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Question 1
Incorrect
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A 35-year-old expectant mother seeks guidance regarding the likelihood of her child inheriting polycystic kidney disease. Despite her diagnosis, she is presently in good health. Her father, who also has the condition, is currently undergoing dialysis. What is the probability that her offspring will develop the disease?
Your Answer: 50% if male
Correct Answer: 50%
Explanation:Autosomal dominant polycystic kidney disease (ADPKD) is a prevalent genetic condition that affects approximately 1 in 1,000 Caucasians. The disease is caused by mutations in two genes, PKD1 and PKD2, which produce polycystin-1 and polycystin-2, respectively. ADPKD type 1 accounts for 85% of cases, while ADPKD type 2 accounts for the remaining 15%. Individuals with ADPKD develop multiple fluid-filled cysts in their kidneys, which can lead to renal failure.
To diagnose ADPKD in individuals with a positive family history, an abdominal ultrasound is typically performed. The diagnostic criteria for ultrasound include the presence of two cysts, either unilateral or bilateral, in individuals under 30 years of age, two cysts in both kidneys for those aged 30-59 years, and four cysts in both kidneys for those over 60 years of age.
Management of ADPKD may involve the use of tolvaptan, a vasopressin receptor 2 antagonist, for select patients. Tolvaptan has been recommended by NICE as an option for treating ADPKD in adults with chronic kidney disease stage 2 or 3 at the start of treatment, evidence of rapidly progressing disease, and if the company provides it with the agreed discount in the patient access scheme. The goal of treatment is to slow the progression of cyst development and renal insufficiency. An enlarged kidney with extensive cysts is a common finding in individuals with ADPKD.
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This question is part of the following fields:
- Genetics
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Question 2
Incorrect
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A 68-year-old woman is referred with fatigue. Her primary care physician observes that she has jaundice and suspects liver disease. She also presents with angular cheilitis. She has a history of taking steroid inhalers for asthma, but no other significant medical history. A blood smear shows signs of megaloblastic anemia, and her serum bilirubin level is elevated, but her other laboratory results are normal. There are no indications of gastrointestinal (GI) issues.
What is the most appropriate diagnosis for this clinical presentation?Your Answer:
Correct Answer: Pernicious anaemia
Explanation:Differential Diagnosis of Anaemia: Understanding the Causes
Anaemia is a common condition that can be caused by a variety of factors. Here, we will discuss some of the possible causes of anaemia and their corresponding laboratory findings.
Pernicious Anaemia: This type of anaemia is caused by a deficiency in vitamin B12 due to impaired intrinsic factor (IF) production. It is usually seen in adults aged 40-70 years and is characterized by megaloblastic changes in rapidly dividing cells. Anti-parietal cell antibodies are present in 90% of patients with pernicious anaemia. The Schilling test is useful in confirming the absence of IF. Treatment involves parenteral administration of cyanocobalamin or hydroxycobalamin.
Chronic Myeloid Leukaemia: CML is a myeloproliferative disorder that results in increased proliferation of granulocytic cells. Symptoms include fatigue, anorexia, weight loss, and hepatosplenomegaly. Mild to moderate anaemia is usually normochromic and normocytic. Diagnosis is based on histopathological findings in the peripheral blood and Philadelphia chromosome in bone marrow cells.
Iron Deficiency Anaemia: This type of anaemia is primarily a laboratory diagnosis and is characterized by microcytic and hypochromic erythropoiesis. It is caused by chronic iron deficiency and can be due to multiple causes, including chronic inflammation, iron malabsorption, chronic blood loss, and malabsorption of vitamin B12 or folate.
Crohn’s Disease: This chronic inflammatory process can affect any part of the GI tract and can cause anaemia due to chronic inflammation, iron malabsorption, chronic blood loss, and malabsorption of vitamin B12 or folate. However, the lack of GI symptoms in the clinical scenario provided is not consistent with a history of inflammatory bowel disease.
Autoimmune Hepatitis: This chronic disease is characterized by continuing hepatocellular inflammation and necrosis, with a tendency to progress to cirrhosis. Elevated serum aminotransferase levels are present in 100% of patients at initial presentation. Anaemia, if present, is usually normochromic. However, this clinical picture and laboratory findings are not consistent with the scenario given.
In conclusion, understanding the different causes of anaemia and their corresponding laboratory findings is crucial in making an accurate diagnosis and providing appropriate treatment.
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This question is part of the following fields:
- Haematology/Oncology
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Question 3
Incorrect
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A 26-year-old man presents to the GUM clinic with penile discharge and dysuria for the past 5 days. Urethral swabs are taken and microscopy reveals the presence of diplococci. Sensitivities are not yet available, and he is diagnosed with gonorrhoea. What is the recommended initial treatment?
Your Answer:
Correct Answer: IM ceftriaxone
Explanation:Gonorrhoea is best treated with intramuscular ceftriaxone, and it is crucial to notify and treat sexual partners. All patients with gonorrhoea should undergo a test of cure after 2 weeks.
Understanding Gonorrhoea: Causes, Symptoms, Microbiology, and Management
Gonorrhoea is a sexually transmitted infection caused by the Gram-negative diplococcus Neisseria gonorrhoeae. It can occur on any mucous membrane surface, including the genitourinary tract, rectum, and pharynx. The incubation period of gonorrhoea is typically 2-5 days. Symptoms in males include urethral discharge and dysuria, while females may experience cervicitis leading to vaginal discharge. Rectal and pharyngeal infections are usually asymptomatic.
Immunisation against gonorrhoea is not possible, and reinfection is common due to antigen variation of type IV pili and Opa proteins. Local complications may develop, including urethral strictures, epididymitis, and salpingitis, which can lead to infertility. Disseminated infection may also occur, with gonococcal infection being the most common cause of septic arthritis in young adults.
Management of gonorrhoea involves the use of antibiotics. Ciprofloxacin used to be the treatment of choice, but there is now increased resistance to it. Cephalosporins are now more widely used, with a single dose of IM ceftriaxone 1g being the new first-line treatment. If ceftriaxone is refused, oral cefixime 400mg + oral azithromycin 2g should be used. Disseminated gonococcal infection (DGI) and gonococcal arthritis may also occur, with symptoms including tenosynovitis, migratory polyarthritis, and dermatitis. Later complications include septic arthritis, endocarditis, and perihepatitis.
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This question is part of the following fields:
- Infectious Diseases
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Question 4
Incorrect
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A 32-year-old man is brought to the emergency department by his physician due to bone pain, weakness, and splenomegaly. He has been experiencing increasing fatigue and weakness while performing his daily tasks over the past few weeks. During the examination, he appears extremely pale and has petechiae on his lower limbs. After a bone marrow sample is taken, he is diagnosed with acute promyelocytic leukemia (APML). What is the most probable finding on his blood film?
