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Question 1
Incorrect
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You perform a routine examination on a 6-month-old baby with newly diagnosed Down syndrome. The mother mentions 'white speckles on his eyes'. Upon examination, you find a bilateral red reflex and no abnormalities. What is the mother describing?
Your Answer: Congenital glaucoma
Correct Answer: Brushfield spots
Explanation:Brushfield spots, which are small grey or brown spots found on the outer edge of the iris, are commonly observed in individuals with Down syndrome. Cataracts, on the other hand, involve clouding of the lens and are not likely present in this patient as their red reflex appears normal. Coloboma, a congenital defect that causes a gap in the lens, iris, or retina, is associated with Patau syndrome rather than Down syndrome. While there have been links between Down syndrome and congenital glaucoma, the patient’s history does not suggest this condition. A squint, or deviation in the gaze of an eye, is a separate issue altogether.
Down’s syndrome is a genetic disorder that is characterized by various clinical features. These features include an upslanting of the palpebral fissures, epicanthic folds, Brushfield spots in the iris, a protruding tongue, small low-set ears, and a round or flat face. Additionally, individuals with Down’s syndrome may have a flat occiput, a single palmar crease, and a pronounced sandal gap between their big and first toe. Hypotonia, congenital heart defects, duodenal atresia, and Hirschsprung’s disease are also common in individuals with Down’s syndrome.
Cardiac complications are also prevalent in individuals with Down’s syndrome, with multiple cardiac problems potentially present. The most common cardiac defect is the endocardial cushion defect, also known as atrioventricular septal canal defects, which affects 40% of individuals with Down’s syndrome. Other cardiac defects include ventricular septal defect, secundum atrial septal defect, tetralogy of Fallot, and isolated patent ductus arteriosus.
Later complications of Down’s syndrome include subfertility, learning difficulties, short stature, repeated respiratory infections, hearing impairment from glue ear, acute lymphoblastic leukaemia, hypothyroidism, Alzheimer’s disease, and atlantoaxial instability. Males with Down’s syndrome are almost always infertile due to impaired spermatogenesis, while females are usually subfertile and have an increased incidence of problems with pregnancy and labour.
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This question is part of the following fields:
- Paediatrics
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Question 2
Correct
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A 63-year-old male presents to the Emergency Department with chest pain and shortness of breath. He reports that the pain started after he slipped and fell in his home. The pain is rated at 7/10 but increases to 9/10 when he takes a deep breath.
The doctor suspects a possible pulmonary embolism (PE) based on the patient's medical history. The doctor calculates a 2-level PE Wells score of 1.0 (for recent surgery) and orders a D-dimer test. The patient is started on anticoagulation while waiting for the test results, which are expected to take over 4 hours to return.
The patient's chest x-ray appears normal, and the D-dimer test comes back negative.
What is the most appropriate next step?Your Answer: Stop the anticoagulation and consider an alternative diagnosis
Explanation:When investigating a suspected pulmonary embolism (PE), a low Wells score of ≤ 4 and a negative D-dimer result suggest that an alternative diagnosis should be considered and anticoagulation should be stopped. In this case, the patient’s symptoms and history of trauma suggest a musculoskeletal injury may be the cause of their chest pain and shortness of breath. An urgent CTPA would only be necessary if the Wells score was 4 or higher or if the D-dimer test was positive. As neither of these occurred, repeating the D-dimer test is unnecessary. Continuing anticoagulation without a confirmed PE would increase the risk of bleeding. If a PE is confirmed, anticoagulation with warfarin or a direct oral anticoagulant would be appropriate.
Investigating Pulmonary Embolism: Key Features and Diagnostic Criteria
Pulmonary embolism (PE) can be challenging to diagnose as it can present with a wide range of cardiorespiratory symptoms and signs depending on its location and size. The PIOPED study in 2007 found that tachypnea, crackles, tachycardia, and fever were the most common clinical signs associated with PE. To aid in the diagnosis of PE, NICE updated their guidelines in 2020 to include the use of the pulmonary embolism rule-out criteria (PERC) and the 2-level PE Wells score. The PERC rule should be used when there is a low pre-test probability of PE, and a negative PERC result reduces the probability of PE to less than 2%. The 2-level PE Wells score should be performed if a PE is suspected, with a score of more than 4 points indicating a likely PE and a score of 4 points or less indicating an unlikely PE.
If a PE is likely, an immediate computed tomography pulmonary angiogram (CTPA) should be arranged, and interim therapeutic anticoagulation should be given if there is a delay in getting the CTPA. If a PE is unlikely, a D-dimer test should be arranged, and if positive, an immediate CTPA should be performed. The consensus view from the British Thoracic Society and NICE guidelines is that CTPA is the recommended initial lung-imaging modality for non-massive PE. However, V/Q scanning may be used initially if appropriate facilities exist, the chest x-ray is normal, and there is no significant symptomatic concurrent cardiopulmonary disease.
Other diagnostic tools include age-adjusted D-dimer levels, ECG, chest x-ray, V/Q scan, and CTPA. It is important to note that a chest x-ray is recommended for all patients to exclude other pathology, but it is typically normal in PE. While investigating PE, it is crucial to consider other differential diagnoses and to tailor the diagnostic approach to the individual patient’s clinical presentation and risk factors.
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This question is part of the following fields:
- Respiratory Medicine
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Question 3
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: Episcleritis
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 4
Correct
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A 9-month-old boy is presented to the GP with a 4-week history of rash. He has no significant medical history and is meeting developmental milestones appropriately. He has received all of his scheduled immunizations, has no known allergies, and is feeding and urinating well. Upon examination, there is a symmetrical, poorly defined erythematous rash on his elbows and knees. What is the most probable diagnosis?
