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  • Question 1 - What is the correct statement about megaloblastic anaemia from the given list? ...

    Incorrect

    • What is the correct statement about megaloblastic anaemia from the given list?

      Your Answer: Anaemia appears before the neurological changes

      Correct Answer: Folic acid alone should not be given if vitamin B12 deficiency has not been ruled out

      Explanation:

      Understanding the Importance of Vitamin B12 in Megaloblastic Anemia Treatment

      Megaloblastic anemia is a condition characterized by the presence of abnormally large red blood cells. It is commonly caused by deficiencies in vitamin B12 and/or folic acid. However, it is important to note that folic acid deficiency alone is rare in developed countries and a diagnosis should be made with consideration of other nutrient deficiencies.

      When treating megaloblastic anemia, it is crucial to rule out vitamin B12 deficiency before starting folic acid therapy. This is because folic acid can improve anemia but not the neurological complications of vitamin B12 deficiency, which can worsen if left untreated. Both vitamin B12 and folic acid should be given if B12 deficiency has not been ruled out or if treatment with B12 has already been initiated.

      It is also important to note that the neurological and hematological complications of megaloblastic anemia can present independently of each other. Some patients may present with neurological impairment without anemia and vice versa.

      Treatment with vitamin B12 can stop the progression of the condition and improve neurological deficits in most patients. However, the response to treatment may vary depending on the severity of the deficiency and the time elapsed between the onset of symptoms and initiation of therapy. Treatment with folic acid, on the other hand, is usually slow and may take weeks or months to show clinical improvement.

      When using hydroxocobalamin to treat megaloblastic anemia, the dosage and frequency of injections will depend on the presence of neurological involvement. For pernicious anemia and other macrocytic anemias without neurological involvement, the initial dose is 1 mg three times a week for two weeks, followed by 1 mg every 2-3 months. For those with neurological involvement, the initial dose is 1 mg on alternate days until no further improvement, then 1 mg every two months.

    • This question is part of the following fields:

      • Haematology
      28.3
      Seconds
  • Question 2 - A 50-year-old woman comes to the clinic complaining of an itchy patch on...

    Correct

    • A 50-year-old woman comes to the clinic complaining of an itchy patch on her back that has been present for six months. She also experiences pins and needles in the same area. The patch is located over the border of her left scapula. Upon examination, the skin sensation seems normal, and there is a clearly defined hyperpigmented patch without any scaling.

      What is the probable diagnosis?

      Your Answer: Notalgia paraesthetica

      Explanation:

      Notalgia paraesthetica is a condition that causes chronic itching or tingling on the medial border of the scapula. This can lead to the development of post-inflammatory hyperpigmentation due to repeated rubbing and scratching of the affected area. The exact cause of this sensory neuropathy is not fully understood.

      Causes of Pruritus

      Pruritus, commonly known as itching, can be caused by various underlying conditions. Liver disease, often associated with a history of alcohol excess, can present with stigmata of chronic liver disease such as spider naevi, bruising, palmar erythema, and gynaecomastia. Evidence of decompensation such as ascites, jaundice, and encephalopathy may also be present. Iron deficiency anaemia can cause pallor and other signs such as koilonychia, atrophic glossitis, post-cricoid webs, and angular stomatitis. Pruritus after a warm bath and a ruddy complexion may indicate polycythaemia. Gout and peptic ulcer disease can also cause itching. Chronic kidney disease may present with lethargy, pallor, oedema, weight gain, hypertension, lymphadenopathy, splenomegaly, hepatomegaly, and fatigue. Other causes of pruritus include hyper- and hypothyroidism, diabetes, pregnancy, senile pruritus, urticaria, and skin disorders such as eczema, scabies, psoriasis, and pityriasis rosea. It is important to identify the underlying cause of pruritus in order to provide appropriate treatment.

    • This question is part of the following fields:

      • Dermatology
      59.9
      Seconds
  • Question 3 - A 50-year-old woman comes in with a complaint of experiencing dizzy spells for...

    Correct

    • A 50-year-old woman comes in with a complaint of experiencing dizzy spells for the past 4 days. She reports feeling nauseous and seeing the room spinning for a brief period before returning to normal. The patient specifically notes that looking down seems to trigger these episodes. Upon examination, there are no abnormalities found in the ears or cranial nerves. Her blood pressure measures at 126/82 mmHg. What diagnostic test can be conducted to confirm the diagnosis?

      Your Answer: Dix- Hallpike manoeuvre

      Explanation:

      The Dix-Hallpike manoeuvre is employed for the diagnosis of benign paroxysmal positional vertigo (BPPV), while the Epley manoeuvre or Brandt Daroff exercises are utilized for its treatment. It should be noted that these manoeuvres are not used for the diagnosis of BPPV. Simmond’s test is utilized for the diagnosis of Achilles tendon rupture, while Finkelstein’s test is employed for the diagnosis of De Quervain’s tenosynovitis.

      Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo that occurs suddenly when there is a change in head position. It is more prevalent in individuals over the age of 55 and is less common in younger patients. Symptoms of BPPV include dizziness and vertigo, which can be accompanied by nausea. Each episode typically lasts for 10-20 seconds and can be triggered by rolling over in bed or looking upwards. A positive Dix-Hallpike manoeuvre, which is indicated by vertigo and rotatory nystagmus, can confirm the diagnosis of BPPV.

      Fortunately, BPPV has a good prognosis and usually resolves on its own within a few weeks to months. Treatment options include the Epley manoeuvre, which is successful in around 80% of cases, and vestibular rehabilitation exercises such as the Brandt-Daroff exercises. While medication such as Betahistine may be prescribed, it tends to have limited effectiveness. However, it is important to note that around half of individuals with BPPV may experience a recurrence of symptoms 3-5 years after their initial diagnosis.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      44.2
      Seconds
  • Question 4 - A 56-year-old Polish waitress has come to see you for review. She has...

    Incorrect

    • A 56-year-old Polish waitress has come to see you for review. She has visited the surgery on several occasions over the preceding 12 months complaining of abdominal pain. She was initially treated with PPI, but on her most recent review one of your colleagues felt that she had IBS and gave her an antispasmodic.

      Unfortunately, her pain persists and is continuous. Her appetite is poor since starting the antispasmodic and she is complaining that she is putting on weight because she is having difficulty doing up her skirt. On further questioning, she has been slightly constipated in recent months and passing urine more frequently.

