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  • Question 1 - A 68-year old gentleman is seen for follow up. He has recently been...

    Incorrect

    • A 68-year old gentleman is seen for follow up. He has recently been diagnosed with heart failure. His echocardiogram shows a reduced ejection fraction. On reviewing his medications you can see that he has been taking atenolol going back many years for hypertension.

      Which of the following beta blockers would you recommend he switches to in order to enhance his heart failure treatment?

      Your Answer: Propranolol

      Correct Answer: Bisoprolol

      Explanation:

      Beta Blockers for Heart Failure

      Beta blockers have been proven to increase the survival rate of patients with heart failure in numerous clinical trials. In the UK, there are three licensed drugs for this purpose: Bisoprolol, Carvedilol, and Nebivolol. If a patient is newly diagnosed with left ventricular systolic function and is already taking a beta blocker, it is recommended to switch them to one of the beta blockers that have been shown to be effective in treating heart failure. This can help improve the patient’s overall health and increase their chances of survival.

    • This question is part of the following fields:

      • Older Adults
      67.9
      Seconds
  • Question 2 - A 54-year-old man has come in for his annual health check-up. He has...

    Correct

    • A 54-year-old man has come in for his annual health check-up. He has a history of hypertension and is currently taking ramipril 10 mg once daily, felodipine 10 mg once daily, and bendroflumethiazide 2.5mg once daily. His blood pressure readings today are consistently high. Additionally, blood tests have been taken as part of the check-up. Based on this information, what would be the most suitable medication to initiate?

      Your Answer: Bisoprolol

      Explanation:

      To manage poorly controlled hypertension in a patient who is already taking an ACE inhibitor, calcium channel blocker, and a standard-dose thiazide diuretic with a potassium level of >4.5mmol/l, the appropriate medication to add would be an alpha- or beta-blocker. Bisoprolol is the correct choice in this scenario. Furosemide is not indicated for hypertension alone, and indapamide is contraindicated as the patient is already taking a thiazide-like diuretic. While an ARB like losartan could replace an ACE inhibitor, it should not be used in combination with one. Spironolactone is not the appropriate choice as the patient’s potassium level is already elevated.

      Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

      Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

      Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

      The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

      If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

    • This question is part of the following fields:

      • Cardiovascular Health
      167.4
      Seconds
  • Question 3 - A 28 year old woman with no pre-existing medical conditions comes to you...

    Incorrect

    • A 28 year old woman with no pre-existing medical conditions comes to you after discovering she is expecting. During your discussion about pregnancy supplements, she inquires if she can simply continue taking her regular over-the-counter multivitamin tablet. Can you inform her which vitamin, when consumed in excessive amounts, can be harmful to the developing fetus?

      Your Answer: Vitamin B12

      Correct Answer: Vitamin A

      Explanation:

      To prevent birth defects, pregnant women should not consume more than 10,000IU of vitamin A per day as it can be harmful in high doses. It is recommended that they avoid taking any supplements that contain vitamin A, including regular multivitamins, during pregnancy. In the UK, supplements are now restricted to a maximum of 6,000IU of vitamin A, so if a pregnant woman has been taking one, there is no need to worry. Additionally, liver should be avoided as it contains high levels of vitamin A.

      Vitamin A, also known as retinol, is a type of fat soluble vitamin that plays several important roles in the body. One of its key functions is being converted into retinal, which is a crucial visual pigment. Additionally, vitamin A is essential for proper epithelial cell differentiation and acts as an antioxidant to protect cells from damage.

      When the body lacks sufficient vitamin A, it can lead to a condition known as night blindness. This is because retinal is necessary for the eyes to adjust to low light conditions, and a deficiency can impair this process. Therefore, it is important to ensure adequate intake of vitamin A through a balanced diet or supplements to maintain optimal health.

    • This question is part of the following fields:

      • Eyes And Vision
      78.4
      Seconds
  • Question 4 - A 24-year-old man is seen with a severe asthma exacerbation, which is typically...

    Correct

    • A 24-year-old man is seen with a severe asthma exacerbation, which is typically controlled with maximal inhaled corticosteroid and LABA. He has presented with worsening symptoms of cough and wheeze, which his partner reports began two days ago with a heavy cold. What is the appropriate clinical management for this patient?

      Your Answer: Normal heart rate is always associated with a good prognosis

      Explanation:

      Understanding Tachycardia and Bradycardia in Acute Asthma

      Tachycardia is a common symptom in acute asthma, but severe attacks may also lead to episodes of bradycardia. A peak flow measurement of only 30% of predicted indicates severe airway obstruction and requires immediate admission and aggressive treatment. While oximetry is useful for assessing oxygenation, it cannot provide information on CO2 retention or acid-base status. Therefore, high-flow oxygen should always be administered in the management of acute asthma.

      Understanding the symptoms and measurements associated with acute asthma is crucial for effective management. Tachycardia and bradycardia are two possible heart rate changes that may occur during an asthma attack. Additionally, a peak flow measurement of 30% or less of predicted indicates severe airway obstruction and requires prompt medical attention. While oximetry is useful for assessing oxygenation, it cannot provide a complete picture of the patient’s respiratory status. Therefore, high-flow oxygen should always be given to patients with acute asthma.

    • This question is part of the following fields:

      • Respiratory Health
      158.8
      Seconds
  • Question 5 - Which one of the following statements regarding hand, foot and mouth disease is...

    Incorrect

    • Which one of the following statements regarding hand, foot and mouth disease is incorrect?

      Your Answer: Children do not need to be excluded from school

      Correct Answer: Palm and sole lesions tend to occur before oral ulcers

      Explanation:

      Oral lesions typically manifest before palm and sole lesions in cases of hand, foot and mouth disease.

      Hand, Foot and Mouth Disease: A Contagious Condition in Children

      Hand, foot and mouth disease is a viral infection that commonly affects children. It is caused by intestinal viruses from the Picornaviridae family, particularly coxsackie A16 and enterovirus 71. This condition is highly contagious and often occurs in outbreaks in nurseries.

      The clinical features of hand, foot and mouth disease include mild systemic upset such as sore throat and fever, followed by the appearance of oral ulcers and vesicles on the palms and soles of the feet.

      Symptomatic treatment is the only management option available, which includes general advice on hydration and analgesia. It is important to note that there is no link between this disease and cattle, and children do not need to be excluded from school. However, the Health Protection Agency recommends that children who are unwell should stay home until they feel better. If there is a large outbreak, it is advisable to contact the agency for assistance.

