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  • Question 1 - A 20-year-old male presents to the emergency department with a three day history...

    Incorrect

    • A 20-year-old male presents to the emergency department with a three day history of dizziness and headache. He has no significant past medical history and is on no medications. He is studying computer science at university and lives in poorly ventilated student accommodation with eight other people. He follows a vegetarian diet.

      His observations are heart rate 110 beats per minute, respiratory rate 23/minute, oxygen saturation 96% on room air, blood pressure 98/66 mmHg and temperature 37.2ÂșC.

      On examination, he has an ataxic gait. Neurological, cardiovascular, abdominal, ENT and respiratory examinations are otherwise normal.

      Urinalysis is normal.

      An ECG demonstrated sinus tachycardia.

      A chest x-ray is unremarkable.

      Blood gas:

      pH 7.25 (7.35-7.45)
      PaO2 10.2 kPa (10-14)
      PaCO2 5.4kPa (4.5-6)
      HCO3 15 mmol/L (22-26)
      SaO2 87% (94-98%)
      Hb 112g/L (130-180)
      Lactate 3.1 mmol/L (<2)
      BE -3.5 (-2 - +2)
      Glucose 5.3 mmol/L (4-6)
      COHb 26% (<2%)
      MetHb 0.2% (< 2%)

      A CT head is normal.

      What is the likely diagnosis and what could explain the low oxygen saturation reading on the arterial blood gas?

      Your Answer: Low haemoglobin

      Correct Answer: Left shift of oxygen dissociation curve

      Explanation:

      Carbon monoxide poisoning results in a leftward shift of the oxygen dissociation curve, leading to a decrease in the oxygen saturation of haemoglobin. This is due to the high affinity of carbon monoxide for haemoglobin, which competes with oxygen for binding. As a result, oxygen delivery to the tissues is impaired, causing hypoxia. The patient’s elevated carboxyhaemoglobin level, dissociation between peripheral and blood gas saturations, lactic acidosis, dizziness, headache, and ataxia all indicate carbon monoxide poisoning. The decreased partial pressure of environmental oxygen, alveolar destruction, and low haemoglobin are not the causes of his hypoxia.

      Carbon monoxide poisoning occurs when carbon monoxide binds to haemoglobin and myoglobin, leading to tissue hypoxia. Symptoms include headache, nausea, vomiting, vertigo, confusion, and in severe cases, pink skin and mucosae, hyperpyrexia, arrhythmias, extrapyramidal features, coma, and death. Diagnosis is made through measuring carboxyhaemoglobin levels in arterial or venous blood gas. Treatment involves administering 100% high-flow oxygen via a non-rebreather mask for at least six hours, with hyperbaric oxygen therapy considered for more severe cases.

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      • General Principles
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  • Question 2 - A 32-year-old motorcyclist is admitted to the emergency department following a collision with...

    Incorrect

    • A 32-year-old motorcyclist is admitted to the emergency department following a collision with a car. Upon secondary survey, a deep penetrating injury is discovered in the patient's left lateral thigh. The wound is surgically debrided and the patient is subsequently admitted to the neurological intensive care unit.

      After a few days, the patient develops a fever and experiences significant swelling in the affected area. Upon applying pressure, crackling sounds are heard, leading to a suspected diagnosis of gas gangrene.

      What is the mechanism behind the bacterial toxin responsible for the patient's clinical symptoms?

      Your Answer: Inhibition of presynaptic GABA release

      Correct Answer: Degradation of phospholipids

      Explanation:

      The correct answer is degradation of phospholipids. Gas gangrene, which is characterized by deep tissue crepitus surrounding a penetrating wound, is caused by Clostridium perfringens, an organism that releases an alpha-toxin, a lecithinase enzyme that degrades phospholipids.

      The mechanisms of diphtheria toxin and pseudomonas exotoxin A involve ADP-ribosylation of elongation factor II, which inhibits protein synthesis in human cells but does not cause gas gangrene.

      Protein A, a virulence factor of Staphylococcus aureus, binds the Fc region of IgA, but infection with Staphylococcus aureus is not associated with gas gangrene.

      The tetanus toxin inhibits presynaptic GABA release, causing trismus and opisthotonus rather than gas gangrene.

      Exotoxins vs Endotoxins: Understanding the Differences

      Exotoxins and endotoxins are two types of toxins produced by bacteria. Exotoxins are secreted by bacteria, while endotoxins are only released when the bacterial cell is lysed. Exotoxins are typically produced by Gram-positive bacteria, with some exceptions like Vibrio cholerae and certain strains of E. coli.

      Exotoxins can be classified based on their primary effects, which include pyrogenic toxins, enterotoxins, neurotoxins, tissue invasive toxins, and miscellaneous toxins. Pyrogenic toxins stimulate the release of cytokines, resulting in fever and rash. Enterotoxins act on the gastrointestinal tract, causing either diarrheal or vomiting illness. Neurotoxins act on the nerves or neuromuscular junction, causing paralysis. Tissue invasive toxins cause damage to tissues, while miscellaneous toxins have various effects.

      On the other hand, endotoxins are lipopolysaccharides that are released from Gram-negative bacteria like Neisseria meningitidis. These toxins can cause fever, sepsis, and shock. Unlike exotoxins, endotoxins are not actively secreted by bacteria but are instead released when the bacterial cell is lysed.

      Understanding the differences between exotoxins and endotoxins is important in diagnosing and treating bacterial infections. While exotoxins can be targeted with specific treatments like antitoxins, endotoxins are more difficult to treat and often require supportive care.

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      • General Principles
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  • Question 3 - A pediatrician is considering whether or not to prescribe a new medication for...

    Correct

    • A pediatrician is considering whether or not to prescribe a new medication for a young patient.

      Upon researching, the pediatrician discovers that a reputable medical journal had rejected a well-conducted study that found no significant difference between the medication and a placebo.

      However, the same journal later published a study that showed positive results for the medication.

      What type of bias is demonstrated in this scenario?

      Your Answer: Publication bias

      Explanation:

      Publication bias refers to the tendency of journals to prioritize the publication of studies with positive results, leading to the failure to publish valid studies that show negative or uninteresting results. In this case, the original study was not published due to its negative outcome.

      Expectation bias, on the other hand, occurs when observers unconsciously report or measure data in a way that supports the expected outcome of the study. This is only a concern in non-blinded trials.

      Selection bias arises when individuals are assigned to groups in a way that may influence the study’s outcome.

      The Hawthorne effect is a phenomenon where a group alters its behavior due to the knowledge that it is being studied.

      Understanding Bias in Clinical Trials

      Bias refers to the systematic favoring of one outcome over another in a clinical trial. There are various types of bias, including selection bias, recall bias, publication bias, work-up bias, expectation bias, Hawthorne effect, late-look bias, procedure bias, and lead-time bias. Selection bias occurs when individuals are assigned to groups in a way that may influence the outcome. Sampling bias, volunteer bias, and non-responder bias are subtypes of selection bias. Recall bias refers to the difference in accuracy of recollections retrieved by study participants, which may be influenced by whether they have a disorder or not. Publication bias occurs when valid studies are not published, often because they showed negative or uninteresting results. Work-up bias is an issue in studies comparing new diagnostic tests with gold standard tests, where clinicians may be reluctant to order the gold standard test unless the new test is positive. Expectation bias occurs when observers subconsciously measure or report data in a way that favors the expected study outcome. The Hawthorne effect describes a group changing its behavior due to the knowledge that it is being studied. Late-look bias occurs when information is gathered at an inappropriate time, and procedure bias occurs when subjects in different groups receive different treatment. Finally, lead-time bias occurs when two tests for a disease are compared, and the new test diagnoses the disease earlier, but there is no effect on the outcome of the disease. Understanding these types of bias is crucial in designing and interpreting clinical trials.