      Her mother and sister died of breast cancer aged 52 and 43 respectively and many family members have had renal calculi.

      On examination, she appears anxious but there is no clinical evidence of anaemia or jaundice. She weighs 66 kg but there are no previous recordings for comparison. Her abdomen is soft and there are no masses. There is tenderness in the left iliac fossa and suprapubic area. Rectal examination is normal.

      How would you manage this patient?

      Your Answer: Perform a pelvic examination and blood test for CA125

      Correct Answer: Dipstick her urine and refer for renal ultrasound if positive for blood

      Explanation:

      Detecting Ovarian Cancer: A Challenging Diagnosis

      Detecting ovarian cancer can be a challenging diagnosis as the symptoms are often vague, especially in the early stages of the disease. However, there are certain risk factors and cardinal symptoms that can help in identifying the disease. Women with a family history of breast cancer, carriers of the BRCA1 and BRCA2 gene, and Polish women are at an increased risk of ovarian cancer. Patients presenting with persistent bloating, abdominal or pelvic pain, and difficulty in eating or fullness after eating small quantities of food should be evaluated for ovarian cancer.

      NICE recommends that women over the age of 50 who have one or more symptoms associated with ovarian cancer occurring more than 12 times a month or for more than a month should be offered CA125 testing. If the CA125 is 35 IU/mL or greater, an urgent ultrasound scan of the pelvis should be arranged. Therefore, performing a pelvic examination and arranging testing for CA125 is the most appropriate way forward for patients with symptoms suggestive of ovarian cancer. Early detection and prompt treatment can improve the prognosis of ovarian cancer.

    • This question is part of the following fields:

      • Gastroenterology
      119.1
      Seconds
  • Question 5 - An 80-year-old, frail elderly man on the geriatric ward is experiencing difficulty sleeping...

    Correct

    • An 80-year-old, frail elderly man on the geriatric ward is experiencing difficulty sleeping and asks for medication to aid his insomnia. The doctor prescribes a brief course of zopiclone.

      What is one of the potential risks of administering zopiclone to elderly patients?

      Your Answer: Increased risk of falls

      Explanation:

      Elderly patients taking zopiclone are at an increased risk of falling.

      Zopiclone works by binding to GABA-containing receptors, which enhances the effects of GABA and produces both the desired and undesired effects of the drug. Its mechanism of action is similar to that of benzodiazepines.

      Some of the side effects of zopiclone include agitation, dry mouth, constipation, dizziness, decreased muscle tone, and a bitter taste in the mouth. Elderly patients are particularly susceptible to falls when taking zopiclone.

      While diarrhoea is not a known side effect of zopiclone, withdrawal from the drug may cause convulsions, tremors, and hyperventilation.

      Understanding Z Drugs

      Z drugs are a class of medications that have comparable effects to benzodiazepines but differ in their chemical structure. They work by targeting the α2-subunit of the GABA receptor. Z drugs can be categorized into three groups: imidazopyridines, cyclopyrrolones, and pyrazolopyrimidines. Examples of these drugs include zolpidem, zopiclone, and zaleplon, respectively.

      Like benzodiazepines, Z drugs can cause similar adverse effects. Additionally, they can increase the risk of falls in older adults. It is important to understand the potential risks and benefits of these medications before use and to follow the prescribed dosage and instructions carefully.

    • This question is part of the following fields:

      • Mental Health
      53.6
      Seconds
  • Question 6 - A 35-year-old gentleman has come to discuss the result of a routine annual...

    Incorrect

    • A 35-year-old gentleman has come to discuss the result of a routine annual blood test at work. He is otherwise well with no symptoms reported.

      He was found to have a serum phosphate of 0.7.
      Other tests done include FBC, U+Es, LFTs, Calcium and PTH which were all normal.
      Serum phosphate normal range (0-8-1.4 mmol/L)

      What is the most appropriate next step in management?

      Your Answer: Refer to secondary care

      Correct Answer: Ultrasound neck

      Explanation:

      Management of Mild Hypophosphataemia

      In cases of mild hypophosphataemia, monitoring is often sufficient. It may be helpful to check vitamin D levels as it can affect phosphate uptake and renal excretion, along with parathyroid hormone (PTH). If there is a concurrent low magnesium level, it may indicate dietary deficiencies.

      An ultrasound of the neck is not necessary unless there are signs of enlarged parathyroid glands. Oral phosphate is typically reserved for preventing refeeding syndrome in cases of anorexia, starvation, or alcoholism. Mild hypophosphataemia usually resolves on its own.

      Parenteral phosphate may be considered in acute situations but requires inpatient monitoring of calcium, phosphate, and other electrolytes. Referral should only be considered if the patient is symptomatic, has short stature or skeletal deformities consistent with rickets, or if the hypophosphataemia is chronic or severe.

    • This question is part of the following fields:

      • Cardiovascular Health
      170.8
      Seconds
  • Question 7 - A 49-year-old man holds a Group 2 licence and drives coaches for a...

    Correct

    • A 49-year-old man holds a Group 2 licence and drives coaches for a holiday company. He developed a moderately severe depressive illness 12 months ago, presenting with poor memory, poor concentration and suicidal thoughts. He has been off work since then.

      He has responded well to a selective serotonin receptor inhibitor (SSRI) antidepressant and feels that the medication doesn't impair him in any way. He feels ready to return to work.

      What is the recommended duration of stability on medication for a patient with moderate depression before driving with a Group 2 licence?

      Your Answer: 6 months

      Explanation:

      Driving with Anxiety and Depression: DVLA Guidelines

      The DVLA has specific guidelines for individuals with anxiety and depressive illnesses who wish to drive. If the illness is more than just mild, meaning it includes significant memory or concentration problems, agitation, behavioral disturbance, or suicidal thoughts, the DVLA must be informed. However, if the person is well and stable for a period of six months, driving may be permitted. It is important to note that medication must not cause side effects that interfere with alertness or concentration. If the anxiety or depression is long-standing and maintained symptom-free on doses of psychotropic medication that do not impair, driving is usually permitted. In some cases, the DVLA may require psychiatric reports. It is crucial to follow these guidelines to ensure the safety of both the driver and others on the road.

    • This question is part of the following fields:

      • Consulting In General Practice
      25.2
      Seconds
  • Question 8 - A 71-year-old man presents with progressive gait disturbance and fluctuating confusion. His symptoms...

