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Question 1
Incorrect
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A 25 year-old female patient visits her GP complaining of a two week history of pale and homogenous vaginal discharge that has an offensive odor but is not causing any itching or irritation. Upon examination, there is no inflammation of the cervix or vagina and the discharge has a pH of 6.3. A sample of the discharge is collected. What is the probable result of the analysis of the discharge sample?
Your Answer: Lactobacilli
Correct Answer: Gram-positive and negative bacteria
Explanation:Bacterial vaginosis is the identified condition, primarily caused by an overgrowth of anaerobic organisms in the vagina, with Gardnerella vaginalis being the most prevalent. This results in the displacement of lactobacilli, which would not be detected in the sample. The presence of hyphae suggests the existence of Candida (thrush).
Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.
Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimes. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.
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This question is part of the following fields:
- Reproductive Medicine
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Question 2
Correct
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A 15-year-old girl comes to the clinic with concerns about not having started her periods yet. She is shorter than most girls her age. She has gone through adrenarche but has not yet experienced thelarche. Her mother and sister both began menstruating at age 12. The following are her blood test results:
- FSH: 60 IU/L (normal range: 0-10)
- LH: 40 IU/L (normal range: 0-16)
- Oestradiol: 6.4 pmol/L (normal range: 73-407)
- Thyroid stimulating hormone (TSH): 5.0 mU/L (normal range: 0.5-5.5)
- Free thyroxine (T4): 12 pmol/L (normal range: 9.0-18)
- Prolactin: 323 mIU/L (normal range: <700)
Based on the patient's symptoms and test results, what is the most likely cause of her amenorrhoea?Your Answer: Turner's syndrome
Explanation:Understanding Turner’s Syndrome
Turner’s syndrome is a genetic disorder that affects approximately 1 in 2,500 females. It is caused by the absence of one sex chromosome (X) or a deletion of the short arm of one of the X chromosomes. This condition is denoted as 45,XO or 45,X.
The features of Turner’s syndrome include short stature, a shield chest with widely spaced nipples, a webbed neck, a bicuspid aortic valve (15%), coarctation of the aorta (5-10%), primary amenorrhea, cystic hygroma (often diagnosed prenatally), a high-arched palate, a short fourth metacarpal, multiple pigmented naevi, lymphoedema in neonates (especially feet), and elevated gonadotrophin levels. Hypothyroidism is much more common in Turner’s syndrome, and there is also an increased incidence of autoimmune disease (especially autoimmune thyroiditis) and Crohn’s disease.
In summary, Turner’s syndrome is a chromosomal disorder that affects females and can cause a range of physical features and health issues. Early diagnosis and management can help individuals with Turner’s syndrome lead healthy and fulfilling lives.
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This question is part of the following fields:
- Paediatrics
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Question 3
Correct
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A 48-year-old man comes to the General Practitioner complaining of feeling dizzy and experiencing shortness of breath during physical activity. He has a bicuspid aortic valve and is waiting for valve replacement surgery.
Which of the following murmurs would be the most likely to occur in this patient?Your Answer: Ejection systolic murmur loudest over the 2nd intercostal space, right sternal edge
Explanation:Differentiating Heart Murmurs Based on Location and Type
Heart murmurs are abnormal sounds heard during a heartbeat and can indicate various cardiac conditions. The location and type of murmur can help differentiate between different conditions.
Ejection systolic murmur loudest over the 2nd intercostal space, right sternal edge: This is typical for aortic stenosis, which is more likely to occur in a bicuspid aortic valve. The murmur may radiate to the carotids. Pulmonary stenosis, hypertrophic obstructive cardiomyopathy, and atrial septal defect can also cause this type of murmur, but the location would be different.
Ejection systolic murmur loudest over the 2nd intercostal space, left sternal edge: This location is typical for pulmonary stenosis, not aortic stenosis. The patient’s history indicates symptomatic aortic stenosis, making this finding inconsistent.