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      • General Principles
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  • Question 4 - A team of researchers conducts a study to assess the safety of a...

    Incorrect

    • A team of researchers conducts a study to assess the safety of a new medication for lowering cholesterol levels. One thousand participants are randomly divided into two groups, with 500 individuals in each group, and given either the medication or a placebo. The researchers find that acute myositis is more common in those who received the medication than in those who received the placebo, and the difference is statistically significant (p = 0.03).

      What is the most precise interpretation of these findings?

      Your Answer: The study has insufficient power to reach any conclusion

      Correct Answer: There is a 3% probability that the result is obtained by chance

      Explanation:

      The study found a significant difference between the groups and concluded that the new hypolipidaemic drug increases the risk of developing acute myositis. However, it is unclear what the incidence of this side effect is with the drug as the question did not provide information on how many patients developed acute myositis in each group. The p value of 0.03 indicates that there is a three percent probability of obtaining the observed result by chance, assuming the null hypothesis is true.

      Significance tests are used to determine the likelihood of a null hypothesis being true. The null hypothesis states that two treatments are equally effective, while the alternative hypothesis suggests that there is a difference between the two treatments. The p value is the probability of obtaining a result by chance that is at least as extreme as the observed result, assuming the null hypothesis is true. Two types of errors can occur during significance testing: type I, where the null hypothesis is rejected when it is true, and type II, where the null hypothesis is accepted when it is false. The power of a study is the probability of correctly rejecting the null hypothesis when it is false, and it can be increased by increasing the sample size.

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      • General Principles
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  • Question 5 - A 54-year-old male on the gastroenterology ward has been experiencing recurrent episodes of...

    Incorrect

    • A 54-year-old male on the gastroenterology ward has been experiencing recurrent episodes of diarrhoea following the completion of antibiotics for severe community-acquired pneumonia.

      There is no significant medical history to report.

      The patient has a known allergy to metronidazole.

      The consultant has requested that you initiate treatment with vancomycin and discuss potential side effects with the patient.

      What adverse effect should be highlighted during this discussion?

      Your Answer: Risk of cholestasis

      Correct Answer: Risk of nephrotoxicity

      Explanation:

      Vancomycin can cause nephrotoxicity as an adverse effect, along with Redman’s syndrome and blood dyscrasias such as thrombocytopenia and neutropenia. Erythromycin is often linked to gastrointestinal upset, while flucloxacillin and amoxicillin are associated with cholestasis. Tendonitis is a known adverse effect of ciprofloxacin, and patients with mononucleosis may experience a rash when taking amoxicillin.

      Vancomycin is an antibiotic that is effective in treating infections caused by Gram-positive bacteria, especially those that are resistant to methicillin, such as Staphylococcus aureus. Its mechanism of action involves inhibiting the formation of the bacterial cell wall by binding to D-Ala-D-Ala moieties, which prevents the polymerization of peptidoglycans. However, bacteria can develop resistance to vancomycin by altering the terminal amino acid residues of the NAM/NAG-peptide subunits, which are the sites where the antibiotic binds.

      Despite its effectiveness, vancomycin can cause adverse effects such as nephrotoxicity, ototoxicity, and thrombophlebitis. Rapid infusion of vancomycin can also lead to a condition called red man syndrome, which is characterized by flushing and itching of the skin. Therefore, it is important to use vancomycin only when necessary and under the guidance of a healthcare professional.

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      • General Principles
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  • Question 6 - A new serological test is used to diagnose Helicobacter pylori infection in elderly...

    Incorrect

    • A new serological test is used to diagnose Helicobacter pylori infection in elderly patients. The sensitivity and specificity of the test is 70% and 60%, respectively.

      What is the negative likelihood ratio?

      Your Answer: 0.6

      Correct Answer: 0.5

      Explanation:

      The formula for the likelihood ratio of a negative test result is (1 – sensitivity) divided by specificity.

      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.

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      • General Principles
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  • Question 7 - As a medical student working on a general medical ward, you receive a...

    Incorrect

    • As a medical student working on a general medical ward, you receive a call from the on-call microbiologist informing you that a blood culture from one of your patients, who happens to be in their mid-twenties, has grown a gram-positive organism. Can you identify what distinguishes the structure of a gram-positive microorganism?

      Your Answer: Inner and outer cell wall

      Correct Answer: Teichoic acid in their cell wall

      Explanation:

      Gram-positive bacteria are characterized by their blue/purple color and possess an inner cytoplasmic membrane and a cell wall rich in peptidoglycan, which is the target of penicillin. They are able to survive in dry conditions, produce exotoxins, and some can form spores that are highly resistant to heat, making them important in sterilization processes. Additionally, they have teichoic acid in their cell wall, which can interfere with the immune system.

      Gram-positive bacteria are able to colonize the skin due to their high tolerance for salt, urea, and fatty acids found on the skin. In contrast, gram-negative bacteria are unable to do so, making it common to be colonized by gram-positive but not gram-negative bacteria.

      Gram-negative bacteria have a peptidoglycan cell wall, lipopolysaccharides, and porins. They also possess both an inner and outer cell membrane, while gram-positive bacteria only have an inner cell membrane and a peptidoglycan layer. Gram-negative bacteria do not survive well in dry conditions and have endotoxins in their cell wall, but do not produce spores.

      Identifying Gram-Positive Bacteria: A Guide

      Gram-positive bacteria can be identified through the use of gram staining, which results in a purple/blue coloration. Upon microscopy, the shape of the bacteria can be determined, either cocci or rods.

      Rods, or bacilli, include Actinomyces, Bacillus anthracis, Clostridium, Corynebacterium diphtheriae, and Listeria monocytogenes.

      Cocci can be further divided into those that make catalase (Staphylococci) and those that do not (Streptococci). Staphylococci can be differentiated based on their ability to make coagulase, with S. aureus being coagulase-positive and S. epidermidis (novobiocin sensitive) and S. saprophyticus (novobiocin resistant) being coagulase-negative.

      Streptococci can be identified based on their hemolytic properties. Those with partial hemolysis (green coloration on blood agar) are α-haemolytic, while those with complete hemolysis (clear) are ÎČ-haemolytic. Those with no hemolysis are Îł-haemolytic.

      α-haemolytic streptococci can be further differentiated based on their sensitivity to optochin, with S. pneumoniae being optochin-sensitive and Viridans streptococci being optochin-resistant.

      ÎČ-haemolytic streptococci can be differentiated based on their sensitivity to bacitracin, with Group A (S. pyogenes) being bacitracin-sensitive and Group B (S. agalactiae) being bacitracin-resistant.

      In summary, identifying gram-positive bacteria involves gram staining and microscopy to determine shape, followed by differentiation based on coagulase production (Staphylococci), hemolytic properties (Streptococci), and sensitivity to optochin and bacitracin.

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      • General Principles
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  • Question 8 - A 26-year-old 38/40 primigravida woman arrives in labour and reports a familial condition....

    Correct

    • A 26-year-old 38/40 primigravida woman arrives in labour and reports a familial condition. She inquires about the possibility of her baby being affected due to consanguinity. What is the condition that poses the highest risk to the child?

      Your Answer: Cystic fibrosis

      Explanation:

      Consanguinity and Inherited Defects

      Consanguinity refers to the practice of marrying within the same family or bloodline. When couples who are related marry, the risk of inherited defects is approximately double that of a non-related couple. This is because the genetic material passed down from both parents is more likely to contain the same harmful mutations. However, when second cousins marry, the risk of inherited defects is reduced to that of a non-related couple. This is because second cousins share a smaller percentage of their genetic material compared to first cousins or closer relatives. It is important for couples who are considering marriage to be aware of the potential risks associated with consanguinity and to seek genetic counseling if necessary. By understanding the risks and taking appropriate measures, couples can make informed decisions about their future together.