    Incorrect

    • A 71-year-old man presents with progressive gait disturbance and fluctuating confusion. His symptoms began about six months ago when he noticed a heaviness in his legs on walking to work. Since then, his handwriting has become more untidy. His wife reports that he has become increasingly forgetful at home, although he denies this. Over the last two months, he has become restless at night and has reported seeing unidentified objects moving on the walls and in the room. On examination, his Mini-Mental State Examination score is 24/30. He is symmetrically rigid and slow, with a mild, jerky tremor in the upper limbs. Cranial nerve examination is unremarkable. His gait is shuffling, with mildly impaired postural reflexes.
      The accumulation of which protein causes the underlying diagnosis?

      Your Answer: Serum amyloid A protein

      Correct Answer: Alpha-synuclein

      Explanation:

      Neurodegenerative Disorders and Associated Proteins

      Dementia with Lewy bodies (DLB) is a neurodegenerative disorder characterized by cognitive decline, visual hallucinations, and sleep disturbances. It is caused by the accumulation of alpha-synuclein into Lewy bodies in vulnerable neurons.

      Beta-amyloid plaques are insoluble and associated with Alzheimer’s disease. They can be detected in the brain before diagnosis and have subtle effects on cognition.

      Prions are abnormal proteins that induce abnormal folding of other proteins. They are difficult to inactivate and can cause Creutzfeldt-Jakob disease, a rapidly progressive neurodegenerative disorder.

      Tau proteins are microtubule-binding proteins associated with local neurodegeneration and cognitive impairment. They are seen in Alzheimer’s disease as flame-shaped neurofibrillary tangles.

      Overall, DLB is a good differential diagnosis for vascular dementia, but the clinical picture is more suggestive of DLB.

    • This question is part of the following fields:

      • Mental Health
      70.6
      Seconds
  • Question 9 - A parent brings her 5-year-old son to the pediatrician's office. She informs you...

    Correct

    • A parent brings her 5-year-old son to the pediatrician's office. She informs you that her son has head lice and the school nurse has recommended keeping him at home until the treatment is finished to prevent the spread of head lice to other children. The parent asks for your advice on what to do next.

      Your Answer: No school exclusions apply

      Explanation:

      There is no need to exclude children with head lice from school, so the answer to the question is no. The mother should be comforted that her daughter can still attend school, and there is no reason for the patient to stay home. Therefore, the other answer options for this question are incorrect.

      The Health Protection Agency has provided guidance on when children should be excluded from school due to infectious conditions. Some conditions, such as conjunctivitis, fifth disease, roseola, infectious mononucleosis, head lice, threadworms, and hand, foot and mouth, do not require exclusion. Scarlet fever requires exclusion for 24 hours after commencing antibiotics, while whooping cough requires exclusion for 2 days after commencing antibiotics or 21 days from onset of symptoms if no antibiotics are taken. Measles requires exclusion for 4 days from onset of rash, rubella for 5 days from onset of rash, and Chickenpox until all lesions are crusted over. Mumps requires exclusion for 5 days from onset of swollen glands, while diarrhoea and vomiting require exclusion until symptoms have settled for 48 hours. Impetigo requires exclusion until lesions are crusted and healed, or for 48 hours after commencing antibiotic treatment, and scabies requires exclusion until treated. influenza requires exclusion until the child has recovered for 48 hours.

      Regarding Chickenpox, Public Health England recommends that children should be excluded until all lesions are crusted over, while Clinical Knowledge Summaries suggest that infectivity continues until all lesions are dry and have crusted over, usually about 5 days after the onset of the rash. It is important to follow official guidance and consult with healthcare professionals if unsure about exclusion periods for infectious conditions.

    • This question is part of the following fields:

      • Children And Young People
      29.8
      Seconds
  • Question 10 - A study testing a new prostate cancer screening tool enrolls 52,820 participants. Among...

    Correct

    • A study testing a new prostate cancer screening tool enrolls 52,820 participants. Among the 8950 participants diagnosed with prostate cancer through histological examination, 8900 had a positive test outcome. Meanwhile, 13,750 healthy participants had a positive screening result. What is the specificity of this novel screening tool?

      Your Answer: 68.70%

      Explanation:

      To calculate specificity, we need to use a 2*2 table with the following values for a sample size of 11,000 participants:

      Disease Healthy
      Positive TP=8900 FP=13750
      Negative FN=50 TN=30120

      Specificity is the probability of getting a negative test result when the person is healthy/doesn’t have the screened disease. We can calculate specificity using the formula:

      Specificity = TN / (TN+FP)

      Plugging in the values from our table, we get:

      Specificity = 30120 / (30120 + 13750) =

      Precision refers to the consistency of a test in producing the same results when repeated multiple times. It is an important aspect of test reliability and can impact the accuracy of the results. In order to assess precision, multiple tests are performed on the same sample and the results are compared. A test with high precision will produce similar results each time it is performed, while a test with low precision will produce inconsistent results. It is important to consider precision when interpreting test results and making clinical decisions.

    • This question is part of the following fields:

      • Evidence Based Practice, Research And Sharing Knowledge
      11.4
      Seconds
  • Question 11 - A 60-year-old man is brought to his General Practitioner (GP) by his son....

    Correct

    • A 60-year-old man is brought to his General Practitioner (GP) by his son. The son complains that his father's personality has changed completely over the past year. Even at his best, he is forgetful and ‘switched off’. At worst, he is drowsy and unresponsive. He is particularly concerned that his father has been claiming to 'see things that aren't really there'. Over the past few weeks, he has also been tripping a lot on the carpet and is no longer safe on the stairs going to his bedroom unaccompanied. The GP gave the patient a small dose of a neuroleptic which 'made things a million times worse'.
      On examination, he has an inexpressive face, with a mild resting tremor and some axial rigidity. There is no other focal neurology. On mini-mental state examination, he scores 20/30.
      What is the most likely primary brain pathology?

      Your Answer: Lewy bodies

      Explanation:

      Understanding Lewy Body Dementia: A Comparison with Other Neurological Conditions

      Lewy body dementia is a neurological condition characterized by extrapyramidal signs, visual hallucinations, and a variable symptom profile. Patients with this condition are also highly sensitive to the anticholinergic side-effects of neuroleptics. The presence of eosinophilic inclusions bodies called Lewy bodies in the limbic areas of the brain is a hallmark of this condition.