Your Answer: Eczema
Explanation:Atopic eczema commonly appears in children before the age of 2, with symptoms often affecting the face and extensor surfaces of the body. This patient’s visible dermatitis in the extensor aspects of her body suggests a diagnosis of atopic eczema based on clinical presentation. Impetigo, pemphigus vulgaris, and psoriasis are unlikely diagnoses given the patient’s symmetrical dry rash involving the extensor aspects of the limbs.
Eczema in Children: Symptoms and Management
Eczema is a common skin condition that affects around 15-20% of children and is becoming more prevalent. It usually appears before the age of 2 and clears up in around 50% of children by the age of 5 and in 75% of children by the age of 10. The symptoms of eczema include an itchy, red rash that can worsen with repeated scratching. In infants, the face and trunk are often affected, while in younger children, it typically occurs on the extensor surfaces. In older children, the rash is more commonly seen on the flexor surfaces and in the creases of the face and neck.
To manage eczema in children, it is important to avoid irritants and use simple emollients. Large quantities of emollients should be prescribed, roughly in a ratio of 10:1 with topical steroids. If a topical steroid is also being used, the emollient should be applied first, followed by waiting at least 30 minutes before applying the topical steroid. Creams are absorbed into the skin faster than ointments, and emollients can become contaminated with bacteria, so fingers should not be inserted into pots. Many brands have pump dispensers to prevent contamination.
In severe cases, wet wrapping may be used, which involves applying large amounts of emollient (and sometimes topical steroids) under wet bandages. Oral ciclosporin may also be used in severe cases. Overall, managing eczema in children involves a combination of avoiding irritants, using emollients, and potentially using topical steroids or other medications in severe cases.
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This question is part of the following fields:
- Paediatrics
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Question 5
Incorrect
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A 70-year-old man with a 12-year history of gastro-oesophageal reflux disease presents with dysphagia. Upon endoscopy, an obstructive lesion is observed that is highly suspicious of oesophageal cancer. What is the expected result of the biopsy?
Your Answer: Squamous cell carcinoma
Correct Answer: Adenocarcinoma
Explanation:Gastroesophageal reflux disease (GORD) or Barrett’s esophagus are linked to the development of oesophageal adenocarcinoma.
Oesophageal Cancer: Types, Risk Factors, Features, Diagnosis, and Treatment
Oesophageal cancer used to be mostly squamous cell carcinoma, but adenocarcinoma is now becoming more common, especially in patients with a history of gastro-oesophageal reflux disease (GORD) or Barrett’s. Adenocarcinoma is usually located near the gastroesophageal junction, while squamous cell tumours are found in the upper two-thirds of the oesophagus.
Risk factors for adenocarcinoma include GORD, Barrett’s oesophagus, smoking, achalasia, and obesity. Squamous cell cancer is more common in the developing world and is associated with smoking, alcohol, achalasia, Plummer-Vinson syndrome, and diets rich in nitrosamines.
The most common presenting symptom for both types of oesophageal cancer is dysphagia, followed by anorexia and weight loss. Other possible features include odynophagia, hoarseness, melaena, vomiting, and cough.
Diagnosis is done through upper GI endoscopy with biopsy, endoscopic ultrasound for locoregional staging, CT scanning for initial staging, and FDG-PET CT for detecting occult metastases. Laparoscopy may also be performed to detect occult peritoneal disease.
Operable disease is best managed by surgical resection, with the most common procedure being an Ivor-Lewis type oesophagectomy. However, the biggest surgical challenge is anastomotic leak, which can result in mediastinitis. Adjuvant chemotherapy may also be used in many patients.
Overall, oesophageal cancer is a serious condition that requires prompt diagnosis and treatment. Understanding the types, risk factors, features, diagnosis, and treatment options can help patients and healthcare providers make informed decisions about managing this disease.
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This question is part of the following fields:
- Haematology/Oncology
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Question 6
Correct
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A 65-year-old woman is brought to the Emergency Department (ED) following a fall at home. During examination in the ED, there is no evidence of external bleeding, but her blood pressure is 100/50 mmHg, and her heart rate is 110 bpm. She has distended neck veins and muffled heart sounds. What is the most probable finding on an echocardiogram?
Your Answer: Pericardial effusion
Explanation:Medical Conditions and Trauma: Understanding the Differences
Pericardial Effusion: A Serious Condition
When a patient presents with hypotension, tachycardia, and Beck’s triad (hypotension, distended neck veins, and muffled heart sounds), it is suggestive of pericardial effusion. This condition occurs when fluid accumulates in the pericardial space, compressing the heart and causing low cardiac output. Trauma to the chest is a common cause of pericardial effusion, leading to bleeding into the pericardial space.
Haemothorax, Mitral Regurgitation, Pleural Effusion, and Pneumothorax: Other Trauma-Related Conditions
While haemothorax refers to blood in the pleural space, it would not cause Beck’s triad or be detected on an echocardiogram. Mitral regurgitation could be detected on an echocardiogram, but it would not likely lead to Beck’s triad as blood would remain within the heart chambers. Pleural effusion refers to any fluid in the pleural space and would not cause Beck’s triad, nor would it be detected on echocardiography. Pneumothorax, which refers to air in the pleural space, can also occur with trauma. Tension pneumothorax may cause Beck’s triad, but it would not be detected on an echocardiogram.
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This question is part of the following fields:
- Cardiovascular
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Question 7
Incorrect
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A patient in their early 50s with type 2 diabetes mellitus and chronic heart failure (NYHA class II) presents for a check-up. Their diabetes is currently managed through diet, but their HbA1c has increased to 64 mmol/mol (8.0%). Which of the following medications should be avoided due to contraindication?
