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  • Question 1 - A 42-year-old man visits his General Practitioner with complaints of pain and tightness...

    Correct

    • A 42-year-old man visits his General Practitioner with complaints of pain and tightness in his head, affecting the frontal and occipital regions and radiating to his neck. The symptoms have been present for four months and occur most days, usually soon after he wakes up in the morning. He is able to work despite the headaches, but they tend to resolve with paracetamol, which he tries to avoid taking most days. He works in a high-pressure environment where there have been recent layoffs. On examination, there are no concerning findings, and he denies feeling depressed.
      What is the most appropriate course of action for managing this patient?

      Your Answer: Amitriptyline

      Explanation:

      Treatment and Management of Chronic Tension-Type Headaches

      Chronic tension-type headaches (TTH) are a common condition that can significantly impact a patient’s quality of life. The following is a guide to the treatment and management of chronic TTH.

      Diagnosis and Explanation
      Patients with chronic TTH should receive a positive diagnosis and explanation of their condition. It is important to reassure patients that TTH is self-limiting and not a serious condition.

      Pharmacological Treatment
      Amitriptyline is the treatment of choice for prophylaxis of chronic TTH. A starting dose of 10-15 mg at night can be increased to 150 mg, but usually, no more than 20-30 mg is needed. If higher doses are required, this may indicate an alternative diagnosis, such as depression. The dose can be reduced once improvement is maintained for four to six months or held if headaches recur.

      Non-Pharmacological Approaches
      Non-pharmacological approaches to TTH often incorporate relaxation and physical and psychological therapies.

      Neuroimaging
      Neuroimaging should only be considered to rule out a serious underlying cause if there is a history of new, severe headache that is progressive and associated with neurological abnormalities on examination. Atypical aura, visual disturbance, and vomiting may also be seen.

      Medication Overuse Headache
      Codeine should be avoided in patients with chronic TTH as there is a risk of developing medication-overuse headache, given the frequency of headaches seen in this case.

      Migraine Prophylaxis
      Propanolol is used as prophylaxis for recurrent migraine. However, this medication is not suitable for patients with chronic TTH as their headaches do not fit the diagnosis of migraine.

      Mental Health Referral
      Patients with chronic TTH may benefit from stress management techniques, but referral to the local mental health team is not necessary unless the patient exhibits symptoms of depression.

    • This question is part of the following fields:

      • Neurology
      263.7
      Seconds
  • Question 2 - A 16-year-old male is brought to see you by his mother following an...

    Incorrect

    • A 16-year-old male is brought to see you by his mother following an episode of collapse. He tells you that on a few occasions whilst playing basketball he has had some chest pain and breathlessness, and has felt as though he were going to faint. Last night during practice he collapsed and 'blacked out' for a few seconds. On examination he has a harsh ejection systolic murmur with a palpable systolic thrill at the left sternal edge; and a prominent jerky carotid pulse. What is the underlying diagnosis?

      Your Answer: Wolff-Parkinson-White syndrome

      Correct Answer: Hypertrophic obstructive cardiomyopathy

      Explanation:

      Hypertrophic obstructive cardiomyopathy (HOCM) is a condition caused by left ventricular outflow tract obstruction due to septal hypertrophy. It can be inherited or sporadic, and a family history of sudden death should be considered. Symptoms include chest pain, shortness of breath, palpitations, pre-syncope, and syncope. Clinical signs include a ‘jerky’ pulse, double apex impulse, and a prominent systolic thrill with a harsh ejection systolic murmur.

      Brugada syndrome is a rare inherited cardiac condition that can cause sudden cardiac death. It is caused by a genetic mutation affecting the cardiac sodium channels and is inherited in an autosomal dominant pattern.

      Long-QT syndrome can be inherited or acquired and predisposes to ventricular tachycardia and sudden death. Causes include various drugs, ischaemic heart disease, and metabolic abnormalities such as hypocalcaemia.

      Pericarditis can present acutely with chest pain that worsens when lying flat and with inspiration. A pericardial rub may be audible, and causes include viruses, bacteria, fungi, and systemic diseases.

      Constrictive pericarditis occurs when the pericardium becomes rigid and mainly leads to signs of right heart failure. Clinical signs include a diffuse apex beat, quiet heart sounds, and Kussmaul’s sign (JVP rises with inspiration paradoxically). It can occur after an episode of acute pericarditis.

      Wolff-Parkinson-White syndrome is caused by an accessory pathway that conducts between the atrium and ventricle, facilitating abnormal conduction and often presenting with supraventricular tachycardia.

    • This question is part of the following fields:

      • Urgent And Unscheduled Care
      117.9
      Seconds
  • Question 3 - What is the most precise statement about the effectiveness of cervical spine X-rays...

    Correct

    • What is the most precise statement about the effectiveness of cervical spine X-rays in evaluating degenerative cervical myelopathy (DCM) in elderly patients?

      Your Answer: Cervical spine radiographs cannot diagnose DCM

      Explanation:

      Degenerative Cervical Myelopathy (DCM) is a condition that affects the spinal cord in the neck region. It is caused by the compression of the spinal cord due to degenerative changes in the cervical spine. DCM is a common condition, with an estimated prevalence of 1-2% in the general population [1]. The condition is more common in older adults, with a peak incidence in the sixth decade of life [2].

      The pathophysiology of DCM involves the gradual degeneration of the cervical spine, which can lead to the compression of the spinal cord. This compression can cause a range of symptoms, including neck pain, arm pain, weakness, and numbness. In severe cases, DCM can lead to paralysis and loss of bladder and bowel control [2].

      Diagnosis of DCM requires the finding of MRI compression in conjunction with appropriate signs and symptoms. Asymptomatic degenerative disk disease and spondylosis of the cervical spine can be seen on MRI, but these findings alone do not indicate DCM [3].

      In conclusion, DCM is a common condition that affects the spinal cord in the neck region. It is caused by the compression of the spinal cord due to degenerative changes in the cervical spine. Diagnosis of DCM requires the finding of MRI compression in conjunction with appropriate signs and symptoms.

      Degenerative cervical myelopathy (DCM) is a condition that has several risk factors, including smoking, genetics, and certain occupations that expose individuals to high axial loading. The symptoms of DCM can vary in severity and may include pain, loss of motor function, loss of sensory function, and loss of autonomic function. Early symptoms may be subtle and difficult to detect, but as the condition progresses, symptoms may worsen or new symptoms may appear. An MRI of the cervical spine is the gold standard test for diagnosing cervical myelopathy. All patients with DCM should be urgently referred to specialist spinal services for assessment and treatment. Decompressive surgery is currently the only effective treatment for DCM, and early treatment offers the best chance of a full recovery. Physiotherapy should only be initiated by specialist services to prevent further spinal cord damage.

    • This question is part of the following fields:

      • Musculoskeletal Health
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  • Question 4 - A 25-year-old asthmatic woman has a disabling headache syndrome consisting of recurrent, severe,...

