrhoeic dermatitis is often associated with other medical conditions, such as HIV and Parkinson’s disease. The management of the condition depends on the affected area. For scalp disease, over-the-counter preparations containing zinc pyrithione and tar are usually the first-line treatment. If these are not effective, ketoconazole is the preferred second-line agent. Selenium sulphide and topical corticosteroids may also be useful.
For the face and body, topical antifungals such as ketoconazole and topical steroids are often used. However, it is important to use steroids for short periods only to avoid side effects. Seborrhoeic dermatitis can be difficult to treat, and recurrences are common. Therefore, it is important to work closely with a healthcare provider to manage the condition effectively.
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This question is part of the following fields:
- Dermatology
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Question 14
Incorrect
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A 5-year-old girl is brought to the pediatrician's office by her father, who is concerned about a red rash on her arms and chest. She has been feeling sick, with cold-like symptoms preceding the rash. The rash is erythematous, macular and symmetrical to both arms and chest and is non-blanching. She is currently without fever and appears to be in good health.
What is the most probable cause?Your Answer: Meningococcal disease
Correct Answer: Henoch–Schönlein purpura
Explanation:Distinguishing Between Different Skin Conditions: A Guide for Healthcare Professionals
Henoch–Schönlein purpura, eczema, intertrigo, meningococcal disease, and systemic lupus erythematosus are all skin conditions that can present with various rashes and symptoms. It is important for healthcare professionals to be able to distinguish between these conditions in order to provide appropriate treatment.
Henoch–Schönlein purpura is an autoimmune hypersensitivity vasculitis that presents with a non-blanching rash, joint and abdominal pain, and nephritis. Eczema is characterized by areas of erythema that are blanching, dry skin with fine scales, and excoriations. Intertrigo primarily affects the flexures with erythematous patches that may progress to intense inflammation. Meningococcal disease presents with a non-blanching rash that rapidly progresses to purpura and requires immediate treatment. Systemic lupus erythematosus is rare in children and presents with a malar or butterfly rash on the face, joint pain, fever, or weight loss.
By understanding the unique features of each condition, healthcare professionals can accurately diagnose and treat their patients.
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This question is part of the following fields:
- Dermatology
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Question 15
Correct
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A 50-year-old woman with a history of alcoholic liver disease presents to the clinic with advanced cirrhosis and ascites. A recent ascitic tap revealed a protein concentration of 12 g/L and no evidence of organisms. What is the best course of action to manage the risk of spontaneous bacterial peritonitis?
Your Answer: Oral ciprofloxacin
Explanation:To prevent spontaneous bacterial peritonitis, it is recommended to administer oral ciprofloxacin or norfloxacin as prophylaxis to patients with ascites and protein concentration of 15 g/L or less.
Understanding Spontaneous Bacterial Peritonitis
Spontaneous bacterial peritonitis (SBP) is a type of peritonitis that typically affects individuals with ascites caused by liver cirrhosis. The condition is characterized by symptoms such as abdominal pain, fever, and ascites. Diagnosis is usually made through paracentesis, which involves analyzing the ascitic fluid for a neutrophil count of over 250 cells/ul. The most common organism found on ascitic fluid culture is E. coli.
Management of SBP typically involves the administration of intravenous cefotaxime. Antibiotic prophylaxis is also recommended for patients with ascites who have previously experienced an episode of SBP or have a fluid protein level of less than 15 g/l and a Child-Pugh score of at least 9 or hepatorenal syndrome. NICE recommends prophylactic oral ciprofloxacin or norfloxacin until the ascites has resolved.
Alcoholic liver disease is a significant predictor of poor prognosis in SBP. Understanding the symptoms, diagnosis, and management of SBP is crucial for healthcare professionals to provide appropriate care and improve patient outcomes.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 16
Incorrect
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A 65-year-old male presents to his GP with a 6-month history of progressive shortness of breath. He is now needing to stop a few times on the way to the grocery store to catch his breath, which is not normal for him. He smokes 20 cigarettes a day and has done so for the past 45 years, and drinks no alcohol. His only medication is atorvastatin.
