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  • Question 1 - A mother of a 5-year-old child with cystic fibrosis (CF) visits the clinic...

    Correct

    • A mother of a 5-year-old child with cystic fibrosis (CF) visits the clinic to inquire about the likelihood of having another child with CF. She is still with the same partner as before. What is the probability of them having another child with CF?

      Your Answer: 25%

      Explanation:

      Understanding Autosomal Recessive Inheritance

      Autosomal recessive inheritance is a genetic pattern where a disorder is only expressed when an individual inherits two copies of a mutated gene, one from each parent. This means that only homozygotes, individuals with two copies of the mutated gene, are affected. Both males and females are equally likely to be affected, and the disorder may not manifest in every generation, as it can skip a generation.

      When two heterozygote parents, carriers of the mutated gene, have children, there is a 25% chance of having an affected (homozygote) child, a 50% chance of having a carrier (heterozygote) child, and a 25% chance of having an unaffected child. On the other hand, if one parent is homozygote for the gene and the other is unaffected, all the children will be carriers.

      Autosomal recessive disorders are often metabolic in nature and can be life-threatening compared to autosomal dominant conditions. Understanding the inheritance pattern of autosomal recessive disorders is crucial in genetic counseling and family planning.

    • This question is part of the following fields:

      • Paediatrics
      8.4
      Seconds
  • Question 2 - A 75-year-old man presents to the emergency department with nosebleeds, extensive bruising, and...

    Incorrect

    • A 75-year-old man presents to the emergency department with nosebleeds, extensive bruising, and mucosal bleeding. His vital signs are stable, and laboratory results reveal a platelet count of 23 * 109/L (150 - 400), which is significantly lower than his previous blood test taken a week ago. The patient reports taking a new medication for nocturnal leg cramps. Which of the following medications could be responsible for his thrombocytopenia?

      Your Answer: Cabergoline

      Correct Answer: Quinine

      Explanation:

      Quinine is the only medication in this list that is strongly linked to the development of drug-induced thrombocytopaenia. However, excessive consumption of tonic water containing quinine can also lead to this condition in certain individuals. While all the other medications in the list can be used to treat nocturnal leg cramps, they do not have a significant association with thrombocytopaenia.

      Understanding Drug-Induced Thrombocytopenia

      Drug-induced thrombocytopenia is a condition where a person’s platelet count drops due to the use of certain medications. This type of thrombocytopenia is believed to be immune-mediated, meaning that the body’s immune system mistakenly attacks and destroys platelets. Some of the drugs that can cause this condition include quinine, abciximab, NSAIDs, diuretics like furosemide, antibiotics such as penicillins, sulphonamides, and rifampicin, anticonvulsants like carbamazepine and valproate, and heparin.

      It is important to note that not everyone who takes these medications will develop drug-induced thrombocytopenia. However, those who do may experience symptoms such as easy bruising, bleeding gums, nosebleeds, and prolonged bleeding from cuts. In severe cases, the condition can lead to life-threatening bleeding.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      28.8
      Seconds
  • Question 3 - A 25-year-old female patient complains of red, itchy, and sore eyelids with crusts...

    Correct

    • A 25-year-old female patient complains of red, itchy, and sore eyelids with crusts on the eyelashes and a gritty feeling in both eyes. What is the primary treatment for this condition?

      Your Answer: Eyelid hygiene with warm compresses, lid massage and lid margin cleaning

      Explanation:

      The initial step in treating blepharitis is to apply hot compresses to the affected area. This is followed by eyelid hygiene, which involves cleaning the lid margins and massaging them. If this does not work, chloramphenicol eye drops and oral antibiotics may be prescribed. Oily tear eye drops can be used to prevent rapid evaporation of tears caused by blepharitis. While an omega-3 rich diet may help improve the condition, it is not considered a first-line treatment.

      Blepharitis is a condition where the eyelid margins become inflamed. This can be caused by dysfunction of the meibomian glands (posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (anterior blepharitis). It is more common in patients with rosacea. The meibomian glands secrete oil to prevent rapid evaporation of the tear film, so any problem affecting these glands can cause dryness and irritation of the eyes. Symptoms of blepharitis are usually bilateral and include grittiness, discomfort around the eyelid margins, sticky eyes in the morning, and redness of the eyelid margins. Styes and chalazions are also more common in patients with blepharitis, and secondary conjunctivitis may occur.

      Management of blepharitis involves softening the lid margin with hot compresses twice a day and practicing lid hygiene to remove debris from the lid margins. This can be done using cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo or sodium bicarbonate in cooled boiled water. Artificial tears may also be given for symptom relief in people with dry eyes or an abnormal tear film.

    • This question is part of the following fields:

      • Ophthalmology
      16.6
      Seconds
  • Question 4 - A 29 week pregnant woman presents to her GP with a rash that...

    Incorrect

    • A 29 week pregnant woman presents to her GP with a rash that has developed over the past 12 hours. Upon examination, lesions indicative of chickenpox are observed. The patient's vital signs are stable and she appears to be in good health. What course of action is recommended for management?

      Your Answer: Varicella-zoster immunoglobulin (VZIG)

      Correct Answer: Oral aciclovir

      Explanation:

      Pregnant women who contract chickenpox after 20 weeks of gestation should seek medical attention immediately. This is because chickenpox can lead to serious complications such as pneumonia, hepatitis, and encephalitis. Treatment with oral aciclovir is recommended if the woman presents within 24 hours of developing the rash. Aciclovir can help reduce the duration of fever and other symptoms. Symptomatic treatment can also be used alongside aciclovir. If the chickenpox is severe, the woman should be referred to the hospital for intravenous aciclovir. Additionally, a referral to fetal medicine may be necessary due to the small risk of fetal varicella syndrome in the first 28 weeks of pregnancy. It is important to advise anyone with chickenpox to avoid contact with pregnant women and neonates until all lesions have crusted over, which usually takes about 5 days after the onset of the rash. VZIG has no therapeutic benefit once the rash has started. These guidelines are based on the RCOG Greentop guidelines for chickenpox in pregnancy.

      Chickenpox 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.

    • This question is part of the following fields:

      • Reproductive Medicine
      17.6
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  • Question 5 - A 30-year-old woman presents with a productive cough, weight loss, and night sweats,...

    Incorrect

    • A 30-year-old woman presents with a productive cough, weight loss, and night sweats, four months after returning from India. She is diagnosed with pulmonary tuberculosis and started on appropriate antibiotics. However, six weeks into her treatment, she experiences numbness and tingling in her distal extremities, a known side effect of isoniazid. What medication should have been prescribed alongside her antibiotic regimen to minimize this side effect?

      Your Answer: Pyrazinamide

      Correct Answer: Pyridoxine

      Explanation:

      To treat active tuberculosis, isoniazid is often prescribed alongside other antibiotics such as rifampicin, ethambutol, or pyrazinamide. However, it is important to note that isoniazid alone does not protect against peripheral neuropathy, a potential side effect of tuberculosis treatment.

      Rifampicin is an antibiotic that can increase the rate of B6 excretion, which may lead to a deficiency in some individuals.

      Ethambutol is another antibiotic used to treat tuberculosis, but it can cause a loss of visual acuity and color blindness.

      Prednisolone is typically only prescribed for meningeal or pericardial tuberculosis and can cause side effects such as mood changes, weight gain, and immunosuppression.

      Pyrazinamide is another antibiotic used to treat tuberculosis, but it can cause liver toxicity.

      Side-Effects and Mechanism of Action of Tuberculosis Drugs

      Rifampicin is a drug that inhibits bacterial DNA dependent RNA polymerase, which prevents the transcription of DNA into mRNA. However, it is a potent liver enzyme inducer and can cause hepatitis, orange secretions, and flu-like symptoms.

      Isoniazid, on the other hand, inhibits mycolic acid synthesis. It can cause peripheral neuropathy, which can be prevented with pyridoxine (Vitamin B6). It can also cause hepatitis and agranulocytosis. Additionally, it is a liver enzyme inhibitor.

      Pyrazinamide is converted by pyrazinamidase into pyrazinoic acid, which in turn inhibits fatty acid synthase (FAS) I. However, it can cause hyperuricaemia, leading to gout, as well as arthralgia, myalgia, and hepatitis.

      Lastly, Ethambutol inhibits the enzyme arabinosyl transferase, which polymerizes arabinose into arabinan. It can cause optic neuritis, so it is important to check visual acuity before and during treatment. Additionally, the dose needs adjusting in patients with renal impairment.

      In summary, these tuberculosis drugs have different mechanisms of action and can cause various side-effects. It is important to monitor patients closely and adjust treatment accordingly to ensure the best possible outcomes.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      24.6
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  • Question 6 - A 55-year-old man comes to the clinic with a facial droop. Upon examination,...

    Incorrect

    • A 55-year-old man comes to the clinic with a facial droop. Upon examination, he displays a crooked smile that droops on the right side. He is unable to close his right eye or wrinkle the right side of his forehead. There are no signs of weakness or sensory changes in his upper or lower limbs. What is the probable cause of this presentation?

      Your Answer: Right cranial nerve VII upper motor neuron lesion

      Correct Answer: Left cranial nerve VII lower motor neuron lesion

      Explanation:

      Bell’s palsy affects the lower motor neurons and results in weakness of the entire side of the face. A left cranial nerve VII lower motor neuron lesion would cause left-sided facial weakness without forehead sparing. However, lateral medullary syndrome, caused by ischemia to the lateral medulla oblongata, would present with vertigo, dizziness, nystagmus, ataxia, nausea and vomiting, and dysphagia. A left cranial nerve VII upper motor neuron lesion would result in right-sided facial weakness with forehead sparing, while a right cranial nerve VII lower motor neuron lesion would cause right-sided facial weakness without forehead sparing.

      Understanding Bell’s Palsy

      Bell’s palsy is a sudden, one-sided facial nerve paralysis of unknown cause. It is more common in individuals aged 20-40 years and pregnant women. The condition is characterized by lower motor neuron facial nerve palsy, which affects the forehead. Unlike upper motor neuron lesions, the upper face is spared. Patients may also experience post-auricular pain, altered taste, dry eyes, and hyperacusis.

      The management of Bell’s palsy has been a subject of debate. However, it is now widely accepted that all patients should receive oral prednisolone within 72 hours of onset. The addition of antiviral medications is still a matter of discussion, but it may be beneficial for severe facial palsy. Eye care is also crucial to prevent exposure keratopathy, and patients should be prescribed artificial tears and eye lubricants. If they are unable to close their eyes at bedtime, they should tape them closed using microporous tape.

      If the paralysis shows no sign of improvement after three weeks, an urgent referral to ENT is necessary. Patients with long-standing weakness may require a referral to plastic surgery. The prognosis for Bell’s palsy is generally good, with most patients making a full recovery within 3-4 months. However, untreated patients may experience permanent moderate to severe weakness in around 15% of cases.