    Incorrect

    • A 25-year-old asthmatic woman has a disabling headache syndrome consisting of recurrent, severe, unilateral (either right or left) headaches twice a week lasting for 8 hours each. The pain is constant and associated with nausea. It has not responded to ibuprofen or paracetamol. The headaches frequently disturb sleep. She has identified no dietary triggers and there is no family history of migraine. She is very worried about her increasing weight.
      Select the most sensible treatment course.

      Your Answer: Pizotifen (for prophylaxis) and ergotamine (for the acute attacks)

      Correct Answer: Amitriptyline (for prophylaxis) and a triptan (for the acute attacks)

      Explanation:

      Prophylactic Treatment for Common Migraine: A Clinical Scenario

      The history of a patient is consistent with common migraine, which justifies prophylaxis due to the frequency of attacks. Pizotifen, which has been widely used for many years, is no longer recommended due to little clinical trial evidence of efficacy and weight gain side effects. Ergotamine and Methysergide are also not commonly used for acute treatment due to associated side effects. Regular analgesics can lead to chronic daily headache, especially those containing opiates.

      The British Association for the Study of Headache (BASH) guidelines recommend amitriptyline as a first-line prophylactic drug for migraine coexisting with other chronic pain conditions, disturbed sleep, or depression. Topiramate and sodium valproate are second-line prophylactic drugs with significant side effect profiles. NICE (2012) recommends topiramate and propranolol as first-line drugs, but neither are given as an answer to this clinical scenario. Therefore, the best available option should be sought for this patient.

    • This question is part of the following fields:

      • Neurology
      266.6
      Seconds
  • Question 5 - A 55-year-old woman comes to you with a history of multiple recurrent and...

    Incorrect

    • A 55-year-old woman comes to you with a history of multiple recurrent and frequently changing symptoms that are 'functional' in nature (somatisation disorder).

      Which of the following statements regarding her management is accurate?

      Your Answer: An understanding of her early childhood experiences is necessary

      Correct Answer: She should be persuaded to understand that her symptoms are psychological

      Explanation:

      Understanding Somatisation Disorder

      Somatisation disorder is a complex condition that has been frequently asked about in previous examinations. It is important to note that knowledge of early childhood experiences is not necessary for diagnosis. However, depression is often found in individuals with somatisation disorder, making antidepressants a useful treatment option. In addition, involving relatives in the management of the disorder can be beneficial. It is important to approach management with empathy rather than persuasion. Understanding the complexities of somatisation disorder is crucial for effective treatment and management.

      Spacing:

      Somatisation disorder is a complex condition that has been frequently asked about in previous examinations. It is important to note that knowledge of early childhood experiences is not necessary for diagnosis. However, depression is often found in individuals with somatisation disorder, making antidepressants a useful treatment option.

      In addition, involving relatives in the management of the disorder can be beneficial. It is important to approach management with empathy rather than persuasion. Understanding the complexities of somatisation disorder is crucial for effective treatment and management.

    • This question is part of the following fields:

      • Mental Health
      56.1
      Seconds
  • Question 6 - A 28-year-old lady seeks your advice on contraception. She has recently entered a...

    Incorrect

    • A 28-year-old lady seeks your advice on contraception. She has recently entered a new relationship and wants to protect herself against pregnancy. She is in good health, doesn't experience migraines, and is a non-smoker. Her mother had breast cancer a decade ago, but has since been declared cancer-free. The patient has a confirmed BRCA1 gene mutation. Her BMI is 23 and her blood pressure is 124/82. Based on this information, what form of contraception would you recommend for her?

      Your Answer: Intrauterine system

      Correct Answer: Intrauterine copper coil

      Explanation:

      UK Medical Eligibility Criteria for Contraception

      The UK medical eligibility criteria for contraception categorizes contraceptive methods into four categories. Category 1 indicates that there are no restrictions for use, while Category 4 indicates that use poses an unacceptable health risk. For patients with a BRCA gene mutation, the combined contraceptive pill has a UK Category rating of 3 and should definitely not be used. All of the other options are rated a UK Category 2, so will still need careful follow-up. The intrauterine copper coil is the only method that is rated a UK Category 1, making it the safest option to use here. There is no restriction on the use of this method for this condition. It is important to consider the UK medical eligibility criteria when choosing a contraceptive method to ensure the safety and effectiveness of the chosen method.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
      49.6
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  • Question 7 - A 21-year-old man has had a tendency to have complex tics since childhood....

    Incorrect

    • A 21-year-old man has had a tendency to have complex tics since childhood. He repeatedly squats down on the ground and also has another repetitive action of rubbing his nose. He is prone to loud vocalisations, sometimes swear words. The symptoms prevent him from working and having a normal social life.
      Which of the following conditions is often associated with his diagnosis?

      Your Answer: Huntington’s disease

      Correct Answer: Attention deficit hyperactivity disorder

      Explanation:

      Differential Diagnosis for Tics: Tourette Syndrome, Epilepsy, Huntington’s Disease, Parkinson’s Disease, and Restless Legs Syndrome

      When a patient presents with sudden involuntary repeated movements or sounds, a tic disorder may be suspected. Tourette syndrome is a likely diagnosis if the symptoms have lasted longer than a year, started in childhood, and include at least two motor tics and one vocal tic. Tourette syndrome is often associated with other conduct disorders such as attention deficit hyperactivity disorder and obsessive-compulsive disorder.

      Myoclonic epilepsy may be considered as a differential diagnosis for tics, but the brief shock-like jerks of a muscle or group of muscles in myoclonic seizures are distinct from the complex tics and vocal tics seen in Tourette syndrome. There is no association between epilepsy and Tourette syndrome.

      Huntington’s disease, a hereditary condition characterized by chronic progressive chorea and mental deterioration, usually presents around the age of 40 years old. However, there is no association between Huntington’s disease and Tourette syndrome.

      Parkinson’s disease, a chronic neurological disorder characterized by bradykinesia, resting tremors, and rigidity, is not associated with Tourette syndrome.

      Restless legs syndrome, a common condition in which patients experience an unpleasant sensation in their legs that is temporarily relieved by movement, is not associated with Tourette syndrome. However, symptoms can affect sleep and may include periodic leg movements during sleep.

      In summary, when evaluating a patient with tics, it is important to consider the differential diagnosis, including Tourette syndrome, epilepsy, Huntington’s disease, Parkinson’s disease, and restless legs syndrome.

    • This question is part of the following fields:

      • Neurology
      16.9
      Seconds
  • Question 8 - A 35-year-old man has been diagnosed with autosomal-dominant polycystic kidney disease (ADPKD). He...

    Incorrect

    • A 35-year-old man has been diagnosed with autosomal-dominant polycystic kidney disease (ADPKD). He underwent screening after his brother was recently diagnosed with the condition. He is currently otherwise well with no other medical issues.
      Which extra-renal complication of ADPKD is this patient most likely to develop?