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      • General Principles
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  • Question 9 - A 55-year-old woman is currently experiencing menopausal symptoms and seeks advice from her...

    Incorrect

    • A 55-year-old woman is currently experiencing menopausal symptoms and seeks advice from her GP regarding treatment options. She has been having irregular periods for a few months and is bothered by reduced libido, vaginal dryness, night sweats, and hot flushes. Initially, she expresses interest in an oestrogen-only HRT based on her friend's experience, but after reviewing her medical history, the GP recommends a combined HRT instead. What is the contraindication that led the GP to suggest this alternative treatment?

      Your Answer: Current smoker

      Correct Answer: Presence of a uterus

      Explanation:

      Women with a uterus taking HRT need a preparation with progestogen to reduce the risk of endometrial cancer. SSRIs can be used as a non-hormonal option for menopausal symptoms. Smoking and uncontrolled hypertension are contraindications to HRT use, but migraines with aura are not. COCP has different contraindications than HRT.

      Hormone Replacement Therapy: Uses and Varieties

      Hormone replacement therapy (HRT) is a treatment that involves administering a small amount of estrogen, combined with a progestogen (in women with a uterus), to alleviate menopausal symptoms. The indications for HRT have changed significantly over the past decade due to the long-term risks that have become apparent, primarily as a result of the Women’s Health Initiative (WHI) study.

      The most common indication for HRT is vasomotor symptoms such as flushing, insomnia, and headaches. Other indications, such as reversal of vaginal atrophy, should be treated with other agents as first-line therapies. HRT is also recommended for women who experience premature menopause, which should be continued until the age of 50 years. The most important reason for giving HRT to younger women is to prevent the development of osteoporosis. Additionally, HRT has been shown to reduce the incidence of colorectal cancer.

      HRT generally consists of an oestrogenic compound, which replaces the diminished levels that occur in the perimenopausal period. This is normally combined with a progestogen if a woman has a uterus to reduce the risk of endometrial cancer. The choice of hormone includes natural oestrogens such as estradiol, estrone, and conjugated oestrogen, which are generally used rather than synthetic oestrogens such as ethinylestradiol (which is used in the combined oral contraceptive pill). Synthetic progestogens such as medroxyprogesterone, norethisterone, levonorgestrel, and drospirenone are usually used. A levonorgestrel-releasing intrauterine system (e.g. Mirena) may be used as the progestogen component of HRT, i.e. a woman could take an oral oestrogen and have endometrial protection using a Mirena coil. Tibolone, a synthetic compound with both oestrogenic, progestogenic, and androgenic activity, is another option.

      HRT can be taken orally or transdermally (via a patch or gel). Transdermal is preferred if the woman is at risk of venous thromboembolism (VTE), as the rates of VTE do not appear to rise with transdermal preparations.

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      • General Principles
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  • Question 10 - A father brings his 3-year-old child to the pediatrician with a 3-week history...

    Incorrect

    • A father brings his 3-year-old child to the pediatrician with a 3-week history of perianal itching that is not improving. The father mentions that the itching seems to be more severe at night. He is worried because his older son, who shares a room with the affected child, has also started experiencing similar symptoms in the past few days.

      What organism is most likely causing these symptoms?

      Your Answer: Wuchereria bancrofti

      Correct Answer: Enterobius vermicularis

      Explanation:

      A 3-year-old child is experiencing perianal itching, especially at night, which may be caused by Enterobius vermicularis (pinworm). This condition is usually asymptomatic, but the itching can be bothersome. Diagnosis involves applying sticky tape to the perianal area and sending it to the lab for analysis.

      Clonorchis sinensis infection is caused by eating undercooked fish and can lead to biliary tract obstruction, resulting in symptoms such as abdominal pain, nausea, and jaundice. It is also a risk factor for cholangiocarcinoma.

      Echinococcus granulosus is a tapeworm that is commonly found in farmers who keep sheep. Dogs can become infected by ingesting hydatid cysts from sheep, and the eggs are then spread through their feces. Patients may not experience symptoms for a long time, but they may eventually develop abdominal discomfort and nausea. A liver ultrasound scan can reveal the presence of hepatic cysts.

      Taenia solium is another type of tapeworm that is often transmitted through the consumption of undercooked pork. It can cause neurological symptoms and brain lesions that appear as a swiss cheese pattern on imaging.

      Helminths are a group of parasitic worms that can infect humans and cause various diseases. Nematodes, also known as roundworms, are one type of helminth. Strongyloides stercoralis is a type of roundworm that enters the body through the skin and can cause symptoms such as diarrhea, abdominal pain, and skin lesions. Treatment for this infection typically involves the use of ivermectin or benzimidazoles. Enterobius vermicularis, also known as pinworm, is another type of roundworm that can cause perianal itching and other symptoms. Diagnosis is made by examining sticky tape applied to the perianal area. Treatment typically involves benzimidazoles.

      Hookworms, such as Ancylostoma duodenale and Necator americanus, are another type of roundworm that can cause gastrointestinal infections and anemia. Treatment typically involves benzimidazoles. Loa loa is a type of roundworm that is transmitted by deer fly and mango fly and can cause red, itchy swellings called Calabar swellings. Treatment involves the use of diethylcarbamazine. Trichinella spiralis is a type of roundworm that can develop after eating raw pork and can cause fever, periorbital edema, and myositis. Treatment typically involves benzimidazoles.

      Onchocerca volvulus is a type of roundworm that causes river blindness and is spread by female blackflies. Treatment involves the use of ivermectin. Wuchereria bancrofti is another type of roundworm that is transmitted by female mosquitoes and can cause blockage of lymphatics and elephantiasis. Treatment involves the use of diethylcarbamazine. Toxocara canis, also known as dog roundworm, is transmitted through ingestion of infective eggs and can cause visceral larva migrans and retinal granulomas. Treatment involves the use of diethylcarbamazine. Ascaris lumbricoides, also known as giant roundworm, can cause intestinal obstruction and occasionally migrate to the lung. Treatment typically involves benzimidazoles.

      Cestodes, also known as tapeworms, are another type of helminth. Echinococcus granulosus is a tapeworm that is transmitted through ingestion of eggs in dog feces and can cause liver cysts and anaphylaxis if the cyst ruptures

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      • General Principles
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  • Question 11 - A 53-year-old woman arrives at the emergency department with a sudden and severe...

    Incorrect

    • A 53-year-old woman arrives at the emergency department with a sudden and severe headache that is most intense in the occipital region. Despite a CT scan, subarachnoid haemorrhage cannot be identified, and a lumbar puncture is necessary to rule out this condition. The hospital is conducting internal audits to improve the quality of lumbar puncture technique.

      What is the hospital's approach to evaluating lumbar puncture technique?

      Your Answer: Assessing clinicians lumbar puncture technique on a model

      Correct Answer: Systematic review of lumbar punctures against criteria

      Explanation:

      Clinical audit aims to enhance patient care and outcomes by systematically evaluating care against specific criteria and implementing changes accordingly.

      Understanding Clinical Audit

      Clinical audit is a process that aims to improve the quality of patient care and outcomes by systematically reviewing care against specific criteria and implementing changes. It is a quality improvement process that involves the collection and analysis of data to identify areas where improvements can be made. The process involves reviewing current practices, identifying areas for improvement, and implementing changes to improve patient care and outcomes.

      Clinical audit is an essential tool for healthcare professionals to ensure that they are providing the best possible care to their patients. It helps to identify areas where improvements can be made and provides a framework for implementing changes. The process involves a team of healthcare professionals working together to review current practices and identify areas for improvement. Once areas for improvement have been identified, changes can be implemented to improve patient care and outcomes.

      In summary, clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. It is an essential tool for healthcare professionals to ensure that they are providing the best possible care to their patients. By identifying areas for improvement and implementing changes, clinical audit helps to improve patient care and outcomes.