    • This question is part of the following fields:

      • Neurology
      39
      Seconds
  • Question 7 - A woman contacts the local psychiatry crisis team, worried about her daughter -...

    Correct

    • A woman contacts the local psychiatry crisis team, worried about her daughter - who has previously been diagnosed with schizophrenia - becoming more isolated and paranoid about her surroundings. She reports that her daughter is increasingly concerned about her neighbors eavesdropping on her conversations. Her symptoms were previously well managed on daily risperidone. When the woman visited her daughter, she discovered unopened boxes of her medication on the counter.

      What would be a suitable course of treatment for this patient?

      Your Answer: Depot risperidone injections

      Explanation:

      Considering the patient’s increasing symptoms of psychosis, it is possible that non-compliance with their risperidone medication is an issue. In such cases, it is recommended to consider once monthly IM antipsychotic depot injections for patients with poor oral compliance. However, the patient’s risperidone dose would need to be re-titrated to their previous level.

      Clozapine is typically used for treatment-resistant psychosis after trying two other antipsychotics. However, there is no evidence of the patient having tried multiple antipsychotics, and it appears that risperidone was effectively controlling their symptoms. If risperidone is not effective, quetiapine could be tried before considering Clozapine, provided there are no contraindications.

      While cognitive behavioural therapy (CBT) can be helpful in reducing symptoms of psychosis, it is less likely to be effective than monthly depot injections.

      Based on the patient’s history, there is no indication that they pose a risk to themselves or others that would warrant admission. Therefore, efforts should be made to manage the patient in the community.

      Atypical antipsychotics are now recommended as the first-line treatment for patients with schizophrenia, as per the 2005 NICE guidelines. These medications have the advantage of significantly reducing extrapyramidal side-effects. However, they can also cause adverse effects such as weight gain, hyperprolactinaemia, and in the case of clozapine, agranulocytosis. The Medicines and Healthcare products Regulatory Agency has issued warnings about the increased risk of stroke and venous thromboembolism when antipsychotics are used in elderly patients. Examples of atypical antipsychotics include clozapine, olanzapine, risperidone, quetiapine, amisulpride, and aripiprazole.

      Clozapine, one of the first atypical antipsychotics, carries a significant risk of agranulocytosis and requires full blood count monitoring during treatment. Therefore, it should only be used in patients who are resistant to other antipsychotic medication. The BNF recommends introducing clozapine if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs, one of which should be a second-generation antipsychotic drug, each for at least 6-8 weeks. Adverse effects of clozapine include agranulocytosis, neutropaenia, reduced seizure threshold, constipation, myocarditis, and hypersalivation. Dose adjustment of clozapine may be necessary if smoking is started or stopped during treatment.

    • This question is part of the following fields:

      • Psychiatry
      22.9
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  • Question 8 - A 28-year-old primip nurse has presented to you 5 days after being in...

    Correct

    • 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: RCOG

      Chickenpox 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.

    • This question is part of the following fields:

      • Reproductive Medicine
      4.5
      Seconds
  • Question 9 - A 56-year-old man has been diagnosed with gout and you are discussing ways...

    Incorrect

    • A 56-year-old man has been diagnosed with gout and you are discussing ways to prevent future attacks. What is the most probable trigger for a gout attack?

      Your Answer: Smoking

      Correct Answer: Sardines

      Explanation:

      To prevent gout, it is recommended to steer clear of foods that are rich in purines such as liver, kidneys, seafood, oily fish like mackerel and sardines, and yeast-based products.

      Gout is caused by chronic hyperuricaemia and is managed acutely with NSAIDs or colchicine. Urate-lowering therapy (ULT) is recommended for patients with >= 2 attacks in 12 months, tophi, renal disease, uric acid renal stones, or prophylaxis if on cytotoxics or diuretics. Allopurinol is first-line ULT, with an initial dose of 100 mg od and titrated to aim for a serum uric acid of < 300 µmol/l. Lifestyle modifications include reducing alcohol intake, losing weight if obese, and avoiding high-purine foods. Consideration should be given to stopping precipitating drugs and losartan may be suitable for patients with coexistent hypertension.

    • This question is part of the following fields:

      • Musculoskeletal
      16.4
      Seconds
  • Question 10 - A 50-year-old woman with a history of severe disabling arthritis presents to the...

    Incorrect

    • A 50-year-old woman with a history of severe disabling arthritis presents to the Emergency Department with a 3-week history of dyspnoea. She reports a dry cough of similar duration. She has never smoked and has never been employed. On cardiovascular examination, no abnormalities are detected. Respiratory examination reveals reduced air entry at the left base, which is stony dull to percussion. A chest X-ray shows blunting of the left costophrenic angle.
      What is the most likely diagnosis associated with her current respiratory problem?

      Your Answer: Behçet’s disease

      Correct Answer: Rheumatoid arthritis (RA)

      Explanation:

      Respiratory Manifestations of Rheumatoid Arthritis

      Rheumatoid arthritis (RA) is an inflammatory arthritis that can affect various parts of the body, including the respiratory tract. One common manifestation of RA in the respiratory system is pleural involvement, which can present as pleural effusion, pleural nodules, or pleurisy. Other respiratory complications associated with RA include pulmonary fibrosis and bronchiolitis obliterans.

      It is important to note that other types of arthritis, such as ankylosing spondylitis, Behçet’s disease, gout, and psoriatic arthritis, do not typically present with respiratory complications like pleural effusion. Ankylosing spondylitis is associated with apical fibrosis, while Behçet’s disease is known for neurological complications. Gout is caused by purine metabolism abnormality and affects the joints and renal tract, while psoriatic arthritis is strongly associated with psoriasis and can lead to ocular and cardiovascular complications.

      Overall, if a patient with RA presents with respiratory symptoms, it is important to consider the possibility of pleural involvement and other respiratory complications associated with the disease.

    • This question is part of the following fields:

      • Respiratory Medicine
      27.2
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  • Question 11 - A 68-year-old man comes to the Emergency Department with severe inflammation of his...

    Incorrect

    • A 68-year-old man comes to the Emergency Department with severe inflammation of his first metatarsophalangeal joint. He reports swelling and tenderness of the joint and a sample of fluid is sent for microscopy. He has a medical history of hypertension and duodenal ulcers.
      What is the most suitable initial medication to prescribe?
      Choose ONE option from the list provided.

      Your Answer: Diclofenac

      Correct Answer: Colchicine

      Explanation:

      Managing Gout: Treatment Options and Contraindications

      Gout is a type of arthritis caused by the deposition of urate crystals in the synovial fluid. Chronic hyperuricemia is the primary cause of this condition. The acute management of gout involves the use of non-steroidal anti-inflammatory drugs (NSAIDs) or colchicine as first-line treatment. However, the maximum dose of NSAIDs should be prescribed until 1-2 days after the symptoms have settled, and gastroprotection may also be necessary. Colchicine has a slower onset of action and may cause diarrhea as a side effect. Oral steroids or intra-articular steroid injections may be considered if NSAIDs and colchicine are contraindicated. Allopurinol is not recommended during the acute phase but is useful for preventing recurrent attacks of gout. Diclofenac and indomethacin are contraindicated in patients with duodenal ulcers, and colchicine is a suitable alternative for the treatment of gout. Diazepam, a benzodiazepine, is not useful in the treatment of gout as it does not have anti-inflammatory or analgesic properties.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      25.4
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  • Question 12 - A 52-year-old woman with a body mass index (BMI) of 32 was diagnosed...

    Correct

    • A 52-year-old woman with a body mass index (BMI) of 32 was diagnosed with type 2 diabetes mellitus during a routine check-up six months ago. Despite being advised about a low-energy, weight-reducing diet and exercise, she has not followed through with these recommendations and her postprandial blood glucose concentration is 13.8 mmol/l (reference range <11.1 mmol/l). What would be the drug of choice in this case?

      Your Answer: Metformin

      Explanation:

      Medications for Type 2 Diabetes

      Metformin: The Initial Drug Treatment of Choice
      For adults with type 2 diabetes, standard-release metformin is the recommended initial drug treatment. The dose should be gradually increased to avoid gastrointestinal side effects. If significant GI side effects occur, modified-release metformin can be tried. Metformin reduces hepatic gluconeogenesis and increases insulin sensitivity, leading to an increase in peripheral glucose uptake. However, caution should be exercised when using metformin in patients with renal failure, and it should be stopped if the estimated glomerular filtration rate is less than 30 ml/min per 1.73m2.

      Tolbutamide and Chlorpropamide: First-Generation Sulfonylureas
      Tolbutamide and chlorpropamide are first-generation sulfonylureas that are no longer routinely used in the treatment of type 2 diabetes due to a higher incidence of side effects compared to newer, second-generation sulfonylureas. Chlorpropamide is not available in the UK.

      Insulin: Considered for Dual Therapy
      Insulin-based treatment should be considered in type 2 diabetes patients who have not achieved optimal glycated haemoglobin control with dual therapy using metformin and another oral drug. Metformin should continue to be offered to patients without contraindications or intolerance.

      Pioglitazone: An Alternative Second-Line Agent
      Pioglitazone can be considered as an alternative second-line agent for patients with type 2 diabetes who cannot take metformin or have not tolerated it well. It can also be used in dual therapy for first intensification of treatment.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      44.9
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  • Question 13 - A 50-year-old man came to the clinic complaining of pain, redness, and blurring...

    Incorrect

    • A 50-year-old man came to the clinic complaining of pain, redness, and blurring of vision in his left eye. Upon fundoscopy, a combination of white and red retinal lesions was observed, indicating chorioretinitis. What is the essential test that must be performed to determine the underlying cause of chorioretinitis in this patient?

      Your Answer: Full blood count

      Correct Answer: HIV test

      Explanation:

      Performing an HIV test is crucial in patients with AIDS, as it is the primary diagnostic tool for identifying the underlying cause. While options 1, 2, and 3 may be necessary as baseline investigations in most patients, they are not sufficient for diagnosing the specific condition in this case.

      Causes of Chorioretinitis

      Chorioretinitis is a medical condition that affects the retina and choroid, which are the layers of tissue at the back of the eye. There are several causes of chorioretinitis, including syphilis, cytomegalovirus, toxoplasmosis, sarcoidosis, and tuberculosis.

      Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum. It can cause chorioretinitis as part of its secondary stage. Cytomegalovirus is a common virus that can cause chorioretinitis in people with weakened immune systems, such as those with HIV/AIDS. Toxoplasmosis is a parasitic infection that can be contracted from contaminated food or water, and it can cause chorioretinitis in some cases.

      Sarcoidosis is a condition that causes inflammation in various parts of the body, including the eyes. It can lead to chorioretinitis in some cases. Tuberculosis is a bacterial infection that can affect the lungs, but it can also spread to other parts of the body, including the eyes. It can cause chorioretinitis as a rare complication.

    • This question is part of the following fields:

      • Ophthalmology
      61.8
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  • Question 14 - A 30-year-old woman has been diagnosed with breast cancer. She had been using...