Your Answer: Exenatide
Correct Answer: Pioglitazone
Explanation:Medications to Avoid in Patients with Heart Failure
Heart failure is a serious condition that requires careful management of medications. Some medications can exacerbate heart failure and should be avoided. Thiazolidinediones, such as pioglitazone, are contraindicated as they cause fluid retention. Verapamil has a negative inotropic effect and should be used with caution. NSAIDs and glucocorticoids can also cause fluid retention and should be used with caution. However, low-dose aspirin is an exception as many patients with heart failure also have coexistent cardiovascular disease and the benefits of taking aspirin easily outweigh the risks. Class I antiarrhythmics, such as flecainide, have a negative inotropic and proarrhythmic effect and should be avoided. It is important for healthcare providers to be aware of these medications and to carefully consider their use in patients with heart failure.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 8
Correct
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A 55-year-old woman with a history of diabetes, obesity, and smoking developed sudden pain in her left foot with a dusky colour change. On examination, in the Emergency Department, she had a cold, blue, painful foot with an absent dorsalis pedis and posterior tibial pulse.
Which of the following will be the most appropriate investigation for this patient?Your Answer: Lower limb angiography
Explanation:Diagnostic Tests for Lower Limb Ischaemia
Lower limb ischaemia is a medical emergency that requires prompt diagnosis and treatment. Several diagnostic tests can be used to determine the cause and severity of the condition. Here are some of the most common tests:
1. Lower limb angiography: This test can identify the site of arterial occlusion and help plan the appropriate treatment, such as embolectomy or fasciotomy.
2. Focused assessment with sonography for trauma (FAST) scan of the abdomen: This test is useful in cases of trauma or suspected abdominal aortic aneurysm rupture.
3. Ankle-brachial pressure index (ABPI): This quick and easy test can provide an early indication of the severity of ischaemia. A value of 0.9-1.2 is considered normal, while values below 0.3 indicate critical ischaemia.
4. Echocardiogram: This test can rule out a cardiac source of embolisation, but lower limb angiography is the priority in cases of acute ischaemia.
5. Lower limb Doppler: This test can be used to assess arterial or venous flow, depending on the suspected cause of ischaemia.In summary, a combination of these diagnostic tests can help diagnose and treat lower limb ischaemia effectively.
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This question is part of the following fields:
- Cardiovascular
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Question 9
Correct
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You are invited to a meeting at a nearby daycare center. There has been a rise in the number of children contracting hand, foot, and mouth disease and a plan is being developed to address this issue. What is the most efficient measure to decrease the occurrence of hand, foot, and mouth disease?
Your Answer: Hand hygiene
Explanation:Hand hygiene is the most crucial step in addressing MRSA, although a comprehensive approach is necessary.
Understanding MRSA and Screening for Infection
Methicillin-resistant Staphylococcus aureus (MRSA) is a type of bacteria that can cause serious infections and is particularly dangerous in hospital settings. To prevent the spread of MRSA, certain patients should be screened for the infection, including those awaiting elective admissions and all emergency admissions starting in 2011. Screening involves taking a nasal swab and checking for skin lesions or wounds. If a patient is found to be a carrier of MRSA, treatment involves using antibiotics such as vancomycin, teicoplanin, or linezolid. However, some strains may develop resistance to these antibiotics, so newer options like linezolid, quinupristin/dalfopristin combinations, and tigecycline should be reserved for resistant cases. It is important to suppress MRSA from carriers to prevent the spread of infection. This can be done through the use of mupirocin and chlorhexidine gluconate. By understanding MRSA and screening for infection, healthcare providers can take steps to prevent the spread of this dangerous bacteria.
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This question is part of the following fields:
- Infectious Diseases
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Question 10
Correct
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A 6-month-old infant presents to the Emergency Department with respiratory distress. The child has epicanthic folds and a single palmar crease. Genetic testing confirms an autosomal trisomy. What is the most frequent cardiac anomaly observed in infants with this disorder?
Your Answer: Atrioventricular septal defect
Explanation:Cardiac Abnormalities in Down Syndrome Patients
Down syndrome is a genetic disorder that often presents with physical characteristics such as epicanthic folds, single creases, and an autosomal trisomy. It is common for children with Down syndrome to have congenital heart disease, with 42% of the population affected. Of those, 23% have multiple cardiac abnormalities. The most prevalent cardiac abnormality, found in 37% of cases, is a complete atrioventricular septal defect. Ventricular septal defects are the second most common, affecting 30% of patients. Mitral valve disorders occur in up to 40% of Down syndrome patients, but mitral stenosis is less common. Atrial septal defects affect 15% of patients, while patent ductus arteriosus affects only 2%. Understanding the prevalence of these cardiac abnormalities in Down syndrome patients is crucial for proper diagnosis and treatment.
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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 29-year-old male patient informs you that he has Long QT syndrome and you are contemplating prescribing an antibiotic. Which antibiotic should you avoid prescribing to him?
Your Answer: Doxycycline
Correct Answer: Erythromycin
Explanation:A prolonged QT interval may be caused by Erythromycin.
Understanding Long QT Syndrome
Long QT syndrome (LQTS) is a genetic condition that causes delayed repolarization of the ventricles, which can lead to ventricular tachycardia and sudden death. The most common types of LQTS are caused by defects in the alpha subunit of the slow delayed rectifier potassium channel. A normal corrected QT interval is less than 430 ms in males and 450 ms in females.