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  • Question 12 - A 36-year-old woman has been diagnosed with iron deficiency and is prescribed oral...

    Incorrect

    • A 36-year-old woman has been diagnosed with iron deficiency and is prescribed oral iron supplements. As a first-time user, she is concerned about other medications, foods, and drinks that may hinder the absorption of iron. Can you suggest any substance that can enhance the absorption of her prescribed supplement?

      Your Answer:

      Correct Answer: Gastric acid

      Explanation:

      Iron absorption is increased by gastric acid.

      To test the candidates’ ability to identify substances that enhance the absorption of iron supplements, this question requires them to select the correct option, which is gastric acid. This is because gastric acid lowers the pH of the stomach, facilitating the conversion of iron into forms that are more easily absorbed in the gastrointestinal tract. The key idea here is that substances that decrease stomach pH generally aid in iron absorption, while those that raise stomach pH tend to impede it.

      Antacids are not the correct answer. They contain alkaline ions that neutralize stomach acid, leading to an increase in pH. When antacids are taken with iron supplements, iron forms macromolecular polymers that reduce its absorption through the gastrointestinal tract.

      Milk is not the correct answer. Some substances in milk, such as calcium, have been found to decrease the amount of iron that the body absorbs. Therefore, it is recommended to take iron supplements two hours after consuming milk or dairy products.

      Proton pump inhibitors are not the correct answer. They interfere with iron absorption by reducing gastric acid secretion. The decrease in gastric acid leads to an increase in gastric pH, making it more difficult for iron to be absorbed.

      Iron Metabolism: Absorption, Distribution, Transport, Storage, and Excretion

      Iron is an essential mineral that plays a crucial role in various physiological processes. The absorption of iron occurs mainly in the upper small intestine, particularly the duodenum. Only about 10% of dietary iron is absorbed, and ferrous iron (Fe2+) is much better absorbed than ferric iron (Fe3+). The absorption of iron is regulated according to the body’s need and can be increased by vitamin C and gastric acid. However, it can be decreased by proton pump inhibitors, tetracycline, gastric achlorhydria, and tannin found in tea.

      The total body iron is approximately 4g, with 70% of it being present in hemoglobin, 25% in ferritin and haemosiderin, 4% in myoglobin, and 0.1% in plasma iron. Iron is transported in the plasma as Fe3+ bound to transferrin. It is stored in tissues as ferritin, and the lost iron is excreted via the intestinal tract following desquamation.

      In summary, iron metabolism involves the absorption, distribution, transport, storage, and excretion of iron in the body. Understanding these processes is crucial in maintaining iron homeostasis and preventing iron-related disorders.

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  • Question 13 - A 50-year-old woman was referred to gastroenterology to investigate unresolved dyspepsia. She has...

    Incorrect

    • A 50-year-old woman was referred to gastroenterology to investigate unresolved dyspepsia. She has been receiving NSAID treatment to manage a flare-up of osteoarthritis. Endoscopy reveals the presence of a gastric ulcer.

      What factors may have contributed to the endoscopy findings?

      Your Answer:

      Correct Answer: Reduced PGE2 (prostaglandin)

      Explanation:

      The use of NSAIDs can lead to the formation of peptic ulcers by reducing the production of PGE2, which is responsible for increasing gastric mucus secretion. NSAIDs inhibit the COX enzymes that convert arachidonic acid into endoperoxides, which then form PGE2. PGI2 is another product of endoperoxides that causes vasodilation, reduces platelet aggregation, and has no effect on gastric mucus production. Thromboxane A2 is also a product of endoperoxides, but it causes vasoconstriction and increases platelet aggregation without affecting gastric mucus production. Inhibition of COX enzymes does not result in a deficiency of arachidonic acid, which is a precursor for prostaglandins. NSAID use does not affect leukotriene production, which is independent of COX enzymes and causes bronchoconstriction but does not impact gastric mucus production.

      Arachidonic Acid Metabolism: The Role of Leukotrienes and Endoperoxides

      Arachidonic acid is a fatty acid that plays a crucial role in the body’s inflammatory response. The metabolism of arachidonic acid involves the production of various compounds, including leukotrienes and endoperoxides. Leukotrienes are produced by leukocytes and can cause constriction of the lungs. LTB4 is produced before leukocytes arrive, while the rest of the leukotrienes (A, C, D, and E) cause lung constriction.

      Endoperoxides, on the other hand, are produced by the cyclooxygenase enzyme and can lead to the formation of thromboxane and prostacyclin. Thromboxane is associated with platelet aggregation and vasoconstriction, which can lead to thrombosis. Prostacyclin, on the other hand, has the opposite effect and can cause vasodilation and inhibit platelet aggregation.

      Understanding the metabolism of arachidonic acid and the role of these compounds can help in the development of treatments for inflammatory conditions and cardiovascular diseases.

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  • Question 14 - A 49-year-old man presents to a tertiary hospital with symptoms of fatigue, malaise,...

    Incorrect

    • A 49-year-old man presents to a tertiary hospital with symptoms of fatigue, malaise, fever, and weight loss. He has a chronic cough with green sputum and reports emigrating from India to the UK 17 years ago. A Mantoux test is positive, and his two children are offered an interferon-gamma release assay to detect exposure. Which type of cell is responsible for releasing interferon-gamma as part of the immune response?

      Your Answer:

      Correct Answer: T Helper 1 cells (Th1 cells)

      Explanation:

      Overview of Cytokines and Their Functions

      Cytokines are signaling molecules that play a crucial role in the immune system. Interleukins are a type of cytokine that are produced by various immune cells and have specific functions. IL-1, produced by macrophages, induces acute inflammation and fever. IL-2, produced by Th1 cells, stimulates the growth and differentiation of T cell responses. IL-3, produced by activated T helper cells, stimulates the differentiation and proliferation of myeloid progenitor cells. IL-4, produced by Th2 cells, stimulates the proliferation and differentiation of B cells. IL-5, also produced by Th2 cells, stimulates the production of eosinophils. IL-6, produced by macrophages and Th2 cells, stimulates the differentiation of B cells and induces fever. IL-8, produced by macrophages, promotes neutrophil chemotaxis. IL-10, produced by Th2 cells, inhibits Th1 cytokine production and is known as an anti-inflammatory cytokine. IL-12, produced by dendritic cells, macrophages, and B cells, activates NK cells and stimulates the differentiation of naive T cells into Th1 cells.

      In addition to interleukins, there are other cytokines with specific functions. Tumor necrosis factor-alpha, produced by macrophages, induces fever and promotes neutrophil chemotaxis. Interferon-gamma, produced by Th1 cells, activates macrophages. Understanding the functions of cytokines is important in developing treatments for various immune-related diseases.

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  • Question 15 - A 55-year-old man is scheduled to undergo a splenectomy to treat his refractory...

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    • A 55-year-old man is scheduled to undergo a splenectomy to treat his refractory haemolytic anaemia, which is believed to be caused by a Type 2 hypersensitivity response. What is the primary mechanism involved in this process?

      A) Deposition of immune complexes
      B) Cell-mediated immune response
      C) IgE-mediated response
      D) Formation of autoantibodies against cell surface antigens
      E) None of the above

      Your Answer:

      Correct Answer: Formation of autoantibodies against cell surface antigens

      Explanation:

      Type 2 hypersensitivity reactions, such as haemolytic anaemia, involve the production of antibodies against cell surface antigens.

      Classification of Hypersensitivity Reactions

      Hypersensitivity reactions are classified into four types according to the Gell and Coombs classification. Type I, also known as anaphylactic hypersensitivity, occurs when an antigen reacts with IgE bound to mast cells. This type of reaction is commonly seen in atopic conditions such as asthma, eczema, and hay fever. Type II hypersensitivity occurs when cell-bound IgG or IgM binds to an antigen on the cell surface, leading to autoimmune conditions such as autoimmune hemolytic anemia, ITP, and Goodpasture’s syndrome. Type III hypersensitivity occurs when free antigen and antibody (IgG, IgA) combine to form immune complexes, leading to conditions such as serum sickness, systemic lupus erythematosus, and post-streptococcal glomerulonephritis. Type IV hypersensitivity is T-cell mediated and includes conditions such as tuberculosis, graft versus host disease, and allergic contact dermatitis.