On examination, there is a bilateral wheeze and coarse crackles at the lung bases. A chest x-ray is ordered by the GP which shows flattening of the diaphragm bilaterally, but is otherwise normal. Spirometry is carried out, with the following results:
Result Reference Range
FEV1 (of predicted) 72% >80%
FEV1:FVC 0.62 >0.7
What is the most appropriate management for this likely diagnosis?Your Answer: Beclomethasone
Correct Answer: Ipratropium
Explanation:The patient’s history, examination, and obstructive spirometry results suggest that he has COPD, likely due to his smoking history. Malignancy has been ruled out by the chest x-ray. As per NICE guidelines, the first-line pharmacological treatment for COPD is either a SABA or SAMA to alleviate breathlessness and improve exercise tolerance. Ipratropium, a SAMA, is the most suitable option for this patient. Beclomethasone, an inhaled corticosteroid, is used as a second-line treatment with a LABA for those with asthmatic features or steroid responsiveness. Montelukast, a LTRA, is used as a third-line treatment in asthmatic patients, while Salmeterol, a LABA, is used as a second-line treatment in COPD patients.
NICE guidelines recommend smoking cessation advice, annual influenza and one-off pneumococcal vaccinations, and pulmonary rehabilitation for COPD patients. Bronchodilator therapy is first-line treatment, with the addition of LABA and LAMA for patients without asthmatic features and LABA, ICS, and LAMA for those with asthmatic features. Theophylline is recommended after trials of bronchodilators or for patients who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients. Mucolytics should be considered for patients with a chronic productive cough. Loop diuretics and long-term oxygen therapy may be used for cor pulmonale. Smoking cessation and long-term oxygen therapy may improve survival in stable COPD patients. Lung volume reduction surgery may be considered in selected patients.
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This question is part of the following fields:
- Respiratory Medicine
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Question 17
Incorrect
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A mother requests a home visit for her 10-year-old daughter who is too unwell to come to the clinic. Upon arrival, the girl is observed to have a fever, cold extremities, and purplish spots on her legs. What steps should be taken?
Your Answer: IM benzylpenicillin 600mg
Correct Answer: IM benzylpenicillin 1200mg
Explanation:The RCGP has previously provided feedback that doctors are required to have knowledge of emergency medication dosages, with a specific emphasis on suspected cases of meningococcal septicaemia.
Paediatric Drug Doses for Emergency Situations
When it comes to prescribing drugs for children in emergency situations, it is important to consult the current British National Formulary (BNF) beforehand. However, as a guide, the following doses can be used for intramuscular (IM) benzylpenicillin in suspected cases of meningococcal septicaemia in the community. For children under one year old, the dose is 300 mg. For children between one and ten years old, the dose is 600mg. For children over ten years old, the dose is 1200mg. It is important to note that these doses are only a guide and should be adjusted based on the individual child’s weight and medical history. Always consult with a healthcare professional before administering any medication to a child.
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This question is part of the following fields:
- Paediatrics
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Question 18
Correct
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A 50-year-old man with a persistent chest infection visits the clinic for evaluation. Despite two rounds of antibiotics, there has been no significant improvement. The medical team decides to conduct a chest x-ray and screening blood tests. When analyzing the blood tests, which of the following markers is typically not elevated in response to an acute infection?
Your Answer: Albumin
Explanation:A decrease in albumin levels is frequently observed after an acute phase response.
Acute phase proteins are a group of proteins that are produced by the liver in response to inflammation or infection. These proteins are involved in various physiological processes such as immune response, blood clotting, and iron metabolism. Examples of acute phase proteins include CRP, procalcitonin, ferritin, fibrinogen, alpha-1 antitrypsin, caeruloplasmin, serum amyloid A, serum amyloid P component, haptoglobin, and complement.
During the acute phase response, the liver decreases the production of other proteins known as negative acute phase proteins. These proteins include albumin, transthyretin, transferrin, retinol binding protein, and cortisol binding protein. The levels of acute phase proteins, particularly CRP, are commonly measured in acutely unwell patients. Elevated levels of CRP are indicative of inflammation or infection, and levels greater than 150 at 48 hours post-surgery suggest the development of complications.
It is important to note that while acute phase proteins play a significant role in humans, some of these proteins, such as serum amyloid P component, have a more significant role in other mammals like mice. Overall, the production of acute phase proteins is a crucial part of the body’s response to inflammation or infection, and monitoring their levels can aid in the diagnosis and management of various medical conditions.