    Incorrect

    • A 30-year-old woman has been diagnosed with breast cancer. She had been using the combined pill for contraception before her diagnosis. Now, she wants to switch to a different method of contraception before starting chemotherapy. What would be the most suitable option?

      Your Answer: Mirena (levonorgestrel releasing) Intrauterine System

      Correct Answer: Copper Intrauterine Device

      Explanation:

      The copper intrauterine device is the recommended form of contraception for individuals with breast cancer. Hormonal forms of contraception are not recommended and are rated as a Category 4 risk, which is deemed unacceptable for the patient’s health.

      The decision to prescribe the combined oral contraceptive pill is now based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential contraindications and cautions on a four-point scale. UKMEC 1 indicates no restrictions for use, while UKMEC 2 suggests that the benefits outweigh the risks. UKMEC 3 indicates that the disadvantages may outweigh the advantages, and UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, a family history of thromboembolic disease in first-degree relatives under 45 years old, and current gallbladder disease. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. In 2016, breast feeding between 6 weeks and 6 months postpartum was changed from UKMEC 3 to UKMEC 2.

    • This question is part of the following fields:

      • Reproductive Medicine
      30.4
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  • Question 15 - A 68-year-old woman presents to her General Practitioner to discuss some recent blood...

    Incorrect

    • A 68-year-old woman presents to her General Practitioner to discuss some recent blood tests which were taken for tri-monthly monitoring of her methotrexate. She has rheumatoid arthritis (RA) and takes methotrexate, folic acid and co-codamol.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 91 g/l 115–165 g/l
      White cell count (WCC) 5.2 × 109/l 4.0–11.0 × 109/l
      Platelets 228 × 109/l 150–400 × 109/l
      Neutrophils 5.4 × 109/l 2.0–7.5 × 109/l
      Mean corpuscular volume (MCV) 96 fl 85–105 fl
      Mean corpuscular haemoglobin (MCH) 29 pg 27–32 pg
      Sodium 138 mmol/l 135–145 mmol/l
      Potassium 4.1 mmol/l 3.5–5.3 mmol/l
      Urea 3.2 mmol/l 2.5–7.5 mmol/l
      Creatinine 68 µmol/l 53–100 µmol/l
      Estimated glomerular filtration rate > 90 ml/min per 1.73m2 > 90 ml/min per 1.73m2
      What is the most likely cause of this patient’s anaemia?

      Your Answer: Folate deficiency

      Correct Answer: Anaemia of chronic disease

      Explanation:

      Understanding the Causes of Normocytic Anaemia in a Patient with Rheumatoid Arthritis

      The patient in question has been diagnosed with normocytic anaemia, which is characterized by normal MCV and MCH results. There are several potential causes of this type of anaemia, including renal failure, anaemia of chronic disease, and mixed iron and vitamin B12 or folate deficiency. However, given that the patient has rheumatoid arthritis (RA) and normal renal function, the most likely cause of her anaemia is a chronic disease. This is thought to be the result of chronic inflammation associated with diseases such as RA.

      One potential complication of RA is Felty syndrome, which is characterized by a triad of conditions: RA, splenomegaly, and neutropenia. However, this patient has a normal WCC and neutrophil count, which rules out this diagnosis.

      Vitamin B12 deficiency can also cause anaemia, but it typically results in macrocytic anaemia characterized by a raised MCV. In contrast, this patient has a normal MCV. Vitamin B12 deficiency is typically treated with oral supplements, unless intrinsic antibodies are present, in which case intramuscular B12 is needed.

      Folate deficiency can also drive macrocytic anaemia, but this patient demonstrates normocytic anaemia. Methotrexate, which is commonly used to treat RA, is a folate antagonist, which is why the patient is also taking folic acid supplements to reduce the risk of developing folate deficiency.

      Iron deficiency is another potential cause of anaemia, but it typically results in microcytic hypochromic anaemia characterized by low MCV and MCH. In contrast, this patient has normal MCV and MCH results. A combination of iron and vitamin B12 or folate deficiencies may result in normocytic anaemia, as can acute blood loss.

    • This question is part of the following fields:

      • Haematology/Oncology
      50.5
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  • Question 16 - A 24-year-old teacher attends her first cervical smear appointment. She has never been...

    Incorrect

    • A 24-year-old teacher attends her first cervical smear appointment. She has never been pregnant before, but she had pelvic inflammatory disease that was treated 3 years ago. Currently, she has an intrauterine device in place. She has no other significant medical or social history. During the appointment, she asks what the test is for.
      How would you explain it to her?

      Your Answer: The sample is tested for all types of HPV including types 6, 11, 16, and 18

      Correct Answer: The sample is tested for high-risk HPV first

      Explanation:

      The human papillomavirus (HPV) is a common sexually transmitted infection that can lead to cervical cancer. There are over 100 types of HPV, with types 16 and 18 being high-risk types that are responsible for the majority of cervical cancers. Types 6 and 11 are low-risk types that typically cause benign genital warts. Although not part of the screening process, the Gardasil vaccine can protect against both HPV types 6 and 11.

      Contrary to popular belief, not all samples undergo both HPV testing and cytology. Only samples that test positive for high-risk HPV undergo cytology testing. Samples that test negative for high-risk HPV do not require further testing.

      In the past, samples were first examined under a microscope (cytology) before HPV testing. However, research has shown that testing for high-risk HPV first is more effective. If a woman tests positive for HPV, she will receive a single letter informing her of her HPV status and whether any abnormal cells were detected.

      The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.

    • This question is part of the following fields:

      • Reproductive Medicine
      30.5
      Seconds
  • Question 17 - A 27-year-old man visits his doctor with worries about his increased risk of...

    Incorrect

    • A 27-year-old man visits his doctor with worries about his increased risk of breast cancer due to his sister's recent diagnosis at the age of 30 years with a BRCA2 mutation. He is considering getting tested for the mutation. If he were to test positive for BRCA2, what other type of cancer would he be at a higher risk for?

      Your Answer: Malignant melanoma

      Correct Answer: Prostate

      Explanation:

      Men with BRCA2 mutation are at a higher risk of developing prostate cancer, while both men and women with this mutation have a significantly increased risk of developing breast cancer. Additionally, women with BRCA2 mutation are more likely to develop ovarian cancer. Although young-onset colorectal cancer is linked to BRCA1 mutation, there is no such association observed in individuals with BRCA2 mutation.

      Li-Fraumeni Syndrome is caused by mutations in the p53 gene and increases the risk of developing sarcomas and leukemias. BRCA 1 and 2 mutations increase the risk of breast and ovarian cancer, and BRCA 2 is also associated with prostate cancer in men. Lynch Syndrome increases the risk of colon and endometrial cancer, and can be identified using the Amsterdam criteria. Gardner’s Syndrome is a familial colorectal polyposis that can lead to colectomy to reduce the risk of colorectal cancer.

    • This question is part of the following fields:

      • Genetics
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  • Question 18 - A 62-year-old man is undergoing a drug therapy evaluation following a myocardial infarction...

    Incorrect

    • A 62-year-old man is undergoing a drug therapy evaluation following a myocardial infarction (MI).
      Which of the following options has not been shown to have a beneficial effect on mortality after an MI?

      Your Answer: Ramipril

      Correct Answer: Isosorbide mononitrate

      Explanation:

      Medications for Post-Myocardial Infarction (MI) Care

      After a myocardial infarction (MI), certain medications are recommended to reduce mortality and manage symptoms. Nitrates, such as isosorbide mononitrate, offer no mortality benefit but can be used for angina symptoms. β-blockers, like timolol, provide both mortality and anti-anginal benefits and should be continued for at least 12 months post-MI. Statins, specifically atorvastatin 80 mg, are recommended for secondary prevention to reduce mortality. Angiotensin-converting enzyme (ACE) inhibitors, such as ramipril, offer good mortality benefit, but angiotensin receptor blockers (ARBs) can be used if the patient cannot tolerate ACE inhibitors. Aspirin, in combination with another antiplatelet therapy, is recommended for 12 months post-MI. Studies have shown that tirofiban, timolol, and ramipril reduce mortality after an MI, while isosorbide mononitrate showed no benefit. The MIRACL study found that atorvastatin reduced cardiovascular events by 17% when given for 3 months post-MI.

    • This question is part of the following fields:

      • Cardiovascular
      9.5
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  • Question 19 - You are assessing an 80-year-old man who has a medical history of hypothyroidism,...

    Incorrect

    • You are assessing an 80-year-old man who has a medical history of hypothyroidism, Parkinson's disease, and depression. His conditions are well-managed with levothyroxine, co-careldopa, and citalopram. He reports experiencing symptoms indicative of gastroesophageal reflux disease. What medication should be avoided to manage his symptoms effectively?

      Your Answer:

      Correct Answer: Metoclopramide

      Explanation:

      Patients with Parkinsonism should not take metoclopramide due to its dopamine antagonist properties, which can exacerbate their symptoms.

      Metoclopramide is a medication that is commonly used to manage nausea. It works by blocking D2 receptors in the chemoreceptor trigger zone, which helps to alleviate feelings of sickness. In addition to its antiemetic properties, metoclopramide also has other uses, such as treating gastro-oesophageal reflux disease and gastroparesis caused by diabetic neuropathy. It is often combined with analgesics to treat migraines, which can cause gastroparesis and slow the absorption of pain medication.

      However, metoclopramide can have some adverse effects, such as extrapyramidal effects, acute dystonia, diarrhoea, hyperprolactinaemia, tardive dyskinesia, and parkinsonism. These side effects are particularly problematic in children and young adults. It is important to note that metoclopramide should not be used in cases of bowel obstruction, but it may be helpful in cases of paralytic ileus.

      Although metoclopramide primarily works as a D2 receptor antagonist, its mechanism of action is quite complex. It also acts as a mixed 5-HT3 receptor antagonist and 5-HT4 receptor agonist. The antiemetic effects of metoclopramide are due to its D2 receptor antagonist activity in the chemoreceptor trigger zone, while its gastroprokinetic effects are mediated by both D2 receptor antagonist and 5-HT4 receptor agonist activity. At higher doses, the 5-HT3 receptor antagonist activity also comes into play.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      0
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  • Question 20 - As a junior doctor in General Practice, you come across a 27-year-old woman...

    Incorrect

    • As a junior doctor in General Practice, you come across a 27-year-old woman who is worried about her declining work performance. Her boss has labeled her as 'neurotic' due to her frequent missing of deadlines. She identifies herself as a 'perfectionist' and is unable to comprehend why this is happening. She has always found solace in keeping her workspace clean and organized and struggles to handle situations where she is not in control, especially at work. She recalls being an anxious child but has never sought help from a psychiatrist. What is the most probable cause of her difficulties?

