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Question 1
Correct
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A 10-year-old boy is brought to the Emergency Department after being hit on the side of his head by a cricket ball during a match. According to his teacher, he initially fell to the ground and complained of a sore head. However, he got up after two minutes, claimed to feel fine, and resumed playing. Unfortunately, after 30 minutes, he suddenly collapsed and lost consciousness. What kind of injury is he likely to have suffered?
Your Answer: Extradural haematoma
Explanation:Extradural (epidural) hematoma – Head injury with a lucid interval
Types of Traumatic Brain Injury
Traumatic brain injury can result in primary and secondary brain injury. Primary brain injury can be focal or diffuse. Diffuse axonal injury occurs due to mechanical shearing, which causes disruption and tearing of axons. Intra-cranial haematomas can be extradural, subdural, or intracerebral, while contusions may occur adjacent to or contralateral to the side of impact. Secondary brain injury occurs when cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury. The normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia. The Cushings reflex often occurs late and is usually a pre-terminal event.
Extradural haematoma is bleeding into the space between the dura mater and the skull. It often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of epidural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Subdural haematoma is bleeding into the outermost meningeal layer. It most commonly occurs around the frontal and parietal lobes. Risk factors include old age, alcoholism, and anticoagulation. Subarachnoid haemorrhage classically causes a sudden occipital headache. It usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury. Intracerebral haematoma is a collection of blood within the substance of the brain. Causes/risk factors include hypertension, vascular lesion, cerebral amyloid angiopathy, trauma, brain tumour, or infarct. Patients will present similarly to an ischaemic stroke or with a decrease in consciousness. CT imaging will show a hyperdensity within the substance of the brain. Treatment is often conservative under the care of stroke physicians, but large clots in patients with impaired consciousness may warrant surgical evacuation.
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This question is part of the following fields:
- Neurology
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Question 2
Correct
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A 70-year-old retired ship-builder has a 6-month history of increasing shortness of breath, dull right-sided chest pain, loss of appetite and sweats. He is a non-smoker. Examination of his lungs reveals dullness to percussion and reduced air entry at the right base.
Which of the following is the most likely diagnosis?Your Answer: Malignant mesothelioma
Explanation:Distinguishing Mesothelioma from Other Lung Diseases
Mesothelioma is a type of cancer that affects the pleura and peritoneum, and is almost always caused by exposure to asbestos. Symptoms include chest pain, shortness of breath, cough, fever, weight loss, and fatigue. A pleural effusion is also common in mesothelioma cases.
Small-cell lung cancer, on the other hand, is highly aggressive and life expectancy is only weeks without treatment. Smoking is the major risk factor, although asbestos can also cause this type of lung cancer. Symptoms are similar to mesothelioma, but lack of smoking history and longer onset of symptoms point more towards mesothelioma.
Chronic obstructive pulmonary disease (COPD) is usually caused by smoking and presents with progressive shortness of breath, productive cough, frequent chest infections, and wheeze. Examination could reveal cyanosis, barrel chest, hyperresonance on percussion, poor air entry, and wheeze or coarse crackles. However, this presentation does not fit with COPD.
Chronic thromoboembolic pulmonary hypertension (CPTH) can develop months or years after a large pulmonary embolism (PE) or after several episodes. Symptoms include shortness of breath, chest pain on exertion, and fatigue. The patient can go on to develop right heart failure, but this diagnosis would not explain the weight loss and sweats.
Tuberculosis usually presents with a persistent productive cough, weight loss, night sweats, fevers, lymphadenopathy, and general malaise. In this patient, the symptoms, along with history of asbestos exposure, are highly suggestive of mesothelioma rather than tuberculosis.
In summary, distinguishing mesothelioma from other lung diseases requires careful consideration of symptoms, risk factors, and examination findings.
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This question is part of the following fields:
- Respiratory Medicine
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Question 3
Correct
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A 32-year-old woman presents with flank pain and a 48-hour history of dysuria. Her past medical history includes polycystic ovary syndrome. She is not sexually active at present. There is haematuria on urine dipstick testing. Examination reveals a pyrexia of 38.1 °C and flank pain.
What diagnosis fits best with this clinical picture?Your Answer: Pyelonephritis
Explanation:Differential Diagnosis of Abdominal Pain: Overview of Common Conditions
Abdominal pain is a common presenting symptom in clinical practice. It can be caused by a wide range of conditions, including gastrointestinal, genitourinary, gynecological, and systemic disorders. Here, we provide an overview of some of the most common conditions that can cause abdominal pain and their characteristic features.
Pyelonephritis: This is a potentially life-threatening infection that affects the renal parenchyma. It typically presents with fever, unilateral costovertebral angle pain, and nausea/vomiting. Antibiotic therapy is essential, and empirical therapy should be tailored to the infecting pathogen.
Ovarian cyst pain: Ovarian cysts are usually asymptomatic, but severe pain can occur if there is torsion or rupture. The pain is sudden, sharp, and unilateral, and can be associated with trauma, exercise, or coitus.
Nephrolithiasis: This refers to the presence of calculi in the kidneys and/or ureters. The classic presentation is sudden onset of severe flank pain that radiates anteriorly and inferiorly, often accompanied by nausea and vomiting. Fever is not a typical feature.
Pelvic inflammatory disease: PID is an infectious and inflammatory disorder of the upper female genital tract. It typically presents with lower abdominal pain and abnormal vaginal discharge.
Acute glomerulonephritis: This is a specific set of renal diseases that can result in damage to the glomerular tissue. Acute nephritic syndrome is the most serious form, but it typically presents with haematuria, proteinuria, and red blood cell casts in the urine, often accompanied by hypertension and oedema.
In summary, the differential diagnosis of abdominal pain is broad and includes a range of conditions that can affect different organ systems. A careful history and physical examination, along with appropriate investigations, can help to narrow down the possible causes and guide management.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 4
Incorrect
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A 3-year-old boy is taken to his pediatrician by his father due to constant scratching of his bottom at night. The father reports observing some unusual white particles when cleaning his son's bottom after a bowel movement. What would be the best course of action for management?
Your Answer: Prescribe a single dose of mebendazole for the daughter and issue hygiene advice.
Correct Answer: Prescribe a single dose of mebendazole for the whole household and issue hygiene advice.
Explanation:Threadworm Infestation in Children
Threadworm infestation, caused by Enterobius vermicularis or pinworms, is a common occurrence among children in the UK. The infestation happens when eggs present in the environment are ingested. In most cases, threadworm infestation is asymptomatic, but some possible symptoms include perianal itching, especially at night, and vulval symptoms in girls. Diagnosis can be made by applying Sellotape to the perianal area and sending it to the laboratory for microscopy to see the eggs. However, most patients are treated empirically, and this approach is supported in the CKS guidelines.
The CKS recommends a combination of anthelmintic with hygiene measures for all members of the household. Mebendazole is the first-line treatment for children over six months old, and a single dose is given unless the infestation persists. It is essential to treat all members of the household to prevent re-infection. Proper hygiene measures, such as washing hands regularly, keeping fingernails short, and washing clothes and bedding at high temperatures, can also help prevent the spread of threadworm infestation.