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This question is part of the following fields:
- Infectious Diseases
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Question 19
Incorrect
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A 42-year-old man visits his doctor, reporting crusting of both eyelids that is more severe in the morning and accompanied by an itchy feeling. He states that he has not experienced any changes in his vision.
During the eyelid examination, the doctor observes crusting at the eyelid margins, which are inflamed and red. The conjunctivae seem normal, and the pupils react equally to light.
What is the probable diagnosis?Your Answer: Entropion
Correct Answer: Blepharitis
Explanation:Common Eye Conditions and Their Symptoms
Blepharitis: This condition presents with crusting of both eyelids, redness, swelling, and itching. It can be treated with eyelid hygiene and warm compress. If necessary, chloramphenicol ointment can be used.
Conjunctivitis: Patients with conjunctivitis have watery/discharging eyes, a gritty sensation, and conjunctival erythema. Most cases resolve on their own, but some may require topical antibiotics.
Chalazion: A painless swelling or lump on the eyelid caused by a blocked gland. Patients report a red, swollen, and painless area on the eyelid that settles within a few days but leaves behind a firm, painless swelling. Warm compresses and gentle massaging can help with drainage.
Entropion: The margin of the eyelid turns inwards towards the surface of the eye, causing irritation. It is more common in elderly patients and requires surgical treatment.
Hordeolum: An acute-onset localised swelling of the eyelid margin that is painful. It is usually localised around an eyelash follicle, and plucking the affected eyelash can aid drainage. Styes are usually self-limiting, but eyelid hygiene and warm compress can help with resolution.
Understanding Common Eye Conditions and Their Symptoms
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This question is part of the following fields:
- Ophthalmology
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Question 20
Correct
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A 30-year-old female patient complains of vision problems. Upon examination, a left inferior homonymous quadrantanopia is observed. What is the most probable location of the lesion?
Your Answer: Right parietal lobe
Explanation:A visual field defect known as left homonymous hemianopia indicates a loss of vision to the left side, which is caused by a lesion in the right optic tract. Homonymous quadrantanopias, which affect the parietal-inferior and temporal-superior areas, are also a type of visual field defect. Incongruous defects are caused by optic tract lesions, while congruous defects are caused by lesions in the optic radiation or occipital cortex.
Understanding Visual Field Defects
Visual field defects refer to the loss of vision in certain areas of the visual field. One common type of visual field defect is left homonymous hemianopia, which means that there is a visual field defect to the left due to a lesion of the right optic tract. Another type is homonymous quadrantanopias, which can be remembered using the acronym PITS (Parietal-Inferior, Temporal-Superior). Incongruous defects indicate an optic tract lesion, while congruous defects suggest a lesion of the optic radiation or occipital cortex. A congruous defect means complete or symmetrical visual field loss, while an incongruous defect is incomplete or asymmetric.
Homonymous hemianopia can also be caused by a lesion of the optic tract, with macula sparing indicating a lesion of the occipital cortex. Homonymous quadrantanopias can be caused by a lesion of the inferior optic radiations in the temporal lobe (Meyer’s loop) for superior defects, and a lesion of the superior optic radiations in the parietal lobe for inferior defects.
Bitemporal hemianopia, on the other hand, is caused by a lesion of the optic chiasm. An upper quadrant defect that is greater than the lower quadrant defect suggests inferior chiasmal compression, which is commonly caused by a pituitary tumor. Conversely, a lower quadrant defect that is greater than the upper quadrant defect suggests superior chiasmal compression, which is commonly caused by a craniopharyngioma. It is important to note that while this information is useful for exams, actual studies suggest that the majority of quadrantanopias are caused by occipital lobe lesions.
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This question is part of the following fields:
- Neurology
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Question 21
Incorrect
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A 50-year-old man with a history of ischaemic heart disease complains of myalgia. He has been taking aspirin, simvastatin, and atenolol for a long time. A creatine kinase test is performed due to his statin use, and the results show:
Creatine kinase 1,420 u/l (< 190 u/l)
The patient's symptoms appeared after starting a new medication. Which of the following is the most probable cause of the elevated creatine kinase levels?Your Answer: Felodipine
Correct Answer: Clarithromycin
Explanation:The interaction between statins and erythromycin/clarithromycin is significant and frequent, and in this case, the patient has experienced statin-induced myopathy due to clarithromycin.