      Your Answer:

      Correct Answer: Obsessive compulsive personality disorder

      Explanation:

      The individual in question is exhibiting symptoms of anankastic personality disorder, also known as obsessive-compulsive personality disorder (OCPD). This disorder is characterized by a preoccupation with orderliness, perfectionism, and an excessive focus on details, as well as a need for control over one’s environment and interpersonal relationships. However, this often comes at the expense of flexibility, openness to new experiences, and efficiency. Unlike obsessive-compulsive disorder (OCD), where thoughts and behaviors are seen as unwanted and unhealthy, those with OCPD view their behaviors as rational and desirable. This can lead to difficulty completing tasks, as the individual becomes overly focused on perfectionism and attention to detail. Generalized anxiety disorder is less likely to be the diagnosis in this case, as the individual’s worries are specific to work-related issues. Schizoid personality disorder, on the other hand, is characterized by a lack of interest in forming close relationships with others and a preference for solitude. These individuals may appear cold and uninterested in intimacy or pleasure from life.

      Personality disorders are a set of personality traits that are maladaptive and interfere with normal functioning in life. It is estimated that around 1 in 20 people have a personality disorder, which are typically categorized into three clusters: Cluster A, which includes Odd or Eccentric disorders such as Paranoid, Schizoid, and Schizotypal; Cluster B, which includes Dramatic, Emotional, or Erratic disorders such as Antisocial, Borderline (Emotionally Unstable), Histrionic, and Narcissistic; and Cluster C, which includes Anxious and Fearful disorders such as Obsessive-Compulsive, Avoidant, and Dependent.

      Paranoid individuals exhibit hypersensitivity and an unforgiving attitude when insulted, a reluctance to confide in others, and a preoccupation with conspirational beliefs and hidden meanings. Schizoid individuals show indifference to praise and criticism, a preference for solitary activities, and emotional coldness. Schizotypal individuals exhibit odd beliefs and magical thinking, unusual perceptual disturbances, and inappropriate affect. Antisocial individuals fail to conform to social norms, deceive others, and exhibit impulsiveness, irritability, and aggressiveness. Borderline individuals exhibit unstable interpersonal relationships, impulsivity, and affective instability. Histrionic individuals exhibit inappropriate sexual seductiveness, a need to be the center of attention, and self-dramatization. Narcissistic individuals exhibit a grandiose sense of self-importance, lack of empathy, and excessive need for admiration. Obsessive-compulsive individuals are occupied with details, rules, and organization to the point of hampering completion of tasks. Avoidant individuals avoid interpersonal contact due to fears of criticism or rejection, while dependent individuals have difficulty making decisions without excessive reassurance from others.

      Personality disorders are difficult to treat, but a number of approaches have been shown to help patients, including psychological therapies such as dialectical behavior therapy and treatment of any coexisting psychiatric conditions.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 21 - A man with a 5-year history of human immunodeficiency virus (HIV) attends the...

    Incorrect

    • A man with a 5-year history of human immunodeficiency virus (HIV) attends the clinic for a routine check-up and to receive the results of his latest CD4 count and viral load. He is currently taking lopinavir, tenofovir and 3TC medications as part of his antiretroviral treatment. Management of HIV aims to reduce the patient’s viral load and improve their CD4 count.
      Above what level in the blood should you aim to keep this patient's CD4 count?

      Your Answer:

      Correct Answer: > 350 cells/mm3

      Explanation:

      A man with a 5-year history of HIV is on antiretroviral treatment with atazanavir, emtricitabine, and tenofovir. The aim of this treatment is to reduce viral load (< 50 copies/ml), improve CD4 count (above 350 cells/mm3), reduce transmission, and increase quality of life without unacceptable drug side-effects. During routine check-ups, the patient's CD4 count, HIV viral RNA load, renal and hepatic function, cholesterol, blood sugar, triglycerides, and lactate are assessed. The target level for this patient's CD4 count is above 350 cells/mm3. A CD4 count below 200 cells/mm3 greatly exposes the patient to opportunistic infections. Antiretroviral treatment usually involves a combination of at least three drugs classified as nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs), or 'others'. These drugs may have side-effects such as lipoatrophy, hepatotoxicity, lipodystrophy syndrome, lactic acidosis, Steven-Johnson syndrome, drug-drug interactions, hyperbilirubinemia, peripheral neuropathy, bone marrow suppression, anaemia, pancreatitis, and insulin resistance/hyperglycaemia.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 22 - A 63-year-old man presents to his General Practitioner with a 1-month history of...

    Incorrect

    • A 63-year-old man presents to his General Practitioner with a 1-month history of lethargy, extreme thirst and increased urinary frequency. Two days ago, he also started to experience a dull pain in his left flank, which seems to occasionally radiate down into his groin. He has also not opened his bowels for four days and he is usually fairly regular.
      On examination, he is found to have a blood pressure of 115/85 mmHg. The rest of the examination is unremarkable.
      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Primary hyperparathyroidism

      Explanation:

      Differential Diagnosis: Polyuria, Polydipsia, Constipation, and Loin-to-Groin Pain

      Possible Causes and Clinical Features

      Primary Hyperparathyroidism: This condition can cause hypercalcemia, leading to symptoms such as bone pain, osteopenia, kidney stones, constipation, nausea, vomiting, abdominal pain, fatigue, depression, and memory impairment. In severe cases, cardiac and metabolic disturbances, delirium, or coma may occur. Diagnosis is made by measuring serum-adjusted calcium and parathyroid hormone (PTH) levels at the same time.

      Acute Pancreatitis: This condition can cause severe epigastric pain radiating to the back, vomiting, epigastric tenderness, ileus, and low-grade fever. Aetiological factors include alcohol and gallstones.

      Addison’s Disease: This condition can cause generalised fatigue, abdominal pain, anorexia, nausea, vomiting, weight loss, ‘salt craving’, hyperpigmentation, vitiligo, loss of pubic hair in women, hypotension, hypoglycaemia, hyponatraemia, and hyperkalaemia.

      Anxiety Attack: This condition can cause chest pain, palpitations, nausea, vomiting, sweating, insomnia, flushing, tremor, and urinary frequency. It typically occurs in an individual who is excessively worried about a number of different events, causing increased tension.

      Diabetic Ketoacidosis (DKA): This condition can cause polyuria, polydipsia, abdominal pain, Kussmaul respiration, and pear-drops-smelling breath.

      Differential Diagnosis of Polyuria, Polydipsia, Constipation, and Loin-to-Groin Pain

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 23 - A 23-year-old man is sent to your office for evaluation by his family....

    Incorrect

    • A 23-year-old man is sent to your office for evaluation by his family. The patient recently graduated from university and has had trouble adapting and fitting in. His parents note that he has always been a loner, preferring to stay in his room. They hoped graduation would bring him out of his shell. He has not made any new friends, but only his parents are bothered by this. Instead of socialising, he seems to have continued to stay alone in his room.
      On interview, he is withdrawn and quiet. His range of affect is restricted, and he displays no clear happiness or joy when discussing activities that he reports enjoying. He denies any auditory or visual hallucinations and has no suicidal or homicidal intent. He reports that he has no change in his sleep, appetite, energy or concentration.
      What is the most likely diagnosis in this patient?

      Your Answer:

      Correct Answer: Schizoid personality disorder

      Explanation:

      Understanding Schizoid Personality Disorder: Differentiating from Other Psychiatric Conditions

      Personality disorders are characterized by enduring patterns of perception, processing, and engagement that become ingrained, inflexible, and maladaptive. Schizoid personality disorder is a type of personality disorder that falls under the weird cluster of disorders. Patients with this disorder are withdrawn loners with flat affects, but they do not have weird/magical thinking (schizotypal) or psychotic symptoms (schizophrenia, schizoaffective disorder). They classically have a very flat affect and no interest in interpersonal relationships, preferring to work and play alone. It is important to differentiate schizoid personality disorder from other psychiatric conditions such as schizophrenia, avoidant personality disorder, schizoaffective disorder, and schizotypal personality disorder, as they have distinct features and treatment approaches.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 24 - Nosocomial wound infections are often caused by various factors. However, which of the...

    Incorrect

    • Nosocomial wound infections are often caused by various factors. However, which of the following is the most frequent cause of such infections?

      Your Answer:

      Correct Answer: Inadequate hand disinfection

      Explanation:

      Preventing Hospital-Acquired Wound Infections: Common Causes and Solutions

      Hospital-acquired wound infections are a serious concern for patients and healthcare providers alike. While all wounds are contaminated by microbes, proper hygiene and disinfection can greatly reduce the risk of infection. However, there are several common causes of hospital-acquired wound infections that must be addressed to prevent their occurrence.

      The most frequent cause of nosocomial wound infection is inadequate hand disinfection. Hands are a major source of transmission for hospital infections, and compliance with handwashing protocols can be suboptimal for a variety of reasons. These include lack of accessible equipment, insufficient knowledge of staff about risks and procedures, and too long a duration recommended for washing.

      Inadequate instrument disinfection is another common cause of hospital-acquired wound infections. Different levels of disinfection are recommended for patient equipment depending on the type of care, with surgical instruments presenting a critical level of risk. Sterilisation or high-level disinfection is necessary to minimise the risk of infection.

      While strict schedules for cleaning and disinfection of rooms are in place in hospitals, inadequate room disinfection is still a concern. However, this is not the main cause of surgical wound infection.

      The use of wrong disinfectants during skin disinfection can also contribute to hospital-acquired wound infections. Specific hand disinfectants are used for skin disinfection, including alcoholic rubs and emollient gels.

      Finally, too frequent skin disinfection can lead to the destruction of the normal skin flora, which can increase the risk of infection. Disinfecting agents must be chosen with care to avoid sensitisation or irritation of the skin.

      In conclusion, preventing hospital-acquired wound infections requires a multifaceted approach that addresses the common causes of infection. Proper hand hygiene, instrument disinfection, and skin disinfection are all essential components of a comprehensive infection prevention program.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 25 - A 32-year-old woman has been referred by her General Practitioner (GP), as she...

    Incorrect

    • A 32-year-old woman has been referred by her General Practitioner (GP), as she is passing a substantial volume of urine. She complains that she is continuously thirsty.
      Random plasma reveals the following:
      Investigation Result Normal values
      Sodium (Na+) 155 mmol
      Osmolality 300 mOsmol/kg
      Glucose 4.5 mmol
      Urine analysis reveals the following:
      Investigation Result
      Osmolality 90 mOsmol/kg
      Glucose 0.1 mmol/l
      In healthy patients, the urine : plasma osmolality ratio is > 2.
      A water deprivation test reveals the following:
      After 6.5 hours of fluid deprivation, the patient’s weight had dropped by > 3%, and the serum osmolality was 310 mOsmol/kg. Urine osmolality at this stage was 210 mOsmol/kg. The patient was then given desmopressin intramuscularly (IM) and allowed to drink. The urine osmolality increased to 700 mOsmol/kg, and her plasma osmolality was 292 mOsmol/kg.
      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: A pituitary tumour

      Explanation:

      Diagnosing Cranial Diabetes Insipidus: A Pituitary Tumour as the Likely Cause

      Cranial diabetes insipidus (DI) is a condition where the kidneys are unable to reabsorb free water, resulting in excessive water loss. The most likely cause of this condition is reduced antidiuretic hormone (ADH) secretion, which can be caused by a pituitary tumour. In this case, the patient’s low urine osmolality and reduced response to the water deprivation test confirm the presence of cranial DI.