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This question is part of the following fields:
- Paediatrics
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Question 5
Incorrect
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A 30-year-old man presents to the General Practitioner (GP) with hypertension which fails to fall into the normal range after three successive measurements at the practice nurse. These were 155/92 mmHg, 158/96 mmHg and 154/94 mmHg. He has a past history of some urinary tract infections as a child. The GP arranges some routine blood tests.
Investigations reveal the following:
Investigation Result Normal value
Haemoglobin (Hb) 139 g/l 135–175 g/l
White cell count (WCC) 5.4 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 201 × 109/l 150–400 × 109/l
Sodium (Na+) 139 mmol/l 135–145 mmol/l
Potassium (K+) 4.9 mmol/l 3.5–5.0 mmol/l
Creatinine (Cr) 187 μmol/l 50–120 μmol/l
Ultrasound scan (USS) Left kidney 8.4 cm and appears scarred.
Right kidney 10.3 cm
Which of the following is the most likely diagnosis?Your Answer: Renal artery stenosis
Correct Answer: Chronic reflux nephropathy
Explanation:Differential Diagnosis for a 25-Year-Old Man with Renal Issues
Upon reviewing the history and test results of a 25-year-old man with renal issues, several potential diagnoses can be considered. Chronic reflux nephropathy appears to be the most likely diagnosis, given the patient’s history of urinary tract infections as a child, ultrasound scan results, and elevated creatinine levels. Further testing, such as renal tract computed tomography and a voiding cystourethrogram, can confirm this diagnosis.
Essential hypertension, while a risk factor for reno-vascular disease, is unlikely to be the cause of the patient’s symptoms. It would not lead to a rise in creatinine or asymmetrical kidneys in a young patient.
IgA nephropathy is another potential diagnosis, but the patient’s lack of haematuria or history of recent illness does not support this diagnosis. The history of urinary tract infections also does not align with IgA nephropathy.
Renal artery stenosis is relatively rare in young patients and would lead to a unilaterally reduced kidney size, which does not fit with the patient’s symptoms.
White coat hypertension, while a possibility, would not explain the rise in creatinine or the reduced size and scarring of the left kidney. A 24-hour blood pressure monitor may be needed to differentiate between persistent hypertension and white coat hypertension.
In conclusion, chronic reflux nephropathy is the most likely diagnosis for this patient, but further testing may be necessary to confirm the diagnosis and rule out other potential causes.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 6
Incorrect
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A 28-year-old woman is referred by her General Practitioner due to irregular and unpredictable menstrual cycle and headaches. Magnetic resonance imaging of the brain shows a midline lesion. Further investigations reveal that her prolactin level is 2314 ng/ml (normal range: 2–29 ng/ml). To reduce the prolactin level, which mediator is manipulated for medical treatment?
Your Answer: Somatostatin
Correct Answer: Dopamine
Explanation:Targeting Hormones in Prolactinoma Treatment
Prolactinoma is a pituitary lesion that results in excessive prolactin secretion. To reduce prolactin levels, dopamine agonists like bromocriptine are used to target dopamine receptors in the anterior pituitary. While increased prolactin can indirectly decrease gonadotropin-releasing hormone (GnRH) secretion, GnRH receptors are not a therapeutic target in prolactin disorders. Corticotropin-releasing hormone (CRH) increases adrenocorticotropic hormone secretion and is not a target in prolactin disorders. Somatostatin decreases thyroid-stimulating hormone (TSH) and growth hormone secretion but does not affect prolactin levels. Thyrotropin-releasing hormone (TRH) increases prolactin and TSH release, but its use is limited due to side-effects on thyroid regulation and the superiority of dopamine agonists.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 7
Incorrect
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A 65-year-old woman with a recent diagnosis of heart failure with reduced ejection fraction (on echo) has a blood pressure (BP) of 160/95 mmHg. She is currently on lisinopril (maximum doses).
Which of the following new agents would you add in?Your Answer: Bendroflumethiazide
Correct Answer: Bisoprolol
Explanation:Medications for Heart Failure: Benefits and Guidelines
Heart failure is a serious condition that requires proper management through medications. Among the drugs commonly used are bisoprolol, bendroflumethiazide, clopidogrel, spironolactone, and diltiazem.
Bisoprolol and an angiotensin-converting enzyme (ACE) inhibitor are recommended for all heart failure patients as they have been shown to reduce mortality. Bendroflumethiazide and loop diuretics like furosemide can help alleviate symptoms but do not have a mortality benefit. Clopidogrel, on the other hand, is not indicated for heart failure but is used for vascular diseases like NSTEMI and stroke.
Spironolactone is recommended for patients who remain symptomatic despite treatment with an ACE inhibitor and a b blocker. It is also beneficial for those with left ventricular systolic dysfunction (LVSD) after a myocardial infarction (MI). However, diltiazem should be avoided in heart failure patients.
According to NICE guidelines, b blockers and ACE inhibitors should be given to all LVSD patients unless contraindicated. Spironolactone can be added if symptoms persist. Proper medication management is crucial in improving outcomes for heart failure patients.
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This question is part of the following fields:
- Cardiovascular
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Question 8
Correct
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A 35-year-old woman, who has been struggling with drug addiction and living on the streets, presents to the Emergency Department complaining of epigastric pain. The patient reports that she developed acute abdominal pain two hours prior to the presentation after eating a hot dog. The patient otherwise has no significant past medical history, takes no medications and admits to smoking and occasional alcohol consumption.
On examination, the patient has normal vital signs. Her abdominal examination demonstrates normoactive bowel sounds, no tenderness to palpation in the epigastrium and no guarding or rebound tenderness. Rectal exam for stool occult blood is negative and a chest X-ray does not reveal free air under the diaphragm. A right upper quadrant ultrasound does not demonstrate stones. The doctor recommends antacids. When the doctor tells the patient that she is safe for discharge, the patient insists that she must be admitted to the hospital for further tests.
Which of the following is the most likely diagnosis?Your Answer: Malingering
Explanation:Differentiating between Malingering, Hypochondriasis, Conversion Disorder, Factitious Disorder, and Munchausen Syndrome by Proxy
When evaluating patients, it is important to differentiate between various conditions that may present with similar symptoms. Malingering is a condition where a patient feigns or exaggerates symptoms for secondary gain, such as meals or a place to sleep. Hypochondriasis, on the other hand, is a condition where a patient fears having a medical illness despite negative tests and reassurance. Conversion disorder refers to the manifestation of psychological illness as neurologic pathology, while factitious disorder involves a patient who assumes the sick role for personal satisfaction. Finally, Munchausen syndrome by proxy is similar to factitious disorder but involves a patient seeking the sick role vicariously through a second patient, often a child. By understanding the differences between these conditions, healthcare providers can provide appropriate care and treatment for their patients.
