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Question 1
Correct
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A 59-year-old postmenopausal woman with a history of chronic hypertension and diabetes mellitus presents with mild vaginal bleeding. Bimanual pelvic examination reveals a relatively large mass on the right side of the pelvis. The patient undergoes an abdominal and pelvic computed tomography scan with contrast injection. The scan shows multiple enlarged lymph nodes in the pelvis, along the iliac arteries. The para-aortic lymph nodes appear normal.
What is the most likely diagnosis?Your Answer: Cervical squamous cell carcinoma
Explanation:Diagnosing Gynaecological Malignancies: Understanding the Differences
When a postmenopausal woman presents with vaginal bleeding, pelvic mass, and pelvic lymphadenopathy, it is important to consider the different types of Gynaecological malignancies that could be causing these symptoms. The most likely diagnosis in this case is cervical squamous cell carcinoma, which typically metastasises to the pelvic lymph nodes along the iliac arteries.
While endometrial carcinoma (adenocarcinoma) is the most common Gynaecological malignancy, it would also be a possibility in this patient. Ovarian cancer, the second most common Gynaecological cancer, typically metastasises to the para-aortic lymph nodes and is not associated with vaginal bleeding.
Vulval cancers tend to metastasise to the superficial inguinal node and are unlikely to present with a pelvic mass or vaginal bleeding. Cervical adenocarcinomas are rare and derived from the endocervix, while uterine leiomyosarcoma often extends beyond the uterine serosa and occasionally metastasises to distant organs through blood vessels. However, neither of these malignancies typically present with vaginal bleeding and pelvic lymphadenopathy.
In summary, understanding the differences between the various types of Gynaecological malignancies is crucial in accurately diagnosing and treating patients with these conditions.
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This question is part of the following fields:
- Gynaecology
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Question 2
Incorrect
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What feature is typical of the early stages of Alzheimer's disease?
Your Answer: Ataxic gait
Correct Answer: Impaired short term memory
Explanation:Identifying Dementia: Symptoms and Differential Diagnosis
Dementia is a progressive neurological disorder that affects cognitive function, including memory, language, and decision-making abilities. Alzheimer’s disease is the most common form of dementia, and it is characterised by short-term memory loss in the early stages. However, other symptoms may suggest an alternative diagnosis.
For instance, gait ataxia and urinary incontinence may indicate normal pressure hydrocephalus, while myoclonic jerks may suggest Creutzfeldt-Jakob disease. Visual hallucinations and delirium are common in Lewy body dementia.
It is important to differentiate between different types of dementia to provide appropriate treatment and care. Early diagnosis and intervention can help slow down the progression of the disease and improve the quality of life for patients and their families. Healthcare professionals should be aware of the various symptoms and differential diagnosis of dementia to provide accurate diagnosis and management.
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This question is part of the following fields:
- Miscellaneous
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Question 3
Incorrect
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A 35-year-old woman arrives at 28 weeks gestation for her third pregnancy. During an ultrasound at 12 weeks, it was discovered that she was carrying dichorionic diamniotic twins. She is admitted to the hospital due to painless, bright red bleeding per vaginum. She has undergone two previous caesarian sections. What is the probable diagnosis?
Your Answer: Placenta abruption
Correct Answer: Placenta praevia
Explanation:Placenta praevia is a pregnancy complication characterized by the attachment of the placenta to the lower part of the uterus. The main symptom is painless bleeding occurring after the 24th week of gestation. Risk factors include a history of placenta praevia, previous caesarean section, damage to the endometrium, and multiple pregnancies. Placenta praevia frequently results in a high presenting part or abnormal lie due to the placenta’s low position.
Understanding Placenta Praevia
Placenta praevia is a condition where the placenta is located wholly or partially in the lower uterine segment. It is a relatively rare condition, with only 5% of women having a low-lying placenta when scanned at 16-20 weeks gestation. However, the incidence at delivery is only 0.5%, as most placentas tend to rise away from the cervix.
There are several factors associated with placenta praevia, including multiparity, multiple pregnancy, and embryos implanting on a lower segment scar from a previous caesarean section. Clinical features of placenta praevia include shock in proportion to visible loss, no pain, a non-tender uterus, abnormal lie and presentation, and a usually normal fetal heart. Coagulation problems are rare, and small bleeds may occur before larger ones.