Early diastolic murmur loudest over the 3rd intercostal space, left sternal edge: This type and location of murmur is typical for aortic regurgitation, not aortic stenosis. The location is Erb’s point, where S1 and S2 should both be heard.
Mid-diastolic murmur loudest over the apex: This type and location of murmur is typical for mitral stenosis, not aortic stenosis. The apex is the mitral area, located at the 5th intercostal space in the midclavicular line.
Pansystolic murmur loudest over the apex: This type and location of murmur is typical for mitral regurgitation, not aortic stenosis. The apex is the mitral area, located at the 5th intercostal space in the midclavicular line.
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This question is part of the following fields:
- Cardiovascular
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Question 4
Incorrect
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Among the following individuals, which one has the highest risk of suicide?
Your Answer: A married man with two children
Correct Answer: A 50-year-old man with alcohol dependence and prior suicide attempts
Explanation:Understanding the Risk Factors for Suicide
Suicide is a complex issue with a variety of risk factors. The strongest indicators of suicide are the presence of a mental disorder, including alcohol-use disorder, and a history of previous suicide attempts. Age and sex also play a role, with the risk increasing with age and men being more likely to complete suicide. Marital status, unemployment, living alone, and chronic illnesses are also associated with an increased risk. It is important to understand these risk factors in order to identify and prevent suicide.
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This question is part of the following fields:
- Psychiatry
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Question 5
Correct
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A 4-year-old child is presented for surgery due to the mother's observation of 'cross-eyed' appearance. The corneal light reflection test confirms the diagnosis. What is the best course of action?
Your Answer: Refer to ophthalmology
Explanation:It is recommended to refer children who have a squint to ophthalmology for further evaluation.
Squint, also known as strabismus, is a condition where the visual axes are misaligned. There are two types of squints: concomitant and paralytic. Concomitant squints are more common and are caused by an imbalance in the extraocular muscles. On the other hand, paralytic squints are rare and are caused by the paralysis of extraocular muscles. It is important to detect squints early on as they can lead to amblyopia, where the brain fails to process inputs from one eye and favours the other eye over time.
To detect a squint, a corneal light reflection test can be performed by holding a light source 30cm from the child’s face to see if the light reflects symmetrically on the pupils. The cover test is also used to identify the nature of the squint. This involves asking the child to focus on an object, covering one eye, and observing the movement of the uncovered eye. The test is then repeated with the other eye covered.
If a squint is detected, it is important to refer the child to secondary care. Eye patches may also be used to help prevent amblyopia.
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This question is part of the following fields:
- Ophthalmology
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Question 6
Incorrect
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Which of the following skin conditions is not linked to diabetes mellitus?
Your Answer: Vitiligo
Correct Answer: Sweet's syndrome
Explanation:Sweet’s syndrome is a condition associated with acute myeloid leukemia, also known as acute febrile neutrophilic dermatosis, but not with diabetes mellitus.
Skin Disorders Linked to Diabetes
Diabetes mellitus is a chronic metabolic disorder that affects various organs in the body, including the skin. Several skin disorders are associated with diabetes, including necrobiosis lipoidica, infections such as candidiasis and staphylococcal, neuropathic ulcers, vitiligo, lipoatrophy, and granuloma annulare. Necrobiosis lipoidica is characterized by shiny, painless areas of yellow, red, or brown skin, typically on the shin, and is often associated with surrounding telangiectasia. Infections such as candidiasis and staphylococcal can also occur in individuals with diabetes. Neuropathic ulcers are a common complication of diabetes, and vitiligo and lipoatrophy are also associated with the condition. Granuloma annulare is a papular lesion that is often slightly hyperpigmented and depressed centrally, but recent studies have not confirmed a significant association between diabetes mellitus and this skin disorder. It is important for individuals with diabetes to be aware of these potential skin complications and to seek medical attention if they notice any changes in their skin.