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This question is part of the following fields:
- Psychiatry
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Question 9
Correct
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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: 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.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 10
Incorrect
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A 28-year-old male came to the emergency department complaining of shortness of breath during exertion. He had no medical history to report. During the examination, a midsystolic murmur was detected, which was most audible at the left lower sternal border. The murmur became louder when the Valsalva manoeuvre was performed. An echocardiogram revealed mitral regurgitation, asymmetric hypertrophy, systolic anterior motion of the anterior mitral valve leaflet, and left ventricular outflow tract obstruction. What medication should be avoided in this patient?
Your Answer: Verapamil
Correct Answer: Ramipril
Explanation:Patients with HOCM should avoid ACE-inhibitors.
The correct answer is Ramipril. In patients with hypertrophic obstructive cardiomyopathy (HOCM) and left ventricular outflow tract (LVOT) obstruction, ACE inhibitors are not recommended. This is because ACE inhibitors can decrease afterload, which may exacerbate the LVOT gradient. The patient in this case has echocardiographic evidence of HOCM, including asymmetric hypertrophy, systolic anterior motion of the anterior mitral valve leaflet, and mitral regurgitation.
However, amiodarone, atenolol, disopyramide, and verapamil are all viable treatment options for HOCM.
Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic disorder that affects muscle tissue and is inherited in an autosomal dominant manner. It is estimated to have a prevalence of 1 in 500. The condition is caused by defects in the genes that encode contractile proteins.
The management of HOCM involves several approaches. Amiodarone is a medication that can be used to treat the condition. Beta-blockers or verapamil may also be prescribed to alleviate symptoms. In some cases, a cardioverter defibrillator or dual chamber pacemaker may be necessary. It is important to note that certain drugs, such as nitrates, ACE-inhibitors, and inotropes, should be avoided in patients with HOCM. Additionally, endocarditis prophylaxis may be recommended, although the 2008 NICE guidelines should be consulted for specific recommendations.
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This question is part of the following fields:
- Cardiovascular
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Question 11
Correct
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A 32-year-old woman presents to the Eye Hospital Emergency Department with a 4-day history of blurred vision and left-eye pain worse on movement. On examination, there is decreased visual acuity and impaired colour vision in the left eye and a left relative afferent pupillary defect. Fundoscopy reveals a mildly swollen left optic disc. Intraocular pressure is 20 mmHg in the left eye. Her past medical history includes type II diabetes mellitus and hyperlipidemia. What is the most likely diagnosis?
Your Answer: Optic neuritis
Explanation:Understanding Optic Neuritis: Symptoms and Differential Diagnosis
Optic neuritis is a condition that can be either idiopathic or secondary to multiple sclerosis. Patients with optic neuritis typically experience periocular pain associated with eye movement, as well as a loss of color vision. Visual field defects, such as a central scotoma, can also occur. If the other eye is uninvolved, there is typically a relative afferent pupillary defect.
It is important to differentiate optic neuritis from other conditions that can cause similar symptoms. A stroke, for example, would not typically cause eye pain or affect color vision. Acute-angle-closure glaucoma can also be ruled out if intraocular pressure is within the normal range. Cerebral venous thrombosis would usually cause sudden painless loss of vision with severe retinal hemorrhages on fundoscopy. In cases of raised intracranial pressure, papilledema would be seen in both optic discs.
Overall, understanding the symptoms and differential diagnosis of optic neuritis is crucial for proper diagnosis and treatment.
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This question is part of the following fields:
- Neurology
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Question 12
Incorrect
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As a physician on the night shift cardiac arrest team, you receive an emergency page requesting immediate assistance on the geriatric ward. Upon arrival, you discover the nursing staff performing chest compressions on an unresponsive patient with no carotid pulse. You instruct them to continue compressions while you apply defibrillator pads to the patient's chest. After a brief pause in compressions, the defibrillator monitor displays a monomorphic, broad complex tachycardia. What is the next best course of action?
Your Answer: Intravenous adenosine
Correct Answer: Immediately give 1 defibrillator shock followed by CPR
Explanation:When pulseless ventricular tachycardia (VT) is identified, the immediate and correct treatment is a single defibrillator shock followed by 2 minutes of CPR. This is in contrast to using intravenous adenosine or amiodarone, which are not appropriate in this scenario. The Resuscitation Council (UK) guidelines now recommend a single shock for ventricular fibrillation (VF) or pulseless VT. Administering 3 back-to-back shocks followed by 1 minute of CPR is part of the Advanced Life Support (ALS) algorithm, but it is not the most appropriate next step in management for a delayed recognition of rhythm like in the above case. In contrast, continued CPR with 30 chest compressions to 2 breaths is appropriate in a basic life support scenario where a defibrillator is not yet available.
The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.
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This question is part of the following fields:
- Cardiovascular
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Question 13
Correct
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A 76-year-old man comes to his General Practitioner with one-sided visual loss. During the examination, a relative afferent pupillary defect is observed. Fundoscopy reveals a 'cherry-red spot' with a red centre of the macula and a pale surrounding of the retina.
What is the most suitable next step in managing this patient, considering the probable diagnosis?Your Answer: Send patient to the Eye Hospital for immediate review by an Ophthalmologist
Explanation:Central Retinal-Artery Occlusion: An Ocular Emergency
Central retinal-artery occlusion (CRAO) is a serious condition that requires immediate attention from an ophthalmologist. It is diagnosed through a dilated eye examination that reveals a cherry-red spot in the center of the macula, surrounded by pale retina due to lack of blood flow. Other signs include segmentation of the blood column in the arteries and cattle-trucking.
CRAO is an ocular emergency because the retinal damage becomes irreversible with time, and urgent management is necessary to protect the other eye and the cardiovascular and cerebrovascular systems. The primary goal of management is to re-perfuse ischaemic tissue as quickly as possible and to institute secondary prevention early.
If giant-cell arteritis is suspected, immediate treatment is necessary, including intravenous steroids followed by oral steroids.
Referral under the 2-week-wait rule is necessary when there is a suspicion of cancer, but no signs of a tumor from history or fundoscopy findings.
It is crucial to refer the patient for urgent brain imaging and immediate review by an eye specialist. Starting the patient on topical antibiotics and anti-inflammatories would be inappropriate since there are no signs of an infection process.
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This question is part of the following fields:
- Ophthalmology
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Question 14
Correct
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A 25-year-old man visits his GP complaining of a rash that has spread across his trunk over the last 4 days. He is worried about the appearance of the rash. The patient has no significant medical history except for completing a course of phenoxymethylpenicillin for tonsillitis last week and takes no other regular medications. Upon examination, the doctor observes multiple scaly papules on the patient's trunk and upper limbs. The lesions are small and have a teardrop shape. What is the most probable diagnosis?
Your Answer: Guttate psoriasis
Explanation:The tear-drop scaly papules that have suddenly appeared on the patient’s trunk and limbs suggest guttate psoriasis. This type of psoriasis is commonly seen in children and young adults who have recently had a Streptococcus infection, such as the tonsillitis infection that this patient had. The rash is characterized by multiple small scaly and red patches that have a teardrop shape.