      In recent times, a fifth category has been added to the classification of hypersensitivity reactions. Type V hypersensitivity occurs when antibodies recognize and bind to cell surface receptors, either stimulating them or blocking ligand binding. This type of reaction is seen in conditions such as Graves’ disease and myasthenia gravis. Understanding the classification of hypersensitivity reactions is important in the diagnosis and management of these conditions.

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  • Question 16 - A 65-year-old man has been experiencing acute breathlessness and fatigue alongside his pre-existing...

    Incorrect

    • A 65-year-old man has been experiencing acute breathlessness and fatigue alongside his pre-existing myelodysplastic syndrome. Upon initial blood tests, a significantly elevated white cell count with a high percentage of blast cells was observed. A subsequent bone marrow biopsy has confirmed a transformation to acute myeloid leukemia.

      In order to gain a better understanding of his prognosis, what biochemical technique can be utilized to identify mutated oncogenes?

      Your Answer:

      Correct Answer: Polymerase chain reaction (PCR)

      Explanation:

      Polymerase chain reactions are commonly utilized to identify mutated oncogenes. This technique involves the use of specific primers that bind to a particular segment of genetic material. If the targeted sequence is present, the DNA is amplified, doubling in quantity during each cycle. Various methods are then employed to determine whether the target DNA sequence has indeed been amplified and is present.

      Absorption spectroscopy is a technique that utilizes light absorption to measure the concentrations of absorptive substances in a solution. It does not play a role in detecting oncogenes.

      Emulsion tests are used to detect lipids, not DNA.

      ELISA testing is an immunological technique that can identify various peptides, proteins, antibodies, and antigens. It is notably used to diagnose HIV through the detection of antibodies.

      Similarly, western blotting is a technique used to detect proteins, not DNA.

      Reverse Transcriptase PCR

      Reverse transcriptase PCR (RT-PCR) is a molecular genetic technique used to amplify RNA. This technique is useful for analyzing gene expression in the form of mRNA. The process involves converting RNA to DNA using reverse transcriptase. The resulting DNA can then be amplified using PCR.

      To begin the process, a sample of RNA is added to a test tube along with two DNA primers and a thermostable DNA polymerase (Taq). The mixture is then heated to almost boiling point, causing denaturing or uncoiling of the RNA. The mixture is then allowed to cool, and the complimentary strands of DNA pair up. As there is an excess of the primer sequences, they preferentially pair with the DNA.

      The above cycle is then repeated, with the amount of DNA doubling each time. This process allows for the amplification of the RNA, making it easier to analyze gene expression. RT-PCR is a valuable tool in molecular biology and has many applications in research, including the study of diseases and the development of new treatments.

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  • Question 17 - When two medical conditions are related through the presence of a confounding factor,...

    Incorrect

    • When two medical conditions are related through the presence of a confounding factor, the association is said to be:

      Your Answer:

      Correct Answer: Indirect

      Explanation:

      Association and Causation: Understanding the Difference

      Association refers to the relationship between two variables where one is more commonly found in the presence of the other. However, not all associations are causal. There are three types of association: spurious, indirect, and direct. Spurious associations are those that arise by chance and are not real, while indirect associations are due to the presence of another factor, also known as a confounding variable. Direct associations, on the other hand, are true associations not linked by a third variable.

      To establish causation, the Bradford Hill Causal Criteria are used. These criteria include strength, temporality, specificity, coherence, and consistency. The strength of the association is an important factor in determining causation, as a stronger association is more likely to be truly causal. Temporality refers to whether the exposure precedes the outcome, while specificity asks whether the suspected cause is associated with a specific outcome or disease. Coherence considers whether the association fits with other biological knowledge, and consistency looks at whether the same association is found in many studies.

      Understanding the difference between association and causation is important in research and decision-making. While an association may suggest a relationship between two variables, it does not necessarily mean that one causes the other. By using the Bradford Hill Causal Criteria, researchers can determine whether an association is truly causal and make informed decisions based on their findings.

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  • Question 18 - A 6-year-old girl is brought to the Emergency Department by her mother after...

    Incorrect

    • A 6-year-old girl is brought to the Emergency Department by her mother after she began experiencing increasing dyspnoea.

      On examination, she is cyanotic, drooling, and refuses to lie back, opting instead to crouch forwards with one arm out.

      A lateral X-ray radiograph of the neck displays thumb sign.

      What is the most likely causative pathogen in this presentation, given the most likely diagnosis?

      Your Answer:

      Correct Answer: Haemophilus influenzae

      Explanation:

      Acute epiglottitis is commonly caused by Haemophilus influenzae type B, although cases are now rare in the UK due to the Hib vaccine. It is crucial to not miss this condition as it can be fatal. Haemophilus haemolyticus is not associated with acute epiglottitis as it is a non-pathogenic bacteria. Parainfluenza virus causes croup, which is a differential diagnosis for acute epiglottitis but has a more gradual onset. Streptococcus pyogenes can be associated with epiglottitis, but it is a rarer cause than H. influenzae and is usually linked to other conditions such as impetigo, cellulitis, tonsillitis, scarlet fever, rheumatic fever, and post-streptococcal glomerulonephritis. However, it is not typically linked with acute epiglottitis.

      Acute epiglottitis is a rare but serious infection caused by Haemophilus influenzae type B. It is important to recognize and treat it promptly as it can lead to airway obstruction. Although it was once considered a disease of childhood, it is now more common in adults in the UK due to the immunization program. The incidence of epiglottitis has decreased since the introduction of the Hib vaccine. Symptoms include a rapid onset, high temperature, stridor, drooling of saliva, and a tripod position where the patient leans forward and extends their neck to breathe easier.

      Diagnosis is made by direct visualization, but only by senior or airway trained staff. X-rays may be done if there is concern about a foreign body. A lateral view in acute epiglottitis will show swelling of the epiglottis, while a posterior-anterior view in croup will show subglottic narrowing, commonly called the steeple sign.

      Immediate senior involvement is necessary, including those able to provide emergency airway support such as anaesthetics or ENT. Endotracheal intubation may be necessary to protect the airway. If suspected, do NOT examine the throat due to the risk of acute airway obstruction. Oxygen and intravenous antibiotics are also important in management.

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  • Question 19 - What is the characteristic finding on a blood film after a splenectomy? ...

    Incorrect

    • What is the characteristic finding on a blood film after a splenectomy?

      Your Answer:

      Correct Answer: Howell-Jolly bodies

      Explanation:

      In cases of hyposplenism, the blood film may show the presence of Howell-Jolly bodies, Pappenheimer bodies, poikilocytes (specifically target cells), erythrocytes containing siderotic granules, and Heinz bodies.

      Splenectomy and its Management

      Splenectomy is a surgical procedure that involves the removal of the spleen. After the operation, patients are at a higher risk of infections caused by pneumococcus, Haemophilus, meningococcus, and Capnocytophaga canimorsus. To prevent these infections, patients should receive vaccinations such as Hib, meningitis A & C, annual influenzae, and pneumococcal vaccines. Antibiotic prophylaxis with penicillin V is also recommended for at least two years and until the patient is 16 years old, although some patients may require lifelong prophylaxis.