Diagnosis of placenta praevia should not involve digital vaginal examination before an ultrasound, as this may provoke severe haemorrhage. The condition is often picked up on routine 20-week abdominal ultrasounds, but the Royal College of Obstetricians and Gynaecologists recommends the use of transvaginal ultrasound for improved accuracy and safety. Placenta praevia is classified into four grades, with grade IV being the most severe, where the placenta completely covers the internal os.
In summary, placenta praevia is a rare condition that can have serious consequences if not diagnosed and managed appropriately. It is important for healthcare professionals to be aware of the associated factors and clinical features, and to use appropriate diagnostic methods for accurate grading and management.
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This question is part of the following fields:
- Obstetrics
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Question 4
Incorrect
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A 32-year-old female patient is experiencing a prolonged postoperative ileus following extensive small bowel resection due to Crohn's disease. The surgical consultant suspects total intestinal failure as her remaining gut has failed to absorb nutrients. What is the most suitable method of delivering nutrition to this patient?
Your Answer: Nasogastric tube
Correct Answer: Subclavian line
Explanation:Total parenteral nutrition must be given through a central vein to minimize the risk of phlebitis. The most appropriate central line for administering TPN is a subclavian line, which places the tip of the line in the right atrium/superior vena cava. TPN is the preferred method of nutrition for patients with suspected total intestinal failure, as the gut is unable to absorb nutrients. Administering TPN through a peripheral cannula would be highly irritating to the vein and could cause it to collapse. TPN should not be given through a nasogastric tube, as it is a parenteral method of administration. Medications should never be given through an arterial line, as it could lead to distal ischaemia. Although a midline catheter is more central than a traditional cannula, it is still considered a peripheral IV line and should not be used for TPN administration. The tip of a midline catheter is located within the vein, such as the basilic vein.
Nutrition Options for Surgical Patients
When it comes to providing nutrition for surgical patients, there are several options available. The easiest and most common option is oral intake, which can be supplemented with calorie-rich dietary supplements. However, this may not be suitable for all patients, especially those who have undergone certain procedures.
nasogastric feeding is another option, which involves administering feed through a fine bore nasogastric feeding tube. While this method may be safe for patients with impaired swallow, there is a risk of aspiration or misplaced tube. It is also usually contra-indicated following head injury due to the risks associated with tube insertion.
Naso jejunal feeding is a safer alternative as it avoids the risk of feed pooling in the stomach and aspiration. However, the insertion of the feeding tube is more technically complicated and is easiest if done intra-operatively. This method is safe to use following oesophagogastric surgery.
Feeding jejunostomy is a surgically sited feeding tube that may be used for long-term feeding. It has a low risk of aspiration and is thus safe for long-term feeding following upper GI surgery. However, there is a risk of tube displacement and peritubal leakage immediately following insertion, which carries a risk of peritonitis.
Percutaneous endoscopic gastrostomy is a combined endoscopic and percutaneous tube insertion method. However, it may not be technically possible in patients who cannot undergo successful endoscopy. Risks associated with this method include aspiration and leakage at the insertion site.
Finally, total parenteral nutrition is the definitive option for patients in whom enteral feeding is contra-indicated. However, individualised prescribing and monitoring are needed, and it should be administered via a central vein as it is strongly phlebitic. Long-term use is associated with fatty liver and deranged LFTs.
In summary, there are several nutrition options available for surgical patients, each with its own benefits and risks. The choice of method will depend on the patient’s individual needs and circumstances.
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This question is part of the following fields:
- Surgery
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Question 5
Correct
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A 50-year-old male with type 2 diabetes presents for his annual review. Despite following a diet plan, his glycaemic control is not optimal and his most recent HbA1c is 63 mmol/mol (20-46). You decide to initiate treatment with metformin 500 mg bd. As per NICE NG28 guidelines for diabetes management, what is the recommended interval for rechecking his HbA1c after each intensification of treatment?
Your Answer: Three to six months
Explanation:HbA1c as a Tool for Glycaemic Control
The glycated haemoglobin (HbA1c) is a measure of the glucose levels in the blood over a period of time. It reflects the glycosylation of the haemoglobin molecule by glucose, and there is a strong correlation between the glycosylation of this molecule and average plasma glucose concentrations. This makes it a widely used tool in clinical practice to assess glycaemic control. Studies have also shown that HbA1c has prognostic significance in both microvascular and macrovascular risk.