Statins are drugs that inhibit the action of an enzyme called HMG-CoA reductase, which is responsible for producing cholesterol in the liver. However, they can cause some adverse effects such as myopathy, which includes muscle pain, weakness, and damage, and liver impairment. Myopathy is more common in lipophilic statins than in hydrophilic ones. Statins may also increase the risk of intracerebral hemorrhage in patients who have had a stroke before. Therefore, they should be avoided in these patients. Statins should not be taken during pregnancy and should be stopped if the patient is taking macrolides.
Statins are recommended for people with established cardiovascular disease, those with a 10-year cardiovascular risk of 10% or more, and patients with type 2 diabetes mellitus. Patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago, are over 40 years old, or have established nephropathy should also take statins. It is recommended to take statins at night as this is when cholesterol synthesis takes place. Atorvastatin 20mg is recommended for primary prevention, and the dose should be increased if non-HDL has not reduced for 40% or more. Atorvastatin 80 mg is recommended for secondary prevention. The graphic shows the different types of statins available.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 22
Incorrect
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A 35-year-old Japanese man presents with recurrent oral and genital ulcers, as well as painful nodules on his shin. He has a history of recurrent episodes of red eyes and thrombophlebitis in his legs.
What is the most probable diagnosis?Your Answer: Familial Mediterranean fever (FMF)
Correct Answer: Behçet syndrome
Explanation:Differentiating Behçet Syndrome from Other Rheumatic Diseases
Behçet syndrome is a rare inflammatory disorder that is most commonly seen in Turkey, Iran, and Japan. It is characterized by recurrent oral ulceration and can also involve the eyes, skin, joints, and other organs. Diagnosis is based on international criteria that require oral ulceration plus any two of genital ulcers, defined eye lesions, defined skin lesions, or a positive skin pathergy test. Treatment involves corticosteroids, immunosuppressants, and other medications.
It is important to differentiate Behçet syndrome from other rheumatic diseases that can present with similar symptoms. Familial Mediterranean fever is another rare genetic disorder that can cause recurrent fever, arthritis, and serositis, but it typically affects different ethnic groups and has a different pattern of symptoms. Polyarteritis nodosa is a type of vasculitis that can cause systemic inflammation and damage to blood vessels, but it typically presents with different symptoms than Behçet syndrome. Reactive arthritis is a type of arthritis that can occur after a bacterial infection, but it typically involves urethritis and conjunctivitis in addition to joint pain. Palindromic rheumatism is a rare type of arthritis that involves sudden attacks of joint pain, but it typically does not cause lasting joint damage.
By carefully considering the patient’s symptoms and medical history, healthcare providers can make an accurate diagnosis and provide appropriate treatment for patients with Behçet syndrome and other rheumatic diseases.
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This question is part of the following fields:
- Musculoskeletal
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Question 23
Correct
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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: 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 24
Incorrect
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You are asked to evaluate a 60-year-old man who has been experiencing increasing dryness in his eyes and mouth for several years but has not sought medical attention for it. He has a medical history of osteoarthritis and rheumatoid arthritis, as well as ongoing arthralgia in his large joints. At the age of 42, he underwent an ileocaecal resection due to Crohn's disease. Which of his risk factors is most closely linked to Sjogren's syndrome?
Your Answer: Male sex
Correct Answer: Rheumatoid arthritis
Explanation:Rheumatoid arthritis cases are often accompanied by Sjogren’s syndrome, which primarily affects women aged 40 to 60. This condition is characterized by arthralgia and sicca symptoms such as dry mouth and dry eyes. Other connective tissue disorders, as well as SLE, are also linked to Sjogren’s syndrome.
Understanding Sjogren’s Syndrome
Sjogren’s syndrome is a medical condition that affects the exocrine glands, leading to dry mucosal surfaces. It is an autoimmune disorder that can either be primary or secondary to other connective tissue disorders, such as rheumatoid arthritis. The onset of the condition usually occurs around ten years after the initial onset of the primary disease. Sjogren’s syndrome is more common in females, with a ratio of 9:1. Patients with this condition have a higher risk of developing lymphoid malignancy, which is 40-60 times more likely.