      It is important to differentiate Lewy body dementia from other neurological conditions that may present with similar symptoms. Normal brain is an unlikely diagnosis given the neurological symptoms seen in patients with Lewy body dementia. Multiple infarcts in the grey matter, on the other hand, typically have a stepwise course with an acute onset and patchy cognitive impairment. Neurofibrillary tangles are characteristic of Alzheimer’s disease, which presents with early impairment of memory that evolves into more general deficits in concentration and attention. Finally, Pick bodies are associated with fronto-temporal dementias and tend to involve disinhibition as an early feature.

      In summary, understanding the unique features of Lewy body dementia and its differences from other neurological conditions is crucial for accurate diagnosis and appropriate management of patients.

    • This question is part of the following fields:

      • Mental Health
      52.8
      Seconds
  • Question 12 - A 48-year-old man presents with complaints of blurred vision, redness and itching of...

    Correct

    • A 48-year-old man presents with complaints of blurred vision, redness and itching of the eyes. He reports having this chronic 'eye infection' on and off for the past four years. He has been using chloramphenicol drops without much relief. Upon examination, there is evidence of blepharitis, lid margin telangiectasia and mild conjunctival hyperaemia.
      What is the most probable diagnosis?

      Your Answer: Rosacea

      Explanation:

      Common Eye Conditions Associated with Systemic Diseases

      Rosacea is a skin condition that can also affect the eyes, causing chronic blepharitis, meibomian cysts, conjunctivitis, and keratitis. Ocular rosacea symptoms may occur before, during, or after skin symptoms, and may not always match the severity of skin symptoms.

      Ulcerative colitis, an inflammatory bowel disease, can cause scleritis or uveitis, which can lead to eye pain, redness, and vision loss.

      Recurrent herpes simplex can cause a linear branching corneal ulcer, known as a dendritic ulcer, as well as epithelial and disciform keratitis, resulting in foreign-body sensation, light sensitivity, redness, and blurred vision.

      Rheumatoid arthritis may be associated with episcleritis, scleritis, and dry eyes, which can cause eye pain, redness, and irritation.

      Systemic sclerosis, a connective tissue disorder, can cause eyelid tightening and telangiectasia, which are visible blood vessels on the surface of the skin, including the eyelids.

      Overall, it is important for individuals with these systemic diseases to be aware of potential eye complications and to seek prompt medical attention if they experience any changes in their vision or eye health.

    • This question is part of the following fields:

      • Eyes And Vision
      177.6
      Seconds
  • Question 13 - Which of the following is MOST LIKELY to be a feature of uncomplicated...

    Incorrect

    • Which of the following is MOST LIKELY to be a feature of uncomplicated cholesteatoma in elderly patients?

      Your Answer: Retracted intact tympanic membrane

      Correct Answer: Otorrhoea

      Explanation:

      Cholesteatoma: Symptoms and Complications

      Cholesteatoma is a condition characterized by the collection of epidermal and connective tissues within the middle ear. It can be dangerous as it may cause damage to adjacent vital structures such as the dura, lateral sinus, facial nerve, and semi-circular canal. In severe cases, it may lead to fatal central nervous system complications such as brain abscess and meningitis.

      The hallmark symptom of cholesteatoma is a painless otorrhoea, which may be continuous or recurrent. When infected, the infection may be difficult to treat. Hearing loss is also a common symptom, as the cholesteatoma can fill the middle ear space with desquamated epithelium, interfering with sound transmission and causing ossicular damage.

      Dizziness and facial nerve palsy may occur as the cholesteatoma grows and erodes into adjacent structures. These symptoms are worrisome as they may indicate more serious complications.

      A retracted intact tympanic membrane is not a specific feature of cholesteatoma and may be seen in other conditions such as otitis media with effusion. In cholesteatoma, pearly, white, glistening debris may be visible through the otorrhoea, occupying a perforation in the tympanic membrane, usually in the pars flaccida. Alternatively, there may just be crusting in the uppermost part of the drum beneath which lies a cholesteatoma.

      Rhinorrhoea is not a feature of cholesteatoma.

      In summary, cholesteatoma is a serious condition that requires prompt medical attention. Its symptoms include painless otorrhoea, hearing loss, and possible complications such as dizziness and facial nerve palsy.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      22
      Seconds
  • Question 14 - A 44-year-old left-handed man who has played drums for years complains of hearing...

    Incorrect

    • A 44-year-old left-handed man who has played drums for years complains of hearing loss. He rests the drumsticks in his left hand and his upper arm on that side tends to cover the ear.
      What is the most likely finding on audiogram?

      Your Answer:

      Correct Answer: A right-sided high frequency sensorineural hearing loss

      Explanation:

      Understanding Different Types of Hearing Loss: A Case Study on Rifle Shooting

      Rifle shooting can lead to hearing loss, particularly high-frequency sensorineural hearing loss. In this case study, a man who is left-handed and shoots with the gun resting against his left shoulder is more likely to experience hearing loss in his right ear due to the masking effect. Ageing can also cause sensorineural hearing loss, which typically starts in the high-frequency range.

      However, a right-sided conductive hearing loss is not caused by noise exposure. Conductive hearing loss occurs when there is a problem conducting sound through the outer ear, tympanic membrane, or middle ear. Causes of this include wax, serous otitis media, suppurative otitis media, perforated eardrum, and otosclerosis.

      A bilateral mixed hearing loss at all frequencies is also not caused by noise exposure. Mixed hearing loss is caused when conductive damage in the outer or middle ear is combined with sensorineural damage in the inner ear or auditory nerve.

      Similarly, a left-sided low-frequency sensorineural hearing loss is not an early feature of noise-induced deafness. Low-frequency hearing loss may be related to conductive hearing loss, but as a sensorineural hearing loss progresses, the initial high-frequency loss spreads through lower frequencies. Low-frequency hearing loss eventually occurs in Menière’s disease.

      In summary, understanding the different types of hearing loss is crucial in identifying the causes and potential treatments. In the case of rifle shooting, high-frequency sensorineural hearing loss is a common occurrence, but other types of hearing loss may have different causes and require different interventions.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      0
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  • Question 15 - A 56-year-old man visits his General Practice Surgery, requesting travel vaccinations at short...