    • This question is part of the following fields:

      • Children And Young People
      180.6
      Seconds
  • Question 6 - A 65-year-old man visits his doctor with a complaint of blurred vision in...

    Correct

    • A 65-year-old man visits his doctor with a complaint of blurred vision in his left eye for the past week. Upon examination, his right eye has a visual acuity of 6/6 and his left eye has a visual acuity of 6/18. No pupillary defect is observed. Dilated fundal examination shows extensive retinal haemorrhages in all quadrants of the left retina, along with dilated tortuous retinal veins. The right fundus appears normal. The patient has not seen his doctor in the last ten years. He describes himself as healthy and is not taking any regular medication. However, his blood pressure is 185/100 and his random blood sugar is 12 mmol/l. What is the most probable ocular diagnosis?

      Your Answer: Central retinal vein occlusion

      Explanation:

      Understanding Central Retinal Vein Occlusion

      Central retinal vein occlusion (CRVO) is a common type of retinal vascular disorder that can lead to vision loss. It occurs when the vein that carries blood away from the retina becomes blocked, usually due to thickening of the adjacent arteriole. Risk factors for CRVO include arteriosclerosis and hyperviscosity.

      Symptoms of CRVO include painless and unilateral visual loss, with more severe cases presenting with widespread retinal haemorrhages, engorged veins, retinal oedema, and a swollen optic disc. However, less severe cases may also occur.

      It is important to differentiate CRVO from other retinal disorders, such as diabetic retinopathy, branch retinal vein occlusion, hypertensive retinopathy, and ocular ischaemic syndrome. Diabetic retinopathy is associated with retinal haemorrhages, but these are unlikely to be unilateral. Branch retinal vein occlusion affects only part of the retina, while hypertensive retinopathy should be bilateral and accompanied by other changes. Ocular ischaemic syndrome is a rare condition associated with severe carotid artery occlusive disease, causing dot-and-blot haemorrhages within the mid-periphery and dilated retinal veins.

      In summary, understanding the symptoms and risk factors of CRVO can help with early detection and treatment, preventing further vision loss.

    • This question is part of the following fields:

      • Eyes And Vision
      100.2
      Seconds
  • Question 7 - A 30-year-old man presents with a headache. He has never experienced significant headaches...

    Correct

    • A 30-year-old man presents with a headache. He has never experienced significant headaches before but developed this one about a week ago.

      He describes a vague headache on the left side of his head, starting above his left eye and extending to the parietal area. The headache has been fairly constant, and he has taken paracetamol and ibuprofen, which have only provided slight relief and have not significantly reduced the pain.

      There is no history of vomiting, drowsiness, loss of consciousness, seizures, postural related headache, or tinnitus. There are no mental or cognitive changes.

      On clinical examination, all cranial nerves are normal, and there is no focal limb neurological deficit or cerebellar signs. ENT examination is normal, and there is no scalp or temporal tenderness. There is no neck stiffness or restriction of neck movements. Observations, including blood pressure and temperature, are normal, and there is no anxiety, depression, or psychological upset.

      Despite the lack of a clear cause for this new headache, which of the following statements is true regarding papilloedema?

      Your Answer: The absence of papilloedema rules out the presence of a brain tumour

      Explanation:

      Importance of Fundal Examination in Headache Assessment

      Fundal examination is a crucial part of headache assessment, particularly in cases of new and unexplained headaches. It helps to check for papilloedema, which may indicate raised intracranial pressure and requires urgent action, even in the absence of other symptoms or normal examination results. However, the absence of papilloedema doesn’t rule out the possibility of a brain tumor, and papilloedema is not always a sign of a brain tumor.

      According to the latest NICE guidelines, the predictive value of symptoms is more important than clinical signs in referring patients for suspected cancer. However, they recommend an urgent direct access MRI scan of the brain (or CT scan if MRI is contraindicated) within two weeks for adults with progressive, subacute loss of central neurological function. This is to assess for brain or central nervous system cancer and to speed up the diagnostic process for patients with a tumor.

      Some GPs may have direct access to MRI, while others may need to coordinate with secondary care colleagues through locally arranged pathways. Regardless of the means of acquiring an MRI, the finding of papilloedema warrants urgent MRI, regardless of other factors in the history or examination.

    • This question is part of the following fields:

      • Neurology
      1822.2
      Seconds
  • Question 8 - A 55-year-old man is brought to his General Practitioner by his daughter, who...

    Correct

    • A 55-year-old man is brought to his General Practitioner by his daughter, who is concerned about his memory. He has no recollection of recent or distant events, but responds to every question with a very detailed, yet incorrect, answer.

      Upon examination, he displays ataxia and nystagmus. He has not visited a doctor in over 25 years, doesn't take any regular medication, and has consumed eight pints of beer per night for the past 35 years.

      What is the most probable deficiency causing this presentation? Choose ONE option only.

      Your Answer: Vitamin B1

      Explanation:

      The patient is suffering from Korsakoff syndrome, a condition caused by a deficiency of vitamin B1 (thiamine). This syndrome is a late manifestation of untreated Wernicke’s encephalopathy and is characterized by mental confusion, ataxia, ophthalmoplegia, anterograde and retrograde amnesia, and confabulation. It is most common in people in their fifties and sixties and is caused by alcoholism or other factors such as chronic subdural hematoma, nutritional stress, AIDS, hyperemesis gravidarum, thyrotoxicosis, long-term dialysis, or congestive heart failure. Urgent medical assessment and admission for parenteral thiamine is necessary, as it can be fatal if left untreated. Zinc deficiency, on the other hand, is characterized by symptoms such as anorexia, lethargy, diarrhea, growth restriction, impaired immune function, delayed sexual maturation, learning disability, weight loss, and macular degeneration. It is not related to memory or cognitive problems, ataxia, or nystagmus. Vitamin B2 deficiency is more common in vegetarians, vegans, pregnant women, or young children and is thought to have a role in migraines. Vitamin B12 deficiency causes symptoms such as cognitive and memory disturbance, headaches, dyspepsia, loss of appetite, palpitations, visual disturbance, weakness and lethargy, angina, optic neuropathy, symmetrical neuropathy affecting the legs more than the arms, and a megaloblastic anemia. Vitamin E deficiency is rare in healthy people and is strongly associated with conditions affecting absorption, such as Crohn’s disease or cystic fibrosis. However, this patient’s history of alcohol excess makes thiamine deficiency much more likely.