The symptoms of Sjogren’s syndrome include dry eyes, dry mouth, vaginal dryness, arthralgia, Raynaud’s, myalgia, sensory polyneuropathy, recurrent episodes of parotitis, and subclinical renal tubular acidosis. To diagnose the condition, doctors may perform a Schirmer’s test to measure tear formation, check for hypergammaglobulinaemia, and low C4. Nearly 50% of patients with Sjogren’s syndrome test positive for rheumatoid factor, while 70% test positive for ANA. Additionally, 70% of patients with primary Sjogren’s syndrome have anti-Ro (SSA) antibodies, and 30% have anti-La (SSB) antibodies.
The management of Sjogren’s syndrome involves the use of artificial saliva and tears to alleviate dryness. Pilocarpine may also be used to stimulate saliva production. Understanding the symptoms and management of Sjogren’s syndrome is crucial for patients and healthcare providers to ensure proper treatment and care.
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This question is part of the following fields:
- Musculoskeletal
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Question 25
Incorrect
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A 25-year-old woman who uses the combined oral contraceptive pill (COCP) contacted the clinic after missing one dose. She typically takes one tablet at 9 pm every day, but she forgot and remembered the next morning. Her last period was 12 days ago.
What guidance should be provided to this patient?Your Answer: Take the missed pill and start the next pack without the 7 days break
Correct Answer: Take the missed dose immediately and then take the next pill at 10pm
Explanation:If a woman on COCP misses one pill, she should take the missed pill immediately and then take the next pill at the usual time. There is no need for any further action or emergency contraception such as a copper IUD. She can continue with the 7-day pill-free break as normal. Discarding the missed pill is not recommended as it could increase the risk of an unwanted pregnancy. Starting the next pack without the 7-day break is also not necessary in this case. However, if she misses two pills and there are fewer than seven pills left in the pack, she would need to start the next pack without a break.
Missed Pills in Combined Oral Contraceptive Pill
When taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol, it is important to know what to do if a pill is missed. The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their recommendations in recent years. If one pill is missed at any time in the cycle, the woman should take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day. No additional contraceptive protection is needed in this case.
However, if two or more pills are missed, the woman should take the last pill even if it means taking two pills in one day, leave any earlier missed pills, and then continue taking pills daily, one each day. In this case, the woman should use condoms or abstain from sex until she has taken pills for 7 days in a row. If pills are missed in week 1 (Days 1-7), emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1. If pills are missed in week 2 (Days 8-14), after seven consecutive days of taking the COC there is no need for emergency contraception.
If pills are missed in week 3 (Days 15-21), the woman should finish the pills in her current pack and start a new pack the next day, thus omitting the pill-free interval. Theoretically, women would be protected if they took the COC in a pattern of 7 days on, 7 days off. It is important to follow these guidelines to ensure the effectiveness of the COC in preventing pregnancy.
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This question is part of the following fields:
- Reproductive Medicine
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Question 26
Incorrect
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A 68-year-old man presents with lower back pain. He has a medical history of prostate cancer, asthma, diabetes, and hypertension. The pain is radiating down his right leg and he is experiencing reduced power in that leg. Additionally, he has a decreased anal tone. Although the lumbar spine x-ray shows no apparent fracture, what would be the most appropriate next investigation to perform?
Your Answer: CT thorax
Correct Answer: MRI lumbosacral spine
Explanation:Lower back pain accompanied by lower limb pain, limb weakness, numbness or tingling, and decreased perianal tone are red flags that suggest spinal cord compression. In this case, the patient has a history of prostate cancer, which further raises suspicion. Urgent MRI is necessary to rule out spinal cord compression, and the results should be discussed with the on-call neurosurgical team. Additional x-rays or ultrasound would not be helpful, as MRI is the preferred diagnostic tool.
Neoplastic Spinal Cord Compression: An Oncological Emergency
Neoplastic spinal cord compression is a medical emergency that affects around 5% of cancer patients. The majority of cases are due to vertebral body metastases, resulting in extradural compression. This condition is more common in patients with lung, breast, and prostate cancer.