The life span of a red blood cell is 120 days, and HbA1c reflects the average blood glucose levels during the half-life of the red cell, which is about 60 days. According to NICE guidelines, it is recommended to re-check HbA1c with each treatment intensification at 3/6 monthly intervals. HbA1c as a tool for glycaemic control is crucial in managing diabetes and reducing the risk of complications.
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This question is part of the following fields:
- Endocrinology
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Question 6
Correct
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A survey is conducted to determine the number of people in a retirement community suffering from arthritis. The community's population is 25 000 people. The total number of people found to have a confirmed diagnosis of arthritis is 125.
According to the result of this survey, what is the prevalence of arthritis in this population?Your Answer: 0.50%
Explanation:Understanding Prevalence: Calculating and Interpreting Disease Burden in a Population
Prevalence is a measure of disease burden in a population at a specific point in time. It is calculated by dividing the number of people with a particular condition by the total number of people in the sample. Unlike incidence, which measures the number of new cases over a period of time, prevalence takes into account both new and existing cases.
It is important to note that prevalence is dependent on both the rate at which new cases arise (incidence) and the average length of time that people survive after acquiring the condition. An overestimate or underestimate of prevalence can have significant implications for public health interventions and resource allocation.
Therefore, accurate calculation and interpretation of prevalence is crucial for understanding the burden of disease in a population.
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This question is part of the following fields:
- Statistics
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Question 7
Incorrect
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A 58-year-old man with long-standing multiple sclerosis (MS) is admitted due to increasing problems with his care in the community. He is bed-bound with a spastic paraparesis. He is noted to have a permanent 14-gauge urinary catheter in situ and has a history of recurrent urinary tract infections. The family informs the nursing staff that this has not been changed for some time. Your senior colleague wishes for the catheter to be replaced due to recurrent UTIs.
Which one of the following statements is the most accurate?Your Answer: A male chaperone is required
Correct Answer: A single dose of prophylactic gentamicin is advisable
Explanation:Best Practices for Permanent Indwelling Urinary Catheters
Introduction:
Permanent indwelling urinary catheters are commonly used in patients with urinary retention or incontinence. However, they can pose a risk of infection and other complications. Therefore, it is important to follow best practices when placing and maintaining these catheters.Prophylactic Gentamicin:
When replacing a permanent catheter, it is recommended to administer a single dose of prophylactic gentamicin to prevent infection.Regular Replacement:
It is essential to have measures in place for regular routine replacement of permanent catheters. This is because they are a foreign body and can be a portal of entry for infection. Urinary sepsis in these patients can be devastating and fatal.Same-Sized Catheter:
When replacing a catheter, it is not necessary to change the size unless there are symptoms of catheter bypass. Increasing the size can cause pain and trauma.Local Anaesthetic Gel:
Even if a patient has paraparesis, local anaesthetic gel must be used during catheter insertion to prevent pain.Chaperone:
It is good practice to offer a chaperone during any intimate examination/procedure. The patient may accept or decline a chaperone. If a chaperone is required, they do not have to be a man as long as there is consent from the patient.Regular Replacement Schedule:
Long-term catheters require changing every 12 weeks due to the design of the catheter and the risk of infection. This can be done in the community by district nurses.Best Practices for Permanent Indwelling Urinary Catheters
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This question is part of the following fields:
- Urology
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Question 8
Incorrect
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A 25-year-old female patient arrives at the emergency department complaining of headache and nausea. The medical team suspects carbon monoxide poisoning. What diagnostic test should be conducted next to assist in the diagnosis?
Your Answer: Chest x-ray
Correct Answer: Arterial blood gas
Explanation:Understanding Carbon Monoxide Poisoning
Carbon monoxide poisoning occurs when carbon monoxide, a toxic gas, is inhaled and binds to haemoglobin and myoglobin in the body, resulting in tissue hypoxia. This leads to a left-shift of the oxygen dissociation curve, causing a decrease in oxygen saturation of haemoglobin. In the UK, there are approximately 50 deaths per year from accidental carbon monoxide poisoning.