There are various causes of a prolonged QT interval, including congenital factors, drugs, and other medical conditions. Some drugs that can prolong the QT interval include amiodarone, tricyclic antidepressants, and selective serotonin reuptake inhibitors. Electrolyte imbalances, acute myocardial infarction, and subarachnoid hemorrhage can also cause a prolonged QT interval.
LQTS may be picked up on routine ECG or following family screening. The symptoms and events associated with LQTS can vary depending on the type of LQTS. Long QT1 is usually associated with exertional syncope, while Long QT2 is often associated with syncope following emotional stress or exercise. Long QT3 events often occur at night or at rest.
Management of LQTS involves avoiding drugs that prolong the QT interval and other precipitants if appropriate. Beta-blockers may be used, and in high-risk cases, implantable cardioverter defibrillators may be necessary. It is important to recognize and manage LQTS to prevent sudden cardiac death.
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This question is part of the following fields:
- Cardiovascular
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Question 12
Correct
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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: 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 13
Correct
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A 48-year-old man presents with a painful erythematous fluctuant swelling over the posterior elbow. There is no history of trauma. He is in good health and has full range of motion at the elbow.
What is the most probable diagnosis?Your Answer: Olecranon bursitis
Explanation:The patient’s symptoms suggest olecranon bursitis, which is inflammation of the bursa over the olecranon process. This can be caused by trauma or may be idiopathic. The patient reports a posterior swelling at the elbow, which is tender and fluctuant. Management includes NSAIDs, RICE, and a compression bandage. If septic bursitis is suspected, antibiotics may be necessary. Golfer’s elbow, gout, and septic joint are less likely diagnoses. Tennis elbow, which is more common than golfer’s elbow, is characterized by pain in the lateral elbow and tenderness over the lateral epicondyle, but is not associated with a posterior swelling.
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This question is part of the following fields:
- Musculoskeletal
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Question 14
Correct
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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: 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 15
Correct
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A 68-year-old man presents with complaints of weight loss and fatigue that have been ongoing for several months. Upon examination, the only notable finding is pallor. A blood film reveals the presence of immature blasts, and genetic testing shows the presence of a chromosomal translocation t(9;22) - the Philadelphia chromosome. Further investigations reveal the following results: Hb of 95 g/l (normal range: 135-175 g/l), leukocytes of 62 × 109/l (normal range: 4.0-11.0 × 109/l), and PLT of 101 × 109/l (normal range: 150-400 × 109/l). What is the most likely diagnosis?
Your Answer: Chronic myeloid leukaemia (CML)
Explanation:Chronic myeloid leukaemia (CML) is a rare form of cancer that occurs due to the abnormal growth of myeloid precursors or blasts. This leads to an increase in white blood cells and a decrease in the normal functions of the bone marrow, resulting in anaemia and thrombocytopenia. CML is most commonly seen in people between the ages of 60 and 70 and has a slow onset that can last for months or even years. The majority of cases are caused by a genetic mutation called the Philadelphia chromosome, which produces a protein that promotes the growth of cancer cells. Symptoms of CML include fatigue, weight loss, night sweats, abdominal distension, and left upper quadrant pain. Treatment for CML involves inhibiting the genetic mutation with a drug called imatinib.
Acute lymphocytic leukaemia (ALL) is a type of cancer that occurs due to the abnormal growth of immature lymphocytes, which replace the normal cells of the bone marrow and lead to a decrease in blood cell production. ALL is most commonly seen in children and presents with symptoms such as anaemia, fever, and abdominal pain. Diagnosis is made through bone marrow biopsy and genetic analysis, which can reveal chromosomal abnormalities associated with the disease.
Hodgkin’s lymphoma (HL) is a type of cancer that typically presents with enlarged lymph nodes and is associated with the presence of Reed-Sternberg cells, which are abnormal B cells. Multiple myeloma (MM) is a cancer that affects plasma cells in the bone marrow, leading to a decrease in blood cell production and other symptoms such as hypercalcemia and kidney dysfunction. Non-Hodgkin’s lymphoma (NHL) is a type of cancer that arises from the abnormal growth of B cells, T cells, or natural killer cells and can be caused by genetic mutations, infections, or chronic inflammation. Symptoms of NHL include enlarged lymph nodes throughout the body.
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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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As a foundation doctor in the surgical assessment unit, you assess a sixty-three-year-old man presenting with jaundice. During examination, you detect a mass in the right upper quadrant, but no other significant findings are present. The patient denies any history of foreign travel and is a non-drinker. Additionally, tests for hepatitis come back negative. What is the most probable diagnosis?
Your Answer: Hepatocellular carcinoma
Correct Answer: Gallbladder malignancy
Explanation:If a patient has an enlarged gallbladder that is not tender and is accompanied by painless jaundice, it is unlikely to be caused by gallstones. Instead, it is important to consider the possibility of malignancy. Therefore, further investigation should be done to check for malignancy of the gallbladder or pancreas, as either of these conditions could lead to biliary obstruction, resulting in a mass and jaundice.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 17
Incorrect
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A 10-year-old girl comes in for a check-up. She was diagnosed with asthma two years ago by her pediatrician. She is currently taking a salbutamol inhaler, using 2 puffs 3 times a day, and a low-dose beclomethasone inhaler. She also takes oral montelukast. However, she still experiences a night time cough and has to use her blue inhaler most days. Unfortunately, the addition of montelukast has not provided much relief. On examination today, her chest is clear with no wheeze and a near-normal peak flow. What should be the next step in her management?
Your Answer: Add theophylline
Correct Answer: Stop montelukast and add salmeterol
Explanation:For children between the ages of 5 and 16 with asthma that is not being effectively managed with a combination of a short-acting beta agonist (SABA), low-dose inhaled corticosteroids (ICS), and a leukotriene receptor antagonist, it is recommended to add a long-acting beta agonist (LABA) to the treatment plan and discontinue the use of the leukotriene receptor antagonist.