Disseminated varicella zoster, pityriasis rosea, and pityriasis versicolor are not likely diagnoses for this patient. Disseminated varicella zoster causes a different type of rash that includes macular, papular, and vesicular lesions that crust over time. Pityriasis rosea presents with a large round herald patch on the chest, abdomen, or back, and is thought to be triggered by viral or bacterial infections. Pityriasis versicolor is a fungal infection that causes patches that are paler than the surrounding skin, and is commonly found on the upper limbs and neck. However, exposure to heat and moisture can increase the risk of developing this rash.
Guttate psoriasis is a type of psoriasis that is more commonly seen in children and adolescents. It is often triggered by a streptococcal infection that occurred 2-4 weeks prior to the appearance of the lesions. The name guttate comes from the Latin word for drop, as the lesions appear as small, tear-shaped papules on the trunk and limbs. These papules are pink and scaly, and the onset of the condition is usually acute, occurring over a few days.
In most cases, guttate psoriasis will resolve on its own within 2-3 months. There is no clear evidence to support the use of antibiotics to treat the underlying streptococcal infection. Treatment options for guttate psoriasis include topical agents commonly used for psoriasis and UVB phototherapy. In cases where the condition recurs, a tonsillectomy may be necessary.
It is important to differentiate guttate psoriasis from pityriasis rosea, another skin condition that can present with similar symptoms. Guttate psoriasis is often preceded by a streptococcal sore throat, while pityriasis rosea may be preceded by a respiratory tract infection. The appearance of guttate psoriasis is characterized by tear-shaped papules on the trunk and limbs, while pityriasis rosea presents with a herald patch followed by multiple oval lesions with a fine scale. While guttate psoriasis resolves within a few months, pityriasis rosea typically resolves after around 6 weeks.
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This question is part of the following fields:
- Dermatology
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Question 15
Correct
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A 25-year-old woman presents to the neurology clinic with a unilateral hand tremor. Her family has noticed changes in her behavior, mood, and speech over the past year. During the examination, a resting tremor is observed in her right hand, along with bradykinesia and a lack of movement. Additionally, dark circular marks are visible around her iris. The patient mentions that her uncle passed away from liver cirrhosis at the age of 42. What is the probable diagnosis?
Your Answer: Wilson's disease
Explanation:Wilson’s disease is indicated by the presence of both liver and neurological conditions, as well as the presence of Kayser-Fleischer rings and a family history of liver disease.
Wilson’s disease is a genetic disorder that causes excessive copper buildup in the body tissues due to increased copper absorption from the small intestine and decreased hepatic copper excretion. It is an autosomal recessive disorder caused by a defect in the ATP7B gene located on chromosome 13. Symptoms usually appear between the ages of 10 and 25, with children presenting with liver disease and young adults with neurological disease. The disease is characterised by excessive copper deposition in the brain, liver, and cornea, resulting in various symptoms such as hepatitis, cirrhosis, basal ganglia degeneration, speech and behavioural problems, Kayser-Fleischer rings, renal tubular acidosis, haemolysis, and blue nails.
To diagnose Wilson’s disease, a slit lamp examination is conducted to check for Kayser-Fleischer rings, and blood and urine tests are performed to measure copper levels. The diagnosis is confirmed by genetic analysis of the ATP7B gene. The traditional first-line treatment for Wilson’s disease is penicillamine, which chelates copper. However, trientine hydrochloride is an alternative chelating agent that may become first-line treatment in the future. Tetrathiomolybdate is a newer agent that is currently under investigation for the treatment of Wilson’s disease.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 16
Correct
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A 48-year-old man comes to the emergency department complaining of sudden onset chest pain. The patient has a medical history of hypertension and is currently taking ramipril. His vital signs are as follows: BP 153/90 mmHg in his right arm and 130/80 in his left arm, heart rate 89/minute, temperature 37.2ºC, respiration rate 17/minute, and oxygen saturation 98% on room air. Upon examination, the patient has absent pulses in his right leg and diminished pulses in his left leg.
What is the recommended diagnostic test for this patient's presentation?Your Answer: CT angiography chest/abdomen/pelvis
Explanation:When a patient presents with symptoms of thoracic aortic dissection and is stable, CT angiography is the preferred diagnostic test. This imaging technique provides a clear view of the aorta and helps plan surgical intervention if necessary. In cases of proximal aortic dissection, inter-arm blood pressure measurements may reveal a difference of over 20 mmHg, with the right arm showing higher pressure due to its proximity to the heart. The absence or reduction of femoral pulses on one or both sides is also a common finding. While a chest x-ray may show signs associated with aortic dissection, it is not specific enough for diagnosis. Transesophageal echocardiography (TOE) is used to confirm the diagnosis if CT angiography is inconclusive or if the patient is unstable. Transthoracic echocardiography (TTE) is less sensitive and specific than TOE for detecting aortic dissection.
Understanding Aortic Dissection: Classification, Investigation, and Management
Aortic dissection is a serious medical condition that requires prompt diagnosis and management. It is classified according to the location of the tear in the aorta, with type A affecting the ascending aorta in two-thirds of cases, and type B affecting the descending aorta distal to the left subclavian origin in one-third of cases. The DeBakey classification further divides aortic dissection into type I, which originates in the ascending aorta and propagates to at least the aortic arch, and type II, which is confined to the ascending aorta. Type III originates in the descending aorta and rarely extends proximally but will extend distally.
To diagnose aortic dissection, imaging studies such as chest x-ray and CT angiography of the chest, abdomen, and pelvis are essential. Transoesophageal echocardiography (TOE) may be more suitable for unstable patients who cannot undergo CT scanning. Management of type A aortic dissection requires surgical intervention, but blood pressure should be controlled to a target systolic of 100-120 mmHg while awaiting surgery. Type B aortic dissection can be managed conservatively with bed rest and IV labetalol to reduce blood pressure and prevent progression.
Complications of aortic dissection depend on the location of the tear. Backward tears can lead to aortic incompetence/regurgitation and myocardial infarction, while forward tears can cause unequal arm pulses and blood pressure, stroke, and renal failure. Endovascular repair of type B aortic dissection may have a role in the future. It is important to remember that patients may present acutely and be clinically unstable, so the choice of investigations and management should take this into account.
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This question is part of the following fields:
- Cardiovascular
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Question 17
Incorrect
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Which one of the following statements regarding allergy testing is inaccurate?
Your Answer: The radioallergosorbent test determines the level of IgE to a specific allergen
Correct Answer: Skin prick testing should be read after 48 hours
Explanation:The results of skin prick testing can be interpreted after 15-20 minutes, while skin patch testing requires 48 hours after the patch is removed to be read.
Types of Allergy Tests
Allergy tests are used to determine if a person has an allergic reaction to a particular substance. There are several types of allergy tests available, each with its own advantages and limitations. The most commonly used test is the skin prick test, which is easy to perform and inexpensive. Drops of diluted allergen are placed on the skin, and a needle is used to pierce the skin. A wheal will typically develop if a patient has an allergy. This test is useful for food allergies and pollen.
Another type of allergy test is the radioallergosorbent test (RAST), which determines the amount of IgE that reacts specifically with suspected or known allergens. Results are given in grades from 0 (negative) to 6 (strongly positive). This test is useful for food allergies, inhaled allergens (e.g. pollen), and wasp/bee venom.