      Chronic renal disease and lithium therapy can also cause nephrogenic DI, but the patient’s response to desmopressin im excludes these as potential causes. Diabetes mellitus may cause polydipsia and polyuria, but it also presents with glycosuria and hyperglycaemia. Primary polydipsia, characterized by a compulsive desire to drink, can cause low urine osmolality, but the patient’s ability to concentrate urine to some extent excludes this as a likely cause.

      In conclusion, a pituitary tumour is the most likely cause of the patient’s cranial DI, as confirmed by the water deprivation test and response to desmopressin im.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 26 - A 14-year-old girl comes to the clinic complaining of right knee pain. She...

    Incorrect

    • A 14-year-old girl comes to the clinic complaining of right knee pain. She is an avid hockey player but has not experienced any recent injuries. During the examination, a painful swelling is observed over the tibial tubercle. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Osgood-Schlatter disease

      Explanation:

      Common Knee Problems in Children and Young Adults

      Knee problems are common in children and young adults, especially those who are active in sports.
      Chondromalacia patellae is a condition that is more common in teenage girls. It is characterized by the softening of the cartilage of the patella, which can cause anterior knee pain when walking up and down stairs or rising from prolonged sitting. This condition usually responds well to physiotherapy.

      Osgood-Schlatter disease, also known as tibial apophysitis, is often seen in sporty teenagers. It causes pain, tenderness, and swelling over the tibial tubercle.

      Osteochondritis dissecans can cause pain after exercise, as well as intermittent swelling and locking of the knee.

      Patellar subluxation can cause medial knee pain due to lateral subluxation of the patella. The knee may also give way.

      Patellar tendonitis is more common in athletic teenage boys. It causes chronic anterior knee pain that worsens after running. On examination, the area below the patella is tender. It is important to note that referred pain may come from hip problems such as slipped upper femoral epiphysis.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 27 - A 45-year-old woman reports leakage of urine, which is happening more often. She...

    Incorrect

    • A 45-year-old woman reports leakage of urine, which is happening more often. She is unable to control her urine when she feels the urge to go and has had a few instances where she couldn't make it to the bathroom in time. There is no pain during urination and her urine dipstick test is negative. Which of the following is the most probable diagnosis?

      Your Answer:

      Correct Answer: Urge incontinence

      Explanation:

      Urinary incontinence is a common problem that affects more women than men and increases with age. There are different types of urinary incontinence, each with its own set of symptoms. Functional incontinence occurs when a person is unable to hold urine due to reasons other than lower urinary tract dysfunction, such as delirium or impaired mobility. Mixed incontinence is a combination of stress and urge incontinence, while overflow incontinence occurs when the bladder is overdistended and urine overflows despite the absence of detrusor contraction. Stress incontinence is characterized by urine loss during periods of increased intra-abdominal pressure, while urge incontinence is associated with a sudden and intense desire to void that cannot be prevented. Symptoms of urge incontinence include urinary frequency and nocturia. Treatment is directed at the underlying cause of the incontinence.

    • This question is part of the following fields:

      • Reproductive Medicine
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  • Question 28 - A 55-year-old woman has been diagnosed with acute cholecystitis and is set to...

    Incorrect

    • A 55-year-old woman has been diagnosed with acute cholecystitis and is set to undergo a cholecystectomy in 4 days. She is currently managing her type 1 diabetes with a daily dose of 20 units of long acting insulin in the morning. What is the appropriate once-daily dose of insulin for her to take the day before her surgery?

      Your Answer:

      Correct Answer: 16 Units

      Explanation:

      Preparation for surgery varies depending on whether the patient is undergoing an elective or emergency procedure. For elective cases, it is important to address any medical issues beforehand through a pre-admission clinic. Blood tests, urine analysis, and other diagnostic tests may be necessary depending on the proposed procedure and patient fitness. Risk factors for deep vein thrombosis should also be assessed, and a plan for thromboprophylaxis formulated. Patients are advised to fast from non-clear liquids and food for at least 6 hours before surgery, and those with diabetes require special management to avoid potential complications. Emergency cases require stabilization and resuscitation as needed, and antibiotics may be necessary. Special preparation may also be required for certain procedures, such as vocal cord checks for thyroid surgery or bowel preparation for colorectal cases.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 29 - A 42-year-old man has been receiving weekly intramuscular injections for rheumatoid arthritis for...

    Incorrect

    • A 42-year-old man has been receiving weekly intramuscular injections for rheumatoid arthritis for the past 8 weeks. Routine urinalysis shows that he has a proteinuria.
      Which of the following is he most likely to have been prescribed?

      Your Answer:

      Correct Answer: Gold

      Explanation:

      Rheumatoid arthritis can be treated with various drugs, including gold, infliximab, d-penicillamine, leflunomide, and celecoxib. Gold is given by injection and can cause side effects such as glomerulonephritis. Infliximab is administered intravenously and can lead to infections and autoimmune syndromes. D-penicillamine can cause proteinuria and is taken orally. Leflunomide blocks T cell expansion and can cause diarrhea, nausea, and abnormal blood test results. Celecoxib is an NSAID taken orally and can increase the risk of vascular events and gastrointestinal issues. Understanding the different drug categories and their side effects is important for effective treatment of rheumatoid arthritis. Monitoring for side effects is necessary for all disease-modifying drugs.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 30 - A 6-year-old girl is presented with a worsening of her asthma symptoms. Upon...

    Incorrect

    • A 6-year-old girl is presented with a worsening of her asthma symptoms. Upon examination, she exhibits bilateral expiratory wheezing, but there are no indications of respiratory distress. Her respiratory rate is 24 breaths per minute, and her PEF is approximately 50% of normal. What is the best course of action regarding steroid treatment?

      Your Answer:

      Correct Answer: Oral prednisolone for 3 days

      Explanation:

      According to the 2016 guidelines of the British Thoracic Society, children should be given a specific dose of steroids based on their age. For children under 2 years, the dose should be 10 mg of prednisolone, for those aged 2-5 years, it should be 20 mg, and for those over 5 years, it should be 30-40 mg. Children who are already taking maintenance steroid tablets should receive a maximum dose of 60 mg or 2 mg/kg of prednisolone. If a child vomits after taking the medication, the dose should be repeated, and if they are unable to retain the medication orally, intravenous steroids should be considered. The duration of treatment should be tailored to the number of days required for recovery, and a course of steroids exceeding 14 days does not require tapering.

      Managing Acute Asthma Attacks in Children

      When it comes to managing acute asthma attacks in children, it is important to assess the severity of the attack and take appropriate action. For children between the ages of 2 and 5, those with severe or life-threatening asthma should be immediately transferred to the hospital. For moderate attacks, children should have a SpO2 level above 92% and no clinical features of severe asthma. However, for severe attacks, children may have a SpO2 level below 92%, be too breathless to talk or feed, have a heart rate above 140/min, and use accessory neck muscles. For life-threatening attacks, children may have a SpO2 level below 92%, a silent chest, poor respiratory effort, agitation, altered consciousness, and cyanosis.

      For children over the age of 5, it is recommended to attempt to measure PEF in all cases. For moderate attacks, children should have a SpO2 level above 92%, a PEF level above 50% best or predicted, and no clinical features of severe asthma. For severe attacks, children may have a SpO2 level below 92%, a PEF level between 33-50% best or predicted, and be unable to complete sentences in one breath or too breathless to talk or feed. For life-threatening attacks, children may have a SpO2 level below 92%, a PEF level below 33% best or predicted, a silent chest, poor respiratory effort, altered consciousness, and cyanosis.

      For children with mild to moderate acute asthma, bronchodilator therapy should be given via a beta-2 agonist and spacer (or close-fitting mask for children under 3 years old). One puff should be given every 30-60 seconds up to a maximum of 10 puffs. If symptoms are not controlled, the beta-2 agonist should be repeated and the child should be referred to the hospital. Steroid therapy should also be given to all children with an asthma exacerbation for 3-5 days, with the usual prednisolone dose varying based on age and weight.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 31 - A 45-year-old man presents to the Emergency Department with worsening epigastric pain and...

    Incorrect

    • A 45-year-old man presents to the Emergency Department with worsening epigastric pain and water brash for the past few weeks. He has been taking ibandronic acid tablets for osteoporosis. There is no history of food sticking or significant weight loss.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Oesophagitis

      Explanation:

      Common Gastrointestinal Conditions and Their Symptoms

      Gastrointestinal conditions can present with a variety of symptoms, making diagnosis challenging. Here are some common conditions and their associated symptoms:

      Oesophagitis: Inflammation of the oesophagus can cause asymptomatic, epigastric or substernal burning pain, dysphagia, and increased discomfort when lying down or straining. It is often caused by gastro-oesophageal reflux disease, alcohol, non-steroidal anti-inflammatory drugs, bisphosphonates, smoking, or Candida albicans infection. Treatment involves eliminating precipitating causes and using proton-pump inhibitors.

      Oesophageal carcinoma: This type of cancer typically presents with worsening dysphagia, weight loss, heartburn, and changes in voice due to compression of the recurrent laryngeal nerve.

      Gastric carcinoma: Symptoms of gastric cancer are often non-specific and include weight loss, anorexia, and fatigue. Heartburn and indigestion are rare.

      Duodenal ulcer: Pain associated with duodenal ulcers is typically improved with eating and severe enough to impact nutritional intake, leading to weight loss. Patients at high risk of gastric ulceration due to medication use may be prescribed a proton-pump inhibitor.

      Pancreatic carcinoma: This type of cancer often presents very late with painless jaundice and weight loss, which are not seen in the presented case.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 32 - A 25-year-old man presents with facial and ankle swelling that has been gradually...

    Incorrect

    • A 25-year-old man presents with facial and ankle swelling that has been gradually developing over the past week. He reports passing 'frothy' urine during the review of systems. A urine dipstick reveals protein +++ and a diagnosis of nephrotic syndrome is confirmed after a 24-hour urine sample. What is the probable cause of this presentation?

      Your Answer:

      Correct Answer: Minimal change disease

      Explanation:

      Minimal change disease is a condition that typically presents as nephrotic syndrome, with children accounting for 75% of cases and adults accounting for 25%. While most cases are idiopathic, around 10-20% have a known cause, such as certain drugs, Hodgkin’s lymphoma, thymoma, or infectious mononucleosis. The pathophysiology of the disease involves T-cell and cytokine-mediated damage to the glomerular basement membrane, resulting in polyanion loss and reduced electrostatic charge, which increases glomerular permeability to serum albumin. The disease is characterized by nephrotic syndrome, normotension (hypertension is rare), and highly selective proteinuria, with only intermediate-sized proteins such as albumin and transferrin leaking through the glomerulus. Renal biopsy shows normal glomeruli on light microscopy, but electron microscopy reveals fusion of podocytes and effacement of foot processes.