Symptoms of carbon monoxide toxicity include headache, nausea and vomiting, vertigo, confusion, and subjective weakness. Severe toxicity can result in pink skin and mucosae, hyperpyrexia, arrhythmias, extrapyramidal features, coma, and even death.
To diagnose carbon monoxide poisoning, pulse oximetry may not be reliable due to similarities between oxyhaemoglobin and carboxyhaemoglobin. Therefore, a venous or arterial blood gas should be taken to measure carboxyhaemoglobin levels. Non-smokers typically have levels below 3%, while smokers have levels below 10%. Symptomatic patients have levels between 10-30%, and severe toxicity is indicated by levels above 30%. An ECG may also be useful to check for cardiac ischaemia.
In the emergency department, patients with suspected carbon monoxide poisoning should receive 100% high-flow oxygen via a non-rebreather mask. This decreases the half-life of carboxyhemoglobin and should be administered as soon as possible, with treatment continuing for a minimum of six hours. Target oxygen saturations are 100%, and treatment is generally continued until all symptoms have resolved. For more severe cases, hyperbaric oxygen therapy may be considered, as it has been shown to have better long-term outcomes than standard oxygen therapy. Indications for hyperbaric oxygen therapy include loss of consciousness, neurological signs other than headache, myocardial ischaemia or arrhythmia, and pregnancy.
Overall, understanding the pathophysiology, symptoms, and management of carbon monoxide poisoning is crucial in preventing and treating this potentially deadly condition.
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This question is part of the following fields:
- Pharmacology
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Question 9
Incorrect
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A 50-year-old male patient complains of a painful swelling at the back of his elbow, without any history of injury. Upon examination, an erythematosus and tender swelling is observed. What is the probable diagnosis?
Your Answer: Septic arthritis
Correct Answer: Olecranon bursitis
Explanation:Common Causes of Elbow Pain
Elbow pain can be caused by a variety of conditions, each with their own characteristic features. Lateral epicondylitis, also known as tennis elbow, is characterized by pain and tenderness localized to the lateral epicondyle. Pain is worsened by resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended. Episodes typically last between 6 months and 2 years, with acute pain lasting for 6-12 weeks.
Medial epicondylitis, or golfer’s elbow, is characterized by pain and tenderness localized to the medial epicondyle. Pain is aggravated by wrist flexion and pronation, and symptoms may be accompanied by numbness or tingling in the 4th and 5th finger due to ulnar nerve involvement.
Radial tunnel syndrome is most commonly due to compression of the posterior interosseous branch of the radial nerve, and is thought to be a result of overuse. Symptoms are similar to lateral epicondylitis, but the pain tends to be around 4-5 cm distal to the lateral epicondyle. Symptoms may be worsened by extending the elbow and pronating the forearm.
Cubital tunnel syndrome is due to the compression of the ulnar nerve. Initially, patients may experience intermittent tingling in the 4th and 5th finger, which may be worse when the elbow is resting on a firm surface or flexed for extended periods. Later, numbness in the 4th and 5th finger with associated weakness may occur.
Olecranon bursitis is characterized by swelling over the posterior aspect of the elbow, with associated pain, warmth, and erythema. It typically affects middle-aged male patients. Understanding the characteristic features of these conditions can aid in their diagnosis and treatment.
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This question is part of the following fields:
- Musculoskeletal
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Question 10
Incorrect
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You are asked to see a 43-year-old man with a stoma in the right lower quadrant of his abdomen. It is sprouted and produces a liquid, light brown fluid.
What form of stoma is this likely to be?Your Answer: Enterocutaneous fistula
Correct Answer: Ileostomy
Explanation:Types of Stomas: Ileostomy, Colostomy, Enterocutaneous Fistula, Mucous Fistula, and Urostomy
Stomas are surgical openings created in the abdomen to allow for the elimination of waste products from the body. There are different types of stomas, each with its unique characteristics and functions.
An ileostomy is a stoma created from the small intestine. The stool from an ileostomy is looser and more acidic, making it more likely to cause skin damage. To prevent this, ileostomies are fashioned with a spout for better delivery of the stoma content into the stoma bag.
A colostomy, on the other hand, is a stoma created from the large intestine. Colostomies are generally flat and placed in the left iliac fossa, although this can vary.