Skin patch testing is useful for contact dermatitis. Around 30-40 allergens are placed on the back, and irritants may also be tested for. The patches are removed 48 hours later, and the results are read by a dermatologist after a further 48 hours. Blood tests may be used when skin prick tests are not suitable, for example if there is extensive eczema or if the patient is taking antihistamines. Overall, allergy tests are an important tool in diagnosing and managing allergies.
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This question is part of the following fields:
- Immunology/Allergy
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Question 18
Correct
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A 68-year-old patient with known stable angina is currently managed on atenolol and isosorbide mononitrate (on an as required or PRN basis). He is experiencing more frequent episodes of angina on exertion.
What is the most appropriate treatment that can be added to his current regimen to alleviate his symptoms?
Your Answer: Nifedipine
Explanation:Medications for Angina: Nifedipine, Aspirin, Dabigatran, ISMN, and Spironolactone
When it comes to treating angina, the first-line anti-anginal treatment should be either a β blocker or a calcium channel blocker like nifedipine, according to NICE guidelines. If this proves ineffective, an alternative or combination of the two should be used. Nifedipine is the calcium channel blocker with the most vasodilating properties.
Aspirin can also be used to reduce the risk of a myocardial infarction (MI) in angina patients, but it does not provide any symptomatic relief. NICE recommends considering aspirin for all patients with angina.
Dabigatran, an anticoagulant, is useful for reducing the risk of strokes in patients with atrial fibrillation, but it does not provide any symptomatic benefit for angina.
If symptoms are not controlled on a combination of β blocker and calcium channel blocker, or if one of these cannot be tolerated, NICE advises considering long-acting nitrates like ISMN.
Spironolactone, an aldosterone antagonist, can be used in heart failure secondary to left ventricular systolic dysfunction (LVSD), especially after a myocardial infarction (MI). NICE recommends starting with either a β blocker or a calcium channel blocker, and switching or combining if ineffective. If one of these medications cannot be tolerated or the combination is ineffective, long-acting nitrate, nicorandil, or ivabradine should be considered.
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This question is part of the following fields:
- Cardiovascular
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Question 19
Correct
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A 35-year-old woman presents to her GP clinic complaining of a left groin lump that has been present for the past month. Although not severely painful, it causes occasional abdominal discomfort, especially when she goes jogging in the mornings. Her medical history includes polycystic ovarian syndrome, but she has been otherwise healthy with no recent illnesses.
During the examination, her vital signs are found to be within normal limits. A 3x3cm lump is observed in her left groin, located superiorly and medially to the pubic tubercle. The lump is visible while standing but disappears when she lies flat.
What is the most likely diagnosis?Your Answer: Inguinal hernia
Explanation:The patient is experiencing an inguinal hernia, which is when abdominal contents protrude through the abdominal wall and create a lump in the groin area. This lump may be more noticeable when the patient coughs or strains, and can cause pain and discomfort. Inguinal hernias are typically located above and towards the middle of the pubic tubercle. Femoral hernias, which are less common, present similarly but are located lower and to the side of the pubic tubercle. A femoral artery aneurysm, lipoma, or saphena varix are not likely causes based on the patient’s symptoms and examination findings.
Understanding Inguinal Hernias
Inguinal hernias are the most common type of abdominal wall hernias, with 75% of cases falling under this category. They are more prevalent in men, with a 25% lifetime risk of developing one. The main feature of an inguinal hernia is a lump in the groin area, which is located superior and medial to the pubic tubercle. This lump disappears when pressure is applied or when the patient lies down. Discomfort and aching are common symptoms, which can worsen with activity, but severe pain is rare. Strangulation, a serious complication, is uncommon.
The clinical management of inguinal hernias involves treating medically fit patients, even if they are asymptomatic. A hernia truss may be an option for patients who are not fit for surgery, but it has little role in other patients. Mesh repair is the preferred method of treatment, as it is associated with the lowest recurrence rate. Unilateral hernias are generally repaired with an open approach, while bilateral and recurrent hernias are repaired laparoscopically. Patients can return to non-manual work after 2-3 weeks following an open repair and after 1-2 weeks following laparoscopic repair, according to the Department for Work and Pensions.
Complications of inguinal hernias include early bruising and wound infection, as well as late chronic pain and recurrence. While traditional textbooks describe the anatomical differences between indirect and direct hernias, this is not relevant to clinical management. Overall, understanding the features, management, and complications of inguinal hernias is crucial for proper diagnosis and treatment.
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This question is part of the following fields:
- Musculoskeletal
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Question 20
Incorrect
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You are taking the history of an Emergency Department patient who was assaulted. The victim is a 20-year-old female who has a deep laceration on her thigh caused by a rusty machete. The wound has exposed tendon, muscle, and subcutaneous fat. According to her medical records, she received all her childhood immunizations on schedule, including 5 doses of tetanus vaccine, with the last one administered when she was 16 years old.
What is the appropriate management for tetanus risk in this patient?Your Answer: Tetanus vaccine booster and antibiotics
Correct Answer: No tetanus vaccine booster and no immunoglobulins required
Explanation:If a patient has received 5 doses of the tetanus vaccine, with the most recent dose administered less than 10 years ago, they do not need a booster vaccine or immunoglobulins, regardless of the severity of the wound. This is the correct course of action. The patient’s childhood vaccinations would have included 5 doses of the tetanus vaccine, with the last dose given at age 14 or later. Therefore, the patient is already adequately protected and does not require a booster or immunoglobulin, regardless of the severity of the wound.
The option of administering a tetanus vaccine booster with antibiotics is not the correct course of action. While antibiotics may be considered for protection against other bacteria, the patient already has sufficient protection against tetanus and does not require vaccination.
Similarly, administering a tetanus vaccine booster with tetanus immunoglobulin is not necessary. As previously mentioned, the patient already has adequate protection from previous vaccinations. Immunoglobulin would only be necessary if the patient had an incomplete or unknown vaccine history or if it had been more than 10 years since the last vaccine.
Lastly, administering a tetanus vaccine booster alone is not necessary. The patient already has protection from previous vaccinations and does not require a booster.
Tetanus Vaccination and Management of Wounds
The tetanus vaccine is a purified toxin that is given as part of a combined vaccine. In the UK, it is given as part of the routine immunisation schedule at 2, 3, and 4 months, 3-5 years, and 13-18 years, providing a total of 5 doses for long-term protection against tetanus.
When managing wounds, the first step is to classify them as clean, tetanus-prone, or high-risk tetanus-prone. Clean wounds are less than 6 hours old and have negligible tissue damage, while tetanus-prone wounds include puncture-type injuries acquired in a contaminated environment or wounds containing foreign bodies. High-risk tetanus-prone wounds include wounds or burns with systemic sepsis, certain animal bites and scratches, heavy contamination with material likely to contain tetanus spores, wounds or burns with extensive devitalised tissue, and wounds or burns that require surgical intervention.