The earliest and most common symptom of neoplastic spinal cord compression is back pain, which may worsen when lying down or coughing. Other symptoms include lower limb weakness and sensory changes such as numbness and sensory loss. The neurological signs depend on the level of the lesion, with lesions above L1 resulting in upper motor neuron signs in the legs and a sensory level. Lesions below L1 usually cause lower motor neuron signs in the legs and perianal numbness. Tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion.
An urgent MRI is recommended within 24 hours of presentation, according to the 2019 NICE guidelines. High-dose oral dexamethasone is used for management, and urgent oncological assessment is necessary for consideration of radiotherapy or surgery.
In summary, neoplastic spinal cord compression is a serious condition that requires prompt diagnosis and management to prevent further neurological damage.
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This question is part of the following fields:
- Neurology
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Question 27
Incorrect
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A 65-year-old woman presents to the emergency department with central abdominal pain. She has vomited twice since the onset of the pain and has not passed any wind or faeces in the last twelve hours. Her medical history includes a partial small bowel resection due to traumatic perforation. On examination, her abdomen appears distended and there is generalised tenderness on palpation. Her blood tests reveal a Hb level of 153 g/L (115 - 160), platelets of 312 * 109/L (150 - 400), WBC count of 10.8 * 109/L (4.0 - 11.0), bilirubin of 17 µmol/L (3 - 17), ALP of 78 u/L (30 - 100), ALT of 29 u/L (3 - 40), and amylase of 880 U/L (70 - 300). What is the most likely diagnosis?
Your Answer: Acute cholecystitis
Correct Answer: Small bowel obstruction
Explanation:Elevated serum amylase levels are not always indicative of acute pancreatitis, as they can also be seen in cases of small bowel obstruction. In this scenario, the patient is experiencing abdominal pain, vomiting, and a lack of bowel movements or gas, which are all typical symptoms of small bowel obstruction. The fact that the patient has a history of abdominal surgery further supports this diagnosis, despite the misleading blood test results. Acute cholecystitis, on the other hand, presents with different symptoms such as fever, right upper quadrant pain, and systemic distress, and does not typically cause elevated amylase levels. Acute pancreatitis may also be considered as a differential diagnosis, but it is not associated with a lack of bowel movements or gas, and previous bowel surgery is not a risk factor. Ascending cholangitis and large bowel obstruction can also be ruled out based on the patient’s symptoms and test results.
Small bowel obstruction occurs when the small intestines are blocked, preventing the passage of food, fluids, and gas. The most common cause of this condition is adhesions, which can develop after previous surgeries, followed by hernias. Symptoms of small bowel obstruction include diffuse, central abdominal pain, nausea and vomiting (often bilious), constipation, and abdominal distension. Tinkling bowel sounds may also be present in early stages of obstruction. Abdominal x-ray is typically the first-line imaging for suspected small bowel obstruction, showing distended small bowel loops with fluid levels. CT is more sensitive and considered the definitive investigation, particularly in early obstruction. Management involves initial steps such as NBM, IV fluids, and nasogastric tube with free drainage. Some patients may respond to conservative management, but others may require surgery.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 28
Incorrect
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An 80-year-old man arrives at the emergency department complaining of difficulty breathing. He had been diagnosed with community-acquired pneumonia by his doctor and treated with antibiotics at home. However, his condition suddenly worsened, and he now has a heart rate of 120/min, respiratory rate of 22/min, oxygen saturation of 77%, and a temperature of 38°C. The patient has a medical history of COPD and is a carbon dioxide retainer. What is the best course of action to address his low oxygen saturation?
Your Answer: Reservoir mask at 15 litres/min
Correct Answer: 28% Venturi mask at 4 litres/min
Explanation:Guidelines for Emergency Oxygen Therapy
The British Thoracic Society has updated its guidelines for emergency oxygen therapy in 2017. The guidelines recommend that in critically ill patients, such as those experiencing anaphylaxis or shock, oxygen should be administered via a reservoir mask at 15 l/min. However, certain conditions, such as stable myocardial infarction, are excluded from this recommendation.
The guidelines also provide specific oxygen saturation targets for different patient groups. Acutely ill patients should aim for a saturation range of 94-98%, while patients at risk of hypercapnia, such as those with COPD, should aim for a lower range of 88-92%. Oxygen therapy should be reduced in stable patients with satisfactory oxygen saturation.