    • This question is part of the following fields:

      • Smoking, Alcohol And Substance Misuse
      256.4
      Seconds
  • Question 9 - A 75-year-old man has recently been diagnosed with diabetes. What is the most...

    Correct

    • A 75-year-old man has recently been diagnosed with diabetes. What is the most significant retinal feature that would indicate the presence of proliferative diabetic retinopathy?

      Your Answer: New vessel formation

      Explanation:

      Understanding Diabetic Retinopathy: Symptoms and Stages

      Diabetic retinopathy is a common complication of diabetes that can lead to blindness if left untreated. It affects up to 80% of patients who have had diabetes for ten years or more. The longer a person has diabetes, the higher the chance of developing diabetic retinopathy.

      The exact mechanism by which diabetes leads to retinopathy is not fully understood. However, it is known that microvascular occlusion causes retinal ischaemia, leading to arteriovenous shunts and neovascularisation. Leakage results in intraretinal haemorrhages and localised or diffuse oedema. These are characteristic features that appear at various stages of diabetic retinopathy.

      As retinopathy progresses, it enters an advanced or proliferative stage. At this stage, blood vessels proliferate/grow (neovascularisation). These can bleed, leading to vitreous haemorrhage and blurring of vision.

      There are several symptoms and stages of diabetic retinopathy that should be recognized. Haemorrhages result from rupture of weakened capillaries and appear as small dots or larger blots. Cotton-wool spots are due to a build-up of axonal debris and have a white fluffy appearance. Hard exudates are precipitates of lipoproteins and other proteins leaking from retinal blood vessels. They form white or yellow deposits usually with sharp margins. Microaneurysms are an early feature of diabetic retinopathy appearing at the non-proliferative stage. They appear as red dots.

      General practitioners should be able to use an ophthalmoscope and recognize significant abnormalities. Fundus photography examines larger areas of the fundus and has the advantage of photo documentation for future reference. It is important to monitor and treat diabetic retinopathy to prevent blindness.

    • This question is part of the following fields:

      • Eyes And Vision
      44.2
      Seconds
  • Question 10 - A 55-year-old woman has vulval lichen sclerosus. You are asked by the gynaecologist...

    Incorrect

    • A 55-year-old woman has vulval lichen sclerosus. You are asked by the gynaecologist to prescribe a very potent topical corticosteroid for her.
      Select from the list the single suitable preparation.

      Your Answer: Betamethasone valerate 0.1% (Betnovate®)

      Correct Answer: Clobetasol propionate 0.05% (Dermovate®)

      Explanation:

      Treatment of Lichen Sclerosus with Topical Corticosteroids

      Lichen sclerosus is a chronic inflammatory skin condition that affects the genital and anal areas. The recommended treatment for this condition is the use of topical corticosteroids. The potency of the corticosteroid used is determined by the formulation and the type of corticosteroid. Mild, moderate, potent, and very potent corticosteroids are available for use.

      The most effective treatment for lichen sclerosus is the very potent topical corticosteroid clobetasol propionate. The recommended regimen for a newly diagnosed case is to apply clobetasol propionate once a night for 4 weeks, then on alternate nights for 4 weeks, and finally twice weekly for the third month. If symptoms return during the reduction of treatment, the frequency that was effective should be resumed.

      Other topical corticosteroids such as mometasone furoate and pimecrolimus have also been shown to be effective in treating genital lichen sclerosus. However, clobetasol propionate has been demonstrated to be more effective than pimecrolimus.

      It is important to note that while treatment with topical corticosteroids can resolve hyperkeratosis, ecchymoses, fissuring, and erosions, atrophy and color change may remain. Maintenance with less frequent use of a very potent corticosteroid or a weaker steroid may be necessary.

      Topical Corticosteroids for Lichen Sclerosus Treatment

    • This question is part of the following fields:

      • Dermatology
      520.4
      Seconds
  • Question 11 - A 4-year-old boy from a traveller community family is brought to the surgery...

    Incorrect

    • A 4-year-old boy from a traveller community family is brought to the surgery by his mother.

      She informs you that he began with what appeared to be a severe catarrhal cold, but now experiences intense paroxysms of coughing, causing him to turn completely red in the face and struggle to catch his breath. Upon examination, he has no fever.

      What feature on history, examination, or investigation, although not conclusive, is consistent with the presence of whooping cough?

      Your Answer: Lymphopenia

      Correct Answer: Lack of pyrexia

      Explanation:

      Whooping Cough: Symptoms and Risk Factors

      The incubation period for whooping cough, also known as pertussis, typically lasts seven to 10 days but can extend up to 21 days. Patients with this condition often experience a paroxysmal cough with an inspiratory whoop, and lymphocytosis is commonly observed. While extensive consolidation is uncommon, pockets of lower respiratory tract infection may occur due to atelectasis. Notably, a lack of fever is a strong indication of whooping cough.

      Children from travelling families may be at a higher risk of contracting whooping cough if they have missed the standard vaccination schedule. It is important to be aware of the symptoms and risk factors associated with this condition to ensure prompt diagnosis and treatment.

    • This question is part of the following fields:

      • Children And Young People
      7.2
      Seconds
  • Question 12 - A 54-year-old man with hypertension and obesity has been diagnosed with obstructive sleep...

    Incorrect

    • A 54-year-old man with hypertension and obesity has been diagnosed with obstructive sleep apnoea after a visit to the sleep clinic. His AHI falls under the mild category with 12 apnoea/hypopnoea events/hour, and his Epworth score indicates mild excessive daytime sleepiness. As a group 1 driver, he is concerned about the impact on his driving and when he should inform the DVLA. When is it necessary to notify the DVLA?

      Your Answer: Moderate

      Correct Answer: All stages

      Explanation:

      If a person has obstructive sleep apnoea (OSA) and is a group 1 driver, they must inform the DVLA if they experience excessive daytime sleepiness (measured by an Epworth score of 11 or higher). However, if the OSA is mild (with an apnoea/hypopnoea index score of 5-15/hour) and doesn’t cause excessive daytime sleepiness, there is no need to notify the DVLA. For those with moderate or severe OSA, the DVLA must be informed and the individual must ensure that their symptoms are under control before driving.

