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Question 1
Incorrect
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A 56-year-old man is evaluated after being diagnosed with hypertension. As part of his assessment, he underwent a series of blood tests to screen for other risk factors:
Na+ 142 mmol/l
K+ 3.9 mmol/l
Urea 6.2 mmol/l
Creatinine 91 µmol/l
Fasting glucose 7.7 mmol/l
Total cholesterol 7.2 mmol/l
Due to the fasting glucose result, you order a HbA1c:
HbA1c 31 mmol/mol (5.0%)
What could account for the discrepancy between the HbA1c and fasting glucose levels?Your Answer: A history of alcohol excess
Correct Answer: Sickle-cell anaemia
Explanation:Understanding Glycosylated Haemoglobin (HbA1c) in Diabetes Mellitus
Glycosylated haemoglobin (HbA1c) is a commonly used measure of long-term blood sugar control in diabetes mellitus. It is produced when glucose attaches to haemoglobin in the blood at a rate proportional to the glucose concentration. The level of HbA1c is influenced by the lifespan of red blood cells and the average blood glucose concentration. However, certain conditions such as sickle-cell anaemia, GP6D deficiency, and haemodialysis can interfere with accurate interpretation of HbA1c levels.
HbA1c is believed to reflect the blood glucose levels over the past 2-4 weeks, although it is generally thought to represent the previous 3 months. It is recommended that HbA1c be checked every 3-6 months until stable, then every 6 months. The Diabetes Control and Complications Trial (DCCT) has studied the complex relationship between HbA1c and average blood glucose. The International Federation of Clinical Chemistry (IFCC) has developed a new standardised method for reporting HbA1c in mmol per mol of haemoglobin without glucose attached.
Understanding HbA1c is crucial in managing diabetes mellitus and achieving optimal blood sugar control.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 2
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A 38-year-old woman with rheumatoid arthritis visits her doctor every three months for blood tests. Which of the following blood tests is necessary for monitoring the use of methotrexate?
Your Answer: FBC, U&Es, LFTs
Explanation:Importance of Drug Monitoring in Primary Care
Patients on methotrexate require regular monitoring of their blood tests to prevent severe side effects. The three essential blood tests that need monitoring are FBC, U&Es, and LFTs. Methotrexate can cause blood dyscrasias, liver cirrhosis, and kidney failure, making it crucial to monitor these tests every 2-3 months once therapy has stabilized. Patients should report any symptoms of infection, bruising, mouth ulcers, abdominal discomfort, dark urine, and shortness of breath. They should also avoid self-medication with over-the-counter aspirin or ibuprofen.
Thyroid function is not affected by methotrexate, and regular monitoring is not necessary unless there is another medical condition that justifies it. However, patients on methotrexate should report any signs of blood disorders such as ecchymosis and telangiectasia.
Drug monitoring is becoming increasingly common in primary care, especially for patients under shared care with secondary/specialty care. Some examples of drug monitoring in primary care include amiodarone, azathioprine, lithium, and methotrexate. Each drug requires specific blood tests, and the frequency of monitoring varies. For instance, patients on methotrexate require FBC, U&Es, and LFTs every 2-3 months.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 3
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A 28-year-old primip nurse has presented to you 5 days after being in contact with a child who had a vesicular rash on their face and chest. She is currently 14 weeks pregnant and has been experiencing some morning sickness, but otherwise feels fine. Her blood tests show that she is not immune to varicella zoster virus. What should be the next course of action in your management plan?
Your Answer: A single dose of varicella-zoster immunoglobulin (VZI)
Explanation:If a pregnant woman is not immune to the varicella zoster virus and has been in close contact with someone who has the virus, it is recommended that she receive varicella-zoster immunoglobulin (VZIG) as soon as possible. VZIG can be effective up to 10 days after contact, or 10 days after the appearance of the rash in the person with the virus if there are continuous exposures.
For pregnant women who are not immune and have been exposed to chickenpox, they should be considered potentially infectious from 8-28 days after exposure if they receive VZIG, and from 8-21 days after exposure if they do not receive VZIG.
Source: RCOGChickenpox exposure in pregnancy can pose risks to both the mother and fetus, including fetal varicella syndrome. Post-exposure prophylaxis (PEP) with varicella-zoster immunoglobulin (VZIG) or antivirals should be given to non-immune pregnant women, with timing dependent on gestational age. If a pregnant woman develops chickenpox, specialist advice should be sought and oral aciclovir may be given if she is ≥ 20 weeks and presents within 24 hours of onset of the rash.
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This question is part of the following fields:
- Reproductive Medicine
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Question 4
Incorrect
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A 28-year-old newly qualified nurse presents with a bilateral erythematous rash on both hands. She has recently moved from the Philippines and has no significant medical history. The suspected diagnosis is contact dermatitis. What is the most appropriate test to determine the underlying cause?
Your Answer: Skin prick test
Correct Answer: Skin patch test
Explanation:The skin patch test can be beneficial in this scenario as it has the potential to detect irritants in addition to allergens.