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This question is part of the following fields:
- Dermatology
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Question 7
Correct
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A 50-year-old man presents to the emergency department with a 24-hour history of worsening right knee pain and limited mobility. He reports falling off his bike a few days ago but did not experience any knee pain until yesterday. Upon examination, the right knee appears red and hot with only 20º of flexion and a small effusion. The patient has a history of a conservatively treated ACL rupture in the other knee.
The patient's vital signs are as follows: heart rate 100 beats/min, respiratory rate 18/min, saturations 98% on room air, blood pressure 102/67 mmHg, and temperature 37.9ºC. Blood tests reveal a hemoglobin level of 145 g/L, platelets of 500 * 109/L, a white cell count of 13.6 * 109/L, a sodium level of 142 mmol/L, a potassium level of 5.0 mmol/L, a urea level of 4.0 mmol/L, a creatinine level of 110 µmol/L, and a CRP level of 130 mg/L. X-ray results show no obvious bony injury.
What is the most appropriate next step in managing this patient?Your Answer: Urgent orthopaedic review
Explanation:Septic arthritis is most commonly observed in adults’ knees, which presents as sudden joint pain and immobility, accompanied by fever and elevated inflammatory markers. Urgent orthopaedic evaluation is necessary for aspiration and potential washout, as untreated septic arthritis can lead to joint destruction within hours to days. Discharging the patient with oral antibiotics or physiotherapy is not recommended. Administering colchicine is not appropriate as there is no history of gout or pseudogout, and X-ray results do not indicate chondrocalcinosis. Ordering an MRI knee scan may delay appropriate treatment and will not impact management.
Septic Arthritis in Adults: Causes, Symptoms, and Treatment
Septic arthritis is a condition that occurs when bacteria infect a joint, leading to inflammation and pain. The most common organism that causes septic arthritis in adults is Staphylococcus aureus, but in young adults who are sexually active, Neisseria gonorrhoeae is the most common organism. The infection usually spreads through the bloodstream from a distant bacterial infection, such as an abscess. The knee is the most common location for septic arthritis in adults. Symptoms include an acute, swollen joint, restricted movement, warmth to the touch, and fever.
To diagnose septic arthritis, synovial fluid sampling is necessary and should be done before administering antibiotics if necessary. Blood cultures may also be taken to identify the cause of the infection. Joint imaging may also be used to confirm the diagnosis.
Treatment for septic arthritis involves intravenous antibiotics that cover Gram-positive cocci. Flucloxacillin or clindamycin is recommended if the patient is allergic to penicillin. Antibiotic treatment is typically given for several weeks, and patients are usually switched to oral antibiotics after two weeks. Needle aspiration may be used to decompress the joint, and arthroscopic lavage may be required in some cases.
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This question is part of the following fields:
- Musculoskeletal
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Question 8
Incorrect
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A 10-year-old girl has been treated in the hospital for her first acute asthma exacerbation. She was previously only taking salbutamol as needed. After 24 hours, she is stable on inhaled salbutamol six puffs four times a day via a spacer and twice-daily steroid inhaler.
What is the most suitable next step in managing this acute asthma exacerbation?Your Answer: Wean down salbutamol to 2 puffs twice a day before hospital discharge
Correct Answer: Course of oral steroids
Explanation:Correct and Incorrect Treatment Approaches for Acute Asthma Exacerbation in Children
Acute asthma exacerbation in children requires prompt and appropriate treatment to prevent complications. Here are some correct and incorrect treatment approaches for this condition:
Course of oral steroids: Giving oral steroids early in the treatment of acute asthma attacks in children is advisable. The initial course length should be tailored to response.
Wean down salbutamol to 2 puffs twice a day before hospital discharge: Weaning down salbutamol to two puffs twice a day before hospital discharge is incorrect. Children may be discharged from hospital once stable on 3- to 4-hourly bronchodilators which can be continued at home.