If the patient has had a full course of tetanus vaccines with the last dose less than 10 years ago, no vaccine or tetanus immunoglobulin is required regardless of the wound severity. If the patient has had a full course of tetanus vaccines with the last dose more than 10 years ago, a reinforcing dose of vaccine is required for tetanus-prone wounds, and a reinforcing dose of vaccine plus tetanus immunoglobulin is required for high-risk wounds. If the vaccination history is incomplete or unknown, a reinforcing dose of vaccine is required regardless of the wound severity, and a reinforcing dose of vaccine plus tetanus immunoglobulin is required for tetanus-prone and high-risk wounds.
Overall, proper vaccination and wound management are crucial in preventing tetanus infection.
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This question is part of the following fields:
- Infectious Diseases
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Question 21
Correct
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At what age would a typical infant develop the skill of crawling?
Your Answer: 9 months
Explanation:Gross Motor Developmental Milestones
Gross motor skills refer to the ability to use large muscles in the body for activities such as crawling, walking, running, and jumping. These skills are essential for a child’s physical development and are achieved through a series of developmental milestones.
At 3 months, a baby should have little or no head lag when pulled to sit and should have good head control when lying on their abdomen. By 6 months, they should be able to lift and grasp their feet when lying on their back, pull themselves to a sitting position, and roll from front to back. At 9 months, they should be able to pull themselves to a standing position and crawl. By 12 months, they should be able to cruise and walk with one hand held. At 18 months, they should be able to walk unsupported and squat to pick up a toy. By 2 years, they should be able to run and walk up and down stairs holding onto a rail. At 3 years, they should be able to ride a tricycle using pedals and walk up stairs without holding onto a rail. By 4 years, they should be able to hop on one leg.It is important to note that while the majority of children crawl on all fours before walking, some children may bottom-shuffle, which is a normal variant that runs in families. These milestones serve as a guide for parents and healthcare professionals to monitor a child’s physical development and identify any potential delays or concerns.
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This question is part of the following fields:
- Paediatrics
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Question 22
Correct
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A 70-year-old man has been taking warfarin for 2 years due to paroxysmal atrial fibrillation. He recently underwent DC cardioversion and is now in sinus rhythm after consulting with his cardiologist. His CHAD-VASC score is 4. Assuming he remains in sinus rhythm, what is the best course of action for his anticoagulation?
Your Answer: Continue anticoagulation lifelong
Explanation:Anticoagulation should be continued long-term, even if sinus rhythm is maintained, following elective DC cardioversion for AF in high-risk patients. The correct answer is to continue anticoagulation lifelong, with regular evaluation of bleeding risk. The options of continuing anticoagulation for 4 weeks or 6 months then stopping are incorrect for this patient who has a high CHAD-VASC score. One week of low molecular weight heparin is not the appropriate answer in this case, although it may be used for thromboprophylaxis in some post-surgical patients.
Atrial Fibrillation and Cardioversion: Elective Procedure for Rhythm Control
Cardioversion is a medical procedure used in atrial fibrillation (AF) to restore the heart’s normal rhythm. There are two scenarios where cardioversion may be used: as an emergency if the patient is haemodynamically unstable, or as an elective procedure where a rhythm control strategy is preferred. In the elective scenario, cardioversion can be performed either electrically or pharmacologically. Electrical cardioversion is synchronised to the R wave to prevent delivery of a shock during the vulnerable period of cardiac repolarisation when ventricular fibrillation can be induced.
According to the 2014 NICE guidelines, rate or rhythm control should be offered if the onset of the arrhythmia is less than 48 hours, and rate control should be started if it is more than 48 hours or is uncertain. If the AF is definitely of less than 48 hours onset, patients should be heparinised and may be cardioverted using either electrical or pharmacological means. However, if the patient has been in AF for more than 48 hours, anticoagulation should be given for at least 3 weeks prior to cardioversion. An alternative strategy is to perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus. If excluded, patients may be heparinised and cardioverted immediately.
NICE recommends electrical cardioversion in this scenario, rather than pharmacological. If there is a high risk of cardioversion failure, it is recommended to have at least 4 weeks of amiodarone or sotalol prior to electrical cardioversion. Following electrical cardioversion, patients should be anticoagulated for at least 4 weeks. After this time, decisions about anticoagulation should be taken on an individual basis depending on the risk of recurrence.
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This question is part of the following fields:
- Cardiovascular
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Question 23
Incorrect
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A 35-year-old woman experiences a seizure while in the emergency department. The seizure began suddenly with an abrupt loss of consciousness and an initial period of stiff muscle contraction, followed by intermittent jerky movements. She has a history of epilepsy and takes carbamazepine, but has been noted to have poor adherence in the past. The seizure persists for more than five minutes despite a dose of IV lorazepam. What is the next best pharmacological approach?
Your Answer: Intravenous phenytoin
Correct Answer: Intravenous lorazepam
Explanation:Convulsive status epilepticus should be initially managed with IV lorazepam, with a repeat dose given 10 minutes later if the seizure persists or recurs. Buccal midazolam may be used if IV access is not available or if the seizure occurs outside of a hospital setting. It is important to note that a maximum of two doses of IV benzodiazepines should be administered during convulsive status epilepticus. Intravenous carbamazepine is not appropriate for acute seizure management, as it is primarily used for preventing tonic-clonic seizures. Intravenous phenytoin should not be given until two doses of benzodiazepines have been administered, and at this point, critical care and anesthesia should also be involved. Rectal diazepam is typically not used unless there is no IV access or the emergency occurs outside of a hospital setting.
Status epilepticus is a medical emergency that occurs when a person experiences a single seizure lasting more than five minutes or two seizures within a five-minute period without returning to normal between them. It is crucial to terminate seizure activity as soon as possible to prevent irreversible brain damage. The first step in managing status epilepticus is to ensure the patient’s airway is clear and provide oxygen while checking their blood glucose levels. The first-line treatment is IV benzodiazepines, such as diazepam or lorazepam, with PR diazepam or buccal midazolam given in the prehospital setting. In the hospital, IV lorazepam is typically used and may be repeated once after 10-20 minutes. If the status epilepticus persists, a second-line agent such as phenytoin or phenobarbital infusion may be administered. If there is no response within 45 minutes, induction of general anesthesia is the best way to achieve rapid control of seizure activity.
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This question is part of the following fields:
- Neurology
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Question 24
Incorrect
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A 14-year-old girl is referred to haematology due to heavy and prolonged periods that have not responded well to tranexamic acid and the combined oral contraceptive pill. Her blood tests reveal Hb of 10.3 g/dl, Plt of 239 * 109/l, WBC of 6.5 * 109/l, PT of 12.9 secs, and APTT of 37 secs. What is the probable diagnosis?
Your Answer:
Correct Answer: Von Willebrand's disease
Explanation:Understanding Von Willebrand’s Disease
Von Willebrand’s disease is a common inherited bleeding disorder that is usually passed down in an autosomal dominant manner. It behaves like a platelet disorder, with symptoms such as nosebleeds and heavy menstrual bleeding being common, while joint and muscle bleeding are rare. The disease is caused by a deficiency or abnormality in von Willebrand factor, a large glycoprotein that promotes platelet adhesion to damaged endothelium and acts as a carrier molecule for factor VIII.