An enterocutaneous fistula is an abnormal passage between the gastrointestinal tract and the skin. It is not a stoma.
A mucous fistula is a stoma that allows the collection of mucous associated with inflammatory bowel disease.
Finally, a urostomy is formed as a result of bladder excision. Urostomies are created by anastomosis of the ureters and drainage into a segment of the small bowel, which has been resected and used to form an ileal conduit. This conduit delivers urine to the skin in the form of a spouted stoma. Urostomies can be differentiated from ileostomies by their output (urine vs. feces).
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This question is part of the following fields:
- Colorectal
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Question 11
Incorrect
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A 45-year-old man came to the clinic during the summer with complaints of itching and blistering on his hands and forehead. Upon examination, small areas of excoriation were found on the backs of his hands. What is the probable diagnosis?
Your Answer: Pemphigoid
Correct Answer: Porphyria cutanea tarda (PCT)
Explanation:Photosensitivity and Skin Lesions: A Possible Case of PCT
The distribution of the skin lesions in this case suggests that there may be a photosensitive element involved. While both lupus erythematosus and porphyria cutanea tarda (PCT) are associated with photosensitivity, it is more commonly seen in PCT. This condition is characterized by blistering of the hands and forehead, which can lead to small scars and milia formation as they heal. Excessive alcohol intake is also a known risk factor for PCT.
Overall, the presence of photosensitivity and the specific distribution of the lesions in this case point towards a possible diagnosis of PCT. Further testing and evaluation will be necessary to confirm this diagnosis and determine the best course of 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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A 55-year-old man with Tourette's and poorly controlled type 2 diabetes presents to you with concerns about intermittent chest pain on exertion. He drinks 21 units of alcohol per week and smokes 20 cigarettes a day. His father died of a myocardial infarction at the age of 56 years. You refer him for suspected angina, provide advice on worsening chest pain, and prescribe a GTN spray for use as needed. While prescribing the GTN spray, you notice a medication on his prescription list that he should avoid taking while being investigated for chest pain or using the GTN spray. What medication is this referring to?
Your Answer: Sitagliptin
Correct Answer: Sildenafil
Explanation:Sildenafil, a type of PDE 5 inhibitor, should not be used together with nitrates and nicorandil due to potential risks of significant hypotension and myocardial infarction. On the other hand, there are no known interactions between nitrates and metformin, gliclazide, sitagliptin, or atorvastatin according to the BNF.
Understanding Phosphodiesterase Type V Inhibitors
Phosphodiesterase type V (PDE5) inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. These drugs work by increasing the levels of cGMP, which leads to the relaxation of smooth muscles in the blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which was the first drug of its kind. It is a short-acting medication that is usually taken one hour before sexual activity.
Other PDE5 inhibitors include tadalafil (Cialis) and vardenafil (Levitra). Tadalafil is longer-acting than sildenafil and can be taken on a regular basis, while vardenafil has a similar duration of action to sildenafil. However, these drugs are not suitable for everyone. Patients taking nitrates or related drugs, those with hypotension, and those who have had a recent stroke or myocardial infarction should not take PDE5 inhibitors.
Like all medications, PDE5 inhibitors can cause side effects. These may include visual disturbances, blue discolouration, non-arteritic anterior ischaemic neuropathy, nasal congestion, flushing, gastrointestinal side-effects, headache, and priapism. It is important to speak to a healthcare professional before taking any medication to ensure that it is safe and appropriate for you.
Overall, PDE5 inhibitors are an effective treatment for erectile dysfunction and pulmonary hypertension. However, they should only be used under the guidance of a healthcare professional and with careful consideration of the potential risks and benefits.
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This question is part of the following fields:
- Pharmacology
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Question 13
Correct
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A 4-year-old girl is brought to the Emergency department by her mother.
The girl is experiencing elbow pain and is refusing to use her arm. Her mother reports that she was lifted up by her outstretched arms earlier in the day.
What is the probable diagnosis for this case?Your Answer: Subluxation of the radial head
Explanation:Subluxation of the Radial Head in Children
Subluxation of the radial head, also known as pulled elbow, is a frequent injury in young children. It occurs when the arm is pulled directly, causing the radial head to dislocate from its ligament. The child may experience pain in the elbow and have limited movement in supination and extension. They may also refuse to use their arm.