Managing Asthma in Children: NICE Guidelines
Asthma management in children has been updated by NICE in 2017, following the 2016 BTS guidelines. The new guidelines for children aged 5-16 are similar to those for adults, with a stepwise approach for treatment. For newly-diagnosed asthma, short-acting beta agonist (SABA) is recommended. If symptoms persist, a combination of SABA and paediatric low-dose inhaled corticosteroid (ICS) is used. Leukotriene receptor antagonist (LTRA) is added if symptoms still persist, followed by long-acting beta agonist (LABA) if necessary. Maintenance and reliever therapy (MART) is used as a combination of ICS and LABA for daily maintenance therapy and symptom relief. For children under 5 years old, clinical judgement plays a greater role in diagnosis. The stepwise approach is similar to that for older children, with an 8-week trial of paediatric moderate-dose ICS before adding LTRA. If symptoms persist, referral to a paediatric asthma specialist is recommended.
It should be noted that NICE does not recommend changing treatment for well-controlled asthma patients simply to adhere to the latest guidelines. The definitions of low, moderate, and high-dose ICS have also changed, with different definitions for adults and children. For children, <= 200 micrograms budesonide or equivalent is considered a paediatric low dose, 200-400 micrograms is a moderate dose, and > 400 micrograms is a high dose. Overall, the new NICE guidelines provide a clear and concise approach to managing asthma in children.
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This question is part of the following fields:
- Paediatrics
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Question 18
Incorrect
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A 68-year-old woman with isolated systolic hypertension, who also has urinary tract infections, osteoporosis and diabetes, attends outpatients with a blood pressure reading of 192/88 mmHg. Which of the following medications would you prescribe for this patient?
Your Answer: Amlodipine
Correct Answer: Valsartan
Explanation:Choosing the Right Medication for Hypertension: A Guide
When it comes to treating hypertension, there are several medications to choose from. The National Institute for Health and Care Excellence (NICE) recommends an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) as first-line treatment for those under 55, while calcium channel blockers (CCBs) are preferred for patients over 55 and those of Afro-Caribbean origin. Beta blockers, once a common choice, are no longer recommended as first-line treatment.
If initial treatment is not effective, a thiazide diuretic can be added to an ACE inhibitor or ARB and CCB. Alpha blockers, such as doxazosin, are no longer commonly used for hypertension and are contraindicated in patients with urinary incontinence. Valsartan, an ARB, is an alternative for patients who cannot tolerate an ACE inhibitor.
For elderly patients with isolated systolic hypertension, a dihydropyridine CCB like amlodipine is the drug of choice, especially if thiazides are not an option. Beta blockers should be used with caution in patients with asthma and are not indicated in this case. By carefully considering the patient’s age, ethnicity, and medical history, healthcare providers can choose the most appropriate medication for treating hypertension.
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This question is part of the following fields:
- Cardiovascular
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Question 19
Incorrect
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A 72-year-old man presents to the Haematology Clinic with symptoms of bone pain and anaemia. The medical team suspects multiple myeloma (MM) and orders a set of blood tests, including a full blood count, urea, serum creatinine and electrolytes, serum calcium, albumin, serum protein electrophoresis, serum-free light-chain assay, and serum beta-2 microglobulin. The team also plans to perform an imaging investigation to look for osteolytic lesions. What initial scan should be ordered?
Your Answer: PET with 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography (FDG-PET-CT)
Correct Answer: Whole-body low-dose CT (WBLD-CT)
Explanation:When investigating suspected multiple myeloma (MM), it is crucial to use whole-body low-dose CT (WBLD-CT) imaging. This method is more effective than traditional radiology in detecting lytic lesions and should be the first option if available. Lesions with a diameter of 5mm or more are considered positive. If WBLD-CT and MRI fail to show lesions with a strong clinical indication, an FDG-PET or FDG-PET-CT can be used to detect bone lesions. During treatment follow-up, an FDG-PET-CT can detect active lesions and provide prognostic information. While a skeletal survey (X-ray) is less sensitive than WBLD-CT, it can still be useful. If suspicion remains high for MM despite negative WBLD-CT or skeletal survey results, a whole-body MRI should be performed. This method can detect focal lesions and bone marrow infiltration and may also be of prognostic value in asymptomatic patients. The presence of focal lesions is a strong predictor of progression to symptomatic MM.
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This question is part of the following fields:
- Haematology/Oncology
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Question 20
Correct
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A 32-year-old man with a history of migraine and asthma seeks medical attention for worsening migraine symptoms. He is experiencing one debilitating migraine attack every two weeks, lasting approximately 24 hours, and only partially relieved by zolmitriptan. This has resulted in frequent work absences. His current medication regimen includes zolmitriptan, salbutamol, and Clenil. What is the most suitable medication to prescribe for reducing the frequency of his migraine attacks?
Your Answer: Topiramate
Explanation:For the prophylaxis of migraines, NICE recommends either topiramate or propranolol. However, propranolol is not suitable for this patient due to his asthma. As for acute treatment, a combination of triptan and NSAID or triptan and paracetamol is recommended.
Managing Migraines: Guidelines and Treatment Options
Migraines can be debilitating and affect a significant portion of the population. To manage migraines, it is important to understand the different treatment options available. According to the National Institute for Health and Care Excellence (NICE) guidelines, acute treatment for migraines involves a combination of an oral triptan and an NSAID or paracetamol. For young people aged 12-17 years, a nasal triptan may be preferred. If these measures are not effective, non-oral preparations of metoclopramide or prochlorperazine may be considered, along with a non-oral NSAID or triptan.