There are three types of Von Willebrand’s disease. Type 1 is the most common and is characterized by a partial reduction in von Willebrand factor. Type 2 is further divided into four subtypes, each with a different abnormality in the von Willebrand factor. Type 3 is the most severe form and is caused by a total lack of von Willebrand factor, inherited in an autosomal recessive manner.
Diagnosis of Von Willebrand’s disease involves tests such as a prolonged bleeding time, APTT, factor VIII levels, and platelet aggregation with ristocetin. Management options include tranexamic acid for mild bleeding, desmopressin to raise levels of von Willebrand factor, and factor VIII concentrate. While there is no clear correlation between symptomatic presentation and type of Von Willebrand’s disease, common themes among patients include excessive mucocutaneous bleeding, bruising in the absence of trauma, and menorrhagia in females.
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This question is part of the following fields:
- Haematology/Oncology
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Question 25
Incorrect
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A 70-year-old man is brought to the Emergency Department by his wife who reports that he has been feeling down lately. She also mentions that he ingested 30 atenolol 50mg tablets about four hours ago. Upon assessment, his pulse is recorded at 42 beats per minute and his blood pressure is 98/62 mmHg. What is the initial treatment option that should be considered?
Your Answer:
Correct Answer: Intravenous atropine
Explanation:If gastric lavage is to be attempted, it should only be done within 1-2 hours of the patient taking the overdose.
Managing Beta-Blocker Overdose
Beta-blocker overdose can lead to various symptoms such as bradycardia, hypotension, heart failure, and syncope. To manage these symptoms, it is important to first identify if the patient is bradycardic. If so, atropine can be administered. However, in cases where atropine is not effective, glucagon may be used as an alternative. It is important to note that haemodialysis is not an effective treatment for beta-blocker overdose. Proper management of beta-blocker overdose is crucial in preventing further complications and ensuring the patient’s safety.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 26
Incorrect
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You are a foundation year 2 Doctor on your GP placement. Your first appointment is 6-year-old Jack. His mother has brought him to see you as he has had a cold over the past 6 days and now has developed a productive cough with green sputum. On examination you hear bilateral crackles at the base of his lungs and there is dullness to percussion at the left base. All basic observations are within normal limits. You diagnose a lower respiratory tract infection and decide to prescribe some antibiotics. Jack has no allergies.
What is the first line antibiotic you would prescribe for Jack?Your Answer:
Correct Answer: Amoxicillin
Explanation:For children without a penicillin allergy, amoxicillin is the primary treatment for pneumonia according to the 2011 guidelines from the British Thoracic Society. If the initial treatment is ineffective, macrolides may be added. Macrolides are recommended if Mycoplasma or Chlamydia is suspected. Co-amoxiclav is suggested for pneumonia associated with influenza.
Pneumonia is a common illness in children, with S. pneumoniae being the most likely cause of bacterial pneumonia. The British Thoracic Society has published guidelines for the management of community acquired pneumonia in children. According to these guidelines, amoxicillin is the first-line treatment for all children with pneumonia. Macrolides may be added if there is no response to first-line therapy, or if mycoplasma or chlamydia is suspected. In cases of pneumonia associated with influenza, co-amoxiclav is recommended. It is important to follow these guidelines to ensure effective treatment and management of pneumonia in children.
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This question is part of the following fields:
- Paediatrics
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Question 27
Incorrect
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A 72-year-old man presents to the cardiology clinic with symptomatic aortic stenosis. Despite his overall good health, he is eager for intervention. What intervention is most likely to be recommended for him?
Your Answer:
Correct Answer: Bioprosthetic aortic valve replacement
Explanation:Mechanical valves are typically preferred for younger patients as they have a longer lifespan compared to other types of prosthetic heart valves.
Prosthetic Heart Valves: Options for Replacement
Prosthetic heart valves are commonly used to replace damaged aortic and mitral valves. There are two main options for replacement: biological (bioprosthetic) or mechanical. Biological valves are usually sourced from bovine or porcine origins and are commonly used in older patients. However, they have a major disadvantage of structural deterioration and calcification over time. On the other hand, mechanical valves have a low failure rate but require long-term anticoagulation due to the increased risk of thrombosis. Warfarin is still the preferred anticoagulant for patients with mechanical heart valves, and the target INR varies depending on the valve type. Aspirin is only given in addition if there is an additional indication, such as ischaemic heart disease. Following the 2008 NICE guidelines, antibiotics are no longer recommended for common procedures such as dental work for prophylaxis of endocarditis.
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This question is part of the following fields:
- Cardiovascular
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Question 28
Incorrect
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A 78-year-old patient with chronic obstructive pulmonary disease (COPD) presents with shortness of breath that has been worsening over the past two days. The patient is experiencing wheezing and is unable to speak in full sentences. Upon examination, the patient has widespread wheezing and crackles. Vital signs are as follows: respiratory rate 30/min, oxygen saturation 92% on FiO2 0.24, heart rate 100/min, blood pressure 115/66 mmHg. A chest x-ray reveals no pneumothorax. The patient is administered nebulized salbutamol and ipratropium bromide driven by air, as well as oral steroids. Intravenous amoxicillin and oral clarithromycin are also given. However, the patient fails to improve after an hour of treatment and is extremely fatigued. An arterial blood gas is performed with the patient on 24% O2, which shows:
pH 7.30
PCO2 8 kPa
PO2 8.4 kPa
Bicarbonate 29 mEq/l
What is the next course of action?Your Answer:
Correct Answer: BIPAP
Explanation:Patient has exacerbation of COPD with maximal treatment for an hour. Remains acidotic with high PCO2 and respiratory acidosis. BTS guidelines suggest starting NIV.
Guidelines for Non-Invasive Ventilation in Acute Respiratory Failure
The British Thoracic Society (BTS) and the Royal College of Physicians have published guidelines for the use of non-invasive ventilation (NIV) in acute respiratory failure. NIV can be used in patients with COPD and respiratory acidosis with a pH of 7.25-7.35. However, patients with a pH lower than 7.25 require greater monitoring and a lower threshold for intubation and ventilation. NIV is also recommended for type II respiratory failure due to chest wall deformity, neuromuscular disease, or obstructive sleep apnea, as well as for cardiogenic pulmonary edema unresponsive to continuous positive airway pressure (CPAP) and weaning from tracheal intubation.
For patients with COPD, the recommended initial settings for bi-level pressure support include an expiratory positive airway pressure (EPAP) of 4-5 cm H2O, an inspiratory positive airway pressure (IPAP) of 10-15 cm H2O, a back-up rate of 15 breaths/min, and a back-up inspiration-to-expiration ratio of 1:3. These guidelines aim to improve patient outcomes and reduce the need for invasive mechanical ventilation.
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This question is part of the following fields:
- Respiratory Medicine
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Question 29
Incorrect
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A 12-year-old boy is asked to come to his General Practice clinic for a vaccine. He is in good health.
Which vaccine is he likely to receive?