Your Answer:
Correct Answer: Auer rods
Explanation:A finding of Auer rods on a blood film strongly indicates the presence of acute promyelocytic leukemia.
The correct answer is ‘Auer rods’. This patient has been diagnosed with APML, and the most common finding on a blood film associated with this is Auer rods. These are needle-like structures that are large, pink or red stained and can be seen within the cytoplasm of myeloid blast cells.
‘Tear-drop’ poikilocytes are typically found in myelofibrosis, which is characterized by flat, elongated red blood cells that resemble a tear-drop in shape. This occurs due to the squeezing of cells through fibrotic tissue in bone marrow in myelofibrotic disorders.
Smear cells are usually seen in chronic lymphocytic leukemia (CLL), which are remnants of cells that lack identifiable plasma membrane or nuclear structure.
Spherocytes are generally found in hereditary spherocytosis or autoimmune hemolytic anemia, which are red blood cells that are sphere-shaped and more fragile than normal red blood cells due to abnormalities in the red cell membrane.
Acute myeloid leukaemia is a common form of acute leukaemia in adults that may occur as a primary disease or following a myeloproliferative disorder. Symptoms are related to bone marrow failure and include anaemia, neutropenia, thrombocytopenia, splenomegaly, and bone pain. Poor prognostic features include age over 60, >20% blasts after first course of chemo, and deletions of chromosome 5 or 7. Acute promyelocytic leukaemia M3 is associated with t(15;17) and has a good prognosis. The French-American-British classification system includes seven subtypes.
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This question is part of the following fields:
- Haematology/Oncology
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Question 5
Incorrect
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A 30-year-old woman visits her GP after a staging CT revealed the presence of gallstones in her gallbladder, following her recent diagnosis of renal cell carcinoma (RCC). She is interested in discussing the available management options. The patient reports no history of abdominal pain and is in good health otherwise. She is scheduled to undergo a left-sided nephrectomy for her RCC in three weeks. During the examination, the GP notes tenderness over the left flank, but no palpable masses. What is the appropriate course of action for this patient?
Your Answer:
Correct Answer: Reassurance
Explanation:If you have been diagnosed with asymptomatic gallbladder stones, there is no need to worry. These stones are often found incidentally during imaging tests that are unrelated to gallstone disease. As long as you have not experienced any symptoms for at least a year before the diagnosis and the stones are located in a normal gallbladder and biliary tree, no intervention is necessary.
However, if you are experiencing symptoms or if the stones are located in the common bile duct, intervention is required. This can be done through surgical removal during laparoscopic cholecystectomy or through endoscopic retrograde cholangiopancreatography (ERCP) before or during the surgery. Rest assured that with proper intervention, you can effectively manage your gallbladder stones and prevent any complications.
Gallstones: Symptoms, Diagnosis, and Treatment
Gallstones are a common condition, with up to 24% of women and 12% of men affected. Local infection and cholecystitis may develop in up to 30% of cases, and 12% of patients undergoing surgery will have stones in the common bile duct. The majority of gallstones are of mixed composition, with pure cholesterol stones accounting for 20% of cases. Symptoms typically include colicky right upper quadrant pain that worsens after fatty meals. Diagnosis involves abdominal ultrasound and liver function tests, with magnetic resonance cholangiography or intraoperative imaging used to confirm the presence of stones in the bile duct. Treatment options include expectant management for asymptomatic gallstones, laparoscopic cholecystectomy for symptomatic gallstones, and early ERCP or surgical exploration for stones in the bile duct. Intraoperative cholangiography or laparoscopic ultrasound may be used to confirm anatomy or exclude CBD stones during surgery. ERCP carries risks such as bleeding, duodenal perforation, cholangitis, and pancreatitis.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 6
Incorrect
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As a general practice doctor, you are attending to a 55-year-old man who has come in as a same-day emergency with new pain in his right leg and foot. The pain has been present for the past 48 hours and is worse at night. He reports that the pain is in the outer side of his calf and the top of his foot and toes. The patient has a medical history of osteoarthritis, gout, and hypertension, and is currently taking paracetamol, amlodipine, naproxen, allopurinol, and omeprazole.
Upon examination, there is no tenderness or joint deformity in the ankle or foot. The patient has limited movement of the ankle and experiences pain when dorsiflexing his foot. There is slightly altered sensation over the dorsum of his foot, but sensation in the rest of his leg is normal. Bilateral palpable dorsalis pedis pulses are present.
What is the most likely cause of this man's leg pain?Your Answer:
Correct Answer: L5 radiculopathy
Explanation:Nerve root pain can be identified by its distribution along the lateral calf and dorsum of the foot, as well as the presence of a neurological deficit such as sensory changes and weakness. This suggests that the L5 nerve is affected.
In contrast, joint diseases like gout and osteoarthritis typically cause pain localized to the affected joint, without any specific distribution on the foot. There is also no associated sensory loss, and movement of the joint is limited in all directions, not just dorsiflexion.
Peripheral vascular disease or deep vein thrombosis can cause symptoms throughout the entire limb, without any discernible distribution. While arterial disease may cause calf pain, it does not lateralize to the medial or lateral side of the calf. Additionally, if the foot is affected, the pain and sensory changes will be present on both the dorsum and sole.
Understanding Prolapsed Disc and its Features
A prolapsed lumbar disc is a common cause of lower back pain that can lead to neurological deficits. It is characterized by clear dermatomal leg pain, which is usually worse than the back pain. The pain is often aggravated when sitting. The features of the prolapsed disc depend on the site of compression. For instance, L3 nerve root compression can cause sensory loss over the anterior thigh, weak quadriceps, reduced knee reflex, and a positive femoral stretch test. On the other hand, L4 nerve root compression can lead to sensory loss in the anterior aspect of the knee, weak quadriceps, reduced knee reflex, and a positive femoral stretch test.
The management of prolapsed disc is similar to that of other musculoskeletal lower back pain. It involves analgesia, physiotherapy, and exercises. According to NICE, the first-line treatment for back pain without sciatica symptoms is NSAIDs +/- proton pump inhibitors, rather than neuropathic analgesia. If the symptoms persist after 4-6 weeks, referral for consideration of MRI is appropriate. Understanding the features of prolapsed disc can help in the diagnosis and management of this condition.
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This question is part of the following fields:
- Musculoskeletal
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Question 7
Incorrect
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Which of the following is the least acknowledged complication of measles infection?