    Incorrect

    • A 56-year-old man visits his General Practice Surgery, requesting travel vaccinations at short notice. His daughter has been taken ill on her gap year and is in hospital in Thailand, and he wants to travel over there within a few days. He is on interferon and ribavirin for chronic asymptomatic hepatitis C infection, which was diagnosed six months ago. He was fully immunised as a child and was given some additional vaccinations on diagnosis with hepatitis C. He wants to know whether there is time to have any travel vaccinations before he travels.
      Which of the following is the most appropriate vaccination to offer, which can be given up to the day of travel?

      Your Answer:

      Correct Answer: Diphtheria, tetanus and pertussis (DTP)

      Explanation:

      The patient is planning to travel to Borneo and needs to know which vaccinations are appropriate to receive before departure. The DTP vaccine, which protects against diphtheria, tetanus, and pertussis, is recommended and can be given up to the day of travel. Rabies vaccination is also advised for those visiting areas where the disease is endemic, but it requires a course of three injections over 28 days and cannot be given within days of travel. Hepatitis A is a common disease in many parts of the world and can be contracted through contaminated food and water, but the patient’s known diagnosis of hepatitis C means that she has likely already been vaccinated against hepatitis A and B. Hepatitis B is generally given as a course of injections over six months, which is not feasible for the patient’s short timeline. Japanese Encephalitis is rare in travelers and requires two separate injections a month apart, which doesn’t fit with the patient’s schedule.

    • This question is part of the following fields:

      • Allergy And Immunology
      0
      Seconds
  • Question 16 - You see a 10-month-old girl with her mother who is concerned as her...

    Incorrect

    • You see a 10-month-old girl with her mother who is concerned as her daughter seems pale and has a high temperature. She states that she has been lethargic and not smiling for the last 24 hours. She has had a snotty nose and a cough for the last 2 days. Everyone at home also has a nasty cold. She is managing to drink milk well and has had a normal amount of wet nappies today. Her mother hasn't noticed any rashes.

      On examination, she looks pale and miserable but lets you examine her. Her temperature is 38.1ºC, she has moist mucous membranes and her capillary refill time is 3 seconds. You observe her heart rate to be 140 beats per minute. Her respiratory rate is 50 breaths per minute and her chest sounds clear. Her oxygen saturations are 98% in air. You undress her fully and there are no rashes and her abdomen is soft. Her throat is red with large tonsils and both her eardrums are bright red and bulging.

      Which observation that you have made is normal in this age group?

      Your Answer:

      Correct Answer: A heart rate of 140 bpm.

      Explanation:

      In children under 12 months old, a heart rate of 140 is within the normal range of 110-160 bpm. However, pallor and not smiling are considered amber symptoms according to the NICE traffic light system for feverish children and should be monitored closely. A respiratory rate of 50 and a capillary refill time of 3 seconds or more are also abnormal and should be evaluated by a healthcare professional.

      Paediatric vital signs refer to the normal range of heart rate and respiratory rate for children of different ages. These vital signs are important indicators of a child’s overall health and can help healthcare professionals identify any potential issues. The table below outlines the age-appropriate ranges for heart rate and respiratory rate. Children under the age of one typically have a higher heart rate and respiratory rate, while older children have lower rates. It is important for healthcare professionals to monitor these vital signs regularly to ensure that children are healthy and developing properly.

      Age Heart rate Respiratory rate
      < 1 110 - 160 30 - 40
      1 – 2 100 – 150 25 – 35
      2 – 5 90 – 140 25 – 30
      5 – 12 80 – 120 20 – 25
      > 12 60 – 100 15 – 20

    • This question is part of the following fields:

      • Children And Young People
      0
      Seconds
  • Question 17 - A 44-year-old woman is seen in an emergency appointment complaining that her cold...

    Incorrect

    • A 44-year-old woman is seen in an emergency appointment complaining that her cold has gone onto her chest, giving her a productive cough and occasional retrosternal chest pain. On examination she has a slight wheeze in her chest but no signs of respiratory distress. She is otherwise fit and well.
      Select the single correct statement about her management.

      Your Answer:

      Correct Answer: She should be advised that she has a viral infection and to take analgesics and antipyretics, with instructions to return if her symptoms worsen

      Explanation:

      Treatment Options for Acute Bronchitis

      Acute bronchitis is often caused by a virus, and in individuals with mild symptoms who are otherwise healthy, bacterial infections typically resolve on their own. Treatment options for acute bronchitis include deferred prescriptions with advice sheets or simple reassurance.

    • This question is part of the following fields:

      • Infectious Disease And Travel Health
      0
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  • Question 18 - Of the given eye injuries, which one would require hospital referral for management?...

    Incorrect

    • Of the given eye injuries, which one would require hospital referral for management?

      Your Answer:

      Correct Answer: Deep corneal foreign body

      Explanation:

      Managing Ocular Trauma: Understanding Different Types of Injuries

      Ocular trauma can be challenging to manage, and it is important to understand the different types of injuries and when to refer to specialists. Deep corneal foreign bodies and large hyphaemas should be managed in centers with slit lamp examinations and intraocular pressure measurements. Urgent referral to secondary care is necessary for open globe injuries, lid lacerations involving the lid margin or canaliculi, blowout orbital fractures with diplopia in the primary position, iris abnormalities, vitreous hemorrhage, and potentially intraocular foreign bodies.

      The most common pitfalls in dealing with ocular trauma are missing tarsal foreign bodies, intraocular foreign bodies, corneal ulcers, scleral lacerations and ruptures, and cranial injuries in sharp orbital trauma.

      Superficial corneal abrasions can usually be managed by a general practitioner or nurse, while corneal foreign bodies can be removed under topical anesthesia. Eyelid lacerations not involving the margin may not require referral, but specialists such as plastic surgeons or ophthalmic surgeons should be consulted for most eyelid lacerations, especially if the lid margin is involved.

      It is crucial to understand the appropriate management and referral for different types of ocular trauma to ensure the best possible outcomes for patients.

    • This question is part of the following fields:

      • Eyes And Vision
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  • Question 19 - Which one of the following statements regarding relative risk is accurate? ...

    Incorrect

    • Which one of the following statements regarding relative risk is accurate?

      Your Answer:

      Correct Answer: It is the usual outcome measure of cohort studies

      Explanation:

      It is important to distinguish between risk and odds. For instance, if 100 individuals experience a myocardial infarction and 20 of them die, the risk of dying is 0.2 (20/100). However, the odds of dying are 0.25 (20/80).