      Management of minimal change disease typically involves oral corticosteroids, which are effective in 80% of cases. For steroid-resistant cases, cyclophosphamide is the next step. The prognosis for the disease is generally good, although relapse is common. Approximately one-third of patients have just one episode, one-third have infrequent relapses, and one-third have frequent relapses that stop before adulthood.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 33 - A 32-year-old woman with a history of primary generalised epilepsy visits her GP...

    Incorrect

    • A 32-year-old woman with a history of primary generalised epilepsy visits her GP as she intends to conceive. She is currently on lamotrigine as a single therapy. What guidance should be provided to prevent neural tube defects?

      Your Answer:

      Correct Answer: Folic acid 5 mg per day starting now

      Explanation:

      During pregnancy, women with epilepsy should take 5mg of folic acid. Additionally, due to the potential harm of antiepileptic drugs to the fetus, they should receive specialized medical care.

      Pregnancy and breastfeeding can be a concern for women with epilepsy. It is generally recommended that women continue taking their medication during pregnancy, as the risks of uncontrolled seizures outweigh the potential risks to the fetus. However, it is important for women to take folic acid before pregnancy to reduce the risk of neural tube defects. The use of antiepileptic medication during pregnancy can increase the risk of congenital defects, but this risk is still relatively low. It is recommended to aim for monotherapy and there is no need to monitor drug levels. Sodium valproate is associated with neural tube defects, while carbamazepine is considered the least teratogenic of the older antiepileptics. Phenytoin is associated with cleft palate, and lamotrigine may require a dose increase during pregnancy. Breastfeeding is generally safe for mothers taking antiepileptics, except for barbiturates. Pregnant women taking phenytoin should be given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn.

      A warning has been issued about the use of sodium valproate during pregnancy and in women of childbearing age. New evidence suggests a significant risk of neurodevelopmental delay in children following maternal use of this medication. Therefore, it should only be used if clearly necessary and under specialist neurological or psychiatric advice. It is important for women with epilepsy to discuss their options with their healthcare provider and make informed decisions about their treatment during pregnancy and breastfeeding.

    • This question is part of the following fields:

      • Reproductive Medicine
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  • Question 34 - A 65-year-old man with a history of myocardial infarction, congestive heart failure, and...

    Incorrect

    • A 65-year-old man with a history of myocardial infarction, congestive heart failure, and chronic obstructive pulmonary disease presents for a diabetes check-up at his GP's office. He was recently diagnosed with type 2 diabetes mellitus, and despite attempting lifestyle changes, his HbA1c remains at 56 mmol/mol. The GP decides to initiate drug therapy.
      Which of the following medications would be inappropriate for this patient?

      Your Answer:

      Correct Answer: Pioglitazone

      Explanation:

      Patients with heart failure should not take pioglitazone due to its potential to cause fluid retention.

      NICE updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022, reflecting advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. The first-line drug of choice remains metformin, which should be titrated up slowly to minimize gastrointestinal upset. HbA1c targets should be agreed upon with patients and checked every 3-6 months until stable, with consideration for relaxing targets on a case-by-case basis. Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates and controlling intake of foods containing saturated fats and trans fatty acids. Blood pressure targets are the same as for patients without type 2 diabetes, and antiplatelets should not be offered unless a patient has existing cardiovascular disease. Only patients with a 10-year cardiovascular risk > 10% should be offered a statin, with atorvastatin 20mg as the first-line choice.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 35 - A 50-year-old female with a history of Sjogren's syndrome presents to the gastroenterology...

    Incorrect

    • A 50-year-old female with a history of Sjogren's syndrome presents to the gastroenterology clinic with elevated liver function tests. She reports experiencing fatigue and itching that has worsened over the past 3 months. On physical examination, her abdomen is soft, nontender, and without any organ enlargement. Laboratory results show a low hemoglobin level, normal platelet count and white blood cell count, elevated bilirubin, alkaline phosphatase, and gamma-glutamyl transferase levels, and positive anti-mitochondrial antibodies. What is the initial treatment recommended to halt the progression of her liver disease?

      Your Answer:

      Correct Answer: Ursodeoxycholic acid

      Explanation:

      Primary biliary cholangitis is a chronic liver disease that primarily affects middle-aged women. It is characterized by the destruction of small bile ducts in the liver, leading to cholestasis and liver damage. The disease is diagnosed through blood tests that measure levels of specific antibodies and liver enzymes, which are highly specific to the condition. Ursodeoxycholic acid is the preferred treatment for slowing disease progression and improving symptoms, while cholestyramine can be used to alleviate itching but does not affect disease progression. In cases of decompensated liver disease, such as when bilirubin levels exceed 100, liver transplantation may be an option. Although recurrence in the graft can occur, it is typically not a significant issue. While fat-soluble vitamins can be supplemented, they are not a primary treatment option.

      Primary Biliary Cholangitis: A Chronic Liver Disorder

      Primary biliary cholangitis, previously known as primary biliary cirrhosis, is a chronic liver disorder that is commonly observed in middle-aged women. The exact cause of this condition is not yet fully understood, but it is believed to be an autoimmune disease. The disease is characterized by the progressive damage of interlobular bile ducts due to chronic inflammation, leading to cholestasis and eventually cirrhosis. The most common symptom of primary biliary cholangitis is itching in middle-aged women.

      This condition is often associated with other autoimmune diseases such as Sjogren’s syndrome, rheumatoid arthritis, systemic sclerosis, and thyroid disease. Early symptoms of primary biliary cholangitis may be asymptomatic or may include fatigue, pruritus, and cholestatic jaundice. Late symptoms may progress to liver failure. Diagnosis of primary biliary cholangitis involves immunology tests such as anti-mitochondrial antibodies (AMA) M2 subtype and smooth muscle antibodies, as well as imaging tests to exclude an extrahepatic biliary obstruction.

      The first-line treatment for primary biliary cholangitis is ursodeoxycholic acid, which slows down the progression of the disease and improves symptoms. Cholestyramine is used to alleviate pruritus, and fat-soluble vitamin supplementation is recommended. In severe cases, liver transplantation may be necessary, especially if bilirubin levels exceed 100. However, recurrence in the graft can occur, but it is not usually a problem. Complications of primary biliary cholangitis include cirrhosis, portal hypertension, ascites, variceal hemorrhage, osteomalacia, osteoporosis, and an increased risk of hepatocellular carcinoma.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 36 - A 16-year-old girl comes to the clinic complaining of upper abdominal pain. She...

    Incorrect

    • A 16-year-old girl comes to the clinic complaining of upper abdominal pain. She is typically healthy and takes a combined oral contraceptive pill. Her mother has a history of hereditary spherocytosis and is with her during the visit. The pain is intermittent but has intensified today. There have been no alterations to her bowel movements, and she has not experienced any nausea or vomiting. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Biliary colic

      Explanation:

      Chronic haemolysis and gallstone formation are present in this patient with hereditary spherocytosis. It is crucial to consider splenic rupture as a potential differential diagnosis in a patient with hereditary spherocytosis who is unwell.

      Understanding Hereditary Spherocytosis

      Hereditary spherocytosis is the most common hereditary haemolytic anaemia in people of northern European descent. It is an autosomal dominant defect of the red blood cell cytoskeleton, which replaces the normal biconcave disc shape with a sphere-shaped red blood cell. This condition reduces the red blood cell survival as they are destroyed by the spleen. Patients with hereditary spherocytosis may present with failure to thrive, jaundice, gallstones, splenomegaly, and aplastic crisis precipitated by parvovirus infection. The degree of haemolysis is variable, and the mean corpuscular haemoglobin concentration (MCHC) is elevated.

      The diagnosis of hereditary spherocytosis is based on a family history of the condition, typical clinical features, and laboratory investigations such as spherocytes, raised MCHC, and an increase in reticulocytes. The osmotic fragility test was previously the recommended investigation of choice, but it is now deemed unreliable and is no longer recommended. If the diagnosis is equivocal, the EMA binding test and the cryohaemolysis test are recommended. For atypical presentations, electrophoresis analysis of erythrocyte membranes is the method of choice.

      The management of hereditary spherocytosis involves supportive treatment during acute haemolytic crisis, including transfusion if necessary. Longer-term treatment includes folate replacement and splenectomy. It is important to note that hereditary spherocytosis differs from G6PD deficiency, which is an X-linked recessive condition that affects males of African and Mediterranean descent. The diagnostic test for G6PD deficiency involves measuring enzyme activity, while the EMA binding test is used for hereditary spherocytosis.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 37 - An expectant mother visits the obstetrician's office with a complaint of a painful...

    Incorrect

    • An expectant mother visits the obstetrician's office with a complaint of a painful nipple and a white discharge from the nipple. It is suspected that she has a candidal infection. What advice and treatment should be provided?

      Your Answer:

      Correct Answer: Continue breast feeding treat both the mother and baby simultaneously

      Explanation:

      It is essential to treat the candidal infection by administering miconazole cream to both the mother and child. The cream should be applied to the nipple after feeding and the infant’s oral mucosa. Breastfeeding should continue during the treatment period. Additionally, the mother should be educated on maintaining good hand hygiene after changing the baby’s nappy and sterilizing any objects that the baby puts in their mouth, such as dummies and teats. This information is provided by NICE CKS.

      Breastfeeding Problems and Their Management

      Breastfeeding is a natural process, but it can come with its own set of challenges. Some of the minor problems that breastfeeding mothers may encounter include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These issues can be managed by seeking advice on proper positioning, trying breast massage, and using appropriate medication.

      Mastitis is a more serious problem that affects around 1 in 10 breastfeeding women. It is characterized by symptoms such as fever, nipple fissure, and persistent pain. Treatment involves the use of antibiotics, such as flucloxacillin, for 10-14 days. Breastfeeding or expressing milk should continue during treatment to prevent complications such as breast abscess.

      Breast engorgement is another common problem that causes breast pain in breastfeeding women. It occurs in the first few days after birth and affects both breasts. Hand expression of milk can help relieve the discomfort of engorgement. Raynaud’s disease of the nipple is a less common problem that causes nipple pain and blanching. Treatment involves minimizing exposure to cold, using heat packs, and avoiding caffeine and smoking.

      If a breastfed baby loses more than 10% of their birth weight in the first week of life, it may be a sign of poor weight gain. This should prompt consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight should continue until weight gain is satisfactory.

    • This question is part of the following fields:

      • Reproductive Medicine
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  • Question 38 - The action of warfarin is characterized by which of the following statements? ...

    Incorrect

    • The action of warfarin is characterized by which of the following statements?