      Understanding Obstructive Sleep Apnoea/Hypopnoea Syndrome

      Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is a condition that causes interrupted breathing during sleep due to a blockage in the airway. This can lead to a range of health problems, including daytime somnolence, respiratory acidosis, and hypertension. There are several predisposing factors for OSAHS, including obesity, macroglossia, large tonsils, and Marfan’s syndrome. Partners of those with OSAHS often complain of excessive snoring and periods of apnoea.

      To assess sleepiness, patients may complete the Epworth Sleepiness Scale questionnaire, and undergo the Multiple Sleep Latency Test (MSLT) to measure the time it takes to fall asleep in a dark room. Diagnostic tests for OSAHS include sleep studies (polysomnography), which measure a range of physiological factors such as EEG, respiratory airflow, thoraco-abdominal movement, snoring, and pulse oximetry.

      Management of OSAHS includes weight loss and the use of continuous positive airway pressure (CPAP) as a first-line treatment for moderate or severe cases. Intra-oral devices, such as mandibular advancement, may be used if CPAP is not tolerated or for patients with mild OSAHS without daytime sleepiness. It is important to inform the DVLA if OSAHS is causing excessive daytime sleepiness. While there is limited evidence to support the use of pharmacological agents, they may be considered in certain cases.

    • This question is part of the following fields:

      • Respiratory Health
      35.8
      Seconds
  • Question 13 - A 25-year-old male presents with a new skin rash, which appeared during his...

    Correct

    • A 25-year-old male presents with a new skin rash, which appeared during his summer vacation spent hiking. He displays several pale brown patches on his neck, upper back, and chest. The patches seem slightly flaky but are not causing any discomfort. He is generally healthy. What is the most suitable initial treatment for this condition?

      Your Answer: Ketoconazole shampoo

      Explanation:

      Pityriasis versicolor is a skin condition caused by an overgrowth of Malassezia yeast, which commonly affects young males. It results in multiple patches of discolored skin, mainly on the trunk, which can appear pale brown, pink, or depigmented. The condition often occurs after exposure to humid, sunny environments.

      According to NICE guidelines, the first-line treatment for pityriasis versicolor is either ketoconazole shampoo applied topically for five days or selenium sulphide shampoo for seven days (off-label indication). While topical antifungal creams like clotrimazole are effective, they are not typically used as first-line treatment unless the affected area is small due to their higher cost.

      Understanding Pityriasis Versicolor

      Pityriasis versicolor, also known as tinea versicolor, is a fungal infection that affects the skin’s surface. It is caused by Malassezia furfur, which was previously known as Pityrosporum ovale. This condition is characterized by patches that are commonly found on the trunk area. These patches may appear hypopigmented, pink, or brown, and may become more noticeable after sun exposure. Scaling is also a common feature, and mild itching may occur.

      Pityriasis versicolor can affect healthy individuals, but it may also occur in people with weakened immune systems, malnutrition, or Cushing’s syndrome. Treatment for this condition typically involves the use of topical antifungal agents. According to NICE Clinical Knowledge Summaries, ketoconazole shampoo is a cost-effective option for treating large areas. If topical treatment fails, alternative diagnoses should be considered, and oral itraconazole may be prescribed.

      In summary, pityriasis versicolor is a fungal infection that affects the skin’s surface. It is characterized by patches that may appear hypopigmented, pink, or brown, and scaling is a common feature. Treatment typically involves the use of topical antifungal agents, and oral itraconazole may be prescribed if topical treatment fails.

    • This question is part of the following fields:

      • Dermatology
      669.7
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  • Question 14 - A 55-year-old woman has advanced breast cancer with bone metastases. She is currently...

    Incorrect

    • A 55-year-old woman has advanced breast cancer with bone metastases. She is currently taking co-codamol 30/500 two tablets six hourly and ibuprofen 400 mg three times a day. Despite this, she is still struggling with pain.
      What is the most appropriate next course of action? Choose ONE option only.

      Your Answer:

      Correct Answer: Modified-release morphine and an oral solution of morphine

      Explanation:

      Choosing the Right Opioid Analgesic for Pain Management: A Guide

      When codeine is no longer effective in controlling pain, the British National Formulary (BNF) recommends prescribing morphine. To ensure optimal pain relief, it is important to convert the patient’s current codeine dose to an equivalent dose of morphine and prescribe it as a modified-release preparation. However, an immediate-release preparation of morphine should also be prescribed for breakthrough pain.

      While transdermal fentanyl can be useful in certain situations, it takes up to 72 hours to reach a steady state, making it difficult to titrate doses as needed. Subcutaneous analgesia with diamorphine is not necessary in this scenario, as the patient doesn’t exhibit any signs of drowsiness or difficulty swallowing.

      For acute pain relief, oxycodone immediate-release tablets can be prescribed as needed. However, for regular use, a modified-release preparation of oxycodone would be more appropriate. By carefully considering the patient’s needs and the characteristics of each opioid analgesic, healthcare providers can choose the most effective and safe option for pain management.

    • This question is part of the following fields:

      • Improving Quality, Safety And Prescribing
      0
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  • Question 15 - A 39-year-old teacher is being evaluated after starting an antidepressant. She initially presented...

    Incorrect

    • A 39-year-old teacher is being evaluated after starting an antidepressant. She initially presented with various symptoms of depression and a PHQ-9 score of 18. She has experienced several significant life events leading up to her diagnosis.

      She is married with a daughter in college, but has a strong support system from her family. You decided to initiate treatment with sertraline 50 mg, but she reports no improvement in her depression and your assessment agrees.

      Despite the lack of effectiveness in her treatment thus far, she appears to be tolerating the medication without any adverse effects.

      Based on NICE guidelines for depression treatment, at what point in her treatment would you consider increasing the dosage if she has not responded?

      Your Answer:

      Correct Answer: Six to eight weeks

      Explanation:

      Treatment for Depression: Considerations for Medication Adjustment

      When treating depression, it is important to monitor the patient’s response to medication. If there is no improvement within three to four weeks, it may be necessary to increase the dose or switch to a different antidepressant. However, if there is some improvement at four weeks, it is recommended to continue treatment for an additional two to four weeks before making any further changes.

      In this particular case, the patient is tolerating the medication well and has support from her husband. Therefore, the focus should be on adjusting the medication. This recommendation is based on NICE guidance on Depression in adults (CG90) and is supported by other publications. By closely monitoring the patient’s response and making appropriate adjustments, healthcare providers can help improve outcomes for those struggling with depression.

    • This question is part of the following fields:

      • Mental Health
      0
      Seconds
  • Question 16 - A 65-year-old woman has type II diabetes. Her HbA1c is 69 mmol/mol. Her...