      Understanding Relative Risk in Clinical Trials

      Relative risk (RR) is a measure used in clinical trials to compare the risk of an event occurring in the experimental group to the risk in the control group. It is calculated by dividing the experimental event rate (EER) by the control event rate (CER). If the resulting ratio is greater than 1, it means that the event is more likely to occur in the experimental group than in the control group. Conversely, if the ratio is less than 1, the event is less likely to occur in the experimental group.

      To calculate the relative risk reduction (RRR) or relative risk increase (RRI), the absolute risk change is divided by the control event rate. This provides a percentage that indicates the magnitude of the difference between the two groups. Understanding relative risk is important in evaluating the effectiveness of interventions and treatments in clinical trials. By comparing the risk of an event in the experimental group to the control group, researchers can determine whether the intervention is beneficial or not.

    • This question is part of the following fields:

      • Evidence Based Practice, Research And Sharing Knowledge
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  • Question 20 - A 56-year-old man with longstanding bipolar disorder has recently joined your practice after...

    Incorrect

    • A 56-year-old man with longstanding bipolar disorder has recently joined your practice after moving to the area. He has been on a stable dosage of lithium for the past 4 years and has been adherent to treatment. He has no other medical history of note and is not taking any medication that interacts with lithium. His previous blood tests have all been within normal limits, with a serum lithium level consistently around 0.5 mmol/litre (within target range).

      What is the minimum ongoing blood monitoring required for this patient in relation to his lithium treatment?

      Your Answer:

      Correct Answer: Serum lithium level, serum electrolytes, eGFR, thyroid function and full blood count annually

      Explanation:

      Lithium Monitoring Requirements

      Lithium is a medication with a narrow therapeutic ratio, which means it requires careful monitoring. The British National Formulary (BNF) outlines the monitoring requirements for patients taking lithium. After initiation and each dose change, serum-lithium monitoring should be carried out weekly until concentrations are stable. After that, it should be checked every 3 months for the first year and every 6 months thereafter as a minimum.

      Patients who are 65 years and above, taking drugs that may interact with lithium, at risk of impaired renal or thyroid function, have high calcium levels, poor symptom control or adherence to treatment, or whose last serum-lithium concentration was 0.8 mmol/litre or higher should be monitored every 3 months. Additionally, serum-lithium measurements should be checked if there is a significant intercurrent illness/disease or a significant change in sodium or fluid intake.

      Before treatment is initiated, renal, cardiac, and thyroid function should be assessed, and an ECG is recommended for those with cardiovascular disease or risk factors. Body-weight/BMI, serum electrolytes, and a full blood count should also be measured. During treatment, body-weight/BMI, serum electrolytes, eGFR, and thyroid function should be monitored every 6 months. If there is evidence of impaired renal or thyroid function or raised calcium levels, monitoring should be more frequent.

    • This question is part of the following fields:

      • Mental Health
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  • Question 21 - A 50-year-old man is to have a prostate specific antigen (PSA) test performed.
    Select...

    Incorrect

    • A 50-year-old man is to have a prostate specific antigen (PSA) test performed.
      Select from the list the option that would allow you to do the test immediately rather than defer it to a later date.

      Your Answer:

      Correct Answer: He says his last ejaculation was 4 days ago

      Explanation:

      PSA levels can be affected by various factors such as digital rectal examination, urinary or prostatic infections, prostate biopsies, urinary catheterization, prostate or bladder surgery, prolonged exercise, and ejaculation. It is advisable to defer DRE for a week, but if necessary, a gentle examination is unlikely to significantly increase PSA levels. PSA levels may remain elevated for several months after infections, and testing should be delayed for at least three months after biopsies or surgeries. Prolonged exercise and ejaculation may raise PSA levels for up to 48 hours.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 22 - A 50-year-old man who has smoked for 35 years has several other symptoms.

    Which...

    Incorrect

    • A 50-year-old man who has smoked for 35 years has several other symptoms.

      Which symptom according to NICE guidance supports the diagnosis of Chronic obstructive pulmonary disease (COPD)?

      Your Answer:

      Correct Answer: Childhood asthma

      Explanation:

      Symptoms and Risk Factors for COPD

      A diagnosis of COPD should be considered in patients who are over 35 years old and have a risk factor, typically smoking. If a patient presents with one or more of the following symptoms, they should be evaluated for COPD: exertional breathlessness, chronic cough, regular sputum production, frequent winter bronchitis, or wheeze. However, chest pain and haemoptysis are uncommon and should lead to consideration of an alternative diagnosis. It is important to recognize these symptoms and risk factors in order to diagnose and treat COPD early, which can improve patient outcomes and quality of life.

    • This question is part of the following fields:

      • Respiratory Health
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  • Question 23 - A 75-year-old male presents with sudden loss of vision in his left eye,...

    Incorrect

    • A 75-year-old male presents with sudden loss of vision in his left eye, associated with a relative afferent pupillary defect.

      He has poorly controlled systemic hypertension and raised cholesterol.

      What is the most likely cause of his condition?

      Your Answer:

      Correct Answer: Retinal vascular occlusion

      Explanation:

      Tips for Answering Tricky Questions in the AKT Exam

      When faced with a tricky question in the AKT exam, it can be easy to feel overwhelmed and unsure of how to proceed. However, there are strategies you can use to help narrow down your options and improve your chances of selecting the correct answer.

      One approach is to look for key information in the question stem, such as the presence of certain risk factors or the sudden onset of symptoms. By considering which answer option is most likely given this information, you can eliminate some of the less plausible choices.

      It’s important to remember that you won’t know the answer to every question in the exam, and that’s okay. By using these strategies and taking a methodical approach, you can increase your hit rate and feel more confident in your overall performance.

      To see an example of this approach in action, check out the Endgames scenario on sudden unilateral painless loss of vision in the BMJ article linked above. With practice and preparation, you can tackle even the trickiest questions on the AKT exam.

    • This question is part of the following fields:

      • Eyes And Vision
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  • Question 24 - Sarah is a 42-year-old woman who has been experiencing acid reflux. Despite making...

    Incorrect

    • Sarah is a 42-year-old woman who has been experiencing acid reflux. Despite making lifestyle changes, her symptoms have not improved and she has returned to seek advice. She doesn't smoke or drink alcohol.

      Sarah's medical history includes peripheral vascular disease, high cholesterol, and hypertension. She is currently taking clopidogrel 75 mg, amlodipine 5mg, and atorvastatin 40 mg.