      Splenectomy is indicated for various reasons such as trauma, spontaneous rupture, hypersplenism, malignancy, splenic cysts, hydatid cysts, and splenic abscesses. Elective splenectomy is different from emergency splenectomy, and it is usually performed laparoscopically. Complications of splenectomy include haemorrhage, pancreatic fistula, and thrombocytosis. Post-splenectomy changes include an increase in platelets, Howell-Jolly bodies, target cells, and Pappenheimer bodies. Patients are at an increased risk of post-splenectomy sepsis, which typically occurs with encapsulated organisms. Therefore, prophylactic antibiotics and pneumococcal vaccines are essential to prevent infections.

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  • Question 20 - A 68-year-old man is hospitalized with pneumonia, which is suspected to be a...

    Incorrect

    • A 68-year-old man is hospitalized with pneumonia, which is suspected to be a complication of a recent infection. He had visited his doctor a week ago, complaining of a high fever and symptoms resembling a cold. Additionally, he had developed a red rash around his hairline that seemed to be spreading down his neck. Based on this information, what is the primary method of transmission for the initial infection?

      Your Answer:

      Correct Answer: Aerosol

      Explanation:

      The most likely mode of transmission for measles is through aerosols. The woman’s symptoms and subsequent rash near the hairline indicate a measles infection, which is highly contagious and can be spread through the air when an infected person coughs or sneezes. While contaminated surfaces may also transmit the virus, it is not the primary mode of transmission. Measles is not transmitted through the faecal-oral route or intravenously, as it is found in the nose and throat of an infected person and not in their faeces or blood.

      Measles: A Highly Infectious Disease

      Measles is a viral infection caused by an RNA paramyxovirus. It is one of the most infectious viruses known and is spread through aerosol transmission. The incubation period is 10-14 days, and the virus is infective from the prodromal phase until four days after the rash starts. Measles is now rare in developed countries due to immunization programs, but outbreaks can occur when vaccination rates drop.

      The prodromal phase of measles is characterized by irritability, conjunctivitis, fever, and Koplik spots. These white spots on the buccal mucosa typically develop before the rash. The rash starts behind the ears and then spreads to the whole body, becoming a discrete maculopapular rash that may become blotchy and confluent. Desquamation may occur after a week, typically sparing the palms and soles. Diarrhea occurs in around 10% of patients.

      Measles is mainly managed through supportive care, and admission may be considered for immunosuppressed or pregnant patients. It is a notifiable disease, and public health should be informed. Complications of measles include otitis media, pneumonia, encephalitis, subacute sclerosing panencephalitis, febrile convulsions, keratoconjunctivitis, corneal ulceration, diarrhea, increased incidence of appendicitis, and myocarditis.

      If an unvaccinated child comes into contact with measles, MMR should be offered within 72 hours. Vaccine-induced measles antibody develops more rapidly than that following natural infection.

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  • Question 21 - A 49-year-old female presents to the hospital with fever, hypotension, and tachycardia. Upon...

    Incorrect

    • A 49-year-old female presents to the hospital with fever, hypotension, and tachycardia. Upon blood tests, her results show:

      - Hb 148 g/l
      - Platelets 380 * 109/l
      - WBC 18.4 * 109/l
      - Neutrophils 12.7 * 109/l (2-7.5 * 109/l)
      - Lymphocytes 1.2 * 109/l (1.3 - 3.5 * 109/l)
      - Monocytes 0.7 * 109/l (0.2 - 1 * 109/l)
      - Eosinophils 0.1 * 109/l (0.04-0.4 * 109/l)

      What is the most likely type of infection she has?

      Your Answer:

      Correct Answer: Bacterial

      Explanation:

      The patient’s raised WCC and symptoms indicate an abnormality, with the likely cause being a bacterial infection due to the raised neutrophil count. It is important to note that viral infections typically result in a raised lymphocyte count, fungal infections result in a raised eosinophil count, and protozoan infections often result in a raised monocyte count, all of which are within normal range for this patient.

      Classification of Bacteria Made Easy

      Bacteria are classified based on their shape, staining properties, and other characteristics. One way to simplify the classification process is to remember that Gram-positive cocci include staphylococci and streptococci, while Gram-negative cocci include Neisseria meningitidis, Neisseria gonorrhoeae, and Moraxella catarrhalis. To categorize all bacteria, only a few Gram-positive rods or bacilli need to be memorized, which can be remembered using the mnemonic ABCD L: Actinomyces, Bacillus anthracis (anthrax), Clostridium, Diphtheria (Corynebacterium diphtheriae), and Listeria monocytogenes.

      The remaining organisms are Gram-negative rods, such as Escherichia coli, Haemophilus influenzae, Pseudomonas aeruginosa, Salmonella sp., Shigella sp., and Campylobacter jejuni. By keeping these classifications in mind, it becomes easier to identify and differentiate between different types of bacteria.

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  • Question 22 - A 19-year-old male visits the clinic with concerns about his acne, which is...

    Incorrect

    • A 19-year-old male visits the clinic with concerns about his acne, which is causing him discomfort and affecting his emotional well-being. Despite using over-the-counter benzoyl peroxide, the lesions on his face, chest, and back persist. The GP decides to prescribe a combination of erythromycin and benzoyl peroxide as a topical treatment. What is the mechanism of action of erythromycin in treating acne?

      Your Answer:

      Correct Answer: Binds to the 50S subunit of the ribosome

      Explanation:

      Macrolides, such as erythromycin, hinder protein synthesis by targeting the 50S subunit of ribosomes in bacteria. This action prevents the creation of proteins, leading to the eventual death of the bacterial cells.

      Quinolone antibiotics, like ciprofloxacin, work by inhibiting bacterial DNA gyrase, which is responsible for unwinding and duplicating bacterial DNA. By hindering this process, bacterial replication is impaired.

      Beta-lactam antibiotics, including penicillins and cephalosporins, damage the bacterial cell wall, ultimately leading to bacterial cell death.

      Trimethoprim works by inhibiting bacterial dihydrofolate reductase, which reduces the amount of purines available for DNA synthesis in bacteria. This reduction in DNA synthesis slows bacterial replication.

      Tetracyclines inhibit the 30S subunit of bacterial ribosomes, which also reduces protein synthesis and leads to bacterial cell death.

      Antibiotics work in different ways to kill or inhibit the growth of bacteria. The commonly used antibiotics can be classified based on their gross mechanism of action. The first group inhibits cell wall formation by either preventing peptidoglycan cross-linking (penicillins, cephalosporins, carbapenems) or peptidoglycan synthesis (glycopeptides like vancomycin). The second group inhibits protein synthesis by acting on either the 50S subunit (macrolides, chloramphenicol, clindamycin, linezolid, streptogrammins) or the 30S subunit (aminoglycosides, tetracyclines) of the bacterial ribosome. The third group inhibits DNA synthesis (quinolones like ciprofloxacin) or damages DNA (metronidazole). The fourth group inhibits folic acid formation (sulphonamides and trimethoprim), while the fifth group inhibits RNA synthesis (rifampicin). Understanding the mechanism of action of antibiotics is important in selecting the appropriate drug for a particular bacterial infection.

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  • Question 23 - John is a 50-year-old African-American male who is admitted to hospital for potential...

    Incorrect

    • John is a 50-year-old African-American male who is admitted to hospital for potential isoniazid toxicity, after he developed worsening nausea, vomiting, rash and fever. During his hospital stay, it is identified that John is a slow acetylator, which led to the isoniazid toxicity.

      As a slow acetylator, which of the following drugs could also be potentially toxic if given to this patient?

      Your Answer:

      Correct Answer: Sulfasalazine

      Explanation:

      Understanding Drug Metabolism: Phase I and Phase II Reactions

      Drug metabolism involves two types of biochemical reactions, namely phase I and phase II reactions. Phase I reactions include oxidation, reduction, and hydrolysis, which are mainly performed by P450 enzymes. However, some drugs are metabolized by specific enzymes such as alcohol dehydrogenase and xanthine oxidase. The products of phase I reactions are typically more active and potentially toxic. On the other hand, phase II reactions involve conjugation, where glucuronyl, acetyl, methyl, sulphate, and other groups are typically involved. The products of phase II reactions are typically inactive and excreted in urine or bile. The majority of phase I and phase II reactions take place in the liver.