Fortunately, a diagnosis can often be made without the need for an x-ray if the history is typical. Treatment involves providing pain relief and manipulating the elbow by supination while it is flexed at a 90° angle. With proper care, most children recover quickly from this injury.
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This question is part of the following fields:
- Emergency Medicine
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Question 14
Incorrect
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A patient 16/40 gestation contacts your clinic via phone. This is her first pregnancy and she is worried about not experiencing any foetal movements yet. You provide reassurance that foetal movements can be felt between 16-20 weeks gestation in first pregnancies. When should further investigation be considered if no foetal movements are felt by this time?
Your Answer: 28 weeks
Correct Answer: 24 weeks
Explanation:According to RCOG guidelines, women typically feel fetal movements by 20 weeks of gestation. However, if no movements are felt by 24 weeks, it is recommended to refer the woman to a maternal fetal medicine unit to assess for potential neuromuscular conditions.
Understanding Reduced Fetal Movements
Introduction:
Reduced fetal movements can indicate fetal distress and are a response to chronic hypoxia in utero. This can lead to stillbirth and fetal growth restriction. It is believed that placental insufficiency may also be linked to reduced fetal movements.Physiology:
Quickening is the first onset of fetal movements, which usually occurs between 18-20 weeks gestation and increases until 32 weeks gestation. Multiparous women may experience fetal movements sooner. Fetal movements should not reduce towards the end of pregnancy. There is no established definition for what constitutes reduced fetal movements, but less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) is an indication for further assessment.Epidemiology:
Reduced fetal movements affect up to 15% of pregnancies, with 3-5% of pregnant women having recurrent presentations with RFM. Fetal movements should be established by 24 weeks gestation.Risk factors for reduced fetal movements:
Posture, distraction, placental position, medication, fetal position, body habitus, amniotic fluid volume, and fetal size can all affect fetal movement awareness.Investigations:
Fetal movements are usually based on maternal perception, but can also be objectively assessed using handheld Doppler or ultrasonography. Investigations are dependent on gestation at onset of RFM. If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used.Prognosis:
Reduced fetal movements can represent fetal distress, but in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication. However, between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis. Recurrent RFM requires further investigations to consider structural or genetic fetal abnormalities. -
This question is part of the following fields:
- Obstetrics
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Question 15
Incorrect
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A 35-year-old female who is post-partum and on the oral contraceptive pill, presents with right upper quadrant pain, nausea and vomiting, hepatosplenomegaly and ascites.
What is the most probable reason for these symptoms?Your Answer: Pylephlebitis after acute appendicitis
Correct Answer: Budd-Chiari syndrome
Explanation:Differential diagnosis of hepatosplenomegaly and portal hypertension
Hepatosplenomegaly and portal hypertension can have various causes, including pre-hepatic, hepatic, and post-hepatic problems. One potential cause is Budd-Chiari syndrome, which results from hepatic vein thrombosis and is associated with pregnancy and oral contraceptive use. Alcoholic cirrhosis is another possible cause, but is unlikely in the absence of alcohol excess. Pylephlebitis, a rare complication of appendicitis, is not consistent with the case history provided. Splenectomy cannot explain the palpable splenomegaly in this patient. Tricuspid valve incompetence can also lead to portal hypertension and hepatosplenomegaly, but given the postpartum status of the patient, Budd-Chiari syndrome is a more probable diagnosis.
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This question is part of the following fields:
- Gastroenterology
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Question 16
Incorrect
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A 70-year-old woman comes to your clinic complaining of ankle swelling. She has started taking a new medication for her blood pressure. She believes that this medication is responsible for her ankle oedema and wants you to investigate. What is the medication most likely to have caused her ankle swelling?
Your Answer: Lisinopril
Correct Answer: Nifedipine
Explanation:Nifedipine is more likely to cause ankle swelling than verapamil or other antihypertensive medications. This is because nifedipine is a dihydropyridine calcium-channel blocker (CCB), which can cause vasodilation and increased leakage of small blood vessels, leading to fluid accumulation in the interstitial space and resulting in ankle edema. Diltiazem, an alternative CCB, is less likely to cause ankle edema but may increase the risk of heart failure. Doxazosin, an alpha-blocker, can also cause edema but is less commonly used than nifedipine. Lisinopril, an ACE inhibitor, is more likely to cause angioedema than peripheral edema.