      Your Answer: Pancreatitis

      Correct Answer: Hepatic cysts

      Explanation:

      Extra-renal Complications of ADPKD

      ADPKD is a genetic disorder that causes the development of cysts in the kidneys. However, it can also lead to the formation of cysts in other organs, resulting in various extra-renal complications.

      Hepatic cysts are the most common extra-renal complication, occurring in 80% of patients. While they are more prevalent in women, they are also common in men. Most cases of polycystic liver disease are asymptomatic, but symptoms can arise from the mass effect or complications of the cyst.

      Seminal vesicle cysts are also common in patients with ADPKD, but they rarely result in male infertility. On the other hand, cerebral aneurysms occur in 10-20% of patients and can cause cranial nerve palsies or seizures. They are not as common as hepatic cysts.

      Pancreatitis is a rare complication that can develop if cysts grow large enough to impact the pancreas. Fortunately, it is unlikely to occur in most patients.

      Mitral valve prolapse and aortic incompetence are also associated with ADPKD. Mitral valve prolapse occurs in 25% of patients, making it a common occurrence but not the most likely extra-renal complication that this patient is likely to develop.

      In summary, ADPKD can lead to various extra-renal complications, but hepatic cysts and cerebral aneurysms are the most common. Regular monitoring and management of these complications are essential to ensure the best possible outcomes for patients.

    • This question is part of the following fields:

      • Kidney And Urology
      25.7
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  • Question 9 - A 47-year-old woman with a history of multiple sclerosis visits her GP after...

    Correct

    • A 47-year-old woman with a history of multiple sclerosis visits her GP after her partner noticed a recent change in her eye appearance. Upon examination, the GP observes ptosis on the right side and a small right pupil. Fundoscopy reveals no abnormalities. What is the probable diagnosis?

      Your Answer: Horner's syndrome

      Explanation:

      Horner’s syndrome is a condition characterized by several features, including a small pupil (miosis), drooping of the upper eyelid (ptosis), a sunken eye (enophthalmos), and loss of sweating on one side of the face (anhidrosis). The cause of Horner’s syndrome can be determined by examining additional symptoms. For example, congenital Horner’s syndrome may be identified by a difference in iris color (heterochromia), while anhidrosis may be present in central or preganglionic lesions. Pharmacologic tests, such as the use of apraclonidine drops, can also be helpful in confirming the diagnosis and identifying the location of the lesion. Central lesions may be caused by conditions such as stroke or multiple sclerosis, while post-ganglionic lesions may be due to factors like carotid artery dissection or cluster headaches. It is important to note that the appearance of enophthalmos in Horner’s syndrome is actually due to a narrow palpebral aperture rather than true enophthalmos.

    • This question is part of the following fields:

      • Eyes And Vision
      162.4
      Seconds
  • Question 10 - A 25-year-old male medical student who has been feeling unwell for several days...

    Correct

    • A 25-year-old male medical student who has been feeling unwell for several days is noticed to have slightly icteric sclerae by his girlfriend and has liver function tests performed. The results of these are normal apart from a serum bilirubin concentration of 44 µmol/l (normal < 21 μmol/L). His urine doesn't contain bilirubin.
      Select from the list the single most likely diagnosis.

      Your Answer: Gilbert syndrome

      Explanation:

      Possible Causes of Jaundice: A Differential Diagnosis

      Jaundice is a common clinical manifestation of various diseases. In this case, the patient presents with jaundice, and the differential diagnosis includes several inherited disorders of bilirubin metabolism, chronic haemolytic disorders, and infectious diseases.

      Gilbert Syndrome: This is a relatively mild inherited disorder caused by a deficiency of glucuronosyl transferase, resulting in an accumulation of unconjugated bilirubin. The jaundice usually subsides in a few days and may be more obvious during an intercurrent illness.

      Dubin–Johnson Syndrome: This is another inherited disorder of bilirubin metabolism, but in this case, there is a defect in the secretion of bilirubin from the liver. The bilirubin that accumulates in the plasma is conjugated, water-soluble, and excreted in the urine. Onset of jaundice may commonly first occur during puberty or early adulthood and can be precipitated by alcohol, infection, pregnancy, or contraceptive pill use.

      Hereditary Spherocytosis: This is a chronic haemolytic disorder due to a defect in the red cell membrane, most frequently in spectrin, a structural protein. It can present with a wide range of severity, from jaundice at birth to asymptomatic anaemia or jaundice in adults.

      Infectious Mononucleosis: This viral infection can cause hepatitis and jaundice, but elevated transaminase activity would be expected.

      Rotor Syndrome: This is a possible differential diagnosis, but this condition would cause a mixed hyperbilirubinaemia. Therefore, Gilbert’s disease is the more likely diagnosis in this scenario.

      In conclusion, the differential diagnosis of jaundice includes several inherited disorders of bilirubin metabolism, chronic haemolytic disorders, and infectious diseases. A thorough evaluation of the patient’s medical history, physical examination, and laboratory tests is necessary to establish the correct diagnosis and provide appropriate treatment.

    • This question is part of the following fields:

      • Gastroenterology
      42
      Seconds
  • Question 11 - A 3-year-old child is brought to see you by his parents as they...

    Incorrect

    • A 3-year-old child is brought to see you by his parents as they have noticed a squint affecting the right eye.

      The child was born at full term via a normal vaginal delivery and had no antenatal or perinatal problems. He has been fit and well with no significant health concerns.

      Which of the following is the most appropriate approach at this stage?

      Your Answer: Check for the red reflex

      Correct Answer: Reassure the parents that this is a 'pseudosquint'

      Explanation:

      Importance of Examining Children with Squint

      Any child who presents with a squint should undergo a thorough examination, including a check for the red reflex. While strabismus is a common condition, it can also be a presenting sign of retinoblastoma, a rare but serious eye cancer. Therefore, it is crucial to be confident in evaluating strabismus in children. A step-by-step approach to diagnosing strabismus in children can be found in the reference below.

      If a white pupillary reflex, also known as leukocoria, is detected during the examination, an urgent referral should be made. Leukocoria may be noticed by parents in photographs and is a significant indicator of potential eye problems. Early detection and intervention can greatly improve the outcome for children with eye conditions, making regular eye exams an essential part of pediatric care.

    • This question is part of the following fields:

      • Children And Young People
      29.1
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  • Question 12 - A 70-year-old man comes to the clinic for a review of his cancer....

    Incorrect

    • A 70-year-old man comes to the clinic for a review of his cancer. He has advanced and progressive prostate cancer but is currently able to get out of the house with his family.
      Which of the following features would most strongly suggest that he has entered the final stage of the illness and that death is near?

      Your Answer: Poor pain control

      Correct Answer: He becomes bed-bound

      Explanation:

      Recognizing the Signs of Dying: What to Look For

      Recognizing the signs of dying is crucial in providing appropriate care for patients and their caregivers during the end-of-life phase. This final phase can last for hours or even days, and patients may exhibit several signs that indicate they are nearing death.