Addition of salmeterol inhaler: Adding a salmeterol inhaler is incorrect. The initial next step of treatment should be inhaled corticosteroids (ICSs) for patients who have had an asthma attack in the last two years.
Continue monitoring in hospital until salbutamol is no longer required: Continuing monitoring in hospital until salbutamol is no longer required is incorrect. Children may be discharged from hospital once stable on 3- to 4-hourly bronchodilators which can be continued at home.
IV hydrocortisone: Administering IV hydrocortisone is incorrect. It is reserved for the treatment of acute life-threatening asthma.
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This question is part of the following fields:
- Respiratory Medicine
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Question 9
Incorrect
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An 83-year-old woman with a history of hypertension and atrial fibrillation arrives at the emergency department with dysarthria and left-sided weakness that she noticed earlier today. During the examination, left-sided hemiparesis is observed, and her blood glucose level is 6.5 mmol/L. What is the next appropriate investigation?
Your Answer: CT head with contrast
Correct Answer: Non-contrast CT head
Explanation:Assessment and Investigations for Stroke
Whilst diagnosing a stroke may be straightforward in some cases, it can be challenging when symptoms are vague. The FAST screening tool, which stands for Face/Arms/Speech/Time, is a well-known tool used by the general public to identify stroke symptoms. However, medical professionals use a validated tool called the ROSIER score, recommended by the Royal College of Physicians. The ROSIER score assesses for loss of consciousness or syncope, seizure activity, and new, acute onset of asymmetric facial, arm, or leg weakness, speech disturbance, or visual field defect. A score of greater than zero indicates a likely stroke.
When investigating suspected stroke, a non-contrast CT head scan is the first line radiological investigation. The key question to answer is whether the stroke is ischaemic or haemorrhagic, as this determines the appropriate management. Ischaemic strokes may show areas of low density in the grey and white matter of the territory, while haemorrhagic strokes typically show areas of hyperdense material surrounded by low density. It is important to identify the type of stroke promptly, as thrombolysis and thrombectomy play an increasing role in acute stroke management. In rare cases, a third pathology such as a tumour may also be detected.
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This question is part of the following fields:
- Neurology
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Question 10
Correct
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A 35-year-old man presented to his GP with bilateral deafness. Rinne’s test was found to be negative bilaterally. Weber's test was referred to both sides. On examination of his tympanic membrane, Schwartz's sign was visible.
Which of the following is the MOST likely cause of his symptoms?
Your Answer: Otosclerosis
Explanation:Understanding the Causes of Hearing Loss: A Comparison of Otosclerosis, Cholesteatoma, Ménière’s Disease, Otitis Externa, and Otitis Media
Hearing loss can be caused by a variety of factors, including otosclerosis, cholesteatoma, Ménière’s disease, otitis externa, and otitis media. When conducting a differential diagnosis, it is important to consider the patient’s age, symptoms, and medical history.
Otosclerosis is a common cause of hearing loss in young adults, typically presenting as unilateral conductive hearing loss that progresses bilaterally. A negative Rinne’s test is indicative of conductive deafness, and a pink tinge on the tympanic membrane (Schwartz’s sign) is a diagnostic indicator for otosclerosis.
Cholesteatoma, on the other hand, typically presents with unilateral conductive hearing loss and/or ear discharge. Given the patient’s bilateral symptoms and young age, cholesteatoma is less likely to be the cause of her hearing loss.
Ménière’s disease is characterized by sudden attacks of tinnitus, vertigo, a sensation of fullness in the ear, and fluctuating sensorineural hearing loss. This is not the likely cause of the patient’s conductive hearing loss.
Otitis externa is inflammation of the external ear canal, which can cause hearing loss in rare cases due to occlusion of the ear canal from inflammation. Otitis media, on the other hand, is inflammation of the middle ear and is more commonly seen in children. It may present with unilateral conductive deafness, but is unlikely to be the cause of the patient’s bilateral symptoms.