Types of Allergy Tests
Allergy tests are used to determine if a person has an allergic reaction to a particular substance. There are several types of allergy tests available, each with its own advantages and limitations. The most commonly used test is the skin prick test, which is easy to perform and inexpensive. Drops of diluted allergen are placed on the skin, and a needle is used to pierce the skin. A wheal will typically develop if a patient has an allergy. This test is useful for food allergies and pollen.
Another type of allergy test is the radioallergosorbent test (RAST), which determines the amount of IgE that reacts specifically with suspected or known allergens. Results are given in grades from 0 (negative) to 6 (strongly positive). This test is useful for food allergies, inhaled allergens (e.g. pollen), and wasp/bee venom.
Skin patch testing is useful for contact dermatitis. Around 30-40 allergens are placed on the back, and irritants may also be tested for. The patches are removed 48 hours later, and the results are read by a dermatologist after a further 48 hours. Blood tests may be used when skin prick tests are not suitable, for example if there is extensive eczema or if the patient is taking antihistamines. Overall, allergy tests are an important tool in diagnosing and managing allergies.
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This question is part of the following fields:
- Dermatology
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Question 5
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A 28-year-old woman presents with complaints of recurring pain in her left ankle for the past 4-5 weeks. She also reports experiencing pain in her left sole and swelling in her right toes. Additionally, she has developed low back pain over the last 2 weeks. Upon further inquiry, she mentions having painless oral ulcers that heal on their own. She recently had chlamydial urethritis. Her full blood count, kidney, and liver function tests are all normal, and an autoimmune screen is negative. What is the most likely diagnosis?
Your Answer: Reactive arthritis
Explanation:Differentiating Reactive Arthritis from Other Arthritic Conditions
Reactive arthritis is a type of arthritis that occurs after an infection, typically dysentery or a sexually transmitted disease. It is characterized by an acute, asymmetrical lower limb arthritis, with common symptoms including enthesitis, sacroiliitis, and spondylosis. Patients may also experience mouth ulcers, conjunctivitis, and cutaneous features such as circinate balanitis and keratoderma blenorrhagia. However, it is important to differentiate reactive arthritis from other arthritic conditions such as disseminated bacterial arthritis, rheumatoid arthritis, ankylosing spondylitis, and hypersensitivity vasculitis. Understanding the unique features of each condition can aid in accurate diagnosis and appropriate treatment.
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This question is part of the following fields:
- Musculoskeletal
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Question 6
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Which of the following is a contraindication to using a triptan for treating migraines in elderly patients?
Your Answer: A history of ischaemic heart disease
Explanation:Triptan use is contraindicated in individuals with cardiovascular disease.
Triptans for Migraine Treatment
Triptans are medications that act as agonists for 5-HT1B and 5-HT1D receptors and are commonly used in the acute treatment of migraines. They are often prescribed in combination with NSAIDs or paracetamol and are typically taken as soon as possible after the onset of a headache, rather than at the onset of an aura. Triptans are available in various forms, including oral tablets, orodispersible tablets, nasal sprays, and subcutaneous injections.
While triptans are generally well-tolerated, some patients may experience triptan sensations, such as tingling, heat, tightness in the throat and chest, heaviness, or pressure. It is important to note that triptans are contraindicated in patients with a history of or significant risk factors for ischaemic heart disease or cerebrovascular disease.
In summary, triptans are a commonly used medication for the acute treatment of migraines. They should be taken as soon as possible after the onset of a headache and are available in various forms. However, patients should be aware of potential adverse effects and contraindications before taking triptans.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 7
Incorrect
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A 56-year-old man undergoes a routine medical check-up for his job. He shows no symptoms and his clinical examination is normal. What test result confirms a diagnosis of impaired fasting glucose?
Your Answer: 75g oral glucose tolerance test 2 hour value of 8.4 mmol/L
Correct Answer: Fasting glucose 6.8 mmol/L on two occasions
Explanation:An oral glucose tolerance test result of 8.4 mmol/L after 2 hours with a 75g glucose load suggests impaired glucose tolerance instead of impaired fasting glucose.
Type 2 diabetes mellitus can be diagnosed through a plasma glucose or HbA1c sample. The diagnostic criteria vary depending on whether the patient is experiencing symptoms or not. If the patient is symptomatic, a fasting glucose level of 7.0 mmol/l or higher or a random glucose level of 11.1 mmol/l or higher (or after a 75g oral glucose tolerance test) indicates diabetes. If the patient is asymptomatic, the same criteria apply but must be demonstrated on two separate occasions.
In 2011, the World Health Organization released supplementary guidance on the use of HbA1c for diagnosing diabetes. A HbA1c level of 48 mmol/mol (6.5%) or higher is diagnostic of diabetes mellitus. However, a HbA1c value of less than 48 mmol/mol (6.5%) does not exclude diabetes and may not be as sensitive as fasting samples for detecting diabetes. For patients without symptoms, the test must be repeated to confirm the diagnosis. It is important to note that increased red cell turnover can cause misleading HbA1c results.