      One of the most common signs is a gradual deterioration in their condition, which may occur over several days or even more rapidly. Patients may also experience reduced mobility and become increasingly fatigued without any apparent cause. They may also become aware of their impending death and express this to their caregivers.

      Other signs include reduced cognition, difficulty communicating, and social withdrawal. Patients may also experience a decline in their level of consciousness, become delirious, and become bed-bound. They may also have difficulty taking food, fluids, and oral medication.

      As death approaches, patients may exhibit peripheral cyanosis, mottled skin, and feel cold to the touch. They may also experience episodes of apnea or Cheyne-Stokes breathing.

      While the four incorrect options may also be present near death, they do not necessarily indicate that death is imminent. However, recognizing the signs of dying can help caregivers provide appropriate care and support during this difficult time.

    • This question is part of the following fields:

      • End Of Life
      21.8
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  • Question 13 - A 35-year-old woman with familial hypercholesterolaemia presents for a check-up. She is considering...

    Correct

    • A 35-year-old woman with familial hypercholesterolaemia presents for a check-up. She is considering starting a family and seeks guidance on medication, as she is currently taking 80 mg of atorvastatin. What would be the most suitable recommendation?

      Your Answer: Stop atorvastatin before trying to conceive

      Explanation:

      To avoid the possibility of congenital defects, it is recommended that women discontinue the use of statins at least 3 months prior to conception.

      Familial Hypercholesterolaemia: Causes, Diagnosis, and Management

      Familial hypercholesterolaemia (FH) is a genetic condition that affects approximately 1 in 500 people. It is an autosomal dominant disorder that results in high levels of LDL-cholesterol, which can lead to early cardiovascular disease if left untreated. FH is caused by mutations in the gene that encodes the LDL-receptor protein.

      To diagnose FH, NICE recommends suspecting it as a possible diagnosis in adults with a total cholesterol level greater than 7.5 mmol/l and/or a personal or family history of premature coronary heart disease. For children of affected parents, testing should be arranged by age 10 if one parent is affected and by age 5 if both parents are affected.

      The Simon Broome criteria are used for clinical diagnosis, which includes a total cholesterol level greater than 7.5 mmol/l and LDL-C greater than 4.9 mmol/l in adults or a total cholesterol level greater than 6.7 mmol/l and LDL-C greater than 4.0 mmol/l in children. Definite FH is diagnosed if there is tendon xanthoma in patients or first or second-degree relatives or DNA-based evidence of FH. Possible FH is diagnosed if there is a family history of myocardial infarction below age 50 years in second-degree relatives, below age 60 in first-degree relatives, or a family history of raised cholesterol levels.

      Management of FH involves referral to a specialist lipid clinic and the use of high-dose statins as first-line treatment. CVD risk estimation using standard tables is not appropriate in FH as they do not accurately reflect the risk of CVD. First-degree relatives have a 50% chance of having the disorder and should be offered screening, including children who should be screened by the age of 10 years if there is one affected parent. Statins should be discontinued in women 3 months before conception due to the risk of congenital defects.

    • This question is part of the following fields:

      • Cardiovascular Health
      1408.5
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  • Question 14 - A young patient of yours has returned from a school trip abroad with...

    Incorrect

    • A young patient of yours has returned from a school trip abroad with a diarrhoeal illness. They were one of twenty-four students on a study abroad program who developed bloody diarrhoea on the third day.

      Which of the following organisms is the likely cause?

      Your Answer: Entamoeba histolytica

      Correct Answer: Schistosoma mansoni

      Explanation:

      Understanding Dysentery and Amoebiasis

      Dysentery is a gastrointestinal infection that is characterized by frequent stools that may contain blood, mucous, or pus. It is caused by Shigella dysenteriae, which is often associated with unsanitary conditions. The disease is transmitted through faecal contamination of water or food, and symptoms usually appear within one to four days of infection. The bacteria penetrate the mucosal epithelial cells of the intestine, causing intense irritation and producing cramps and watery, bloody diarrhoea.

      Amoebiasis, on the other hand, is often asymptomatic initially, with cysts present in the faeces. However, symptoms such as lower abdominal pain and diarrhoea can develop later in the disease course. If left untreated, dysentery can also develop. It is important to note that stool examination has low sensitivity in detecting amoebiasis.

      Other gastrointestinal infections that you should also be familiar with include C. difficile and E. coli toxins, bacterial causes such as salmonella and campylobacter, viral causes such as rotavirus and norovirus, and parasitic causes such as Giardia lamblia. Understanding these conditions is crucial in providing appropriate management and preventing further spread of the disease.

    • This question is part of the following fields:

      • Infectious Disease And Travel Health
      17.6
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  • Question 15 - A 10-year-old boy is brought in by his mother because of dryness and...

    Incorrect

    • A 10-year-old boy is brought in by his mother because of dryness and irritation around the corners of his mouth. He doesn't tend to drink much and licks his lips because they're so dry. On examination he has evidence of angular stomatitis.
      How would you treat his angular stomatitis?

      Your Answer: Prescribe fusidic acid with hydrocortisone cream for 1 week

      Correct Answer: Prescribe aciclovir cream for 1 week

      Explanation:

      Angular Stomatitis and Candida Infection

      Angular stomatitis is a common condition that is often caused by dryness, chapping, and licking of the lips. It can also be caused by salivation and drooling, which can lead to irritation. Candida infection is a common cause of angular stomatitis, although secondary infection with staphylococcal aureus should also be considered.

      When it comes to treatment, the clinical scenario in this case is more in keeping with candida infection. Miconazole cream is usually the first line of treatment for candida infection, while mild topical corticosteroids can be used to treat dermatitis. If the condition is unresponsive to miconazole alone, hydrocortisone can be added.

      It’s important to note that contact dermatitis is often a differential diagnosis for angular stomatitis. Aciclovir cream is used for herpes simplex lesions, while fusidic acid can be used to treat small areas of staphylococcal infection. Hydromol is a simple emollient and will not treat candida infections.

      In some cases, no treatment is needed, and angular cheilitis resolves by itself. However, most cases are accompanied by superimposed candida infection.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      30.4
      Seconds
  • Question 16 - A 65-year-old female with no prior medical history presents with a left-sided hemiparesis...

    Incorrect

    • A 65-year-old female with no prior medical history presents with a left-sided hemiparesis and is found to be in atrial fibrillation. Imaging reveals a cerebral infarction. What anticoagulation approach would be most suitable for this patient?