Prophylaxis should be given if patients are experiencing two or more attacks per month. NICE recommends topiramate or propranolol, depending on the patient’s preference, comorbidities, and risk of adverse events. Propranolol is preferred in women of childbearing age as topiramate may be teratogenic and reduce the effectiveness of hormonal contraceptives. Acupuncture and riboflavin may also be effective in reducing migraine frequency and intensity for some people. For women with predictable menstrual migraines, frovatriptan or zolmitriptan may be recommended as a type of mini-prophylaxis.
Specialists may consider other treatment options, such as candesartan or monoclonal antibodies directed against the calcitonin gene-related peptide (CGRP) receptor, like erenumab. However, pizotifen is no longer recommended due to common adverse effects like weight gain and drowsiness. It is important to exercise caution with young patients as acute dystonic reactions may develop. By following these guidelines and considering various treatment options, migraines can be effectively managed.
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This question is part of the following fields:
- Neurology
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Question 21
Incorrect
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A 75-year-old man with a long-standing history of schizophrenia is being seen by his psychiatrist. He was admitted to the psychiatry unit six months ago due to delusions that he was being tracked by spies. At the time of admission, he was taking quetiapine, but it was changed to aripiprazole 400 mg monthly depot. Recently, he has been expressing to his wife that he believes his food is poisoned. His wife thinks that his new medication is not effective. What is the most suitable course of action for managing this patient?
Your Answer: Haloperidol
Correct Answer: Clozapine
Explanation:Clozapine is the appropriate choice for patients with schizophrenia who have not responded adequately to at least two antipsychotics. In this case, the patient has already tried quetiapine and aripiprazole without success, making clozapine a suitable option. However, it requires careful monitoring and titration. Continuing aripiprazole is not recommended as the patient has been on the highest dose for six months and is still experiencing delusional ideas. Haloperidol is a typical antipsychotic that can be used for schizophrenia, but atypical antipsychotics are preferred due to fewer side effects. Lorazepam is not a long-term antipsychotic and is only useful for managing severe agitation in patients with schizophrenia.
Atypical antipsychotics are now recommended as the first-line treatment for patients with schizophrenia, as per the 2005 NICE guidelines. These medications have the advantage of significantly reducing extrapyramidal side-effects. However, they can also cause adverse effects such as weight gain, hyperprolactinaemia, and in the case of clozapine, agranulocytosis. The Medicines and Healthcare products Regulatory Agency has issued warnings about the increased risk of stroke and venous thromboembolism when antipsychotics are used in elderly patients. Examples of atypical antipsychotics include clozapine, olanzapine, risperidone, quetiapine, amisulpride, and aripiprazole.
Clozapine, one of the first atypical antipsychotics, carries a significant risk of agranulocytosis and requires full blood count monitoring during treatment. Therefore, it should only be used in patients who are resistant to other antipsychotic medication. The BNF recommends introducing clozapine if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs, one of which should be a second-generation antipsychotic drug, each for at least 6-8 weeks. Adverse effects of clozapine include agranulocytosis, neutropaenia, reduced seizure threshold, constipation, myocarditis, and hypersalivation. Dose adjustment of clozapine may be necessary if smoking is started or stopped during treatment.
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This question is part of the following fields:
- Psychiatry
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Question 22
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A 70-year-old retired ship-builder has a 6-month history of increasing shortness of breath, dull right-sided chest pain, loss of appetite and sweats. He is a non-smoker. Examination of his lungs reveals dullness to percussion and reduced air entry at the right base.
Which of the following is the most likely diagnosis?Your Answer: Malignant mesothelioma
Explanation:Distinguishing Mesothelioma from Other Lung Diseases
Mesothelioma is a type of cancer that affects the pleura and peritoneum, and is almost always caused by exposure to asbestos. Symptoms include chest pain, shortness of breath, cough, fever, weight loss, and fatigue. A pleural effusion is also common in mesothelioma cases.
Small-cell lung cancer, on the other hand, is highly aggressive and life expectancy is only weeks without treatment. Smoking is the major risk factor, although asbestos can also cause this type of lung cancer. Symptoms are similar to mesothelioma, but lack of smoking history and longer onset of symptoms point more towards mesothelioma.
Chronic obstructive pulmonary disease (COPD) is usually caused by smoking and presents with progressive shortness of breath, productive cough, frequent chest infections, and wheeze. Examination could reveal cyanosis, barrel chest, hyperresonance on percussion, poor air entry, and wheeze or coarse crackles. However, this presentation does not fit with COPD.
Chronic thromoboembolic pulmonary hypertension (CPTH) can develop months or years after a large pulmonary embolism (PE) or after several episodes. Symptoms include shortness of breath, chest pain on exertion, and fatigue. The patient can go on to develop right heart failure, but this diagnosis would not explain the weight loss and sweats.
Tuberculosis usually presents with a persistent productive cough, weight loss, night sweats, fevers, lymphadenopathy, and general malaise. In this patient, the symptoms, along with history of asbestos exposure, are highly suggestive of mesothelioma rather than tuberculosis.
In summary, distinguishing mesothelioma from other lung diseases requires careful consideration of symptoms, risk factors, and examination findings.
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This question is part of the following fields:
- Respiratory Medicine
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Question 23
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A 10-year-old boy has been referred due to unusual behaviour at school. His teachers have reported that he displays both passive and aggressive behaviours. Sometimes, he becomes withdrawn and cries when he feels he has been mistreated. Other times, he becomes very angry and fights over minor issues. Upon further investigation, it is revealed that the patient has experienced significant abuse at home.