Your Answer:
Correct Answer: Infertility
Explanation:Measles: A Highly Infectious Viral Disease
Measles is a viral disease caused by an RNA paramyxovirus. It is one of the most infectious known viruses and is spread through aerosol transmission. The disease has an incubation period of 10-14 days and is infective from the prodromal phase until four days after the rash starts. Measles is now rare in developed countries due to immunization programs, but outbreaks can occur when vaccination rates drop, such as during the MMR controversy of the early 2000s.
The disease is characterized by a prodromal phase, which includes irritability, conjunctivitis, fever, and Koplik spots. The latter typically develop before the rash and are white spots on the buccal mucosa. The rash starts behind the ears and then spreads to the whole body, becoming a discrete maculopapular rash that may become blotchy and confluent. Desquamation may occur after a week, typically sparing the palms and soles. Diarrhea occurs in around 10% of patients.
Measles is mainly managed through supportive care, and admission may be considered in immunosuppressed or pregnant patients. The disease is notifiable, and public health should be informed. Complications of measles include otitis media, pneumonia (the most common cause of death), encephalitis (typically occurring 1-2 weeks following the onset of the illness), subacute sclerosing panencephalitis (very rare, may present 5-10 years following the illness), febrile convulsions, keratoconjunctivitis, corneal ulceration, diarrhea, increased incidence of appendicitis, and myocarditis.
If an unimmunized child comes into contact with measles, MMR should be offered within 72 hours. Vaccine-induced measles antibody develops more rapidly than that following natural infection.
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This question is part of the following fields:
- Paediatrics
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Question 8
Incorrect
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A 30-year-old pregnant woman comes to you with complaints of weakness in her right hand and tingling and paraesthesia in the lateral three digits. You notice that the sensory symptoms are replicated when you flex her wrist passively and hold it in that position. Can you identify the name of this sign?
Your Answer:
Correct Answer: Phalen's sign
Explanation:The patient has symptoms of median nerve palsy, which can be caused by carpal tunnel syndrome, a known risk factor during pregnancy. Tinel’s sign and Phalen’s sign can reproduce the symptoms, and Froment’s sign is associated with ulnar nerve palsies.
Understanding Carpal Tunnel Syndrome
Carpal tunnel syndrome is a condition that occurs when the median nerve in the carpal tunnel is compressed. Patients with this condition typically experience pain or pins and needles in their thumb, index, and middle fingers. In some cases, the symptoms may even ascend proximally. Patients often shake their hand to obtain relief, especially at night.
During an examination, doctors may observe weakness of thumb abduction and wasting of the thenar eminence (not the hypothenar). Tapping on the affected area may cause paraesthesia, which is known as Tinel’s sign. Flexion of the wrist may also cause symptoms, which is known as Phalen’s sign.
Carpal tunnel syndrome can be caused by a variety of factors, including idiopathic reasons, pregnancy, oedema (such as heart failure), lunate fracture, and rheumatoid arthritis. Electrophysiology tests may show prolongation of the action potential in both motor and sensory nerves.
Treatment for carpal tunnel syndrome may include a 6-week trial of conservative treatments, such as corticosteroid injections and wrist splints at night. If symptoms persist or are severe, surgical decompression (flexor retinaculum division) may be necessary.
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This question is part of the following fields:
- Musculoskeletal
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Question 9
Incorrect
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A 35-year-old woman presents to the Emergency Department with a 2-day history of central abdominal pain, extreme thirst and polyuria. She has no past medical history but her mother and sister both have diabetes. She is noted to be breathing heavily with breath that smells of acetone. An urgent set of investigations is taken.
Which of the following test results are most likely in this patient?
Select the SINGLE most likely results from the list below.
Your Answer:
Correct Answer: pH 7.21, partial pressure of pCO2 2.1 kPa, partial pressure of pO211.2 kPa, Na+ 131 mmol/l, K+ 3.1 mmol/l, HCO3 12 mmol/l, glucose 31 mmol/l, ketones 4.2 mmol/l
Explanation:Interpreting Blood Test Results: Distinguishing Diabetic Ketoacidosis from Other Conditions
Diabetic ketoacidosis (DKA) is a life-threatening condition that requires urgent treatment. It can occur as a complication of existing type I diabetes mellitus (DM) or be the first presentation of type I DM. To diagnose DKA, the Joint British Diabetes Societies have established specific criteria, including a blood glucose of more than 11 mmol/l or known DM, a venous pH of less than 7.3 and/or a serum bicarbonate of less than 15 mmol/l, and ketonaemia of more than 3 mmol/l or ketonuria 2+ on dipstick.
When interpreting blood test results, it is important to distinguish DKA from other conditions that may present with similar symptoms. For example, a metabolic acidosis may indicate DKA, but it would also be present in other conditions. In DKA, you would expect a combination of high blood glucose, low pH and serum bicarbonate, and high ketone levels.
Normal blood test results would rule out DKA, but hyperkalaemia may be present despite low total body potassium levels. Potassium levels may need to be monitored and adjusted during treatment. Respiratory alkalosis, indicated by low pCO2 and high pH, would suggest hyperventilation rather than DKA.
In summary, interpreting blood test results is crucial in diagnosing and distinguishing DKA from other conditions. Understanding the specific criteria for DKA diagnosis and recognizing the patterns of abnormal results can help healthcare professionals provide timely and appropriate treatment.
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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 30-year-old woman visits her doctor with worries about a genetic disorder. Her granddaughter, who is three years old, has been diagnosed with sickle cell anemia. She reports that no one else in the family has the condition.
What is the likelihood of her being a carrier of the sickle cell allele?Your Answer:
Correct Answer: 1 in 2
Explanation:Understanding the Probability of Cystic Fibrosis Inheritance
Cystic fibrosis is a genetic condition that is inherited in an autosomal recessive pattern. This means that for a child to be affected, they must inherit two mutated alleles – one from each parent. If one grandparent is a carrier, there is a 1 in 2 chance that they passed the gene on to their offspring, who is the parent of the affected child.
When both parents are carriers, there is a 1 in 4 chance that their child will be affected by cystic fibrosis. However, the chance of inheriting the condition is always 1 in 2 for boys and girls.
Diagnosis of cystic fibrosis often occurs before the age of two, with up to 75% of patients being diagnosed at this age. It is important to note that carriers of cystic fibrosis are relatively common, with an estimated 1 in 25 people in the UK being carriers.
Understanding the probability of cystic fibrosis inheritance is crucial for families with a history of the condition, as it can help them make informed decisions about family planning and genetic testing.
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This question is part of the following fields:
- Genetics
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Question 11
Incorrect
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A 38-year-old man visits his GP complaining of feeling generally unwell. He reports experiencing daily frontal headaches for the past three months, which have not improved with regular paracetamol. Additionally, he has noticed some unusual symptoms such as his wedding ring no longer fitting, his shoe size apparently increasing, and a small amount of milky discharge from both nipples. During examination, his blood pressure is found to be 168/96 mmHg. What is the probable diagnosis?