In conclusion, when considering the causes of hearing loss, it is important to take into account the patient’s age, symptoms, and medical history. Otosclerosis is the most likely cause of conductive hearing loss in young adults, while cholesteatoma, Ménière’s disease, otitis externa, and otitis media may also be potential causes depending on the individual case.
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This question is part of the following fields:
- ENT
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Question 11
Correct
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A nurse updates you on a 29-year-old woman who is 24 weeks pregnant. The nurse reports that her blood pressure reading is 155/90 mmHg, which has increased from her previous reading of 152/85 mmHg taken 2 days ago. The woman had no health issues before her pregnancy. What is the initial course of action in this scenario?
Your Answer: Oral labetalol
Explanation:Oral labetalol is the recommended initial treatment for this woman with moderate gestational hypertension, as per the current guidelines.
Hypertension during pregnancy is a common occurrence that requires careful management. In normal pregnancies, blood pressure tends to decrease in the first trimester and then gradually increase to pre-pregnancy levels by term. However, in cases of hypertension during pregnancy, the systolic blood pressure is usually above 140 mmHg or the diastolic blood pressure is above 90 mmHg. Additionally, an increase of more than 30 mmHg systolic or 15 mmHg diastolic from the initial readings may also indicate hypertension.
There are three categories of hypertension during pregnancy: pre-existing hypertension, pregnancy-induced hypertension (PIH), and pre-eclampsia. Pre-existing hypertension refers to a history of hypertension before pregnancy or elevated blood pressure before 20 weeks gestation. PIH occurs in the second half of pregnancy and resolves after birth. Pre-eclampsia is characterized by hypertension and proteinuria, and may also involve edema.
The management of hypertension during pregnancy involves the use of antihypertensive medications such as labetalol, nifedipine, and hydralazine. In cases of pre-existing hypertension, ACE inhibitors and angiotensin II receptor blockers should be stopped immediately and alternative medications should be prescribed. Women who are at high risk of developing pre-eclampsia should take aspirin from 12 weeks until the birth of the baby. It is important to carefully monitor blood pressure and proteinuria levels during pregnancy to ensure the health of both the mother and the baby.
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This question is part of the following fields:
- Reproductive Medicine
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Question 12
Incorrect
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A 62-year-old non-smoker with no significant medical history presents to their GP with a cough producing green sputum, fatigue, and shortness of breath that has lasted for several days. During chest examination, coarse crackles are heard in the lower right zone. The patient's observations are as follows: respiratory rate of 20 breaths per minute, oxygen saturation of 97% on air, heart rate of 80 beats per minute, blood pressure of 110/75 mmHg, temperature of 38.1ºC, and an abbreviated mental test score of 10/10. The patient is not on any regular medication and has no allergies. What is the most appropriate treatment?
Your Answer: Discharge with oral doxycycline
Correct Answer: Discharge with oral amoxicillin
Explanation:The recommended first-line antibiotic for patients with low severity community-acquired pneumonia (CAP) is oral amoxicillin. Therefore, it is appropriate to discharge this patient with oral amoxicillin as they present with symptoms of CAP, including a new cough, temperature, purulent sputum, and focal chest signs. While a chest x-ray could confirm the diagnosis, it is not usually necessary for suspected CAP managed in primary care. The patient’s CRB-65 score is 0, indicating that they can be managed in the community. Hospitalization may be required for patients with higher scores or clinical factors that increase the risk of complications, but this is not the case for this patient. Discharge with oral clarithromycin or doxycycline is not appropriate as there is no indication that amoxicillin is unsuitable as the first-line antibiotic.