What defence mechanism is he likely using?Your Answer: Dissociation
Explanation:Understanding Ego Defense Mechanisms: Differentiating Dissociation from Other Defenses
Ego defense mechanisms are psychological strategies that individuals use to cope with stressful situations. One of these mechanisms is dissociation, which involves a temporary modification of one’s personal identity to avoid distress. However, it is important to differentiate dissociation from other defense mechanisms to better understand the patient’s behavior.
Reaction formation is another defense mechanism where unacceptable emotions are repressed and replaced by their opposite. This is not the case with the patient in question, as their behavior is not consistently opposite to their true feelings.
Identification is when someone models the behavior of a more powerful person. This could explain why a victim of child abuse may become an abuser in adulthood. However, the patient’s behavior is not consistently modeled after another person.
Splitting is a defense mechanism where individuals cannot reconcile both good and bad traits in a person, leading them to see people as either all good or all bad. This is not present in the patient’s behavior.
Finally, sublimation is a mature defense mechanism where individuals take an unacceptable trait and use it to drive a respectable work that aligns with their values. This is not relevant to the patient’s behavior.
In conclusion, dissociation is a unique defense mechanism that involves a drastic modification of personal identity to avoid distress. Understanding the differences between dissociation and other defense mechanisms can help clinicians better diagnose and treat patients.
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This question is part of the following fields:
- Psychiatry
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Question 24
Incorrect
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You are a foundation year two doctor on a placement in older adult mental health. You have been caring for an 81-year-old gentleman with bipolar disorder who is being held under the mental health act. He develops fever, cough productive of green sputum and tachycardia and is admitted to the local hospital where he dies of pneumonia. Your consultant, trained in psychiatry with no recent experience in general medicine, asks what the next step will be with regards to the death certificate. What is the appropriate next step for completing the death certificate - who would complete it and what would be the cause of death?
Your Answer: The acute hospital doctors caring for the patient will complete it putting pneumonia as part 1a
Correct Answer: The case will be referred to the coroner
Explanation:If a person passes away while under the mental health act, it is mandatory to report their death to the coroner, regardless of the cause. Therefore, neither the individual nor the acute hospital doctors who complete the certificate should be the first to report the case. Although reporting to the coroner is necessary, a post mortem examination is unlikely to take place. It is not permissible to list old age as the cause of death on the certificate if the patient is under the age of 80.
Sectioning under the Mental Health Act is a legal process used for individuals who refuse voluntary admission. This process excludes patients who are under the influence of drugs or alcohol. There are several sections under the Mental Health Act that allow for different types of admission and treatment.
Section 2 allows for admission for assessment for up to 28 days, which is not renewable. An Approved Mental Health Professional (AMHP) or the nearest relative (NR) can make the application on the recommendation of two doctors, one of whom should be an approved consultant psychiatrist. Treatment can be given against the patient’s wishes.
Section 3 allows for admission for treatment for up to 6 months, which can be renewed. An AMHP and two doctors, both of whom must have seen the patient within the past 24 hours, can make the application. Treatment can also be given against the patient’s wishes.
Section 4 is used as an emergency 72-hour assessment order when a section 2 would involve an unacceptable delay. A GP and an AMHP or NR can make the application, which is often changed to a section 2 upon arrival at the hospital.
Section 5(2) allows a doctor to legally detain a voluntary patient in hospital for 72 hours, while section 5(4) allows a nurse to detain a voluntary patient for 6 hours.
Section 17a allows for Supervised Community Treatment (Community Treatment Order) and can be used to recall a patient to the hospital for treatment if they do not comply with the conditions of the order in the community, such as taking medication.
Section 135 allows for a court order to be obtained to allow the police to break into a property to remove a person to a Place of Safety. Section 136 allows for someone found in a public place who appears to have a mental disorder to be taken by the police to a Place of Safety. This section can only be used for up to 24 hours while a Mental Health Act assessment is arranged.
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This question is part of the following fields:
- Psychiatry
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Question 25
Incorrect
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Which one of the following statements regarding congenital inguinal hernias is accurate?
Your Answer: They should be managed conservatively
Correct Answer: They are more common on the right side
Explanation:Abdominal wall hernias occur when an organ or the fascia of an organ protrudes through the wall of the cavity that normally contains it. Risk factors for developing these hernias include obesity, ascites, increasing age, and surgical wounds. Symptoms of abdominal wall hernias include a palpable lump, cough impulse, pain, obstruction (more common in femoral hernias), and strangulation (which can compromise the bowel blood supply and lead to infarction). There are several types of abdominal wall hernias, including inguinal hernias (which account for 75% of cases and are more common in men), femoral hernias (more common in women and have a high risk of obstruction and strangulation), umbilical hernias (symmetrical bulge under the umbilicus), paraumbilical hernias (asymmetrical bulge), epigastric hernias (lump in the midline between umbilicus and xiphisternum), incisional hernias (which may occur after abdominal surgery), Spigelian hernias (rare and seen in older patients), obturator hernias (more common in females and can cause bowel obstruction), and Richter hernias (a rare type of hernia that can present with strangulation without symptoms of obstruction). In children, congenital inguinal hernias and infantile umbilical hernias are the most common types, with surgical repair recommended for the former and most resolving on their own for the latter.
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This question is part of the following fields:
- Paediatrics
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Question 26
Correct
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What is a factor that leads to cyanotic congenital heart disease?