    Incorrect

    • A 65-year-old woman has type II diabetes. Her HbA1c is 69 mmol/mol. Her body mass index is 25 kg/m². You want to start treatment with a sulfonylurea drug but the patient is hesitant because she has heard about the risk of hypoglycaemia.
      Which of the following statements regarding hypoglycaemia and sulfonylureas is accurate? Choose ONE option only.

      Your Answer:

      Correct Answer: The risk is greatest if there is co-existing hepatic impairment

      Explanation:

      Understanding the Risk of Hypoglycaemia with Sulfonylureas

      Sulfonylureas are commonly used to treat type 2 diabetes, but they come with a risk of hypoglycaemia, which can be dangerous. This risk is greatest in patients with co-existing hepatic impairment, as the drugs are metabolised in the liver and excreted in urine or faeces. Short-acting sulfonylureas are not necessarily riskier than longer-acting ones, but they should be used with caution in patients with renal disease. Hypoglycaemia may persist for many hours and should be treated in the hospital. Excessive dosage is a common cause of hypoglycaemia, so careful monitoring is essential. Combining sulfonylureas with bedtime isophane insulin may be an option when other treatments fail, but it doesn’t reduce the risk of hypoglycaemia. Patients and healthcare providers should be aware of the risks associated with sulfonylureas and take steps to minimise them.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
      0
      Seconds
  • Question 17 - A 50-year-old patient presents you with a research paper on a new screening...

    Incorrect

    • A 50-year-old patient presents you with a research paper on a new screening test for diagnosing breast cancer that is currently on trial. The test is being compared to the current gold standard screening test, mammography. The patient is interested in this test as she finds mammograms uncomfortable and wants to know how the new test compares to the standard screening.

      Given the following data, what is the specificity of the new test?

      Positive mammogram Negative mammogram
      Test positive 32 150
      Test negative 15 439

      Your Answer:

      Correct Answer: 0.75

      Explanation:

      Specificity is the proportion of patients without the condition who have a negative test result. The correct answer is 0.75, which is calculated by dividing the number of true negatives (439) by the sum of true negatives and false positives (150). The other options provided are incorrect: 0.18 is the positive predictive value, 0.68 is the sensitivity, and 0.97 is the negative predictive value.

      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
      0
      Seconds
  • Question 18 - A 55-year-old smoker presents with a persistent hoarse voice for the past three...

    Incorrect

    • A 55-year-old smoker presents with a persistent hoarse voice for the past three to four weeks. He saw a colleague two weeks ago who found nothing focal on examination and advised him to seek review if his hoarseness did not settle after a further week. He has no significant past medical history, is not on any regular medication, and has no known drug allergies. He denies any cough, haemoptysis, swallowing problems, weight loss, or any systemic unwellness. Clinical examination reveals no anaemia, clubbing, lymphadenopathy or neck masses. His chest sounds clear, and an urgent chest x-ray is reported as 'normal'. What is the most appropriate next step in this patient's management?

      Your Answer:

      Correct Answer: Refer urgently to an ear, nose and throat specialist

      Explanation:

      Recognizing and Referring Suspected Cancer: The Case of a Persisting Hoarse Voice

      The NICE guidelines on recognizing and referring suspected cancer do not provide a specific time period for what constitutes persistent symptoms. However, most references suggest that further action should be taken if hoarseness persists for three or more weeks. This could indicate a laryngeal cancer or a lung tumor that has infiltrated the recurrent laryngeal nerve. In such cases, an urgent chest x-ray may help direct referral.

      If the chest x-ray is normal, urgent referral to an ENT (or head and neck) specialist is needed to investigate the persisting hoarse voice. However, if the chest x-ray is abnormal and suggestive of lung malignancy, urgent referral to a lung cancer specialist is warranted.

      In summary, recognizing and referring suspected cancer is crucial in cases of persisting hoarseness. While the NICE guidelines do not provide a specific time period for what constitutes persistent symptoms, most references suggest that three or more weeks of hoarseness warrants further action. A normal chest x-ray requires urgent referral to an ENT (or head and neck) specialist, while an abnormal chest x-ray warrants urgent referral to a lung cancer specialist.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 19 - Which statement is indicative of depression? ...

    Incorrect

    • Which statement is indicative of depression?

      Your Answer:

      Correct Answer: Symptoms present five days of each week

      Explanation:

      Diagnosing Depression: ICD-10 and DSM-IV Classifications

      In diagnosing depression, both ICD-10 and DSM-IV classifications can be used alongside questionnaires. The ICD-10 classification requires four out of 10 depressive symptoms for a diagnosis, while the DSM-IV classification requires five out of nine symptoms. Common symptoms include loss of interest and pleasure, loss of energy, and low mood, which must be present most of every day to be counted.

      However, the NICE guidelines on depression acknowledge that many people may fall just below these criteria. This is known as sub-threshold depressive symptoms, which allows for only one of the key features to be present for less time than is necessary for the major depressive classification.

      It is important to note that once depression is diagnosed or suspected, patients should be offered help and support.

    • This question is part of the following fields:

      • Mental Health
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  • Question 20 - A 28-year-old woman who is 10 weeks postpartum seeks advice. She had unprotected...

    Incorrect

    • A 28-year-old woman who is 10 weeks postpartum seeks advice. She had unprotected sex with her partner two nights ago. She is currently breastfeeding her baby and her partner gives a formula feed at night. She has not had any periods since giving birth and is concerned about the possibility of becoming pregnant again, which she considers not an option at the moment. The incident of unprotected sex occurred approximately 50 hours ago, and she is not open to considering an intrauterine device. What is the best course of action in this situation?

      Your Answer:

      Correct Answer: Prescribe levonorgestrel

      Explanation:

      The lactational amenorrhea method is most effective for women who are less than 6 months postpartum, fully breastfeeding, and not experiencing menstrual periods. However, if the baby is receiving formula at night, this method may not be completely reliable. Additionally, ulipristal, a medication used for emergency contraception, is excreted in breast milk for up to 5 days after use, so it is recommended to avoid breastfeeding for a week after taking it, which could significantly impact a woman’s ability to breastfeed.

      Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, and should be taken as soon as possible after unprotected sexual intercourse (UPSI) for maximum efficacy. The single dose of levonorgestrel is 1.5mg, but should be doubled for those with a BMI over 26 or weight over 70kg. It is safe and well-tolerated, but may cause vomiting in around 1% of women. Ulipristal, on the other hand, is a selective progesterone receptor modulator that inhibits ovulation. It should be taken within 120 hours after intercourse, and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which may inhibit fertilization or implantation. It must be inserted within 5 days of UPSI, or up to 5 days after the likely ovulation date. Prophylactic antibiotics may be given if the patient is at high-risk of sexually transmitted infection. The IUD is 99% effective regardless of where it is used in the cycle, and may be left in-situ for long-term contraception.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
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  • Question 21 - A 50-year-old woman is undergoing a routine health assessment. She admits to consuming...

    Incorrect

    • A 50-year-old woman is undergoing a routine health assessment. She admits to consuming at least 5 standard alcoholic drinks each weekday evening and even more on the weekend. The risks of this intake are discussed with her and a plan is made to reduce her intake.

      Which of the following actions is the most appropriate?

      Your Answer:

      Correct Answer: Prescribe oral thiamine

      Explanation:

      Patients who regularly consume excessive amounts of alcohol should be prescribed thiamine to prevent the onset of Wernicke’s syndrome, which can lead to irreversible Korsakoff psychosis. Admission is not necessary unless the patient is experiencing significant withdrawal symptoms. An intramuscular multivitamin is not appropriate, as oral thiamine is less invasive and effective. Oral multivitamins are also not recommended, as they may not contain enough thiamine. Vitamin B co-strong is no longer recommended for alcohol-consuming patients, as it doesn’t provide sufficient thiamine to prevent Wernicke’s syndrome.

      The Importance of Vitamin B1 (Thiamine) in the Body

      Vitamin B1, also known as thiamine, is a water-soluble vitamin that belongs to the B complex group. It plays a crucial role in the body as one of its phosphate derivatives, thiamine pyrophosphate (TPP), acts as a coenzyme in various enzymatic reactions. These reactions include the catabolism of sugars and amino acids, such as pyruvate dehydrogenase complex, alpha-ketoglutarate dehydrogenase complex, and branched-chain amino acid dehydrogenase complex.

      Thiamine deficiency can lead to clinical consequences, particularly in highly aerobic tissues like the brain and heart. The brain can develop Wernicke-Korsakoff syndrome, which presents symptoms such as nystagmus, ophthalmoplegia, and ataxia. Meanwhile, the heart can develop wet beriberi, which causes dilated cardiomyopathy. Other conditions associated with thiamine deficiency include dry beriberi, which leads to peripheral neuropathy, and Korsakoff’s syndrome, which causes amnesia and confabulation.

      The primary causes of thiamine deficiency are alcohol excess and malnutrition. Alcoholics are routinely recommended to take thiamine supplements to prevent deficiency. Overall, thiamine is an essential vitamin that plays a vital role in the body’s metabolic processes.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
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  • Question 22 - A 62-year-old man with type 2 diabetes mellitus is being evaluated. He is...

    Incorrect

    • A 62-year-old man with type 2 diabetes mellitus is being evaluated. He is currently on metformin, aspirin, and simvastatin, and there have been no changes to his medication for the past 18 months. As per the latest NICE guidelines, what is the recommended frequency for checking his HbA1c?

      Your Answer:

      Correct Answer: 6 monthly

      Explanation:

      NICE suggests that individuals with type 2 diabetes mellitus should have their HbA1c levels checked every six months once their treatment has been stabilized.

      NICE has updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022 to reflect advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. For the average patient taking metformin for T2DM, lifestyle changes and titrating up metformin to aim for a HbA1c of 48 mmol/mol (6.5%) is recommended. A second drug should only be added if the HbA1c rises to 58 mmol/mol (7.5%). Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates, controlling intake of saturated fats and trans fatty acids, and initial target weight loss of 5-10% in overweight individuals.

      Individual HbA1c targets should be agreed upon with patients to encourage motivation, and HbA1c should be checked every 3-6 months until stable, then 6 monthly. Targets should be relaxed on a case-by-case basis, with particular consideration for older or frail adults with type 2 diabetes. Metformin remains the first-line drug of choice, and SGLT-2 inhibitors should be given in addition to metformin if the patient has a high risk of developing cardiovascular disease (CVD), established CVD, or chronic heart failure. If metformin is contraindicated, SGLT-2 monotherapy or a DPP-4 inhibitor, pioglitazone, or sulfonylurea may be used.

      Further drug therapy options depend on individual clinical circumstances and patient preference. Dual therapy options include adding a DPP-4 inhibitor, pioglitazone, sulfonylurea, or SGLT-2 inhibitor (if NICE criteria are met). If a patient doesn’t achieve control on dual therapy, triple therapy options include adding a sulfonylurea or GLP-1 mimetic. GLP-1 mimetics should only be added to insulin under specialist care. Blood pressure targets are the same as for patients without type 2 diabetes, and ACE inhibitors or ARBs are first-line for hypertension. Antiplatelets should not be offered unless a patient has existing cardiovascular disease, and only patients with a 10-year cardiovascular risk > 10% should be offered a statin.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
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  • Question 23 - An overweight 62-year-old woman presents with a two-day history of an acutely painful,...

    Incorrect

    • An overweight 62-year-old woman presents with a two-day history of an acutely painful, tender right knee associated with erythema and a temperature of 37.7°C. She is usually well and suffers only from hypertension, for which she takes bendroflumethiazide. She admits to drinking 20 units of alcohol per week. There is nothing else of significance in the medical history.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Gout

      Explanation:

      Differential Diagnosis for a Painful and Swollen Knee

      When a patient presents with a painful and swollen knee, it is important to consider various differential diagnoses. In this case, gout is a likely possibility, especially given the patient’s weight, alcohol consumption, and use of a diuretic. Gout typically causes severe pain, tenderness, and redness in the affected joint, and can be accompanied by fever and leukocytosis. Aspiration of joint fluid can help distinguish gout from septic arthritis, which is another possible diagnosis. Haemarthrosis, osteoarthritis, and rheumatoid arthritis are less likely causes, as they present differently and have different associated symptoms. Septic arthritis is also a possibility, but is typically associated with fever, impaired range of motion, and other symptoms. Overall, a thorough evaluation and consideration of all possible diagnoses is necessary to properly diagnose and treat a painful and swollen knee.

    • This question is part of the following fields:

      • Musculoskeletal Health
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  • Question 24 - You are summoned to the residence of an 82-year-old man who is receiving...