Your Answer:
Correct Answer: Acromegaly
Explanation:Acromegaly: Excess Growth Hormone and its Features
Acromegaly is a condition characterized by excess growth hormone, which is usually caused by a pituitary adenoma in over 95% of cases. However, a minority of cases are caused by ectopic GHRH or GH production by tumours such as pancreatic. The condition is associated with several features, including a coarse facial appearance, spade-like hands, and an increase in shoe size. Patients may also have a large tongue, prognathism, and interdental spaces. Excessive sweating and oily skin are also common, caused by sweat gland hypertrophy.
In addition to these physical features, patients with acromegaly may also experience symptoms of a pituitary tumour, such as hypopituitarism, headaches, and bitemporal hemianopia. Raised prolactin levels are also seen in about one-third of cases, which can lead to galactorrhoea. It is important to note that 6% of patients with acromegaly have MEN-1, a genetic disorder that affects multiple endocrine glands.
Complications of acromegaly include hypertension, diabetes (seen in over 10% of cases), cardiomyopathy, and an increased risk of colorectal cancer. Early diagnosis and treatment of acromegaly are crucial to prevent these complications and improve patient outcomes.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 12
Incorrect
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You are a GP trainee on attachment in the emergency department. You review a 15-year-old male with a large forearm wound as a result of deliberate self harm. The wound is 6 cm long and appears to involve the tendon sheath. The patient has scars from previous wounds across both forearms.
Which of the following features would require a referral to plastic surgery?Your Answer:
Correct Answer: Involvement of tendon sheath
Explanation:If there is a possibility of tendon sheath involvement in forearm wounds, it is recommended to seek the expertise of plastic surgery for potential surgical exploration. Failure to do so may result in tendon rupture.
The forearm flexor muscles include the flexor carpi radialis, palmaris longus, flexor carpi ulnaris, flexor digitorum superficialis, and flexor digitorum profundus. They originate from the common flexor origin and surrounding fascia, and are innervated by the median and ulnar nerves. Their actions include flexion and abduction of the carpus, wrist flexion, and flexion of the metacarpophalangeal and interphalangeal joints.
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This question is part of the following fields:
- Musculoskeletal
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Question 13
Incorrect
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As a foundation doctor on the postnatal ward, you conduct a newborn examination (NIPE) on a twenty-five hour old baby girl delivered via forceps. During the examination, you observe that the anterior fontanelle is soft but small, and the bones overlap at the sutures. The mother inquires about what she should do in this situation.
Your Answer:
Correct Answer: No intervention required but document clearly
Explanation:It is common for newborns to have positional head molding, which is considered a normal occurrence. However, it is important to document this for review by the general practitioner during the six to eight week baby check. In cases where there is persistent head shape deformity, cranial orthosis (head helmets) may be used, but it is unlikely to be necessary. Physiotherapy can be considered if there is also torticollis. It is important to note that surgical intervention is not appropriate as this is a normal finding.
Common Skull Problems in Children
Two common skull problems in children are plagiocephaly and craniosynostosis. Plagiocephaly is when a child’s head becomes parallelogram-shaped due to flattening on one side. The incidence of plagiocephaly has increased over the past decade, which may be due to the success of the ‘Back to Sleep’ campaign that encourages parents to put their babies to sleep on their backs to reduce the risk of sudden infant death syndrome (SIDS). Craniosynostosis, on the other hand, is the premature fusion of skull bones. This can lead to abnormal head shape and potentially affect brain development. Both plagiocephaly and craniosynostosis require medical attention and treatment.
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This question is part of the following fields:
- Paediatrics
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Question 14
Incorrect
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A 50-year-old man arrives at the emergency department complaining of severe chest pain that radiates to his left arm, accompanied by nausea and sweating. His ECG reveals widespread ST depression with T wave inversion, and his blood tests show a haemoglobin level of 75g/L. What is the appropriate treatment for his anaemia?
Your Answer:
Correct Answer: Transfusion of packed red cells
Explanation:For patients with ACS, the recommended transfusion threshold is a haemoglobin level of 80 g/L. In this case, the patient is presenting with symptoms of ACS and his ECG confirms this. However, his haemoglobin level is below the threshold, indicating severe anaemia. Therefore, an immediate transfusion is necessary to alleviate the anaemia. Anaemia can exacerbate ischaemia in ACS, leading to increased strain on the heart and reduced oxygen supply. The guidelines suggest aiming for a haemoglobin concentration of 80-100 g/L after transfusion. Oral or IV iron would not provide immediate relief, and IV Hartmann’s solution is not a suitable treatment for anaemia and would not address the underlying issue. This highlights the importance of prompt and appropriate treatment for patients with ACS. This information is based on the NICE guideline [NG24].
Guidelines for Red Blood Cell Transfusion
In 2015, NICE released guidelines for the use of blood products, specifically red blood cells. These guidelines recommend different transfusion thresholds for patients with and without acute coronary syndrome (ACS). For patients without ACS, the transfusion threshold is 70 g/L, while for those with ACS, it is 80 g/L. The target hemoglobin level after transfusion is 70-90 g/L for patients without ACS and 80-100 g/L for those with ACS. It is important to note that these thresholds should not be used for patients with ongoing major hemorrhage or those who require regular blood transfusions for chronic anemia.
When administering red blood cells, it is crucial to store them at 4°C prior to infusion. In non-urgent scenarios, a unit of RBC is typically transfused over a period of 90-120 minutes. By following these guidelines, healthcare professionals can ensure that red blood cell transfusions are administered safely and effectively.
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This question is part of the following fields:
- Cardiovascular
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Question 15
Incorrect
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A 30-year-old man presents approximately 2 weeks after a viral illness with petechiae, easy bruising, gum bleeding and lesions of the oral mucosa and tongue. He has no personal or family history of note and is not taking any medication. Physical examination is normal, except for petechiae, bruising and oral lesions. An image of the patient's tongue is shown below. What is the most appropriate initial investigation/management option for this clinical scenario and image?
Your Answer:
Correct Answer: Full blood count
Explanation:Diagnosis and Investigation of Immune Thrombocytopenic Purpura (ITP)
Immune thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by antiplatelet antibodies and immune-mediated platelet destruction, leading to a decrease in peripheral platelet count and an increased risk of severe bleeding. The following are the recommended diagnostic and investigative measures for ITP:
Full Blood Count: An urgent first-line investigation with a full blood count is essential to confirm platelet count, which is the hallmark of ITP. Anaemia and/or neutropenia may indicate other diseases. On peripheral blood smear, the morphology of red blood cells and leukocytes is normal, while the morphology of platelets is usually normal, with varying numbers of large platelets.