Understanding Calcium Channel Blockers
Calcium channel blockers are medications primarily used to manage cardiovascular diseases. These blockers target voltage-gated calcium channels present in myocardial cells, cells of the conduction system, and vascular smooth muscle cells. The different types of calcium channel blockers have varying effects on these three areas, making it crucial to differentiate their uses and actions.
Verapamil is an example of a calcium channel blocker used to manage angina, hypertension, and arrhythmias. However, it is highly negatively inotropic and should not be given with beta-blockers as it may cause heart block. Verapamil may also cause side effects such as heart failure, constipation, hypotension, bradycardia, and flushing.
Diltiazem is another calcium channel blocker used to manage angina and hypertension. It is less negatively inotropic than verapamil, but caution should still be exercised when patients have heart failure or are taking beta-blockers. Diltiazem may cause side effects such as hypotension, bradycardia, heart failure, and ankle swelling.
On the other hand, dihydropyridines such as nifedipine, amlodipine, and felodipine are calcium channel blockers used to manage hypertension, angina, and Raynaud’s. These blockers affect the peripheral vascular smooth muscle more than the myocardium, resulting in no worsening of heart failure but may cause ankle swelling. Shorter-acting dihydropyridines such as nifedipine may cause peripheral vasodilation, resulting in reflex tachycardia and side effects such as flushing, headache, and ankle swelling.
In summary, understanding the different types of calcium channel blockers and their effects on the body is crucial in managing cardiovascular diseases. It is also important to note the potential side effects and cautions when prescribing these medications.
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This question is part of the following fields:
- Pharmacology
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Question 17
Incorrect
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A 21-year-old woman comes to your clinic for an appointment scheduled by her father, who is worried about her lack of sleep. During the consultation, the patient reveals that she no longer feels the need to sleep for more than 2-3 hours. She appears talkative and mentions that she has been working on an online business that will bring her a lot of money. She is annoyed that people are questioning her, especially since she usually feels down, but now feels much better. There are no reports of delusions or hallucinations. What is the most probable diagnosis?
Your Answer: Insomnia
Correct Answer: Hypomanic phase of bipolar disorder
Explanation:The patient is experiencing a significant decrease in sleep, but does not feel tired. This, along with other symptoms such as being excessively talkative and irritable, having an overconfident attitude towards their business, and a history of depression, suggests that they may be in a hypomanic phase of bipolar disorder. Insomnia, which typically results in feelings of tiredness and a desire to sleep, is less likely to be the cause of the patient’s symptoms. The absence of delusions or hallucinations rules out psychosis as a possible explanation. A manic phase of bipolar disorder is also unlikely, as the patient does not exhibit any delusions or hallucinations. The combination of symptoms suggests that there is more to the patient’s condition than just a resolution of depression.
Understanding Bipolar Disorder
Bipolar disorder is a mental health condition that is characterized by alternating periods of mania/hypomania and depression. It typically develops in the late teen years and has a lifetime prevalence of 2%. There are two recognized types of bipolar disorder: type I, which involves mania and depression, and type II, which involves hypomania and depression.
Mania and hypomania both refer to abnormally elevated mood or irritability, but mania is more severe and can include psychotic symptoms for 7 days or more. Hypomania, on the other hand, involves decreased or increased function for 4 days or more. The presence of psychotic symptoms suggests mania.
Management of bipolar disorder may involve psychological interventions specifically designed for the condition, as well as medication. Lithium is the mood stabilizer of choice, but valproate can also be used. Antipsychotic therapy, such as olanzapine or haloperidol, may be used to manage mania/hypomania, while fluoxetine is the antidepressant of choice for depression. It is important to address any co-morbidities, as there is an increased risk of diabetes, cardiovascular disease, and COPD in individuals with bipolar disorder.
If symptoms suggest hypomania, routine referral to the community mental health team (CMHT) is recommended. However, if there are features of mania or severe depression, an urgent referral to the CMHT should be made. Understanding bipolar disorder and its management is crucial for healthcare professionals to provide appropriate care and support for individuals with this condition.