There are certain conditions where HbA1c cannot be used for diagnosis, such as haemoglobinopathies, haemolytic anaemia, untreated iron deficiency anaemia, suspected gestational diabetes, children, HIV, chronic kidney disease, and people taking medication that may cause hyperglycaemia (such as corticosteroids).
Impaired fasting glucose (IFG) is defined as a fasting glucose level of 6.1 mmol/l or higher but less than 7.0 mmol/l. Impaired glucose tolerance (IGT) is defined as a fasting plasma glucose level less than 7.0 mmol/l and an OGTT 2-hour value of 7.8 mmol/l or higher but less than 11.1 mmol/l. People with IFG should be offered an oral glucose tolerance test to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person does not have diabetes but does have IGT.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 8
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A 35-year-old woman presents with a gradual loss of night vision over the past few months. On examination, she has also lost peripheral vision. She reports that her mother had a similar problem and became blind in her early 40s.
What is the most probable diagnosis? Choose ONE answer only.Your Answer: Retinitis pigmentosa
Explanation:Retinitis pigmentosa (RP) is a group of inherited disorders that cause progressive peripheral vision loss and difficulty seeing in low light, which can eventually lead to central vision loss. RP is often diagnosed based on the hallmark symptom of night blindness, and can be inherited in different ways. While there is no cure for RP, patients can receive low-vision evaluations and medications such as vitamins and calcium-channel blockers to help manage their symptoms. Glaucoma is another eye disease that can cause vision loss, particularly in older adults, but the patient’s symptoms and age do not suggest a diagnosis of primary open-angle glaucoma. Leber’s congenital amaurosis is a rare eye disorder that affects infants and young children, and is characterized by severe visual impairment, photophobia, and nystagmus, which is not consistent with the patient’s symptoms. Multiple sclerosis is an immune-mediated disease that can cause optic neuritis, but the patient’s symptoms do not match those typically associated with this condition. Vitreous hemorrhage is a condition where blood leaks into the vitreous body of the eye, causing visual disturbances such as floaters and cloudy vision, but the patient’s symptoms do not suggest this diagnosis either.
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This question is part of the following fields:
- Ophthalmology
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Question 9
Incorrect
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A 50-year-old man is brought to the Emergency Department by his wife after developing a severe cutaneous hypersensitivity reaction. He has a history of rheumatoid arthritis for which he was taking non-steroidal anti-inflammatory drugs (NSAIDs). Still, his symptoms did not improve, and his rheumatologist prescribed him methotrexate a few days ago.
On examination, Nikolsky’s sign is present and affects 45% of his body’s surface area.
What is the underlying condition?Your Answer: Erythema multiforme
Correct Answer: Toxic epidermal necrolysis
Explanation:Common Skin Hypersensitivity Reactions and their Causes
Skin hypersensitivity reactions can range from mild to life-threatening. Here are some common types and their causes:
Toxic Epidermal Necrolysis: This is the most serious skin hypersensitivity reaction, with a high mortality rate. It is usually caused by drugs such as NSAIDs, steroids, methotrexate, allopurinol and penicillins.
Erythema Multiforme: This is a target-like lesion that commonly occurs on the palms and soles. It is usually caused by drugs such as penicillins, phenytoin, NSAIDs and sulfa drugs. Mycoplasma and herpes simplex infections can also cause erythema multiforme.
Erythema Nodosum: This is an inflammatory condition of subcutaneous tissue. The most common causes are recent streptococcal infection, sarcoidosis, tuberculosis and inflammatory bowel disease.
Fixed Drug Reaction: This is a localised allergic drug reaction that recurs at the same anatomic site of the skin with repeated drug exposure. It is most commonly caused by aspirin, NSAIDs, tetracycline and barbiturate.
Morbilliform Rash: This is a mild hypersensitivity skin reaction that manifests as a generalised maculopapular eruption that blanches with pressure. The rash can be caused by penicillin, sulfa drugs, allopurinol and phenytoin.
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This question is part of the following fields:
- Dermatology
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Question 10
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For which condition is the Mini-Mental State Examination (MMSE) a screening questionnaire?
Your Answer: Cognitive impairment
Explanation:The MMSE as a Screening Tool for Cognitive Impairment and Dementia
The Mini-Mental State Examination (MMSE) is a widely used screening tool for cognitive impairment and dementia. It assesses cognitive functioning and gives a score out of 30, which can be used to identify individuals who may require further investigation for dementia. However, the MMSE is sensitive to education, and individuals with limited education may have lower scores without cognitive impairment.
While the MMSE is a valuable screening tool for moderate and severe dementia, it cannot make a diagnosis of any type of dementia on its own. It detects cognitive impairment, not cognitive decline, which requires a history. Additionally, there is no reliable test that assesses mental illnesses as a whole.
Nevertheless, the MMSE has been used in many community studies of older people and has proved to be a valuable screening tool for various types of dementia, including vascular dementia. Overall, the MMSE is a useful tool for identifying cognitive impairment and potential dementia, but it should be used in conjunction with other assessments and evaluations.
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This question is part of the following fields:
- Neurology
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