Surgical Correction: Surgical management is not the first-line intervention for ITP and is reserved for later use in patients with acute ITP, for whom splenectomy usually results in rapid, complete, and life-long clinical remission. Its results in patients with chronic ITP are typically less predictable.
Aspiration for Cytology: Further investigations, such as bone marrow aspiration, could be considered for later use in patients with ITP, such as adults older than 60 years, to exclude myelodysplastic syndrome or leukemia.
Excision Biopsy: Further investigations, such as a biopsy, could be considered further down the line, such as in adults older than 60 years, to exclude myelodysplastic syndrome or leukemia.
None: If a patient presents with purpura/petechiae on the tongue and buccal mucosa, urgent haematological referral is warranted, and not undertaking any further investigations would be inappropriate.
Diagnosis and Investigation of Immune Thrombocytopenic Purpura (ITP)
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This question is part of the following fields:
- Haematology/Oncology
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Question 16
Incorrect
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A 35-year-old woman visits her general practice surgery to discuss her plans to become pregnant. She is taking medication for hypertension but is otherwise fit and well. She has not had any previous pregnancies.
On examination, her blood pressure (BP) is 120/78 mmHg.
Which of the following drugs can this patient continue to take during pregnancy?Your Answer:
Correct Answer: Nifedipine
Explanation:Nifedipine is a medication that blocks calcium channels and is recommended as a second-line treatment for hypertension during pregnancy or pre-eclampsia if labetalol is not effective or well-tolerated. If a woman is already taking nifedipine and has good blood pressure control, it is advisable to continue this treatment throughout pregnancy, with regular monitoring of blood pressure. Women with chronic hypertension are at risk of developing pre-eclampsia and should take 75-150 mg aspirin daily from 12 weeks gestation.
Bendroflumethiazide and other thiazide diuretics should not be taken during pregnancy as they are associated with various adverse effects on the fetus. Beta-blockers, except for labetalol, increase the risk of intrauterine growth restriction, neonatal hypoglycemia, and bradycardia. Therefore, the use of any beta-blockers during pregnancy, except for labetalol, should be avoided. Angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme (ACE) inhibitors are contraindicated in pregnancy as they can cause serious harm to the fetus. Women who become pregnant while taking ARBs or ACE inhibitors should stop taking them immediately and be prescribed a safer alternative antihypertensive medication.
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This question is part of the following fields:
- Cardiovascular
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Question 17
Incorrect
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A 25-year-old male comes to the emergency department complaining of cough, fever and difficulty breathing. During the examination, he is found to be hypoxic and chest x-ray reveals pulmonary infiltrates. He has been experiencing anaemia, jaundice and weakness since he was 6 months old, and also suffers from severe pain when exposed to cold temperatures. What is the probable underlying condition?
Your Answer:
Correct Answer: Sickle cell disease
Explanation:When a patient with sickle cell disease experiences dyspnoea, chest pain, cough, hypoxia, and new pulmonary infiltrates on chest x-ray, it is likely that they are suffering from acute chest syndrome. This is a complication specific to sickle cell anaemia, and is characterized by the presence of these symptoms along with the aforementioned pulmonary infiltrates.
Sickle cell anaemia is a condition that involves periods of good health with intermittent crises. There are several types of crises that can occur, including thrombotic or painful crises, sequestration, acute chest syndrome, aplastic, and haemolytic. Thrombotic crises, also known as painful crises or vaso-occlusive crises, are triggered by factors such as infection, dehydration, and deoxygenation. These crises are diagnosed clinically and can result in infarcts in various organs, including the bones, lungs, spleen, and brain.
Sequestration crises occur when sickling occurs within organs such as the spleen or lungs, leading to pooling of blood and worsening of anaemia. This type of crisis is associated with an increased reticulocyte count. Acute chest syndrome is caused by vaso-occlusion within the pulmonary microvasculature, resulting in infarction in the lung parenchyma. Symptoms include dyspnoea, chest pain, pulmonary infiltrates on chest x-ray, and low pO2. Management involves pain relief, respiratory support, antibiotics, and transfusion.
Aplastic crises are caused by infection with parvovirus and result in a sudden fall in haemoglobin. Bone marrow suppression leads to a reduced reticulocyte count. Haemolytic crises are rare and involve a fall in haemoglobin due to an increased rate of haemolysis. It is important to recognise and manage these crises promptly, as they can lead to serious complications and even death.
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This question is part of the following fields:
- Haematology/Oncology
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Question 18
Incorrect
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A 28-year-old female patient visits your clinic with a complaint of fishy-smelling vaginal discharge. You suspect bacterial vaginosis and decide to prescribe metronidazole. The patient has no known drug allergies and is generally healthy, except for taking the combined oral contraceptive pill (COCP). What is the most crucial advice you should provide her regarding the potential side effects of metronidazole?
Your Answer:
Correct Answer: She should abstain from alcohol whilst taking metronidazole
Explanation:Taking metronidazole and alcohol together can result in a disulfiram-like reaction, so patients should be cautioned against consuming alcohol while on the medication. Metronidazole is not associated with cholestasis, hepatotoxicity, or QT prolongation. As an enzyme inhibitor, metronidazole enhances the efficacy of the COCP. While Stevens-Johnson syndrome is a rare side effect of metronidazole, a photosensitive rash is not typically observed.
Metronidazole is an antibiotic that functions by producing reactive cytotoxic metabolites within bacteria. This medication can cause adverse effects such as a disulfiram-like reaction when combined with alcohol and an increased anticoagulant effect when taken with warfarin.
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This question is part of the following fields:
- Reproductive Medicine
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Question 19
Incorrect
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A 32-year-old man has recently returned from a backpacking trip in Southeast Asia. While there, he consumed food from various street vendors. He complained of abdominal discomfort, bloating and loose stools. Analysis of three stool samples showed cysts in two of them. The patient was treated with metronidazole and showed improvement.
What is the probable medical condition in this scenario?Your Answer:
Correct Answer: Giardiasis
Explanation:Giardiasis: A Protozoal Parasite Causing Diarrhoeal Illness
Giardiasis is a diarrhoeal disease caused by the flagellate protozoan Giardia intestinalis (previously known as G. lamblia). It is prevalent in areas with poor sanitation and can cause asymptomatic colonisation or acute or chronic diarrhoeal illness. Travellers to highly endemic areas are at high risk of infection. Ingestion of as few as ten Giardia cysts can cause infection. Diarrhoea is the most common symptom of acute Giardia infection, occurring in 90% of symptomatic subjects. The traditional basis of diagnosis is identification of G. intestinalis trophozoites or cysts in the stool of infected patients via stool ova and parasite examination. Standard treatment consists of antibiotic therapy, and metronidazole is the most commonly prescribed antibiotic for this condition. Giardia infection may occur more commonly in families with X-linked agammaglobulinaemia and in sexually active men who have sex with men (MSM).