For COPD patients, a 28% Venturi mask at 4 l/min should be used prior to availability of blood gases. The target oxygen saturation range for these patients should be 88-92% if they have risk factors for hypercapnia but no prior history of respiratory acidosis. If the pCO2 is normal, the target range can be adjusted to 94-98%.
The guidelines also highlight situations where oxygen therapy should not be used routinely if there is no evidence of hypoxia. These include myocardial infarction and acute coronary syndromes, stroke, obstetric emergencies, and anxiety-related hyperventilation.
Overall, these guidelines provide clear recommendations for the administration of emergency oxygen therapy in different patient groups and situations.
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This question is part of the following fields:
- Respiratory Medicine
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Question 29
Incorrect
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At what point in the childhood immunisation schedule is the Meningitis B vaccine administered?
Your Answer: 2, 3, and 4 months
Correct Answer: 2, 4, and 12 months
Explanation:The most prevalent cause of meningococcal disease in children in the UK is currently Meningitis B. In 2015, the Meningitis B vaccination was added to the NHS routine childhood immunisation schedule. It is administered at 2, 4, and 12 months of age, in conjunction with other immunisations in the schedule. If given at a different time, doses must be spaced at least 2 months apart. For children over one year old, only two doses are necessary.
Meningitis B Vaccine Now Part of Routine NHS Immunisation
Children in the UK have been vaccinated against meningococcus serotypes A and C for many years, leaving meningococcal B as the most common cause of bacterial meningitis in the country. However, a new vaccine called Bexsero has been developed to combat this strain. Initially, the Joint Committee on Vaccination and Immunisation (JCVI) rejected the use of Bexsero due to a cost-benefit analysis. However, the decision was eventually reversed, and the vaccine has been added to the routine NHS immunisation schedule.
The vaccine is administered in three doses at 2 months, 4 months, and 12-13 months. Additionally, Bexsero will be available on the NHS for individuals at high risk of meningococcal disease, such as those with asplenia, splenic dysfunction, or complement disorder. This new vaccine is a significant step in protecting children and vulnerable individuals from meningitis B.
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This question is part of the following fields:
- Paediatrics
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Question 30
Incorrect
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A 32-year-old male with a history of eczema and asthma complains of rhinorrhoea and nasal congestion for the past six months. His asthma is currently well managed and he rarely uses his blue inhaler. He occasionally feels pressure in his sinuses. What is the first-line treatment option available?
Your Answer:
Correct Answer: Nasal irrigation with saline solution
Explanation:Chronic rhinosinusitis can be treated with nasal irrigation using saline solution as a first-line option. However, it is unlikely that symptoms will resolve without additional interventions such as smoking cessation, avoidance of allergens, and a 3-month course of a steroid nasal spray like fluticasone or mometasone. It is important to note that optimizing asthma control is also crucial in managing chronic rhinosinusitis, but there is no indication of poorly controlled asthma in this case. It is not recommended to initiate long-term antibiotics without consulting a specialist as there is limited evidence of their effectiveness in treating this condition.
Understanding Chronic Rhinosinusitis
Chronic rhinosinusitis is a common condition that affects approximately 1 in 10 people. It is characterized by inflammation of the paranasal sinuses and nasal passages that lasts for 12 weeks or longer. There are several factors that can predispose individuals to this condition, including atopy (such as hay fever or asthma), nasal obstruction (such as a deviated septum or nasal polyps), recent local infections (such as rhinitis or dental extractions), swimming or diving, and smoking.
Symptoms of chronic rhinosinusitis include facial pain, nasal discharge, nasal obstruction, and post-nasal drip. Facial pain is typically felt as pressure in the frontal area and worsens when bending forward. Nasal discharge is usually clear if the condition is caused by allergies or vasomotor issues, but thicker and purulent discharge may indicate a secondary infection. Nasal obstruction can lead to mouth breathing, while post-nasal drip can cause a chronic cough.
Management of chronic rhinosinusitis involves avoiding allergens, using intranasal corticosteroids, and nasal irrigation with saline solution. However, it is important to be aware of red flag symptoms, such as unilateral symptoms, persistent symptoms despite 3 months of treatment compliance, and epistaxis (nosebleeds). If any of these symptoms occur, it is important to seek medical attention promptly.
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This question is part of the following fields:
- ENT
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