      Your Answer: Lifelong warfarin, started immediately

      Correct Answer: Aspirin started immediately switching to Lifelong warfarin after 2 weeks

      Explanation:

      Managing Atrial Fibrillation Post-Stroke

      Atrial fibrillation is a major risk factor for ischaemic stroke, making it crucial to identify and treat the condition in patients who have suffered a stroke or transient ischaemic attack (TIA). However, before starting any anticoagulation or antiplatelet therapy, it is important to rule out haemorrhage. For long-term stroke prevention, NICE Clinical Knowledge Summaries recommend warfarin or a direct thrombin or factor Xa inhibitor. The timing of when to start treatment depends on whether it is a TIA or stroke. In the case of a TIA, anticoagulation for AF should begin immediately after imaging has excluded haemorrhage. For acute stroke patients, anticoagulation therapy should be initiated after two weeks in the absence of haemorrhage. Antiplatelet therapy should be given during the intervening period. However, if imaging shows a very large cerebral infarction, the initiation of anticoagulation should be delayed.

    • This question is part of the following fields:

      • Cardiovascular Health
      33.3
      Seconds
  • Question 17 - You wish to investigate an outbreak of atypical pneumonia cases in the elderly...

    Incorrect

    • You wish to investigate an outbreak of atypical pneumonia cases in the elderly population and determine if there has been exposure to a particular risk factor.

      Which study design would be most appropriate?

      Your Answer: Cohort

      Correct Answer: Case-control

      Explanation:

      The most appropriate study design to investigate an infectious outbreak is a case-control study. This study design allows for the retrospective identification of patients who have developed the disease and compares their past exposure to suspected causal factors with controls who do not have the disease. A cohort study, which follows patients into the future, is not suitable for this scenario as the aim is to trace the cause of the outbreak. A cross-sectional study provides a snapshot of the condition and exposures in the overall population at a set time, but it is not suitable for finding the cause of the outbreak. Randomized controlled trials are not appropriate as there are no interventions being studied. Meta-analysis is not applicable as there is no mention of other research to review.

      There are different types of studies that researchers can use to investigate various phenomena. One of the most rigorous types of study is the randomised controlled trial, where participants are randomly assigned to either an intervention or control group. However, practical or ethical issues may limit the use of this type of study. Another type of study is the cohort study, which is observational and prospective. Researchers select two or more groups based on their exposure to a particular agent and follow them up to see how many develop a disease or other outcome. The usual outcome measure is the relative risk. Examples of cohort studies include the Framingham Heart Study.

      On the other hand, case-control studies are observational and retrospective. Researchers identify patients with a particular condition (cases) and match them with controls. Data is then collected on past exposure to a possible causal agent for the condition. The usual outcome measure is the odds ratio. Case-control studies are inexpensive and produce quick results, making them useful for studying rare conditions. However, they are prone to confounding. Lastly, cross-sectional surveys provide a snapshot of a population and are sometimes called prevalence studies. They provide weak evidence of cause and effect.

    • This question is part of the following fields:

      • Evidence Based Practice, Research And Sharing Knowledge
      20.7
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  • Question 18 - Which one of the following statements regarding the metabolic syndrome is accurate? ...

    Correct

    • Which one of the following statements regarding the metabolic syndrome is accurate?

      Your Answer: Decisions on cardiovascular risk factor modification should be made regardless of whether patients meet the criteria for metabolic syndrome

      Explanation:

      The determination of primary prevention measures for cardiovascular disease should rely on established methods and should not be influenced by the diagnosis of metabolic syndrome.

      Understanding Metabolic Syndrome

      Metabolic syndrome is a condition that has various definitions, but it is generally believed to be caused by insulin resistance. The American Heart Association and the International Diabetes Federation have similar criteria for diagnosing metabolic syndrome. According to these criteria, a person must have at least three of the following: elevated waist circumference, elevated triglycerides, reduced HDL, raised blood pressure, and raised fasting plasma glucose. The International Diabetes Federation also requires the presence of central obesity and any two of the other four factors. In 1999, the World Health Organization produced diagnostic criteria that required the presence of diabetes mellitus, impaired glucose tolerance, impaired fasting glucose or insulin resistance, and two of the following: high blood pressure, dyslipidemia, central obesity, and microalbuminuria. Other associated features of metabolic syndrome include raised uric acid levels, non-alcoholic fatty liver disease, and polycystic ovarian syndrome.

      Overall, metabolic syndrome is a complex condition that involves multiple factors and can have serious health consequences. It is important to understand the diagnostic criteria and associated features in order to identify and manage this condition effectively.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 19 - Which of the following results is atypical in a patient with antiphospholipid syndrome?...

    Incorrect

    • Which of the following results is atypical in a patient with antiphospholipid syndrome?

      Your Answer: Prolonged APTT

      Correct Answer: Thrombocytosis

      Explanation:

      Antiphospholipid syndrome is characterized by arterial and venous thrombosis, miscarriage, and livedo reticularis. Additionally, thrombocytopenia is a common feature of this syndrome.

      Antiphospholipid syndrome is a condition that can be acquired and is characterized by a higher risk of both venous and arterial thromboses, recurrent fetal loss, and thrombocytopenia. It can occur as a primary disorder or secondary to other conditions, with systemic lupus erythematosus being the most common. One important point to remember for exams is that antiphospholipid syndrome causes a paradoxical increase in the APTT due to an ex-vivo reaction of lupus anticoagulant autoantibodies with phospholipids involved in the coagulation cascade.

      Other features of antiphospholipid syndrome include livedo reticularis, pre-eclampsia, and pulmonary hypertension. It is associated with other autoimmune disorders and lymphoproliferative disorders, as well as rare cases of phenothiazines. Management of antiphospholipid syndrome is based on EULAR guidelines, with primary thromboprophylaxis and low-dose aspirin being recommended. For secondary thromboprophylaxis, lifelong warfarin with a target INR of 2-3 is recommended for initial venous thromboembolic events, while recurrent venous thromboembolic events require lifelong warfarin and may benefit from the addition of low-dose aspirin and an increased target INR of 3-4. Arterial thrombosis should also be treated with lifelong warfarin with a target INR of 2-3.

    • This question is part of the following fields:

      • Musculoskeletal Health
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      Seconds
  • Question 20 - Baby Oliver has been brought for numerous appointments since he was born, with...

    Incorrect

    • Baby Oliver has been brought for numerous appointments since he was born, with symptoms of colic. He is now on simethicone drops. His mum, who was previously exclusively breastfeeding, has just introduced a bottle of formula in the evening, and Oliver has now developed a rash. You suspect a possible allergy to the formula and consider prescribing a hypoallergenic infant formula for Oliver, along with some emollient and steroid cream. What other treatments should you consider prescribing for Oliver today?

      Your Answer: Soya milk

      Correct Answer: Calcium and vitamin D for mum

      Explanation:

      It is recommended to consider prescribing calcium supplements and vitamin D for breastfeeding mothers whose babies have or are suspected to have CMPI. This is to prevent deficiency while they exclude dairy from their diet, which puts them at risk of deficiency. Soya milk is not advised for infants due to its phyto-oestrogen content, and lactase enzyme products are not relevant as lactose intolerance is a different condition. Lactulose is also not indicated based on the given history.