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This question is part of the following fields:
- Infectious Diseases
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Question 20
Incorrect
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A 35-year-old man with psoriatic arthritis presents with a severely painful red eye. The pain has been affecting his sleep for a few days. On examination, his visual acuity is normal but there is inflammation of the scleral, episcleral and conjunctival vessels. Both pupils are equal and react normally to light. There is no blanching of the episcleral vessels when 2.5% phenylephrine is applied to the eye.
Which of the following is this patient most likely to be suffering from?
Your Answer:
Correct Answer: Scleritis
Explanation:Differentiating Ocular Inflammatory Conditions: Symptoms and Treatment
Scleritis: A severe inflammation of the sclera, often associated with underlying inflammatory conditions such as rheumatoid arthritis. Symptoms include severe eye pain, watering, photophobia, and affected visual acuity. Treatment requires systemic medication such as non-steroidal anti-inflammatory drugs, corticosteroids, or immunosuppressants.
Sjögren Syndrome: An association of dry eye and/or dry mouth with rheumatoid arthritis or other connective-tissue disorders. Pain is not a feature, but conjunctival hyperemia may be present.
Anterior Uveitis: Inflammation of the iris with or without ciliary body involvement, often seen in patients with inflammatory bowel disease or ankylosing spondylitis. Symptoms include an acutely painful red eye with photophobia and a small, irregular, poorly reactive pupil.
Conjunctivitis: Inflammation of the conjunctival vessels, causing sore red eyes with a sticky discharge. Pain is not a feature, and scleral and episcleral vessels are not affected. Often caused by bacterial or viral infections or irritants/allergens, it is usually self-limiting but may require topical antibiotics.
Episcleritis: A mild inflammation of the episclera, often seen as an extra-articular manifestation of rheumatoid arthritis. Symptoms include mild eye irritation, redness, and sometimes photophobia. Application of 2.5% phenylephrine causes episcleral vessels to blanch, distinguishing it from scleritis. Visual acuity is unaffected, and it is usually self-limiting.
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This question is part of the following fields:
- Musculoskeletal
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Question 21
Incorrect
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A mother brings her 8-year-old daughter into surgery. She is struggling in school and the mother suspects she may have ADHD. Which of the following features is not indicative of a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)?
Your Answer:
Correct Answer: Repetitive behaviour
Explanation:In March 2018, NICE released new guidelines for identifying and managing Attention Deficit Hyperactivity Disorder (ADHD). This condition can have a significant impact on a child’s life and can continue into adulthood, making accurate diagnosis and treatment crucial. According to DSM-V, ADHD is characterized by persistent features of inattention and/or hyperactivity/impulsivity, with an element of developmental delay. Children up to the age of 16 must exhibit six of these features, while those aged 17 or over must exhibit five. ADHD has a UK prevalence of 2.4%, with a higher incidence in boys than girls, and there may be a genetic component.
NICE recommends a holistic approach to treating ADHD that is not solely reliant on medication. After presentation, a ten-week observation period should be implemented to determine if symptoms change or resolve. If symptoms persist, referral to secondary care is necessary, typically to a paediatrician with a special interest in behavioural disorders or to the local Child and Adolescent Mental Health Service (CAMHS). A tailored plan of action should be developed, taking into account the patient’s needs and wants, as well as how their condition affects their lives.
Drug therapy should be considered a last resort and is only available to those aged 5 years or older. Parents of children with mild/moderate symptoms can benefit from attending education and training programmes. For those who do not respond or have severe symptoms, pharmacotherapy may be considered. Methylphenidate is the first-line treatment for children and should be given on a six-week trial basis. It is a CNS stimulant that primarily acts as a dopamine/norepinephrine reuptake inhibitor. Side effects include abdominal pain, nausea, and dyspepsia. Weight and height should be monitored every six months in children. If there is an inadequate response, lisdexamfetamine should be considered, followed by dexamfetamine if necessary. In adults, methylphenidate or lisdexamfetamine are the first-line options, with switching between drugs if no benefit is seen after a trial of the other. All of these drugs are potentially cardiotoxic, so a baseline ECG should be performed before starting treatment, and referral to a cardiologist should be made if there is any significant past medical history or family history, or any doubt or ambiguity.
As with most psychiatric conditions, a thorough history and clinical examination are essential, particularly given the overlap of ADHD with many other psychiatric and
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This question is part of the following fields:
- Paediatrics
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Question 22
Incorrect
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You are conducting an infant assessment. What are the clinical manifestations of a clubfoot?
Your Answer:
Correct Answer: Inverted + plantar flexed foot which is not passively correctable
Explanation:Talipes Equinovarus: A Common Foot Deformity in Newborns
Talipes equinovarus, also known as club foot, is a foot deformity characterized by an inward turning and plantar flexed foot. It is a common condition that affects 1 in 1,000 newborns, with a higher incidence in males. In about 50% of cases, the deformity is present in both feet. While the cause of talipes equinovarus is often unknown, it can be associated with conditions such as spina bifida, cerebral palsy, and oligohydramnios.
Diagnosis of talipes equinovarus is typically made during the newborn exam, and imaging is not usually necessary. The deformity is not passively correctable, and the diagnosis is based on clinical examination.
In recent years, there has been a shift towards conservative management of talipes equinovarus, with the Ponseti method being the preferred approach. This method involves manipulation and progressive casting of the foot, starting soon after birth. The deformity is usually corrected within 6-10 weeks, and an Achilles tenotomy may be required in some cases. Night-time braces are then used until the child is 4 years old to prevent relapse, which occurs in about 15% of cases.
Overall, talipes equinovarus is a common foot deformity in newborns that can be effectively managed with conservative methods such as the Ponseti method.
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This question is part of the following fields:
- Musculoskeletal
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Question 23
Incorrect
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A 42-year-old woman presents with complaints of hot flashes and night sweats. Upon investigation, her blood work reveals a significantly elevated FSH level, indicating menopause. After discussing her options, she chooses to undergo hormone replacement therapy. What is the primary risk associated with prescribing an estrogen-only treatment instead of a combination estrogen-progestogen treatment?
Your Answer:
Correct Answer: Increased risk of endometrial cancer
Explanation:Adverse Effects of Hormone Replacement Therapy
Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progestogen in women with a uterus, to alleviate menopausal symptoms. While it can be effective in reducing symptoms such as hot flashes and vaginal dryness, HRT can also have adverse effects and potential complications.