      First-Pass Metabolism and Drugs Affected by Zero-Order Kinetics and Acetylator Status

      First-pass metabolism is a phenomenon where the concentration of a drug is greatly reduced before it reaches the systemic circulation due to hepatic metabolism. This effect is seen in many drugs, including aspirin, isosorbide dinitrate, glyceryl trinitrate, lignocaine, propranolol, verapamil, isoprenaline, testosterone, and hydrocortisone.

      Zero-order kinetics describe metabolism that is independent of the concentration of the reactant. This is due to metabolic pathways becoming saturated, resulting in a constant amount of drug being eliminated per unit time. Drugs exhibiting zero-order kinetics include phenytoin, salicylates (e.g. high-dose aspirin), heparin, and ethanol.

      Acetylator status is also an important consideration in drug metabolism. Approximately 50% of the UK population are deficient in hepatic N-acetyltransferase. Drugs affected by acetylator status include isoniazid, procainamide, hydralazine, dapsone, and sulfasalazine. Understanding these concepts is important in predicting drug efficacy and toxicity, as well as in optimizing drug dosing.

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  • Question 24 - Which one of the following defines the standard error of the median? ...

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    • Which one of the following defines the standard error of the median?

      Your Answer:

      Correct Answer: Standard deviation / square root (number of patients)

      Explanation:

      Understanding Confidence Interval and Standard Error of the Mean

      The confidence interval is a widely used concept in medical statistics, but it can be confusing to understand. In simple terms, it is a range of values that is likely to contain the true effect of an intervention. The likelihood of the true effect lying within the confidence interval is determined by the confidence level, which is the specified probability of including the true value of the variable. For instance, a 95% confidence interval means that the range of values should contain the true effect of intervention 95% of the time.

      To calculate the confidence interval, we use the standard error of the mean (SEM), which measures the spread expected for the mean of the observations. The SEM is calculated by dividing the standard deviation (SD) by the square root of the sample size (n). As the sample size increases, the SEM gets smaller, indicating a more accurate sample mean from the true population mean.

      A 95% confidence interval is calculated by subtracting and adding 1.96 times the SEM from the mean value. However, if the sample size is small (n < 100), a 'Student's T critical value' look-up table should be used instead of 1.96. Similarly, if a different confidence level is required, such as 90%, the value used in the formula should be adjusted accordingly. In summary, the confidence interval is a range of values that is likely to contain the true effect of an intervention, and its calculation involves using the standard error of the mean. Understanding these concepts is crucial in interpreting statistical results in medical research.

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  • Question 25 - Olivia is a 19-year-old female who has recently started college. She attends a...

    Incorrect

    • Olivia is a 19-year-old female who has recently started college. She attends a party and has many alcoholic drinks and wakes the next morning with a severe headache. She puts this down to being hungover, however, by the next day the headache is worse and she has a widespread non-blanching purpuric rash. She attends the emergency department who suspect meningitis and would like to perform a lumbar puncture to obtain a cerebrospinal fluid (CSF) sample. The doctor would like to take the sample from the cauda equina to avoid spinal cord injury, at which level does the spinal cord terminate?

      Your Answer:

      Correct Answer: L1/L2

      Explanation:

      CSF Analysis for Meningitis

      Cerebrospinal fluid (CSF) analysis is an important diagnostic tool for meningitis. The appearance, glucose level, protein level, and white cell count in the CSF can provide clues to the type of meningitis present. Bacterial meningitis typically results in cloudy CSF with low glucose levels and high protein levels, along with a high number of polymorphs. Viral meningitis, on the other hand, usually results in clear or slightly cloudy CSF with normal or slightly raised protein levels and a high number of lymphocytes. Tuberculous meningitis may result in slightly cloudy CSF with a fibrin web and a high number of lymphocytes, along with low glucose and high protein levels. Fungal meningitis typically results in cloudy CSF with high protein levels and a high number of lymphocytes. In cases of suspected tuberculous meningitis, PCR may be used in addition to the Ziehl-Neelsen stain, which has low sensitivity. It is important to note that mumps and herpes encephalitis may also result in low glucose levels in the CSF.

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  • Question 26 - A 27-year-old woman had an open appendectomy 3 days ago and has been...

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    • A 27-year-old woman had an open appendectomy 3 days ago and has been experiencing abdominal pain and nausea since then. She has also lost her appetite and has not had a bowel movement. On examination, her abdomen is slightly distended and tender to the touch, but her incision wound looks normal. Her vital signs are stable with a normal temperature, blood pressure, heart rate, and respiratory rate. What is the most probable complication causing her symptoms?

      Your Answer:

      Correct Answer: Paralytic ileus

      Explanation:

      Paralytic ileus is a frequent complication that can occur after gastrointestinal surgery, often presenting with symptoms of pseudo-obstruction such as constipation, nausea and vomiting, abdominal discomfort and distension.

      Adhesional small bowel obstruction is less likely as a complication in the first few days after surgery, and typically presents with more severe symptoms such as vomiting, tenderness, and distension. It is also more commonly seen several weeks to years after abdominal surgery.

      Anastomotic leak is a rare but serious complication that can occur when there is a surgical join in the bowel. It is characterized by symptoms such as abdominal pain, fever, and tachycardia, and requires prompt identification and treatment to prevent sepsis and organ failure.

      Infection is another potential complication, but in this case, there were no signs of infection at the wound site such as erythema, pus, or induration. Symptoms of an infected wound may include abdominal pain, fever, and signs of sepsis.

      Postoperative ileus, also known as paralytic ileus, is a common complication that can occur after bowel surgery, particularly if the bowel has been extensively handled. This condition is characterized by reduced bowel peristalsis, which can lead to pseudo-obstruction. Symptoms of postoperative ileus include abdominal distention, bloating, pain, nausea, vomiting, inability to pass flatus, and difficulty tolerating an oral diet. It is important to check for deranged electrolytes, such as potassium, magnesium, and phosphate, as they can contribute to the development of postoperative ileus.

      The management of postoperative ileus typically involves nil-by-mouth initially, which may progress to small sips of clear fluids. If vomiting occurs, a nasogastric tube may be necessary. Intravenous fluids are administered to maintain normovolaemic, and additives may be used to correct any electrolyte disturbances. In severe or prolonged cases, total parenteral nutrition may be required. Overall, postoperative ileus is a common complication that requires careful management to ensure a successful recovery.

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  • Question 27 - You are developing a new drug for hypertension which acts to decrease blood...

    Incorrect

    • You are developing a new drug for hypertension which acts to decrease blood pressure by targeting the rate limiting enzyme. What enzyme will you target?

      Your Answer:

      Correct Answer: Fructose 1,6 bisphosphatase

      Explanation:

      Fructose 1,6 bisphosphatase is the enzyme that limits the rate of gluconeogenesis.

      When glycogen is depleted during prolonged fasting, the liver cells produce glucose through gluconeogenesis using lactate, pyruvate, glycerol, and amino acids. The enzyme fructose 1,6 bisphosphatase limits the rate of this process.

      Ketogenesis is limited by the enzyme HMG-CoA synthase.

      Cholesterol synthesis is limited by the enzyme HMG-CoA reductase.

      De novo purine synthesis is limited by the enzyme glutamine-PRPP amidotransferase.

      Rate-Determining Enzymes in Metabolic Processes

      Metabolic processes involve a series of chemical reactions that occur in living organisms to maintain life. Enzymes play a crucial role in these processes by catalyzing the reactions. However, not all enzymes have the same impact on the rate of the reaction. Some enzymes are rate-determining, meaning that they control the overall rate of the process. The table above lists the rate-determining enzymes involved in common metabolic processes.