Pneumonia is a serious respiratory infection that requires prompt assessment and management. In the primary care setting, the CRB65 criteria are used to stratify patients based on their risk of mortality. Patients with a score of 0 are considered low risk and may be treated at home, while those with a score of 3 or 4 are high risk and require urgent admission to hospital. The use of a point-of-care CRP test can help guide antibiotic therapy. In the secondary care setting, the CURB65 criteria are used, which includes an additional criterion of urea > 7 mmol/L. Chest x-rays and blood and sputum cultures are recommended for intermediate or high-risk patients. Treatment for low-severity community acquired pneumonia typically involves a 5-day course of amoxicillin, while moderate and high-severity cases may require dual antibiotic therapy for 7-10 days. Discharge criteria and advice post-discharge are also provided, including information on expected symptom resolution timeframes and the need for a repeat chest x-ray at 6 weeks.
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This question is part of the following fields:
- Respiratory Medicine
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Question 13
Correct
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You assess a 29-year-old woman who is 24 weeks pregnant. Due to her BMI of 33 kg/m², she underwent a routine oral glucose tolerance test which yielded the following results:
Time (hours) Blood glucose (mmol/l)
0 7.8
2 10.6
Apart from this, there have been no other complications during her pregnancy and her anomaly scan showed no abnormalities. What would be the best course of action?Your Answer: Start insulin + advice about diet / exercise + self-monitor glucose levels
Explanation:The gestational diabetes guidelines of NICE have been updated, stating that insulin treatment must commence if the fasting glucose level is equal to or greater than 7 mmol/l. Additionally, it is recommended to consider administering aspirin due to the heightened risk of pre-eclampsia.
Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.
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This question is part of the following fields:
- Reproductive Medicine
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Question 14
Correct
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A 64-year-old male with a history of mitral regurgitation is scheduled for dental polishing. He has a documented penicillin allergy. What is the recommended prophylaxis for preventing infective endocarditis?
Your Answer: No antibiotic prophylaxis needed
Explanation:In the UK, it is no longer standard practice to use antibiotics as a preventative measure against infective endocarditis during dental or other procedures, as per the 2008 NICE guidelines which have brought about a significant shift in approach.
Infective endocarditis is a serious infection of the heart lining and valves. The 2008 guidelines from NICE have changed the list of procedures for which antibiotic prophylaxis is recommended. According to NICE, dental procedures, gastrointestinal, genitourinary, and respiratory tract procedures do not require prophylaxis. However, if a person at risk of infective endocarditis is receiving antimicrobial therapy because they are undergoing a gastrointestinal or genitourinary procedure at a site where there is a suspected infection, they should be given an antibiotic that covers organisms that cause infective endocarditis. It is important to note that these recommendations differ from the American Heart Association/European Society of Cardiology guidelines, which still advocate antibiotic prophylaxis for high-risk patients undergoing dental procedures.
The guidelines suggest that any episodes of infection in people at risk of infective endocarditis should be investigated and treated promptly to reduce the risk of endocarditis developing. It is crucial to follow these guidelines to prevent the development of infective endocarditis, which can lead to severe complications and even death. It is also important to note that these guidelines may change over time as new research and evidence become available. Therefore, healthcare professionals should stay up-to-date with the latest recommendations to provide the best possible care for their patients.
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This question is part of the following fields:
- Cardiovascular
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Question 15
Correct
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The organism that is becoming increasingly resistant to antimicrobial agents and is responsible for a high number of hospital-acquired infections is which of the following?
Your Answer: Staphylococcus aureus
Explanation:Common Pathogens and Their Associated Infections
Hospital-acquired infections can be caused by various pathogens, including viruses, bacteria, and fungi. The most common types of infections are bloodstream infection, pneumonia, urinary tract infection, and surgical site infection. Staphylococcus aureus is a prevalent pathogen, with approximately 33% of the general population being carriers and 2% carrying the antibiotic-resistant strain MRSA. Toxoplasma gondii can cause severe disease in fetuses, newborns, and immunocompromised patients. Streptococcus pneumoniae is a leading cause of pneumonia and meningitis in children and the elderly, as well as septicaemia in HIV-infected individuals. Pneumocystis jiroveci is a rare cause of infection in the general population but can cause pneumonia in immunocompromised patients, especially those with AIDS. Listeria monocytogenes primarily affects newborns, elderly patients, and immunocompromised individuals. Understanding these common pathogens and their associated infections is crucial in preventing and treating hospital-acquired infections.