Some common side-effects of HRT include nausea, breast tenderness, fluid retention, and weight gain. However, there are also more serious potential complications associated with HRT. For example, the use of HRT has been linked to an increased risk of breast cancer, particularly when a progestogen is added. The Women’s Health Initiative study found a relative risk of 1.26 at 5 years of developing breast cancer with HRT use. The risk of breast cancer is also related to the duration of use, and it begins to decline when HRT is stopped.
Another potential complication of HRT is an increased risk of endometrial cancer. Oestrogen by itself should not be given as HRT to women with a womb, as this can increase the risk of endometrial cancer. The addition of a progestogen can reduce this risk, but it is not eliminated completely. The British National Formulary states that the additional risk is eliminated if a progestogen is given continuously.
HRT has also been associated with an increased risk of venous thromboembolism (VTE), particularly when a progestogen is added. However, transdermal HRT does not appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any treatment, even transdermal, according to the National Institute for Health and Care Excellence (NICE).
Finally, HRT has been linked to an increased risk of stroke and ischaemic heart disease if taken more than 10 years after menopause. It is important for women considering HRT to discuss the potential risks and benefits with their healthcare provider and make an informed decision based on their individual circumstances.
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This question is part of the following fields:
- Reproductive Medicine
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Question 24
Incorrect
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Samantha is a 55-year-old Hispanic woman who visits her primary care physician for a routine check-up of her hypertension. Despite being treated with amlodipine 10 mg once daily, her blood pressure has been poorly controlled during her last two appointments. During her examination today, her blood pressure is 160/100 mmHg, pulse 70/minute, respiratory rate 15/min, and she has no fever. What would be the next appropriate step to attempt to control Samantha's hypertension?
Your Answer:
Correct Answer: Add candesartan
Explanation:To manage poorly controlled hypertension in patients already taking a calcium channel blocker, the recommended next step is to add an ACE inhibitor, an angiotensin receptor blocker (ARB), or a thiazide-like diuretic. In this particular case, since the patient is black, an ARB is the preferred choice. Beta-blockers like metoprolol are not commonly used for hypertension management. Increasing the dose of amlodipine may lead to more side effects, so it is generally better to add multiple drugs at lower doses instead of increasing the dose of one drug to its maximum.
NICE Guidelines for Managing Hypertension
Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.
The guidelines also provide a flow chart for the diagnosis and management of hypertension. Lifestyle advice, such as reducing salt intake, caffeine intake, and alcohol consumption, as well as exercising more and losing weight, should not be forgotten and is frequently tested in exams. Treatment options depend on the patient’s age, ethnicity, and other factors, and may involve a combination of drugs.
NICE recommends treating stage 1 hypertension in patients under 80 years old if they have target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For patients with stage 2 hypertension, drug treatment should be offered regardless of age. The guidelines also provide step-by-step treatment options, including adding a third or fourth drug if necessary.
New drugs, such as direct renin inhibitors like Aliskiren, may have a role in patients who are intolerant of more established antihypertensive drugs. However, trials have only investigated the fall in blood pressure and no mortality data is available yet. Patients who fail to respond to step 4 measures should be referred to a specialist. The guidelines also provide blood pressure targets for different age groups.
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This question is part of the following fields:
- Cardiovascular
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Question 25
Incorrect
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You are the paediatric SHO on call. You receive a call to attend the emergency department to assess a 3-year-old with stridor. Upon arrival, you find the patient sitting on their mother's lap, leaning forward and drooling. Audible stridor can be heard from the end of the bed. The patient's medical history reveals that they have not received any vaccinations.
What is the most suitable course of action in this scenario?Your Answer:
Correct Answer: Call the anaesthetist on call
Explanation:Do not perform oral or throat examination on a child with suspected acute epiglottitis as it may lead to further airway obstruction and distress. Basic observations can be done but call the senior paediatric team and an anaesthetist.
Stridor in Children: Causes and Symptoms
Stridor is a high-pitched, wheezing sound that occurs during breathing and is commonly seen in children. There are several causes of stridor in children, including croup, acute epiglottitis, inhaled foreign body, and laryngomalacia. Croup is a viral infection that affects the upper respiratory tract and is characterized by stridor, barking cough, fever, and coryzal symptoms. Acute epiglottitis is a rare but serious infection caused by Haemophilus influenzae type B, which can lead to airway obstruction. Inhaled foreign body can cause sudden onset of coughing, choking, vomiting, and stridor, depending on the site of impaction. Laryngomalacia is a congenital abnormality of the larynx that typically presents at 4 weeks of age with stridor.
It is important to recognize the symptoms of stridor in children and seek prompt medical attention, especially if the child appears unwell or toxic. Treatment may include medications, such as corticosteroids or nebulized epinephrine, or in severe cases, intubation or tracheostomy. Prevention measures, such as vaccination against Haemophilus influenzae type B, can also help reduce the incidence of acute epiglottitis. Overall, early recognition and management of stridor in children can help prevent complications and improve outcomes.
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This question is part of the following fields:
- Paediatrics
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Question 26
Incorrect
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A 12-year-old girl has excessive bleeding after an adenotonsillectomy for recurrent tonsillitis. Physical examination reveals no abnormalities. The girl's grandmother died of a postoperative bleeding complication at a young age.
Which of the following is the most important investigation to establish a diagnosis?Your Answer:
Correct Answer: Factor VIII assay
Explanation:Diagnostic Tests for Haemophilia: Factor VIII Assay, Prothrombin Time/INR, Platelet Count, Bone Marrow Examination, and Blood Film
Haemophilia is an X-linked bleeding disorder caused by deficiency of clotting factor VIII (haemophilia A) or factor IX (haemophilia B). Patients may present with bruising, inadequate clotting with mild injury, or spontaneous haemorrhage. To diagnose haemophilia A, a factor VIII assay is necessary. Other diagnostic tests include prothrombin time/INR, platelet count, bone marrow examination, and blood film. The prothrombin time and platelet count are normal in haemophilia, while bone marrow sampling carries a risk of significant bleeding. A blood film is not useful in the diagnosis as red blood cells and platelet count are normal.
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This question is part of the following fields:
- Paediatrics
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Question 27
Incorrect
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A 72-year-old patient with chronic lymphocytic leukaemia presents to the emergency department with haematemesis. Urgent blood tests are taken and blood products ordered from the laboratory.