      For example, in the TCA cycle, isocitrate dehydrogenase is the rate-determining enzyme. In glycolysis, phosphofructokinase-1 controls the rate of the process. In gluconeogenesis, fructose-1,6-bisphosphatase is the rate-determining enzyme. Similarly, glycogen synthase controls the rate of glycogenesis, while glycogen phosphorylase controls the rate of glycogenolysis.

      Other metabolic processes, such as lipogenesis, lipolysis, cholesterol synthesis, and ketogenesis, also have rate-determining enzymes. Acetyl-CoA carboxylase controls the rate of lipogenesis, while carnitine-palmitoyl transferase I controls the rate of lipolysis. HMG-CoA reductase is the rate-determining enzyme in cholesterol synthesis, while HMG-CoA synthase controls the rate of ketogenesis.

      The urea cycle, de novo pyrimidine synthesis, and de novo purine synthesis also have rate-determining enzymes. Carbamoyl phosphate synthetase I controls the rate of the urea cycle, while carbamoyl phosphate synthetase II controls the rate of de novo pyrimidine synthesis. Glutamine-PRPP amidotransferase is the rate-determining enzyme in de novo purine synthesis.

      Understanding the rate-determining enzymes in metabolic processes is crucial for developing treatments for metabolic disorders and diseases. By targeting these enzymes, researchers can potentially regulate the rate of the process and improve the health outcomes of individuals with these conditions.

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  • Question 28 - A 70-year-old male is referred to a haematologist for an elevated white blood...

    Incorrect

    • A 70-year-old male is referred to a haematologist for an elevated white blood cell count and an increased quantity of mature myeloid cells on his blood film. The diagnosis of chronic myeloid leukaemia is confirmed with the presence of an oncogene. He is promptly treated with chemotherapy and a tyrosine kinase inhibitor. What is the oncogene associated with chronic myeloid leukaemia?

      Your Answer:

      Correct Answer: ABL

      Explanation:

      Chronic myeloid leukaemia is often associated with the oncogene ABL, which is frequently amplified following the translocation t:(9;22), also known as the Philadelphia chromosome. Other oncogenes commonly found in different types of cancer include n-MYC in neuroblastoma, c-MYC in Burkitt’s lymphoma, and BCL-2 in follicular lymphoma.

      Oncogenes are genes that promote cancer and are derived from normal genes called proto-oncogenes. Proto-oncogenes play a crucial role in cellular growth and differentiation. However, a gain of function in oncogenes increases the risk of cancer. Only one mutated copy of the gene is needed for cancer to occur, making it a dominant effect. Oncogenes are responsible for up to 20% of human cancers and can become oncogenes through mutation, chromosomal translocation, or increased protein expression.

      In contrast, tumor suppressor genes restrict or repress cellular proliferation in normal cells. Their inactivation through mutation or germ line incorporation is implicated in various cancers, including renal, colonic, breast, and bladder cancer. Tumor suppressor genes, such as p53, offer protection by causing apoptosis of damaged cells. Other well-known genes include BRCA1 and BRCA2. Loss of function in tumor suppressor genes results in an increased risk of cancer, while gain of function in oncogenes increases the risk of cancer.

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  • Question 29 - An 89-year-old woman arrives at the ER after a fall resulting in a...

    Incorrect

    • An 89-year-old woman arrives at the ER after a fall resulting in a neck of femur fracture. A total hip replacement is carried out, and vitamin D is prescribed for her bone health. What impact would this have on the ions in her bloodstream?

      Your Answer:

      Correct Answer: Increased plasma calcium and phosphate

      Explanation:

      Plasma calcium and phosphate levels are regulated by various hormones, including parathyroid hormone, vitamin D, and calcitonin. Parathyroid hormone increases plasma calcium but decreases plasma phosphate, while vitamin D increases both plasma calcium and phosphate. On the other hand, calcitonin decreases plasma calcium levels. Understanding these hormonal interactions is important in identifying potential causes of calcium metabolism disorders. For instance, hyperkalemia may result from Addison’s disease, an autoimmune disorder that leads to hypoaldosteronism due to the production of autoantibodies against the adrenal gland.

      Understanding Vitamin D

      Vitamin D is a type of vitamin that is soluble in fat and is essential for the metabolism of calcium and phosphate in the body. It is converted into calcifediol in the liver and then into calcitriol, which is the active form of vitamin D, in the kidneys. Vitamin D can be obtained from two sources: vitamin D2, which is found in plants, and vitamin D3, which is present in dairy products and can also be synthesized by the skin when exposed to sunlight.

      The primary function of vitamin D is to increase the levels of calcium and phosphate in the blood. It achieves this by increasing the absorption of calcium in the gut and the reabsorption of calcium in the kidneys. Vitamin D also stimulates osteoclastic activity, which is essential for bone growth and remodeling. Additionally, it increases the reabsorption of phosphate in the kidneys.

      A deficiency in vitamin D can lead to two conditions: rickets in children and osteomalacia in adults. Rickets is characterized by soft and weak bones, while osteomalacia is a condition where the bones become weak and brittle. Therefore, it is crucial to ensure that the body receives an adequate amount of vitamin D to maintain healthy bones and overall health.

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  • Question 30 - A 14-year-old boy has been brought to see the family physician by his...

    Incorrect

    • A 14-year-old boy has been brought to see the family physician by his mother. He has been unwell for the past 3 days with spiking temperatures, the highest one being 38.7ÂșC. He has been complaining of abdominal pain. He has not had diarrhoea or vomiting, although he complains of nausea. He has coryzal symptoms and you feel that the most likely cause of his illness is a viral infection. As you are about to discharge with some advice on supportive measures and pain-relief, the mother asks you to prescribe some aspirin for his fever and pain-relief because paracetamol has not helped at all. The physician explains that aspirin is not suitable for children younger than 16 years of age and that there is only one exception to this rule.

      What is the reason for not prescribing aspirin in children under 16 years of age and what is the only exception to this rule?

      Your Answer:

      Correct Answer: Causes encephalopathy and brain damage, and the only exception is its use in the management of Kawasaki disease

      Explanation:

      The majority of cases of Reye’s syndrome in children are linked to the use of aspirin (salicylate).

      Kawasaki disease is a type of vasculitis that mainly affects children under the age of 5, causing symptoms such as high fever, swollen blood vessels, and enlarged lymph nodes. Aspirin is an exception and may be used in children under 16 years of age to treat this condition, which can also lead to heart damage.

      Buerger’s disease is not treated with aspirin, so the second option is incorrect.

      How Aspirin Works and its Use in Cardiovascular Disease

      Aspirin is a medication that works by blocking the action of cyclooxygenase-1 and 2, which are responsible for the synthesis of prostaglandin, prostacyclin, and thromboxane. By blocking the formation of thromboxane A2 in platelets, aspirin reduces their ability to aggregate, making it a widely used medication in cardiovascular disease. However, recent trials have cast doubt on the use of aspirin in primary prevention of cardiovascular disease, and guidelines have not yet changed to reflect this. Aspirin should not be used in children under 16 due to the risk of Reye’s syndrome, except in cases of Kawasaki disease where the benefits outweigh the risks. As for its use in ischaemic heart disease, aspirin is recommended as a first-line treatment. It can also potentiate the effects of oral hypoglycaemics, warfarin, and steroids. It is important to note that recent guidelines recommend clopidogrel as a first-line treatment for ischaemic stroke and peripheral arterial disease, while the use of aspirin in TIAs remains a topic of debate among different guidelines.

      Overall, aspirin’s mechanism of action and its use in cardiovascular disease make it a valuable medication in certain cases. However, recent studies have raised questions about its effectiveness in primary prevention, and prescribers should be aware of the potential risks and benefits when considering its use.

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