      What would be an appropriate prescription for Sarah?

      Your Answer:

      Correct Answer: Lansoprazole 30 mg

      Explanation:

      A possible drug interaction may occur between clopidogrel and a proton pump inhibitor, which can reduce the effectiveness of clopidogrel. This interaction is specifically associated with omeprazole and esomeprazole. Given this information, the best option in the given scenario would be to prescribe a full dose of lansoprazole (30 mg).

      Clopidogrel: An Antiplatelet Agent for Cardiovascular Disease

      Clopidogrel is a medication used to manage cardiovascular disease by preventing platelets from sticking together and forming clots. It is commonly used in patients with acute coronary syndrome and is now also recommended as a first-line treatment for patients following an ischaemic stroke or with peripheral arterial disease. Clopidogrel belongs to a class of drugs called thienopyridines, which work in a similar way. Other examples of thienopyridines include prasugrel, ticagrelor, and ticlopidine.

      Clopidogrel works by blocking the P2Y12 adenosine diphosphate (ADP) receptor, which prevents platelets from becoming activated. However, concurrent use of proton pump inhibitors (PPIs) may make clopidogrel less effective. The Medicines and Healthcare products Regulatory Agency (MHRA) issued a warning in July 2009 about this interaction, and although evidence is inconsistent, omeprazole and esomeprazole are still cause for concern. Other PPIs, such as lansoprazole, are generally considered safe to use with clopidogrel. It is important to consult with a healthcare provider before taking any new medications or supplements.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 25 - What is true about acute post-infective polyneuropathy? ...

    Incorrect

    • What is true about acute post-infective polyneuropathy?

      Your Answer:

      Correct Answer: Cranial nerves are not involved

      Explanation:

      Guillain-Barré Syndrome: A Brief Overview

      Guillain-Barré Syndrome is a polyneuropathy that can affect cranial nerves, particularly the facial nerves. It is a lower motor neurone lesion that is often preceded by lumbar or intracapsular pain. While full recovery is possible, some residual weakness is common. In the acute phase, muscle wasting doesn’t occur, but it may develop in the long term. Respiratory muscle involvement can cause reduced peak flow, which may require ventilation. Additionally, sensory disturbance is typically present. Overall, Guillain-Barré Syndrome is a complex condition that requires careful management and monitoring.

    • This question is part of the following fields:

      • Neurology
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  • Question 26 - A 9-year-old girl has been diagnosed with ADHD. What dietary recommendations should be...

    Incorrect

    • A 9-year-old girl has been diagnosed with ADHD. What dietary recommendations should be given to her parents?

      Your Answer:

      Correct Answer: Eat a normal balanced diet

      Explanation:

      In March 2018, NICE released new guidelines for the recognition and management of Attention Deficit Hyperactivity Disorder (ADHD). This condition can have a significant impact on a child’s life and can continue into adulthood, making accurate diagnosis and treatment crucial. ADHD is defined by DSM-V as a persistent condition that includes features of inattention and/or hyperactivity/impulsivity, with an element of developmental delay. The threshold for diagnosis is six features for children up to 16 years old and five features for those aged 17 or over. ADHD has a prevalence of 2.4% in the UK, with a possible genetic component and a higher incidence in boys than girls.

      NICE recommends a holistic approach to treating ADHD that is not solely reliant on medication. After presentation, a ten-week observation period should follow to determine if symptoms change or resolve. If symptoms persist, referral to secondary care is necessary, usually to a paediatrician with a special interest in behavioural disorders or to the local Child and Adolescent Mental Health Service (CAMHS). A tailored plan of action should be developed, taking into account the patient’s needs and wants and how their condition affects their lives.

      Drug therapy should be considered a last resort and is only available to those aged 5 years or older. For patients with mild/moderate symptoms, parents attending education and training programmes can be beneficial. For those who fail to respond or have severe symptoms, pharmacotherapy can be considered. Methylphenidate is the first-line treatment for children and should be given on a six-week trial basis. Lisdexamfetamine can be used if there is an inadequate response, and dexamfetamine can be started in those who have benefited from lisdexamfetamine but cannot tolerate its side effects. In adults, methylphenidate or lisdexamfetamine are first-line options, with switching between drugs if no benefit is seen after a trial of the other.

      All of these drugs have the potential to be cardiotoxic, so a baseline ECG should be performed before starting treatment. Referral to a cardiologist is necessary if there is any significant past medical history or family history, or any doubt or ambiguity. A thorough history and clinical examination are essential for accurate diagnosis, given the overlap of ADHD with many other psychiatric and physical conditions.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 27 - A 9-month-old boy has a temperature of 38.5°C. You first saw the child...

    Incorrect

    • A 9-month-old boy has a temperature of 38.5°C. You first saw the child two days ago and the child has been febrile since then. He now has a faint erythematous macular rash that blanches on pressure. The parents are anxious.
      Which option would be MOST IMPORTANT in making the decision to admit the child to hospital?

      Your Answer:

      Correct Answer: Increasing family anxiety

      Explanation:

      Identifying Red Flags in Febrile Children

      Febrile illness in children can be a cause of concern for parents and healthcare providers. While most cases are self-limiting and resolve without complications, some may require urgent medical attention. It is important to identify red flags that indicate a potentially serious underlying condition.

      Factors that may increase family anxiety include a history of serious illness or death due to feverish illness, other illnesses affecting the child or family members, and parental instinct. Parents should not ignore their intuition and seek medical advice if they are concerned.

      While there are no set rules about how long a fever should last, parents should seek further advice if their child has been febrile for five days without resolution. In infants aged 0-3 months, a temperature of >38°C is a red flag, while a temperature of >39°C in infants aged 3-6 months is an amber flag. After six months of age, the temperature alone is no longer an indicator of intermediate or high risk.

      Reduced fluid intake, dry mucous membranes, reduced urine output, and reduced skin turgor are amber warning signs that require medical attention. A blanching erythematous rash is likely to indicate a viral infection and is not a cause for concern. However, non-blanching petechiae and patches in a sick child suggest meningococcal disease and require urgent medical attention.

      In conclusion, identifying red flags in febrile children is crucial for timely diagnosis and management of potentially serious conditions. Parents should seek medical advice if they are concerned about their child’s health.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 28 - A 44-year-old man collapsed with sudden onset breathlessness associated with haemoptysis earlier that...