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This question is part of the following fields:
- Psychiatry
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Question 18
Incorrect
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A man with mild dementia has just been admitted to the Emergency Department unit in Scotland following a fall. He has total external rotation of his left leg, indicating that he has a fractured neck of femur. He refused to be taken into the ambulance at home, and the GP successfully applied to a Justice of the Peace for a warrant to remove him to hospital. He still does not want any treatment, and will not allow examination of his hip.
What is the best legal option to take?Your Answer: Common law principle of necessity
Correct Answer: A section 47 certificate under Adults with Incapacity (Scotland) Act 2000
Explanation:Appropriate Legal Options for Treatment Refusal in Scotland
When a patient refuses treatment in Scotland, it is important to consider the appropriate legal options available. Depending on the circumstances, different legislation may apply.
If the patient’s refusal does not fall under mental health legislation and their condition is not immediately life-threatening, the Adults with Incapacity (Scotland) Act 2000 may be the operating legislation. In this case, a section 47 certificate can be used to proceed with treatment.
However, if there is an underlying mental health disorder, the Mental Health (Care and Welfare) (Scotland) Act 2003 may be applicable. An Emergency Treatment Certificate can be used in cases where there is an immediate risk to life, while a short-term detention certificate and compulsory treatment order can be used in other situations.
It is also important to consider the common law principle of necessity, which may apply in cases where there is an immediate risk to life.
Overall, it is crucial to carefully consider the circumstances and applicable legislation when determining the appropriate legal options for treatment refusal in Scotland.
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This question is part of the following fields:
- Ethics And Legal
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Question 19
Incorrect
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Primary biliary cirrhosis is most characteristically associated with:
Your Answer: Anti-nuclear antibodies
Correct Answer: Anti-mitochondrial antibodies
Explanation:The M rule for primary biliary cholangitis includes the presence of IgM and anti-Mitochondrial antibodies, specifically the M2 subtype, in middle-aged women.
Primary Biliary Cholangitis: A Chronic Liver Disorder
Primary biliary cholangitis, previously known as primary biliary cirrhosis, is a chronic liver disorder that is commonly observed in middle-aged women. The exact cause of this condition is not yet fully understood, but it is believed to be an autoimmune disease. The disease is characterized by the progressive damage of interlobular bile ducts due to chronic inflammation, leading to cholestasis and eventually cirrhosis. The most common symptom of primary biliary cholangitis is itching in middle-aged women.
This condition is often associated with other autoimmune diseases such as Sjogren’s syndrome, rheumatoid arthritis, systemic sclerosis, and thyroid disease. Early symptoms of primary biliary cholangitis may be asymptomatic or may include fatigue, pruritus, and cholestatic jaundice. Late symptoms may progress to liver failure. Diagnosis of primary biliary cholangitis involves immunology tests such as anti-mitochondrial antibodies (AMA) M2 subtype and smooth muscle antibodies, as well as imaging tests to exclude an extrahepatic biliary obstruction.
The first-line treatment for primary biliary cholangitis is ursodeoxycholic acid, which slows down the progression of the disease and improves symptoms. Cholestyramine is used to alleviate pruritus, and fat-soluble vitamin supplementation is recommended. In severe cases, liver transplantation may be necessary, especially if bilirubin levels exceed 100. However, recurrence in the graft can occur, but it is not usually a problem. Complications of primary biliary cholangitis include cirrhosis, portal hypertension, ascites, variceal hemorrhage, osteomalacia, osteoporosis, and an increased risk of hepatocellular carcinoma.
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This question is part of the following fields:
- Medicine
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Question 20
Incorrect
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A 38-year-old man has been referred to the rheumatology clinic by his GP due to suspicion of systemic lupus erythematosus (SLE). The patient complains of symmetrical arthralgia affecting the MCP and PIP joints for the past 3 months, along with mouth ulcers and photosensitivity. Which of the following medical histories would support a diagnosis of SLE?
Your Answer:
Correct Answer: Pericarditis
Explanation:The revised ARA criteria for the classification of lupus includes serositis (pleuritis or pericarditis) as a defining feature. Pericarditis is the most prevalent cardiac manifestation of SLE and is also included in the classification criteria of the British Society for Rheumatology 2018 guidelines for SLE. It is important to note that the other options are not part of these criteria, which are not comprehensive but are still considered a valuable diagnostic aid.
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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