    Incorrect

    • You are summoned to the residence of an 82-year-old man who is receiving home care for advanced prostate cancer. His condition has been declining for the past week and he has been under the care of community nurses. The nurses inform you that he has become increasingly 'bubbly' in the last 24 hours. Upon examination, you observe that he is experiencing uncontrollable respiratory secretions at the end of his life. What is the most suitable course of action to alleviate these symptoms?

      Your Answer:

      Correct Answer: Hyoscine hydrobromide 400-600 micrograms subcutaneously every 4-8 hours

      Explanation:

      Managing Excessive Respiratory Secretions with Antimuscarinics

      Excessive respiratory secretions can be a distressing symptom for patients, particularly those at the end of life. Antimuscarinics are the most commonly used medications to help manage this symptom. Hyoscine hydrobromide is a commonly used antimuscarinic and can be given at a dose of 400-600 micrograms every four to eight hours. It can also be administered via a patch, which may be more acceptable to some patients. However, dry mouth is a common side effect.

      For patients who are less ill with intermittent symptoms, oral carbocisteine and nebulised saline may be effective in managing secretions. Nebulised saline can also be tried in more severe cases, but for intractable end-of-life secretions, antimuscarinics such as hyoscine hydrobromide are the best treatment option. If indicated, hyoscine hydrobromide can be given via a syringe driver to reduce the need for repeated injections.

      Other antimuscarinics that can be used include hyoscine butylbromide and glycopyrronium bromide. It is important to work closely with healthcare professionals to determine the most appropriate treatment plan for each individual patient.

    • This question is part of the following fields:

      • Older Adults
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  • Question 25 - A 72-year-old man takes medication for hypertension and raised cholesterol. At his annual...

    Incorrect

    • A 72-year-old man takes medication for hypertension and raised cholesterol. At his annual check-up he reports that he is feeling well. Among the results of his blood tests are the following: serum calcium 2.90 mmol/l (normal range 2.05-2.60 mmol/l), serum phosphate 0.75 mmol/l (normal range 0.8-1.4 mmol/l), alkaline phosphatase 215 IU/l (normal range 30-200 IU/l).
      Select from the list the single most likely explanation of these results.

      Your Answer:

      Correct Answer: Primary hyperparathyroidism

      Explanation:

      Understanding Primary Hyperparathyroidism as a Cause of Hypercalcaemia

      Primary hyperparathyroidism is a common endocrine disorder, particularly in postmenopausal women. It is often asymptomatic and discovered incidentally through blood tests. The excess production of parathyroid hormone (PTH) is typically caused by a single adenoma, multi-gland adenoma, or hyperplasia. Surgical removal of the adenoma is the most effective cure, but medical management is possible for mild cases. Malignancy, Paget’s disease of bone, and certain medications can also cause hypercalcaemia, but these can be ruled out based on the patient’s history and symptoms. Other endocrine causes, such as thyrotoxicosis and Addison’s disease, would typically present with additional symptoms.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
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  • Question 26 - A 70-year-old man with a history of hypertension only complains of worsening breathlessness...

    Incorrect

    • A 70-year-old man with a history of hypertension only complains of worsening breathlessness and swollen ankles for the past 3 months. You plan to conduct a BNP test. What could cause a falsely low BNP result in this patient?

      Your Answer:

      Correct Answer: Being on ramipril for his blood pressure

      Explanation:

      Serum levels of B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) can be measured to assess the likelihood of heart failure in patients. NT-proBNP is the inactive prohormone of BNP and is released from the left ventricle in response to ventricular strain. It acts to increase renal excretion of water and sodium, and relax vascular smooth muscle causing vasodilation.

      BNP measurements are recommended for patients with suspected heart failure who have not had a previous myocardial infarction. Elevated BNP levels (>400) indicate a poor prognosis and require an urgent referral for echocardiography and specialist assessment. However, normal BNP levels do not confirm the absence of heart failure, as levels may be elevated due to other conditions such as left ventricular hypertrophy, pulmonary hypertension, or renal impairment.

      NICE guidelines suggest that BNP measurements are not necessary for patients with suspected heart failure who have had a previous myocardial infarction, as urgent referral and assessment are required regardless of BNP levels. BNP levels may also be affected by medications such as ACE inhibitors and beta-blockers, as well as obesity.

      Overall, BNP measurements can be a useful tool in assessing the likelihood of heart failure, but should be interpreted in conjunction with other clinical findings and patient history.

      B-type natriuretic peptide (BNP) is a hormone that is primarily produced by the left ventricular myocardium in response to strain. Although heart failure is the most common cause of elevated BNP levels, any condition that causes left ventricular dysfunction, such as myocardial ischemia or valvular disease, may also raise levels. In patients with chronic kidney disease, reduced excretion may also lead to elevated BNP levels. Conversely, treatment with ACE inhibitors, angiotensin-2 receptor blockers, and diuretics can lower BNP levels.

      BNP has several effects, including vasodilation, diuresis, natriuresis, and suppression of both sympathetic tone and the renin-angiotensin-aldosterone system. Clinically, BNP is useful in diagnosing patients with acute dyspnea. A low concentration of BNP (<100 pg/mL) makes a diagnosis of heart failure unlikely, but elevated levels should prompt further investigation to confirm the diagnosis. Currently, NICE recommends BNP as a helpful test to rule out a diagnosis of heart failure. In patients with chronic heart failure, initial evidence suggests that BNP is an extremely useful marker of prognosis and can guide treatment. However, BNP is not currently recommended for population screening for cardiac dysfunction.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 27 - Which one of the following situations would not automatically require a doctor to...

    Incorrect

    • Which one of the following situations would not automatically require a doctor to contact the coroner to discuss the death?

      Your Answer:

      Correct Answer: 38-year-old man dies from cerebral malaria contracted in India

      Explanation:

      Notifying the coroner is not legally required for this death, but it must be reported to the Local Authority Proper Officer under the Health Protection Regulations 2010.

      Notifiable Deaths and Reporting to the Coroner

      When it comes to death certification, certain deaths are considered notifiable and should be reported to the coroner. These include unexpected or sudden deaths, as well as deaths where the attending doctor did not see the deceased within 28 days prior to their passing (this was increased from 14 days during the COVID pandemic). Additionally, deaths that occur within 24 hours of hospital admission, accidents and injuries, suicide, industrial injury or disease, deaths resulting from ill treatment, starvation, or neglect, deaths occurring during an operation or before recovery from the effect of an anaesthetic, poisoning (including from illicit drugs), stillbirths where there is doubt as to whether the child was born alive, and deaths of prisoners or people in police custody are also considered notifiable.