A full blood count shows:
Hb 76 g/L Male: (135-180) Female: (115 - 160)
Platelets 26 * 109/L (150 - 400)
WBC 21.8 * 109/L (4.0 - 11.0)
Which blood product carries the highest risk for this immunocompromised patient?Your Answer:
Correct Answer: Platelets
Explanation:Platelet transfusions have the highest risk of bacterial contamination due to their short shelf life and refrigeration. This patient requires both red blood cells and platelets, but caution should be taken with platelet transfusions due to the risk of contamination. Cryoprecipitate and plasma have lower contamination risks and can be stored for longer periods. Packed red cells can also be used and have a longer shelf life.
Platelet Transfusion Guidelines for Active Bleeding and Pre-Invasive Procedures
Platelet transfusions are recommended for patients with thrombocytopenia and clinically significant bleeding, such as haematemesis, melaena, or prolonged epistaxis, with a platelet count of less than 30 x 10 9. For severe bleeding or bleeding at critical sites, such as the CNS, platelet thresholds for transfusion are higher, with a maximum of less than 100 x 10 9. However, it should be noted that platelet transfusions have a higher risk of bacterial contamination compared to other types of blood products.
For pre-invasive procedures, platelet transfusions are recommended to maintain platelet levels of greater than 50 x 10 9/L for most patients, 50-75 x 10 9/L for those at high risk of bleeding, and greater than 100 x 10 9/L for surgeries at critical sites. However, if there is no active bleeding or planned invasive procedure, a threshold of 10 x 10 9/L is recommended, unless platelet transfusion is contraindicated or there are alternative treatments available for the patient’s condition.
It is important to note that platelet transfusions should not be performed for chronic bone marrow failure, autoimmune thrombocytopenia, heparin-induced thrombocytopenia, or thrombotic thrombocytopenic purpura. These guidelines aim to provide appropriate and safe platelet transfusion practices for patients with thrombocytopenia.
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This question is part of the following fields:
- Haematology/Oncology
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Question 28
Incorrect
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A 45-year-old woman with multiple sclerosis comes in for evaluation. She reports experiencing worsening issues with painful spasms in her leg muscles. What is the initial treatment option that should be considered?
Your Answer:
Correct Answer: Baclofen
Explanation:The recommended initial treatments for spasticity in multiple sclerosis are baclofen and gabapentin.
Multiple sclerosis is a condition that cannot be cured, but its treatment aims to reduce the frequency and duration of relapses. In the case of an acute relapse, high-dose steroids may be administered for five days to shorten its length. However, it is important to note that steroids do not affect the degree of recovery. Disease-modifying drugs are used to reduce the risk of relapse in patients with MS. These drugs are typically indicated for patients with relapsing-remitting disease or secondary progressive disease who have had two relapses in the past two years and are able to walk a certain distance unaided. Natalizumab, ocrelizumab, fingolimod, beta-interferon, and glatiramer acetate are some of the drugs used to reduce the risk of relapse in MS.
Fatigue is a common problem in MS patients, and amantadine is recommended by NICE after excluding other potential causes such as anaemia, thyroid problems, or depression. Mindfulness training and CBT are other options for managing fatigue. Spasticity is another issue that can be addressed with first-line drugs such as baclofen and gabapentin, as well as physiotherapy. Cannabis and botox are currently being evaluated for their effectiveness in managing spasticity. Bladder dysfunction is also a common problem in MS patients, and anticholinergics may worsen symptoms in some patients. Ultrasound is recommended to assess bladder emptying, and intermittent self-catheterisation may be necessary if there is significant residual volume. Gabapentin is the first-line treatment for oscillopsia, which is a condition where visual fields appear to oscillate.
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This question is part of the following fields:
- Neurology
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Question 29
Incorrect
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A 45-year-old history teacher has contacted his doctor reporting a one-hour episode of weakness in his left arm and leg earlier today, which has since resolved. He denies any facial drooping, residual weakness, or slurred speech. He insists that he feels completely healthy and only called because his wife urged him to. The patient has a previous diagnosis of a pulmonary embolism and is currently taking apixaban. What is the initial approach to managing this patient?
Your Answer:
Correct Answer: Urgent admission to the emergency department for urgent CT head
Explanation:Immediate admission for imaging to rule out a hemorrhage is necessary if a patient with suspected TIA is on warfarin, a DOAC, or has a bleeding disorder.
A transient ischaemic attack (TIA) is a brief period of neurological deficit caused by a vascular issue, lasting less than an hour. The original definition of a TIA was based on time, but it is now recognized that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new ’tissue-based’ definition is now used. The clinical features of a TIA are similar to those of a stroke, but the symptoms resolve within an hour. Possible features include unilateral weakness or sensory loss, aphasia or dysarthria, ataxia, vertigo, or loss of balance, visual problems, and sudden transient loss of vision in one eye (amaurosis fugax).
NICE recommends immediate antithrombotic therapy with aspirin 300 mg unless the patient has a bleeding disorder or is taking an anticoagulant. If the patient has had more than one TIA or has a suspected cardioembolic source or severe carotid stenosis, specialist review is necessary. Urgent assessment is required within 24 hours for patients who have had a suspected TIA in the last 7 days. Referral for specialist assessment is necessary as soon as possible within 7 days for patients who have had a suspected TIA more than a week previously. Neuroimaging and carotid imaging are recommended, and antithrombotic therapy is necessary. Carotid artery endarterectomy should only be considered if the carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.
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This question is part of the following fields:
- Neurology
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Question 30
Incorrect
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A 25-year-old Caucasian female teacher visits the clinic to inquire about preconception care. She intends to conceive and is interested in learning about the supplements she should take. She has never given birth before and is in good health. She is not on any medication and has no known allergies. She does not smoke or consume alcohol.
What supplements do you suggest she take?Your Answer:
Correct Answer: Folic acid 400 micrograms once a day and vitamin D 10 micrograms once a day
Explanation:For this patient, who has a low risk of having a baby with neural tube defects and is not at high risk of vitamin D deficiency, the standard care is recommended. This includes taking a daily supplement of 10 micrograms of vitamin D. There is no need for her to take folic acid 5mg or higher doses of vitamin D, as they exceed the recommended amount.
Antenatal care guidelines were issued by NICE in March 2008, which included specific points for the care of healthy pregnant women. Nausea and vomiting can be treated with natural remedies such as ginger and acupuncture on the ‘p6’ point, as recommended by NICE. Antihistamines, with promethazine as the first-line option according to the BNF, can also be used. Adequate vitamin D intake is crucial for the health of both the mother and baby, and women should be informed about this at their booking appointment. The Chief Medical Officer advises all pregnant and breastfeeding women to take a daily supplement containing 10 micrograms of vitamin D, with particular care taken for those at risk. In 2016, new guidelines were proposed by the Chief Medical Officer regarding alcohol consumption during pregnancy. The government now advises pregnant women not to drink any alcohol to minimize the risk of harm to the baby.
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This question is part of the following fields:
- Reproductive Medicine
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