      Your Answer:

      Correct Answer: It interacts with miconazole to increase anticoagulant effect

      Explanation:

      Warfarin, a medication used to prevent blood clots, can interact with other drugs and have various effects on the body. For example, certain antimicrobial agents can increase the risk of bleeding in patients taking warfarin, including azole antifungals, macrolides, quinolones, co-trimoxazole, penicillins, and cephalosporins. Miconazole, in particular, can greatly enhance the anticoagulant effect of warfarin. Warfarin works by blocking the action of vitamin K epoxide reductase, which reactivates vitamin K1. This decreases the clotting ability of certain factors in the blood. However, warfarin can also have negative effects, such as warfarin necrosis, a rare but serious complication that can lead to skin necrosis and limb gangrene. When taking warfarin, it is important to consider drug interactions, such as displacement from protein-binding sites or enzyme inhibition or induction.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 39 - A 20-year-old with type 1 diabetes presents to the Emergency Department feeling unwell....

    Incorrect

    • A 20-year-old with type 1 diabetes presents to the Emergency Department feeling unwell. She reports experiencing vomiting and diarrhoea for the past 2 days and has not been taking her full insulin doses due to loss of appetite. Her capillary glucose level is 37 mmol/l and urinalysis shows 4+ ketones. An arterial blood gas test is conducted, revealing the following results:
      pH 7.12
      pO2 13 kPa
      pCO2 3.5 kPa
      HCO3 13
      Na 129 mmol/l
      K 6.1 mmol/l
      What is the most appropriate initial management for this patient?

      Your Answer:

      Correct Answer: IV 0.9% NaCl bolus

      Explanation:

      Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus, accounting for around 6% of cases. It can also occur in rare cases of extreme stress in patients with type 2 diabetes mellitus. However, mortality rates have decreased from 8% to under 1% in the past 20 years. DKA is caused by uncontrolled lipolysis, resulting in an excess of free fatty acids that are ultimately converted to ketone bodies. The most common precipitating factors of DKA are infection, missed insulin doses, and myocardial infarction. Symptoms include abdominal pain, polyuria, polydipsia, dehydration, Kussmaul respiration, and acetone-smelling breath. Diagnostic criteria include glucose levels above 13.8 mmol/l, pH below 7.30, serum bicarbonate below 18 mmol/l, anion gap above 10, and ketonaemia.

      Management of DKA involves fluid replacement, insulin, and correction of electrolyte disturbance. Most patients with DKA are depleted around 5-8 litres, and isotonic saline is used initially, even if the patient is severely acidotic. Insulin is administered through an intravenous infusion, and correction of electrolyte disturbance is necessary. Long-acting insulin should be continued, while short-acting insulin should be stopped. DKA resolution is defined as pH above 7.3, blood ketones below 0.6 mmol/L, and bicarbonate above 15.0mmol/L. Complications may occur from DKA itself or the treatment, such as gastric stasis, thromboembolism, arrhythmias, acute respiratory distress syndrome, acute kidney injury, and cerebral oedema. Children and young adults are particularly vulnerable to cerebral oedema following fluid resuscitation in DKA and often need 1:1 nursing to monitor neuro-observations.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 40 - Male infertility is most commonly associated with which of the following? ...

    Incorrect

    • Male infertility is most commonly associated with which of the following?

      Your Answer:

      Correct Answer: Varicocele

      Explanation:

      Male Reproductive Conditions: Varicocele, Spermatocele, BPH, Hydrocele, and Testicular Cancer

      Male infertility can be caused by deficiencies in sperm formation, concentration, or transportation. One common condition that can lead to infertility is varicocele, which is a dilatation of the veins in the scrotum. Although varicoceles are present in 15% of the male population, they are considered the most common correctable cause of infertility. Varicoceles may lead to impaired testicular function and can progress over time, but repair can improve semen parameters and fertility.

      Spermatocele, on the other hand, is a benign cystic accumulation of sperm that arises from the epididymis and is not associated with male infertility. Treatment is usually not recommended in men of reproductive age due to the risk of epididymal damage.

      Benign prostatic hyperplasia (BPH) is a histological diagnosis characterized by prostate enlargement, but it is not associated with male infertility. In patients with spinal cord injury, infertility may be related to functional failure of the prostate gland and hyperactivation of the immune system.

      Hydrocele is a fluid collection within the scrotum or along the spermatic cord, but it is not associated with male infertility. Testicular cancer, the most common solid malignant tumor in young men, is also not directly associated with infertility, but surgical resection may lead to retrograde ejaculation and other fertility issues.

      The initial evaluation of male infertility should be rapid, non-invasive, and cost-effective, as most conditions can be diagnosed with history, physical examination, and hormonal and semen analysis alone. Further studies can be ordered if necessary.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 41 - A 65-year-old patient is brought to the emergency department after falling off a...

    Incorrect

    • A 65-year-old patient is brought to the emergency department after falling off a ladder and hitting their head. The ambulance crew suspects an intracranial haemorrhage. Upon examination, the patient responds to verbal instruction by opening their eyes, but only makes incomprehensible groans. Painful stimulation causes abnormal flexing on the left side, while the right side has no motor response. What is the Glasgow Coma Scale (GCS) score for this patient?

      Your Answer:

      Correct Answer: 8

      Explanation:

      Understanding the Glasgow Coma Scale for Adults

      The Glasgow Coma Scale (GCS) is a tool used to assess the level of consciousness in adults who have suffered a brain injury or other neurological condition. It is based on three components: motor response, verbal response, and eye opening. Each component is scored on a scale from 1 to 6, with a higher score indicating a better level of consciousness.

      The motor response component assesses the patient’s ability to move in response to stimuli. A score of 6 indicates that the patient is able to obey commands, while a score of 1 indicates no movement at all.

      The verbal response component assesses the patient’s ability to communicate. A score of 5 indicates that the patient is fully oriented, while a score of 1 indicates no verbal response at all.

      The eye opening component assesses the patient’s ability to open their eyes. A score of 4 indicates that the patient is able to open their eyes spontaneously, while a score of 1 indicates no eye opening at all.

      The GCS score is expressed as a combination of the scores from each component, with the motor response score listed first, followed by the verbal response score, and then the eye opening score. For example, a GCS score of 13, M5 V4 E4 at 21:30 would indicate that the patient had a motor response score of 5, a verbal response score of 4, and an eye opening score of 4 at 9:30 PM.

      Overall, the Glasgow Coma Scale is a useful tool for healthcare professionals to assess the level of consciousness in adults with neurological conditions.

    • This question is part of the following fields:

      • Neurology
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  • Question 42 - A 45-year-old non-smoker with hypertension and diabetes has been diagnosed with bilateral renal...

    Incorrect

    • A 45-year-old non-smoker with hypertension and diabetes has been diagnosed with bilateral renal artery stenosis. Blood tests reveal that he has normal renal function. He has undergone percutaneous angioplasty to both renal arteries, which was unsuccessful.
      Which medication should this patient be started on?

      Your Answer:

      Correct Answer: Start angiotensin-converting enzyme (ACE) inhibitors

      Explanation:

      Medical Management of Renal Artery Stenosis

      Renal artery stenosis is a condition that requires medical management to control hypertension. Even if the arteries are treated successfully with angioplasty, antihypertensive therapy should be initiated. The ideal agent for this purpose is one that blocks the renin-angiotensin-aldosterone system, such as angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs). Warfarin is not indicated in patients with renal artery stenosis, but may be used for prophylaxis of embolisation in other conditions. Clopidogrel is not indicated for hypertension management in renal artery stenosis. Statins may be used for primary prevention of cardiovascular disease if cholesterol levels are raised, but controlling blood pressure is the primary consideration in renal artery stenosis. Spironolactone should not be used in patients with renal compromise. Control of blood pressure should ideally be achieved using ACE inhibitors or ARBs.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 43 - A 50-year-old woman presents to her GP on the same day with a...

    Incorrect

    • A 50-year-old woman presents to her GP on the same day with a sudden onset of hearing loss in her right ear while having breakfast. She reports feeling well otherwise and denies any ear pain, discharge, or previous ENT issues. The patient has no significant medical history and is not taking any regular medications. Otoscopy reveals no abnormalities, and tuning fork tests confirm a sensorineural loss. What is the best course of action for managing this patient's condition?

      Your Answer:

      Correct Answer: Refer urgently to ENT

      Explanation:

      If someone experiences sudden onset sensorineural hearing loss, it is important to refer them to an ENT specialist within 24 hours for investigation and potential treatment with steroids.

      Understanding Hearing Loss with Weber and Rinnes Tests

      Hearing loss can be classified as either conductive or sensorineural, and a formal assessment with pure tone audiometry is often necessary to determine which type is present. However, in a clinical setting, Weber and Rinnes tests can also be helpful in categorizing different types of hearing loss.

      The Weber test involves using a tuning fork to determine if a patient has symmetrical or asymmetrical hearing loss. In a normal patient, the sound is heard equally loud in both ears. However, in a patient with asymmetrical hearing loss, the sound is heard louder in one ear than the other. This finding should be confirmed by repeating the procedure and having the patient occlude one ear with a finger.

      The Rinne test involves comparing air conduction to bone conduction in both ears. In a patient with normal hearing, air conduction is greater than bone conduction in both ears. However, in a patient with sensorineural hearing loss, air conduction is greater than bone conduction in the unaffected ear. In a patient with conductive hearing loss, bone conduction is greater than air conduction in the affected ear.

      Understanding the results of these tests can help healthcare professionals diagnose and treat hearing loss. By identifying the type and severity of hearing loss, appropriate interventions such as hearing aids or cochlear implants can be recommended.

    • This question is part of the following fields:

      • ENT
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  • Question 44 - A 30-year-old woman presents with chronic diarrhoea. She says that her stools float...

    Incorrect

    • A 30-year-old woman presents with chronic diarrhoea. She says that her stools float and are difficult to flush away.
      Investigations reveal the following:
      Investigation Result Normal value
      Potassium (K+) 3.1 mmol/l 3.5–5.0 mmol/l
      Corrected calcium (Ca2+) 2.08 mmol/l 2.20–2.60 mmol/l
      Albumin 29 g/l 35–55 g/l
      Haemoglobin (Hb) 91 g/l 115–155 g/l
      Mean corpuscular volume (MCV) 89 fl 76–98 fl
      Coeliac disease is suspected.
      Which of the following is the initial investigation of choice?

      Your Answer:

      Correct Answer: Anti-tissue transglutaminase (anti-TTG)

      Explanation:

      Diagnosis and Investigation of Coeliac Disease

      Coeliac disease is a possible diagnosis in patients presenting with chronic diarrhoea and steatorrhoea. The initial investigation of choice is the anti-tissue transglutaminase (anti-TTG) test, which has a sensitivity of over 96%. However, it is important to check immunoglobulin A (IgA) levels concurrently, as anti-TTG is an IgA antibody and may not be raised in the presence of IgA deficiency.

      The treatment of choice for coeliac disease is a lifelong gluten-free diet, avoiding gluten-containing foods such as wheat, barley, rye, and oats. Patients with coeliac disease are at increased risk of small bowel lymphoma and oesophageal carcinoma over the long term.