      It is important to note that these deaths should be reported to the coroner, who will then investigate the circumstances surrounding the death. This is to ensure that any potential criminal activity or negligence is properly addressed and that the cause of death is accurately determined. By reporting notifiable deaths to the coroner, we can help ensure that justice is served and that families receive the closure they need during a difficult time.

    • This question is part of the following fields:

      • End Of Life
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  • Question 28 - A 5-year-old healthy girl is brought to the general practice surgery by her...

    Incorrect

    • A 5-year-old healthy girl is brought to the general practice surgery by her parents, who are concerned about some darker skin patches they have noticed on her arms, legs and back. They think that these have been present since she was a small baby, but they seem more noticeable. They have counted six in total.
      On examination, you observed several hyperpigmented macules with sharp borders and variable diameter: these are seen on the limbs, abdomen and lower back. You also observe some freckly pigmentation under both arms.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Neurofibromatosis type 1 (NF1)

      Explanation:

      Distinguishing Neurofibromatosis Type 1 from Other Skin Conditions

      Neurofibromatosis type 1 (NF1) is a genetic disorder that causes lesions in the skin, nervous system, and skeleton. It is typically diagnosed in children under the age of 8, with 80% of cases being identified by age 6. To diagnose NF1, at least two of seven criteria must be met, including the presence of café au lait macules, cutaneous/subcutaneous neurofibromas, axillary or groin freckling, optic pathway glioma, Lisch nodules, bony dysplasia, or a first-degree relative with NF1.

      Other skin conditions can be mistaken for NF1, including acanthosis nigricans, childhood lentigines, Sturge-Weber syndrome (SWS), and tuberous sclerosis. Acanthosis nigricans is characterized by dark, velvety discolouration in the body’s folds and creases, but lacks café au lait spots. Childhood lentigines are related to sun exposure and occur in sun-exposed areas, whereas NF1 patches develop on the legs, arms, and back. SWS presents with a port-wine stain affecting the facial skin, vascular eye abnormalities, and ipsilateral occipital leptomeningeal angiomas, which are not seen in NF1. Tuberous sclerosis is characterized by ash leaf macules and shagreen patches, which have a rough orange peel appearance, but are not present in NF1. Accurate diagnosis is crucial for appropriate management and treatment of these conditions.

    • This question is part of the following fields:

      • Neurodevelopmental Disorders, Intellectual And Social Disability
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  • Question 29 - A 5-year-old girl presents with intermittent leg pains, which have been occurring for...

    Incorrect

    • A 5-year-old girl presents with intermittent leg pains, which have been occurring for four weeks. They occur at night and wake her from sleep. The pain is relieved when her mother rubs her legs. The girl is otherwise well and examination is normal.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Growing pains

      Explanation:

      Understanding Childhood Musculoskeletal Conditions: Differential Diagnosis

      Childhood musculoskeletal conditions can present with a variety of symptoms, making it important to differentiate between them for proper diagnosis and treatment. One common condition is growing pains, which are episodic muscular pains that typically affect the legs and wake children from sleep. Another condition, Henoch-Schönlein purpura (HSP), can cause joint pain, abdominal pain, and a purpuric rash on the legs and buttocks, as well as renal involvement. Acute lymphoblastic leukaemia may also cause bone and joint pain, but patients usually deteriorate rapidly and become unwell. Juvenile idiopathic arthritis is characterized by joint inflammation persisting for at least six weeks. Perthes’ disease, on the other hand, presents with pain in the hip and limited movement. Understanding the differences between these conditions can aid in accurate diagnosis and appropriate treatment.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 30 - A 35-year-old female patient visits her GP complaining of headaches. She reports experiencing...

    Incorrect

    • A 35-year-old female patient visits her GP complaining of headaches. She reports experiencing throbbing headaches on one side of her head every few weeks, which would subside after resting in a dark room. The patient resorted to taking paracetamol, ibuprofen, and codeine regularly to alleviate the pain. However, she now experiences a constant headache that affects her entire head and doesn't improve with rest in a dark room. The patient's neurological examination shows no abnormalities. What is the best course of action for managing her condition?

      Your Answer:

      Correct Answer: Wean down dose of codeine and stop paracetamol/ibuprofen immediately

      Explanation:

      The correct approach for treating medication overuse headache depends on the type of analgesia being used. Simple analgesia and triptans should be stopped abruptly, while opioid analgesia requires gradual withdrawal. In the case of this patient, who developed medication overuse headache after using daily analgesia for migraine-like symptoms, the paracetamol and ibuprofen can be stopped immediately, but the codeine must be gradually reduced to avoid withdrawal symptoms.

      Stopping all analgesia immediately is not recommended, as codeine withdrawal can cause discomfort. Tapering off current analgesia while introducing propranolol or topiramate is also not appropriate at this stage, as medication overuse headache must be treated first by stopping the current analgesia. Once the analgesia has been withdrawn, migraine prophylaxis can be considered, with propranolol being the preferred option for this patient due to the risk of teratogenicity associated with topiramate in females of childbearing age.

      Understanding Medication Overuse Headache

      Medication overuse headache is a common cause of chronic daily headache that affects up to 1 in 50 people. It is characterized by headaches that occur for 15 days or more per month and are worsened by regular use of symptomatic medication. Patients who use opioids and triptans are at the highest risk of developing this condition. Additionally, there may be psychiatric comorbidity associated with medication overuse headache.

      According to the 2008 SIGN guidelines, the management of medication overuse headache involves abruptly withdrawing simple analgesics and triptans, which may initially worsen headaches. On the other hand, opioid analgesics should be gradually withdrawn. However, withdrawal symptoms such as vomiting, hypotension, tachycardia, restlessness, sleep disturbances, and anxiety may occur when medication is stopped. Therefore, it is important to seek medical advice before discontinuing any medication.

    • This question is part of the following fields:

      • Improving Quality, Safety And Prescribing
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SESSION STATS - PERFORMANCE PER SPECIALTY

Older Adults (0/1) 0%
Cardiovascular Health (1/1) 100%
Eyes And Vision (2/3) 67%
Respiratory Health (1/2) 50%
Children And Young People (0/2) 0%
Neurology (1/1) 100%
Smoking, Alcohol And Substance Misuse (1/1) 100%
Dermatology (1/2) 50%
Passmed