      Cow’s milk protein intolerance/allergy (CMPI/CMPA) is a condition that affects approximately 3-6% of children and typically presents in formula-fed infants within the first 3 months of life. However, it can also occur in exclusively breastfed infants, although this is rare. Both immediate (IgE mediated) and delayed (non-IgE mediated) reactions can occur, with CMPA usually used to describe immediate reactions and CMPI for mild-moderate delayed reactions. Symptoms of CMPI/CMPA include regurgitation and vomiting, diarrhea, urticaria, atopic eczema, colic symptoms such as irritability and crying, wheezing, chronic cough, and rarely, angioedema and anaphylaxis.

      Diagnosis of CMPI/CMPA is often based on clinical presentation, such as improvement with cow’s milk protein elimination. However, investigations such as skin prick/patch testing and total IgE and specific IgE (RAST) for cow’s milk protein may also be performed. If symptoms are severe, such as failure to thrive, referral to a pediatrician is necessary.

      Management of CMPI/CMPA depends on whether the child is formula-fed or breastfed. For formula-fed infants with mild-moderate symptoms, extensive hydrolyzed formula (eHF) milk is the first-line replacement formula, while amino acid-based formula (AAF) is used for infants with severe CMPA or if there is no response to eHF. Around 10% of infants with CMPI/CMPA are also intolerant to soy milk. For breastfed infants, mothers should continue breastfeeding while eliminating cow’s milk protein from their diet. Calcium supplements may be prescribed to prevent deficiency while excluding dairy from the diet. When breastfeeding stops, eHF milk should be used until the child is at least 12 months old and for at least 6 months.

      The prognosis for CMPI/CMPA is generally good, with most children eventually becoming milk tolerant. In children with IgE-mediated intolerance, around 55% will be milk tolerant by the age of 5 years, while in children with non-IgE mediated intolerance, most will be milk tolerant by the age of 3 years. However, a challenge is often performed in a hospital setting as anaphylaxis can occur.

    • This question is part of the following fields:

      • Children And Young People
      32.9
      Seconds
  • Question 21 - A 70-year-old woman presents to the General Practitioner with sudden-onset, sharp, shooting pain...

    Correct

    • A 70-year-old woman presents to the General Practitioner with sudden-onset, sharp, shooting pain in her right cheek that causes her to wince. The pain lasts for about 20 seconds and then gradually subsides over a few minutes. It is often triggered by hot food or drinks. She has experienced several episodes recently, but is otherwise healthy. She recalls having similar episodes two years ago that resolved after a few weeks.
      What is the most probable diagnosis? Choose ONE answer.

      Your Answer: Trigeminal neuralgia

      Explanation:

      Facial Pain Syndromes: Types and Characteristics

      Facial pain syndromes are a group of conditions that cause pain in the face and head. Here are some of the most common types and their characteristics:

      Trigeminal Neuralgia: This syndrome causes recurrent and chronic pain that is usually unilateral and follows the sensory distribution of the trigeminal nerve. The pain is often accompanied by a brief facial spasm or tic and is triggered by activities such as eating, brushing teeth, or exposure to cold air. Carbamazepine is the drug of choice for treatment.

      Atypical Facial Pain: This syndrome is more common than trigeminal neuralgia and is characterized by mild-to-moderate throbbing dull pain that can last for hours or days. It is precipitated by stress or cold and tends to occur along the territory of the trigeminal nerve. Patients are often misdiagnosed or attribute the pain to a prior event such as a dental procedure. Depression and anxiety are common.

      Cluster Headaches: These headaches are usually unilateral and last longer than other facial pain syndromes. They are accompanied by conjunctival injection and a watering eye.

      Migraine: Migraines are also usually unilateral and last longer than other facial pain syndromes. They are accompanied by photophobia and gastrointestinal symptoms.

      Temporomandibular Joint Dysfunction: This syndrome is relatively common and is characterized by facial pain, restricted jaw function, and joint noise. Pain located in front of the tragus, projecting to the ear, temple, cheek, and along the mandible is highly diagnostic for TMJ dysfunction. Pain is chronic rather than spasmodic.

      In conclusion, facial pain syndromes can be difficult to diagnose and treat. It is important to seek medical attention if you are experiencing any type of facial pain.

    • This question is part of the following fields:

      • Neurology
      15.1
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  • Question 22 - You are presented with a 63-year-old female patient who complains of a red...

    Correct

    • You are presented with a 63-year-old female patient who complains of a red eye that she noticed this morning. She reports no pain or discomfort and no changes to her vision. She has been experiencing a cough for the past week but is improving. She is generally healthy and doesn't take any regular medications. Upon examination, you observe a well-defined area of redness in her left eye. Her pupils and visual acuity are normal, and staining the eye reveals no abnormalities.

      What would be an appropriate course of action for management?

      Your Answer: Reassurance and blood pressure check

      Explanation:

      When a patient presents with a Subconjunctival haemorrhage, which is characterised by a distinct area of bleeding in one eye, it is important to provide reassurance and check their blood pressure. This condition is often caused by coughing, constipation, or high blood pressure. Treatment may involve using lubricating eye drops for dry eyes, while infective conjunctivitis can be treated with options 3 and 4. Patients with conjunctivitis typically experience itchy eyes.

      Subconjunctival haemorrhages occur when blood vessels in the subconjunctival space bleed. These vessels typically supply the conjunctiva or episclera. Trauma is the most common cause, followed by spontaneous idiopathic cases, Valsalva manoeuvres, and several systemic diseases. While subconjunctival haemorrhages can look alarming, they are rarely an indicator of anything serious. They are more common in women than men, and the risk increases with age. Newborns are also more susceptible. The incidence of both traumatic and non-traumatic subconjunctival haemorrhages is 2.6%.

      Risk factors for subconjunctival haemorrhages include trauma, contact lens usage, idiopathic causes, Valsalva manoeuvres, hypertension, bleeding disorders, certain drugs, diabetes, arterial disease, and hyperlipidaemia. Symptoms include a red eye, usually unilateral, and mild irritation. Signs include a flat, red patch on the conjunctiva with well-defined edges and normal conjunctiva surrounding it. The patch’s size can vary depending on the size of the bleed and can involve the whole conjunctiva. Traumatic haemorrhages are most common in the temporal region, with the inferior conjunctiva as the next most commonly affected area. Vision should be normal, including acuity, visual fields, and range of eye movements. On examination, the fundus should be normal.

      The diagnosis of a subconjunctival haemorrhage is clinical. If there is no obvious traumatic cause, check the patient’s blood pressure. If raised, refer the patient appropriately. If the patient is taking warfarin, check the INR. If raised, refer for appropriate adjustments to the dose to bring the INR back into the target range. If you cannot see the whole border of the haemorrhage, it may be associated with an intracranial bleed or an orbital roof fracture. Further appropriate investigations should then be done, including a full cranial nerve exam looking for neurological signs as well as a CT head, after discussion with a senior. Recurrent or spontaneous, bilateral subconjunctival haemorrhages warrant investigations for bleeding disorders or other pathology.