      While faecal fat estimation may be useful in estimating steatorrhoea, small bowel biopsy is the gold standard investigation for coeliac disease. However, this would not be the initial investigation of choice as it is invasive. An anti-TTG test is more sensitive and specific than an anti-gliadin test in untreated coeliac disease. Magnesium (Mg2+) levels may be abnormal in coeliac disease, but this would not be diagnostic and therefore not the first investigation of choice.

      In summary, the diagnosis of coeliac disease requires a combination of clinical presentation, laboratory investigations, and small bowel biopsy if necessary. The anti-TTG test is the initial investigation of choice, and a gluten-free diet is the treatment of choice.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
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  • Question 45 - A 52-year-old man has recently been diagnosed with type 2 diabetes mellitus. He...

    Incorrect

    • A 52-year-old man has recently been diagnosed with type 2 diabetes mellitus. He was prescribed medication but a few days later he complained of stomach cramps and loose stools.
      Which of the following medications is most likely responsible for these symptoms?

      Your Answer:

      Correct Answer: Metformin

      Explanation:

      Side Effects of Common Oral Diabetic Medications

      Managing diabetes often involves the use of oral medications to help control blood sugar levels. However, these medications can come with side effects that need to be considered when choosing a treatment plan. Here are some common side effects of four oral diabetic medications:

      Metformin: The most common side effects of metformin are abdominal pain, anorexia, diarrhea, nausea, taste disturbance, and vomiting. There is also a risk of developing lactic acidosis, particularly in patients with a history of heart failure and concomitant use of drugs that can acutely impair renal function.

      Furosemide: Furosemide is a less likely option due to its potential to exacerbate diabetes and cause hypokalemia, which can be dangerous in certain patients. It can also cause urinary retention in patients with enlarged prostates.

      Gliclazide: Gliclazide can encourage weight gain and may cause hypoglycemia if the dosage is excessive.

      Pioglitazone: Pioglitazone should be used with caution in patients with cardiovascular disease or in combination with insulin due to an increased risk of heart failure, particularly in elderly people.

      It is important to be familiar with these side effects to ensure patient compliance with medication and to choose the most appropriate treatment plan for each individual.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 46 - A 28-year-old woman comes to the Endocrine Clinic with a history of hyperthyroidism....

    Incorrect

    • A 28-year-old woman comes to the Endocrine Clinic with a history of hyperthyroidism. Her blood tests confirm that she is currently experiencing thyrotoxicosis. She is hoping to conceive and wants to discuss her treatment options.
      What is the most suitable treatment for her condition in this scenario?

      Your Answer:

      Correct Answer: Thyroidectomy

      Explanation:

      Treatment Options for Hyperthyroidism in Women Planning a Pregnancy

      When it comes to treating hyperthyroidism in women who are planning a pregnancy, there are several options to consider. Definitive treatment, such as thyroidectomy, is the preferred option as it eliminates the risk of thyrotoxicosis during pregnancy and the need for medication that could harm the fetus. However, following thyroidectomy, the patient will need thyroxine replacement and should wait until she is euthyroid before trying to conceive.

      Propylthiouracil and thyroxine are not recommended for use during pregnancy due to the risk of fetal goitre or hypothyroidism. Carbimazole is teratogenic and should not be started in women planning a pregnancy. Propylthiouracil can be used in low doses if there is no other suitable alternative.

      Radioactive iodine is highly effective but is contraindicated in women planning a pregnancy within six months. This option can be considered if the patient is willing to continue contraception until six months after treatment. Ultimately, the best course of action will depend on the individual patient’s needs and preferences, and should be discussed with a healthcare provider.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 47 - A 47-year-old man comes to the clinic complaining of fatigue. Upon examination, his...

    Incorrect

    • A 47-year-old man comes to the clinic complaining of fatigue. Upon examination, his blood pressure is found to be 190/110 mmHg. Routine blood tests show the following results:
      - Sodium: 145 mmol/L
      - Potassium: 2.5 mmol/L
      - Bicarbonate: 33 mmol/L
      - Urea: 5.6 mmol/L
      - Creatinine: 80 µmol/L

      What is the probable diagnosis?

      Your Answer:

      Correct Answer: Primary hyperaldosteronism

      Explanation:

      Understanding Primary Hyperaldosteronism

      Primary hyperaldosteronism is a medical condition that was previously believed to be caused by an adrenal adenoma, also known as Conn’s syndrome. However, recent studies have shown that bilateral idiopathic adrenal hyperplasia is the cause in up to 70% of cases. It is important to differentiate between the two as this determines the appropriate treatment. Adrenal carcinoma is an extremely rare cause of primary hyperaldosteronism.

      The common features of primary hyperaldosteronism include hypertension, hypokalaemia, and alkalosis. Hypokalaemia can cause muscle weakness, but this is seen in only 10-40% of patients. To diagnose primary hyperaldosteronism, the 2016 Endocrine Society recommends a plasma aldosterone/renin ratio as the first-line investigation. This should show high aldosterone levels alongside low renin levels due to negative feedback from sodium retention caused by aldosterone.

      If the plasma aldosterone/renin ratio is high, a high-resolution CT abdomen and adrenal vein sampling are used to differentiate between unilateral and bilateral sources of aldosterone excess. If the CT is normal, adrenal venous sampling (AVS) can be used to distinguish between unilateral adenoma and bilateral hyperplasia. The management of primary hyperaldosteronism depends on the underlying cause. Adrenal adenoma is treated with surgery, while bilateral adrenocortical hyperplasia is treated with an aldosterone antagonist such as spironolactone.

      In summary, primary hyperaldosteronism is a medical condition that can be caused by adrenal adenoma, bilateral idiopathic adrenal hyperplasia, or adrenal carcinoma. It is characterized by hypertension, hypokalaemia, and alkalosis. Diagnosis involves a plasma aldosterone/renin ratio, high-resolution CT abdomen, and adrenal vein sampling. Treatment depends on the underlying cause and may involve surgery or medication.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 48 - A 50-year-old woman is undergoing evaluation for hypertension that is not responding to...

    Incorrect

    • A 50-year-old woman is undergoing evaluation for hypertension that is not responding to treatment. She has a medical history of medullary thyroid carcinoma. Her physical examination is unremarkable. During her work-up, she is found to have hypercalcemia with a level of 2.8 mmol/l. Her parathyroid hormone (PTH) is slightly elevated above the normal range. What is the underlying diagnosis?

      Your Answer:

      Correct Answer: Multiple endocrine neoplasia type 2A

      Explanation:

      Differential Diagnosis for Hypercalcaemia with Elevated PTH Levels

      Hypercalcaemia with elevated parathyroid hormone (PTH) levels can be indicative of several conditions. Here are some possible differential diagnoses:

      Multiple Endocrine Neoplasia Type 2A (MEN 2A)
      MEN 2A is caused by a gain in function mutation in the RET proto-oncogene. The classic triad of MEN 2A is medullary thyroid carcinoma, primary hyperparathyroidism, and phaeochromocytoma. Patients with MEN 2A may also have treatment-resistant hypertension.

      Marfan Syndrome
      Marfan syndrome is a hereditary disorder of connective tissue. Patients with Marfan syndrome are typically tall and thin with hyperlax joints, recurrent dislocation of the lens of the eye, and cardiovascular anomalies (particularly aortic regurgitation). However, dysfunction of the parathyroid hormone axis is not usually associated with this condition.

      Multiple Endocrine Neoplasia Type 1 (MEN 1)
      MEN 1 also occurs due to a mutation in the RET gene. However, patients with MEN 1 classically suffer from hyperparathyroidism, pituitary adenomas (typically prolactinomas), and pancreatic islet cell tumors, and not the features described in the case.

      Multiple Myeloma
      Multiple myeloma is also associated with hypercalcaemia, but PTH levels would be appropriately low.

      Neurofibromatosis
      Neurofibromatosis is a disorder caused by a mutation in the neurofibromin gene on chromosome 17. It is associated with multiple neural tumors together with a variety of skin, musculoskeletal, and ocular manifestations, but disruption of the parathyroid hormone axis is not a feature.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 49 - Neuropathic pain typically does not improve with opioids. Nevertheless, if conventional treatments have...

    Incorrect

    • Neuropathic pain typically does not improve with opioids. Nevertheless, if conventional treatments have been ineffective, which opioid should be considered for initiation in elderly patients?

      Your Answer:

      Correct Answer: Tramadol

      Explanation:

      Understanding Neuropathic Pain and its Management

      Neuropathic pain is a type of pain that occurs due to damage or disruption of the nervous system. It is a complex condition that is often difficult to treat and does not respond well to standard painkillers. Examples of neuropathic pain include diabetic neuropathy, post-herpetic neuralgia, trigeminal neuralgia, and prolapsed intervertebral disc.

      To manage neuropathic pain, the National Institute for Health and Care Excellence (NICE) updated their guidance in 2013. The first-line treatment options include amitriptyline, duloxetine, gabapentin, or pregabalin. If the first-line drug treatment does not work, patients may try one of the other three drugs. Unlike standard painkillers, drugs for neuropathic pain are typically used as monotherapy, meaning that if they do not work, patients should switch to a different drug rather than adding another one.

      Tramadol may be used as rescue therapy for exacerbations of neuropathic pain, while topical capsaicin may be used for localized neuropathic pain, such as post-herpetic neuralgia. Pain management clinics may also be useful for patients with resistant problems. However, it is important to note that for some specific conditions, such as trigeminal neuralgia, the guidance may vary, and carbamazepine may be used as a first-line treatment. Overall, understanding neuropathic pain and its management is crucial for improving the quality of life for patients suffering from this condition.

    • This question is part of the following fields:

      • Neurology
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  • Question 50 - Which one of the following is not a first-rank symptom of schizophrenia for...

    Incorrect

    • Which one of the following is not a first-rank symptom of schizophrenia for individuals?

      Your Answer:

      Correct Answer: Catatonia

      Explanation:

      Schizophrenia is a mental disorder that is characterized by various symptoms. Schneider’s first rank symptoms are divided into four categories: auditory hallucinations, thought disorders, passivity phenomena, and delusional perceptions. Auditory hallucinations can include hearing two or more voices discussing the patient in the third person, thought echo, or voices commenting on the patient’s behavior. Thought disorders can involve thought insertion, thought withdrawal, or thought broadcasting. Passivity phenomena can include bodily sensations being controlled by external influence or actions/impulses/feelings that are imposed on the individual or influenced by others. Delusional perceptions involve a two-stage process where a normal object is perceived, and then there is a sudden intense delusional insight into the object’s meaning for the patient.

      Other features of schizophrenia include impaired insight, incongruity/blunting of affect (inappropriate emotion for circumstances), decreased speech, neologisms (made-up words), catatonia, and negative symptoms such as incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), and avolition (poor motivation). It is important to note that schizophrenia can manifest differently in each individual, and not all symptoms may be present.

    • This question is part of the following fields:

      • Psychiatry
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