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This question is part of the following fields:
- Infectious Diseases
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Question 16
Correct
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A middle-aged patient presents with lethargy, weight loss and fainting episodes. In the Emergency Department, a postural drop in blood pressure is noted of > 20 mmHg systolic from the supine to the standing position. Blood glucose is 2.9 mmol/l, and Na+ is 122 mmol/l.
What is the cause of this patient's condition?Your Answer: Decreased cortisol; decreased aldosterone
Explanation:Understanding Addison’s Disease: Hormonal Imbalances and Clinical Presentation
Addison’s disease, or primary adrenal failure, is a condition characterized by autoimmune destruction of the adrenal cortex, resulting in reduced levels of cortisol and aldosterone. This hormonal imbalance leads to a range of clinical symptoms, including hypotension, hyponatraemia, hyperkalaemia, acidosis, and skin and mucosal hyperpigmentation.
While other hormonal imbalances may occur in the adrenal glands, such as increased cortisol or aldosterone, they are less likely to result in the clinical presentation of Addison’s disease. For example, increased cortisol is unlikely due to autoimmune destruction of the zona fasciculata, while increased aldosterone is rare and typically caused by an adrenal adenoma. Similarly, decreased cortisol with normal aldosterone is more commonly associated with secondary adrenal failure caused by pituitary disease, but does not fit with the hyponatraemia seen in Addison’s disease.
Overall, understanding the hormonal imbalances and clinical presentation of Addison’s disease is crucial for accurate diagnosis and effective treatment.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 17
Correct
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A young girl from a nomadic group has been diagnosed with measles. What is the potential immediate complication she may face following the initial infection?
Your Answer: Pneumonia
Explanation:Pneumonia is a possible complication of measles, while subacute sclerosing panencephalitis may develop 5-10 years after the illness. Mumps infection may lead to pancreatitis and infertility.
Measles: A Highly Infectious Viral Disease
Measles is a viral disease caused by an RNA paramyxovirus. It is one of the most infectious known viruses and is spread through aerosol transmission. The disease has an incubation period of 10-14 days and 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, such as during the MMR controversy of the early 2000s.
The disease is characterized by a prodromal phase, which includes irritability, conjunctivitis, fever, and Koplik spots. The latter typically develop before the rash and are white spots on the buccal mucosa. 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 in immunosuppressed or pregnant patients. The disease is notifiable, and public health should be informed. Complications of measles include otitis media, pneumonia (the most common cause of death), encephalitis (typically occurring 1-2 weeks following the onset of the illness), subacute sclerosing panencephalitis (very rare, may present 5-10 years following the illness), febrile convulsions, keratoconjunctivitis, corneal ulceration, diarrhea, increased incidence of appendicitis, and myocarditis.
If an unimmunized 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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This question is part of the following fields:
- Paediatrics
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Question 18
Incorrect
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A 9-month-old boy is presented to the GP with a 4-week history of rash. He has no significant medical history and is meeting developmental milestones appropriately. He has received all of his scheduled immunizations, has no known allergies, and is feeding and urinating well. Upon examination, there is a symmetrical, poorly defined erythematous rash on his elbows and knees. What is the most probable diagnosis?
Your Answer: Psoriasis
Correct Answer: Eczema
Explanation:Atopic eczema commonly appears in children before the age of 2, with symptoms often affecting the face and extensor surfaces of the body. This patient’s visible dermatitis in the extensor aspects of her body suggests a diagnosis of atopic eczema based on clinical presentation. Impetigo, pemphigus vulgaris, and psoriasis are unlikely diagnoses given the patient’s symmetrical dry rash involving the extensor aspects of the limbs.