      Reassure the patient that subconjunctival haemorrhages are a benign condition that will resolve on their own in 2 to 3 weeks.

    • This question is part of the following fields:

      • Eyes And Vision
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  • Question 23 - A 68-year-old man with a history of prostatism presents to his General Practitioner...

    Incorrect

    • A 68-year-old man with a history of prostatism presents to his General Practitioner (GP) with acute retention of urine. He has a palpable bladder up to his umbilicus and is in significant discomfort. His GP sends him to the emergency department where he is catheterised and blood is taken to test his renal function. His serum creatinine concentration is 520 µmol/l (normal range 60–120 µmol/l).
      Which of the following additional results would be most suggestive that his renal failure was chronic rather than acute?

      Your Answer: Hyperkalaemia

      Correct Answer: Hypocalcaemia

      Explanation:

      Biochemical Markers for Acute and Chronic Renal Failure

      Renal failure can be classified as acute or chronic based on the duration and severity of the condition. Biochemical markers can help distinguish between the two types of renal failure.

      Hypocalcaemia is a common feature of chronic renal failure and occurs due to the gradual increase of phosphorus in the bloodstream. Low serum bicarbonate concentration is indicative of acute kidney injury and can lead to metabolic acidosis. Hyperkalaemia and hyperuricaemia can occur in both acute and chronic renal failure, while mild hyponatraemia is relatively common in both types of renal failure.

      Overall, while these biochemical markers can provide some insight into the type of renal failure, they are not definitive and should be considered in conjunction with other clinical factors.

    • This question is part of the following fields:

      • Kidney And Urology
      37.7
      Seconds
  • Question 24 - A 68-year-old gentleman comes to see you for the result of his x...

    Correct

    • A 68-year-old gentleman comes to see you for the result of his x ray. He was seen by a colleague two weeks ago with knee pain and was referred for plain films of his right knee.

      The x ray report states: 'loss of joint space, osteophyte formation, subchondral sclerosis and subchondral cyst formation'.

      What is the underlying cause of his knee pain?

      Your Answer: Osteoarthritis

      Explanation:

      Radiological Features of Joint Diseases

      Osteoarthritis is a joint disease that can be identified through four core features on plain x-ray examination. These features include loss of joint space, osteophyte formation, subchondral sclerosis, and subchondral cyst formation. All of these features are present on the x-ray, making osteoarthritis the correct diagnosis.

      Chondrocalcinosis, on the other hand, is characterized by calcium deposition in structures such as the cartilage. In gout, x-rays may only show soft tissue swelling, but chronic inflammation can lead to punched out lesions in juxta-articular bone. Late-stage gout is characterized by tophi formation and joint space narrowing.

      In rheumatoid arthritis, plain films can show soft tissue swelling, juxta-articular osteoporosis, and loss of joint space. As the disease progresses, the destructive nature of the disease can lead to bony erosions, subluxation, and massive deformity. Septic arthritis, an infective process, can be identified through early plain film radiographic findings of soft tissue swelling around the joint and a widened joint space from joint effusion. With the progression of the disease, joint space narrowing can occur as articular cartilage is destroyed.

    • This question is part of the following fields:

      • Musculoskeletal Health
      8.8
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  • Question 25 - A 35-year-old lady comes to the clinic seeking guidance regarding her potential risk...

    Correct

    • A 35-year-old lady comes to the clinic seeking guidance regarding her potential risk of developing cancer. She has received proper treatment for CIN II, is a former smoker, and currently takes the combined oral contraceptive pill. Her two paternal aunts passed away from ovarian carcinoma at ages 40 and 48. What is the primary predisposing factor for ovarian cancer in this patient?

      Your Answer: Oral contraceptive therapy

      Explanation:

      Understanding the Risk Factors for Developing Breast Cancer

      Breast cancer is a prevalent disease that affects 1.4% of the overall population. However, the risk of developing breast cancer increases with a family history of the disease. The number of affected first-degree relatives and their age at diagnosis can significantly impact the risk. For instance, having one affected first-degree relative increases the risk to 4-5%, while having two close relatives affected raises the risk to 7%.

      Women with BRCA1 mutation have a 40% carrier risk of developing carcinoma, while those with BRCA2 have a 25% risk. Additionally, women who have had many ovulations, early menarche, and nullipara are more likely to develop breast cancer. However, the use of the combined oral contraceptive pill is associated with a reduced risk of developing the disease.

      In summary, understanding the risk factors for developing breast cancer is crucial in taking preventive measures and seeking early diagnosis and treatment.

    • This question is part of the following fields:

      • End Of Life
      25.7
      Seconds
  • Question 26 - You have serious concerns about the health of a 23-year-old man who has...

    Incorrect

    • You have serious concerns about the health of a 23-year-old man who has a learning disability. You would like to take some blood tests to rule out certain conditions. He has the capacity to make day-to-day decisions (eg what to have for breakfast) but lacks capacity for some other decisions. You assess that he doesn't have capacity to decide whether to have blood tests taken.
      Which of the following is correct regarding appropriate management of this situation?

      Your Answer: Patient consent is required

      Correct Answer: The doctor can act in the patient’s best interests and take blood

      Explanation:

      Best-Interest Decision Making for Blood Tests in Patients Lacking Capacity

      When a patient lacks capacity to make decisions, it is the responsibility of the doctor to act in their best interest. This includes making decisions about whether or not to take blood tests. While consulting with family and those involved in the patient’s care is important, the patient should still be involved in the decision-making process to the extent possible.

      It is important to note that blood cannot be forcibly taken from a patient, even if they lack capacity. Instead, the decision should be made based on what is in the patient’s best interest.

      Confidentiality may need to be broken in order to consult with family members and caregivers, but this should be done only when appropriate.

      Whether the patient is being managed in the community or in a hospital, the same ethical considerations apply when it comes to obtaining blood tests.

      While the patient’s consent is not required in this situation, their opinion should still be taken into account when making a best-interest decision.

    • This question is part of the following fields:

      • Neurodevelopmental Disorders, Intellectual And Social Disability
      39.1
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  • Question 27 - A 48-year-old male with a history of dermatomyositis secondary to small cell lung...

    Correct

    • A 48-year-old male with a history of dermatomyositis secondary to small cell lung cancer presents with roughened red papules on the extensor surfaces of his fingers. What is the medical term for these lesions?

      Your Answer: Gottron's papules

      Explanation:

      Dermatomyositis is characterized by the presence of roughened red papules, known as Gottron’s papules, on the extensor surfaces. Osteoarthritis is associated with the development of Heberden’s and Bouchard’s nodes. Aschoff nodules are a definitive sign of rheumatic fever.