Your Answer: Transposition of the great arteries
Explanation:Congenital heart disease can be categorized into two types: acyanotic and cyanotic. Acyanotic heart diseases are more common and include ventricular septal defects (VSD), atrial septal defect (ASD), patent ductus arteriosus (PDA), coarctation of the aorta, and aortic valve stenosis. VSD is the most common acyanotic heart disease, accounting for 30% of cases. ASDs are less common than VSDs, but they are more frequently diagnosed in adult patients as they tend to present later. On the other hand, cyanotic heart diseases are less common and include tetralogy of Fallot, transposition of the great arteries (TGA), and tricuspid atresia. Fallot’s is more common than TGA, but TGA is the more common lesion at birth as patients with Fallot’s generally present at around 1-2 months. The presence of cyanosis in pulmonary valve stenosis depends on the severity and any other coexistent defects.
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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 65-year-old woman comes in with a tremor. What distinguishing characteristic would indicate a diagnosis of essential tremor instead of Parkinson's disease?
Your Answer: Unilateral symptoms
Correct Answer: Tremor is worse when the arms are outstretched
Explanation:Typical symptoms of Parkinson’s include bradykinesia, postural instability, and initially unilateral symptoms. On the other hand, alcohol can alleviate essential tremor symptoms.
Understanding Essential Tremor
Essential tremor, also known as benign essential tremor, is a genetic condition that typically affects both upper limbs. The most common symptom is a postural tremor, which worsens when the arms are outstretched. However, the tremor can be improved by rest and alcohol consumption. Essential tremor is also the leading cause of head tremors, known as titubation.
When it comes to managing essential tremor, the first-line treatment is propranolol. This medication can help reduce the severity of the tremors. In some cases, primidone may also be used to manage the condition. It’s important to note that essential tremor is a lifelong condition, but with proper management, individuals can lead a normal life. By understanding the symptoms and treatment options, those with essential tremor can take control of their condition and improve their quality of life.
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This question is part of the following fields:
- Neurology
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Question 28
Incorrect
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You are assessing a 10-month-old infant with a viral upper respiratory tract infection. Despite being clinically stable, the mother inquires about the child's development towards the end of the consultation. The infant is observed to point and babble 'mama' and 'dada', but has not yet developed any other words. She appears to be timid and cries when being examined. The infant has an early pincer grip and can roll from front to back, but is unable to sit without support. How would you evaluate her developmental progress?
Your Answer: Normal development
Correct Answer: Isolated delay in gross motor skills
Explanation:A delay in gross motor skills is likely as most babies are able to sit without support by 7-8 months, but the other developmental features are normal for her age. If the delay persists at 12 months, referral to a paediatrician should be considered.
Gross Motor Developmental Milestones
Gross motor skills refer to the ability to use large muscles in the body for activities such as crawling, walking, running, and jumping. These skills are essential for a child’s physical development and are achieved through a series of developmental milestones.
At 3 months, a baby should have little or no head lag when pulled to sit and should have good head control when lying on their abdomen. By 6 months, they should be able to lift and grasp their feet when lying on their back, pull themselves to a sitting position, and roll from front to back. At 9 months, they should be able to pull themselves to a standing position and crawl. By 12 months, they should be able to cruise and walk with one hand held. At 18 months, they should be able to walk unsupported and squat to pick up a toy. By 2 years, they should be able to run and walk up and down stairs holding onto a rail. At 3 years, they should be able to ride a tricycle using pedals and walk up stairs without holding onto a rail. By 4 years, they should be able to hop on one leg.
It is important to note that while the majority of children crawl on all fours before walking, some children may bottom-shuffle, which is a normal variant that runs in families. These milestones serve as a guide for parents and healthcare professionals to monitor a child’s physical development and identify any potential delays or concerns.
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This question is part of the following fields:
- Paediatrics
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Question 29
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A 50-year-old woman was urgently referred for investigation (2-week wait) via the cancer referral pathway by her General Practitioner after presenting with a 2-month history of weight loss and fatigue. Blood tests reveal a carcinoembryonic antigen (CEA) level of 300 μg/l (Normal range: 2.5–5.0 μg/l).
Which of the following is the most probable diagnosis?
Your Answer: Colorectal cancer
Explanation:Overview of Common Cancers and Tumor Markers
Colorectal Cancer, Hepatocellular Cancer, Lung Cancer, Prostate Cancer, and Testicular Cancer are some of the most common types of cancer. Each type presents with different symptoms and may require different diagnostic tests. Tumor markers, such as carcinoembryonic antigen (CEA) for colorectal cancer, alpha-fetoprotein for hepatocellular and testicular cancer, and bombesin for lung cancer, can be used to screen high-risk groups, assess prognosis, detect recurrence, and monitor treatment. Digital rectal examination (DRE) is often used in conjunction with prostate-specific antigen (PSA) as a screening test for prostate cancer. Early detection and treatment can improve outcomes for patients with cancer.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 30
Correct
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A 67-year-old man attending the respiratory clinic receives a suspected diagnosis of chronic obstructive pulmonary disease.
Which of the following is the most appropriate investigation to confirm diagnosis?Your Answer: Spirometry
Explanation:Investigations for COPD: Spirometry is Key
COPD is a chronic obstructive airway disease that is diagnosed through a combination of clinical history, signs, and investigations. While several investigations may be used to support a diagnosis of COPD, spirometry is the most useful and important tool. A spirometer is used to measure functional lung volumes, including forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC). The FEV1:FVC ratio provides an estimate of the severity of airflow obstruction, with a normal ratio being 75-80%. In patients with COPD, the ratio is typically <0.7 and FEV1 <80% predicted. Spirometry is essential for establishing a baseline for disease severity, monitoring disease progression, and assessing the effects of treatment. Other investigations, such as echocardiography, chest radiography, ECG, and peak flow, may be used to exclude other pathologies or assess comorbidities, but spirometry remains the key investigation for diagnosing and managing COPD.
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This question is part of the following fields:
- Respiratory Medicine
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