    Incorrect

    • A 44-year-old man collapsed with sudden onset breathlessness associated with haemoptysis earlier that day. He is usually fit and well with no significant past medical history and is not on any regular medication.

      His family brought him, unannounced, to the surgery reception and when you see him he appears pale and he feels noticeably short of breath at rest. He is complaining of sharp pains in the right side of his chest when he breathes in.

      Clinical examination reveals a patient who is short of breath at rest. His blood pressure is 98/68, pulse rate is 108 bpm and his respiratory rate 24 breaths per minute. Oxygen saturations are 93 % in room air. His temperature is 36.2 °C. Auscultation of the heart and lungs is normal. He has no calf swelling.

      There is no history of gastric ulceration or drug allergies.

      Which of the following would be the most appropriate immediate next step in the assessment and management of this patient?

      Your Answer:

      Correct Answer: Arrange an immediate 'blue-light ambulance' for rapid transfer to hospital without any delay

      Explanation:

      Management of Suspected Pulmonary Embolism

      When a patient presents with sudden onset breathlessness, haemoptysis, pleuritic pain, hypotension, tachycardia, increased respiratory rate, and low oxygen saturations, pulmonary embolism (PE) should be suspected. It is important to note any risk factors that may increase the likelihood of an embolism. The absence of signs of deep vein thrombosis doesn’t exclude the possibility of a PE.

      Immediate admission to the hospital should be arranged for patients with suspected PE who have signs of haemodynamic instability or are pregnant or have given birth within the past 6 weeks. Management should not be delayed for results of a chest X-ray or ECG. Therefore, the correct option is to arrange immediate transfer to the hospital by blue light. Prescribing a non-steroidal anti-inflammatory drug fails to appreciate the possibility of pulmonary embolism and should not be selected.

      In summary, prompt recognition and management of suspected PE is crucial to prevent morbidity and mortality.

    • This question is part of the following fields:

      • Respiratory Health
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  • Question 29 - You are tasked with completing a death certificate for an 85-year-old patient under...

    Incorrect

    • You are tasked with completing a death certificate for an 85-year-old patient under your care. She passed away yesterday due to pneumonia at home, following a joint decision made by her family and medical team not to admit her to the hospital for further treatment. The patient had a history of dementia and osteoporosis, and you had last assessed her two days prior.

      The patient had recently undergone surgery for a fractured neck of femur, which she sustained after tripping on a step at home. Although her surgery had been successful and she had been recovering well, she began experiencing respiratory symptoms shortly after being discharged from the hospital. What is the appropriate course of action regarding the completion of the death certificate?

      Your Answer:

      Correct Answer: Speak to the coroner

      Explanation:

      It is probable that the patient passed away due to the initial fall, which necessitates referral to the coroner as per the guidance that mandates all deaths related to injury or poisoning.

      Death Certification in the UK

      There are no legal definitions of death in the UK, but guidelines exist to verify it. According to the current guidance, a doctor or other qualified personnel should verify death, and nurse practitioners may verify but not certify it. After a patient has died, a doctor needs to complete a medical certificate of cause of death (MCCD). However, there is a list of circumstances in which a doctor should notify the Coroner before completing the MCCD.

      When completing the MCCD, it is important to note that old age as 1a is only acceptable if the patient was at least 80 years old. Natural causes is not acceptable, and organ failure can only be used if the disease or condition that led to the organ failure is specified. Abbreviations should be avoided, except for HIV and AIDS.

      Once the MCCD is completed, the family takes it to the local Registrar of Births, Deaths, and Marriages office to register the death. If the Registrar decides that the death doesn’t need reporting to the Coroner, he/she will issue a certificate for Burial or Cremation and a certificate of Registration of Death for Social Security purposes. Copies of the Death Register are also available upon request, which banks and insurance companies expect to see. If the family wants the burial to be outside of England, an Out of England Order is needed from the coroner.

    • This question is part of the following fields:

      • End Of Life
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  • Question 30 - A GP is concerned about the number of cases of hypertension he is...

    Incorrect

    • A GP is concerned about the number of cases of hypertension he is seeing in his practice. He conducts a search of the practice records to investigate further. In the practice population of 15000 patients, he identifies 200 patients with a diagnosis of hypertension, with 20 of those diagnosed between 1st January 2021 and 31st December 2021. He also notes four deaths in the past year with hypertension named on part one of the death certificate.

      What was the incidence of hypertension for the year 2021 in this GP practice?

      Your Answer:

      Correct Answer: 43 per 100,000

      Explanation:

      The incidence of cirrhosis in the practice population is 43 per 100,000, as there were 6 new cases in the year out of a total population of 14,000. The proportion of patients with cirrhosis who received the diagnosis within the last year is 0.075, or 6 out of 80 patients. The prevalence of cirrhosis in the practice population is 0.00571, or 80 out of 14,000 patients.

      Understanding Incidence and Prevalence

      Incidence and prevalence are two terms used to describe the frequency of a condition in a population. The incidence refers to the number of new cases per population in a given time period, while the prevalence refers to the total number of cases per population at a particular point in time. Prevalence can be further divided into point prevalence and period prevalence, depending on the time frame used to measure it.

      To calculate prevalence, one can use the formula prevalence = incidence * duration of condition. This means that in chronic diseases, the prevalence is much greater than the incidence, while in acute diseases, the prevalence and incidence are similar. For example, the incidence of the common cold may be greater than its prevalence.

      Understanding the difference between incidence and prevalence is important in epidemiology and public health, as it helps to identify the burden of a disease in a population and inform healthcare policies and interventions. By measuring both incidence and prevalence, researchers can track the spread of a disease over time and assess the effectiveness of prevention and treatment strategies.

    • This question is part of the following fields:

      • Evidence Based Practice, Research And Sharing Knowledge
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SESSION STATS - PERFORMANCE PER SPECIALTY

Haematology (0/1) 0%
Dermatology (1/1) 100%
Ear, Nose And Throat, Speech And Hearing (1/2) 50%
Gastroenterology (0/1) 0%
Mental Health (2/3) 67%
Cardiovascular Health (0/1) 0%
Consulting In General Practice (1/1) 100%
Children And Young People (1/1) 100%
Evidence Based Practice, Research And Sharing Knowledge (1/1) 100%
Eyes And Vision (1/1) 100%
Passmed