      Understanding Dermatomyositis

      Dermatomyositis is a condition that causes inflammation and weakness in the muscles, as well as distinct skin lesions. It can occur on its own or be associated with other connective tissue disorders or underlying malignancies. Patients with dermatomyositis may experience symmetrical, proximal muscle weakness, and photosensitive skin rashes. The skin lesions may include a macular rash over the back and shoulders, a heliotrope rash in the periorbital region, Gottron’s papules, and mechanic’s hands. Other symptoms may include Raynaud’s, respiratory muscle weakness, interstitial lung disease, dysphagia, and dysphonia.

      To diagnose dermatomyositis, doctors may perform various tests, including screening for underlying malignancies. The majority of patients with dermatomyositis are ANA positive, and around 30% have antibodies to aminoacyl-tRNA synthetases, such as anti-synthetase antibodies, antibodies against histidine-tRNA ligase (Jo-1), antibodies to signal recognition particle (SRP), and anti-Mi-2 antibodies.

      In summary, dermatomyositis is a condition that affects both the muscles and skin. It can be associated with other disorders or malignancies, and patients may experience a range of symptoms. Proper diagnosis and management are essential for improving outcomes and quality of life for those with dermatomyositis.

    • This question is part of the following fields:

      • Dermatology
      11.2
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  • Question 28 - The husband of one of your elderly patients attends surgery because she is...

    Incorrect

    • The husband of one of your elderly patients attends surgery because she is concerned about her husband's heavy alcohol consumption.

      She explains that he drinks himself to a stupor every day and probably consumes at least a bottle of wine a day, although she suspects that he supplements that secretly when she is not around because his breath often smells of alcohol in the morning. This has been happening for many years and he refuses to see you about it.

      Following an argument the previous night, when she threatened to leave him unless he recognised the problem, he has agreed to stop drinking completely. His wife is worried about him having the DTs and asks you about this.

      On average, how long does it take for delirium tremens (DTs) to develop following complete cessation of drinking?

      Your Answer: More than 2 weeks

      Correct Answer: 48-96 hours

      Explanation:

      Understanding Alcohol Withdrawal Symptoms

      Alcohol withdrawal symptoms can manifest in different ways depending on the severity of the addiction. DTs or delirium tremens usually occur 2-4 days after stopping drinking and are characterized by severe agitation, confusion, and hallucinations. On the other hand, tremulousness or withdrawal convulsions can occur during a drinking spree or within a few hours of cessation. Alcoholic hallucinosis, which is characterized by auditory hallucinations, can occur over days or weeks. However, it is less severe than DTs.

      Admission to a medical facility for appropriate sedation, nursing support, and thiamine replacement is necessary to manage the symptoms and prevent complications. Understanding the different alcohol withdrawal symptoms can help you identify when someone needs medical attention and provide the necessary support.

    • This question is part of the following fields:

      • Smoking, Alcohol And Substance Misuse
      94.5
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  • Question 29 - A 38-year-old smoker requests advice on contraception. She smokes 12 cigarettes per day,...

    Incorrect

    • A 38-year-old smoker requests advice on contraception. She smokes 12 cigarettes per day, has a stable partner, and two children. She doesn't want any more children. She also reports heavy periods and would like to address this issue. During examination, her BMI is 30, and her blood pressure is 140/85. What is the best contraceptive option for her?

      Your Answer: Copper-based IUD

      Correct Answer: Combined oral contraceptive

      Explanation:

      Choosing the Right Contraceptive for a Smoker with Elevated BMI

      Combined oral contraceptive pills are not recommended for smokers over 35 years old due to the increased risk of venous thromboembolism. This risk is further elevated in women with an elevated BMI. While the progesterone-only pill is an alternative, its effectiveness is reduced due to poor compliance. Therefore, the most appropriate choice for this patient would be an IUD or IUS. The IUS may result in reduced menstrual flow after the first few months, and in some cases, periods may become very light or stop altogether. Overall, careful consideration of the patient’s medical history and lifestyle is necessary when selecting the most appropriate contraceptive method.

    • This question is part of the following fields:

      • Sexual Health
      25.1
      Seconds
  • Question 30 - You assess a patient with metastatic melanoma who is presently on MST 50...

    Correct

    • You assess a patient with metastatic melanoma who is presently on MST 50 mg bd. Regrettably, he is encountering notable drowsiness and queasiness, and you opt to attempt switching him to oxycodone. What is the suitable starting dose of Oxycontin (modified release oxycodone) to prescribe for a patient like him?

      Your Answer: Oxycontin 30 mg bd

      Explanation:

      The current conversion factor for oral morphine to oral oxycodone according to the BNF is 1.5 (meaning 10 mg of oral morphine is equivalent to 6.6mg of oral oxycodone). However, other sources such as palliative care formularies suggest a conversion factor of 2. Despite the discrepancy, the most suitable dosage option from the choices provided is 30 mg twice daily, which corresponds to a conversion factor of 1.66.

      Palliative care prescribing for pain is guided by NICE and SIGN guidelines. NICE recommends starting with regular oral modified-release or immediate-release morphine, with immediate-release morphine for breakthrough pain. Laxatives should be prescribed for all patients initiating strong opioids, and antiemetics should be offered if nausea persists. Drowsiness is usually transient, but if it persists, the dose should be adjusted. SIGN advises that the breakthrough dose of morphine is one-sixth the daily dose, and all patients receiving opioids should be prescribed a laxative. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred to morphine in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and all patients should be considered for referral to a clinical oncologist for further treatment. When increasing the dose of opioids, the next dose should be increased by 30-50%. Conversion factors between opioids are also provided. Opioid side-effects include nausea, drowsiness, and constipation, which are usually transient but may persist. Denosumab may be used to treat metastatic bone pain in addition to strong opioids, bisphosphonates, and radiotherapy.

    • This question is part of the following fields:

      • Improving Quality, Safety And Prescribing
      18.3
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SESSION STATS - PERFORMANCE PER SPECIALTY

Neurology (2/4) 50%
Urgent And Unscheduled Care (0/1) 0%
Musculoskeletal Health (2/3) 67%
Mental Health (0/1) 0%
Maternity And Reproductive Health (0/1) 0%
Kidney And Urology (0/2) 0%
Eyes And Vision (2/2) 100%
Gastroenterology (1/1) 100%
Children And Young People (0/2) 0%
End Of Life (1/2) 50%
Cardiovascular Health (2/3) 67%
Infectious Disease And Travel Health (0/1) 0%
Ear, Nose And Throat, Speech And Hearing (0/1) 0%
Evidence Based Practice, Research And Sharing Knowledge (0/1) 0%
Neurodevelopmental Disorders, Intellectual And Social Disability (0/1) 0%
Dermatology (1/1) 100%
Smoking, Alcohol And Substance Misuse (0/1) 0%
Sexual Health (0/1) 0%
Improving Quality, Safety And Prescribing (1/1) 100%
Passmed