Eczema in Children: Symptoms and Management
Eczema is a common skin condition that affects around 15-20% of children and is becoming more prevalent. It usually appears before the age of 2 and clears up in around 50% of children by the age of 5 and in 75% of children by the age of 10. The symptoms of eczema include an itchy, red rash that can worsen with repeated scratching. In infants, the face and trunk are often affected, while in younger children, it typically occurs on the extensor surfaces. In older children, the rash is more commonly seen on the flexor surfaces and in the creases of the face and neck.
To manage eczema in children, it is important to avoid irritants and use simple emollients. Large quantities of emollients should be prescribed, roughly in a ratio of 10:1 with topical steroids. If a topical steroid is also being used, the emollient should be applied first, followed by waiting at least 30 minutes before applying the topical steroid. Creams are absorbed into the skin faster than ointments, and emollients can become contaminated with bacteria, so fingers should not be inserted into pots. Many brands have pump dispensers to prevent contamination.
In severe cases, wet wrapping may be used, which involves applying large amounts of emollient (and sometimes topical steroids) under wet bandages. Oral ciclosporin may also be used in severe cases. Overall, managing eczema in children involves a combination of avoiding irritants, using emollients, and potentially using topical steroids or other medications in severe cases.
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This question is part of the following fields:
- Paediatrics
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Question 19
Incorrect
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You are evaluating a patient who is experiencing hip discomfort. Do you suspect osteoarthritis as the diagnosis? If so, what signs or symptoms would warrant additional testing for a different diagnosis?
Your Answer: A history of development dysplasia of the hip
Correct Answer: Morning stiffness lasting 4 hours
Explanation:If morning stiffness persists for more than 2 hours, it could be a sign of inflammatory arthritis and should be investigated further.
Osteoarthritis (OA) of the hip is a prevalent condition, with the knee being the only joint more commonly affected. It is particularly prevalent in older individuals, and women are twice as likely to develop it. Obesity and developmental dysplasia of the hip are also risk factors. The condition is characterized by chronic groin pain that is exacerbated by exercise and relieved by rest. However, if the pain is present at rest, at night, or in the morning for more than two hours, it may indicate an alternative cause. The Oxford Hip Score is a widely used tool to assess the severity of the condition.
If the symptoms are typical, a clinical diagnosis can be made. Otherwise, plain x-rays are the first-line investigation. Management of OA of the hip includes oral analgesia and intra-articular injections, which provide short-term relief. However, total hip replacement is the definitive treatment.
Total hip replacement is a common operation in the developed world, but it is not without risks. Perioperative complications include venous thromboembolism, intraoperative fracture, nerve injury, surgical site infection, and leg length discrepancy. Postoperatively, posterior dislocation may occur during extremes of hip flexion, presenting with a clunk, pain, and inability to weight bear. Aseptic loosening is the most common reason for revision, and prosthetic joint infection is also a potential complication.
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This question is part of the following fields:
- Musculoskeletal
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Question 20
Incorrect
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A 32-year-old construction worker visits his doctor complaining of hay fever symptoms. He is experiencing frequent sneezing and a runny nose and is seeking medication to alleviate his discomfort. Considering his job, which antihistamine would be safe for him to use?
Your Answer: Cinnarizine
Correct Answer: Loratadine
Explanation:Loratadine is an antihistamine that does not cause drowsiness. It works by targeting histamine H1 receptors to relieve allergy symptoms like sneezing and runny nose. As the patient is a heavy goods vehicle driver, it is advisable to recommend a non-sedating antihistamine like loratadine. Chlorphenamine, on the other hand, is a sedating antihistamine used in anaphylaxis treatment and is not suitable for the patient’s occupation. Cimetidine inhibits stomach acid production and does not help with allergy symptoms. Cinnarizine is a sedating antihistamine used for nausea and vomiting and may not be effective for the patient’s condition. Diphenhydramine is also a sedating antihistamine and not recommended for the patient.
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This question is part of the following fields:
- ENT
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