Your Answer:
Correct Answer: Human papilloma virus (HPV)
Explanation:Vaccination Schedule for Children in the UK
In the United Kingdom, children are offered a range of vaccinations to protect against various diseases. The following is a summary of the vaccines and when they are given:
1. Human papillomavirus (HPV) – offered to all children aged 12-13 years to protect against cervical cancer.
2. Hepatitis A – not part of the routine vaccination schedule for children.
3. 6-in-1 DTaP/IPV/Hib/HepB – given at 2 months, 3 months, and 4 months.
4. Measles, mumps, and rubella (MMR) – administered at 12-13 months, with a booster at 3 years 4 months.
5. Pneumococcal (PCV) – given at 12 weeks and one year.
It is important to follow the recommended vaccination schedule to ensure children are protected against these diseases.
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This question is part of the following fields:
- Immunology/Allergy
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Question 30
Incorrect
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A child is admitted with wheeze and an urticarial rash, which began 10 minutes after ingestion of amoxicillin for a chest infection.
Which type of hypersensitivity reaction is this?Your Answer:
Correct Answer: Type 1
Explanation:Types of Hypersensitivity Reactions and Their Mechanisms
Hypersensitivity reactions are exaggerated immune responses that can cause tissue damage and disease. There are five types of hypersensitivity reactions, each with a different mechanism and clinical presentation.
Type 1 hypersensitivity reactions are mediated by immunoglobulin E (IgE) and mast cell degranulation, leading to the release of histamine and other mediators. This type of reaction is responsible for allergies and anaphylaxis and is treated with antihistamines, epinephrine, and steroids.
Type 2 hypersensitivity reactions are antibody-mediated and involve the interaction of antibodies with antigens on target cells. Examples include haemolytic anaemia of the newborn and Goodpasture Syndrome.
Type 3 hypersensitivity reactions are immune complex-mediated and occur when immune complexes are deposited in tissues, leading to inflammation. Examples include rheumatoid arthritis and systemic lupus erythematosus.
Type 4 hypersensitivity reactions are delayed and involve the activation of sensitised T-helper cells, leading to the accumulation of macrophages and cytotoxic T-cells. Examples include chronic transplant rejection and contact dermatitis.
Type 5 hypersensitivity reactions are receptor-mediated or autoimmune and occur when antibodies bind to cell surface receptors. Examples include Grave’s disease and myasthenia gravis.
Understanding the mechanisms of hypersensitivity reactions is important for diagnosis and treatment.
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This question is part of the following fields:
- Immunology/Allergy
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Question 31
Incorrect
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A 30-year-old woman visits her doctor with worries about a genetic disorder. Her granddaughter, who is three years old, has been diagnosed with sickle cell anemia. She reports that no one else in the family has the condition.
What is the likelihood of her being a carrier of the sickle cell allele?Your Answer:
Correct Answer: 1 in 2
Explanation:Understanding the Probability of Cystic Fibrosis Inheritance
Cystic fibrosis is a genetic condition that is inherited in an autosomal recessive pattern. This means that for a child to be affected, they must inherit two mutated alleles – one from each parent. If one grandparent is a carrier, there is a 1 in 2 chance that they passed the gene on to their offspring, who is the parent of the affected child.
When both parents are carriers, there is a 1 in 4 chance that their child will be affected by cystic fibrosis. However, the chance of inheriting the condition is always 1 in 2 for boys and girls.
Diagnosis of cystic fibrosis often occurs before the age of two, with up to 75% of patients being diagnosed at this age. It is important to note that carriers of cystic fibrosis are relatively common, with an estimated 1 in 25 people in the UK being carriers.
Understanding the probability of cystic fibrosis inheritance is crucial for families with a history of the condition, as it can help them make informed decisions about family planning and genetic testing.
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This question is part of the following fields:
- Genetics
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Question 32
Incorrect
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A 28-year-old female patient complains of symptoms that suggest coeliac disease. What is the primary test that should be employed for screening individuals with coeliac disease?
Your Answer:
Correct Answer: Tissue transglutaminase antibodies
Explanation:According to NICE, the initial serological test for coeliac disease should be tissue transglutaminase antibodies.
Investigating Coeliac Disease
Coeliac disease is a condition caused by sensitivity to gluten, which can lead to villous atrophy and malabsorption. It is often associated with other conditions such as dermatitis herpetiformis and autoimmune disorders. Diagnosis of coeliac disease is made through a combination of serology and endoscopic intestinal biopsy. The gold standard for diagnosis is the biopsy, which should be performed in all patients with suspected coeliac disease to confirm or exclude the diagnosis. The biopsy traditionally takes place in the duodenum, but jejunal biopsies are also sometimes performed. Findings supportive of coeliac disease include villous atrophy, crypt hyperplasia, an increase in intraepithelial lymphocytes, and lamina propria infiltration with lymphocytes. Serology tests for coeliac disease include tissue transglutaminase antibodies and endomyseal antibodies, while anti-gliadin antibodies are not recommended. Patients who are already on a gluten-free diet should reintroduce gluten for at least six weeks prior to testing. Rectal gluten challenge is not widely used. A gluten-free diet can reverse villous atrophy and immunology in patients with coeliac disease.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 33
Incorrect
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A 30-year-old woman is brought to the emergency department with difficulty breathing. Her pulmonary function tests show a peak expiratory flow rate that is 60% below the normal range for her age and height.
What is the most likely diagnosis?Your Answer:
Correct Answer: Asthma
Explanation:Understanding PEFR and Its Role in Diagnosing Asthma
Peak expiratory flow rate (PEFR) is a valuable tool in both the diagnosis and management of asthma. It is measured by a maximal forced expiration through a peak-flow meter and correlates well with forced expiratory volume in one second (FEV1), providing an estimate of airway calibre. Patients with asthma can monitor their PEFR at home to track disease control. A PEFR <80% of predicted is a strong indicator of obstructive airway disease, such as asthma. However, it’s important to note that PEFR is not affected by restrictive defects, such as those caused by kyphoscoliosis. Bronchial carcinoma itself does not cause airflow limitation, but a co-morbid obstructive lung disease, such as asthma or COPD, could produce abnormal PEFR readings. Bronchiectasis can cause an obstructive pattern on spirometry, but it would not typically cause a reduction in PEFR. Whooping cough, despite causing inflammation of the airways, would not typically result in the markedly reduced PEFR readings seen in asthma. In conclusion, understanding PEFR and its role in diagnosing asthma is crucial for both patients and healthcare providers. By monitoring PEFR at home and seeking medical attention when necessary, individuals with asthma can better manage their condition and improve their quality of life.
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This question is part of the following fields:
- Respiratory Medicine
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Question 34
Incorrect
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A 32-year-old woman is brought to the Emergency Department after fainting. She is now conscious and able to provide a medical history. The patient mentions having a condition, but cannot recall the name. She shows the doctor the medication she takes, which is a somatostatin analogue.
What medical condition can be treated with somatostatin analogues?Your Answer:
Correct Answer: Acromegaly
Explanation:Acromegaly is a condition caused by excessive secretion of growth hormone from an anterior pituitary tumor, resulting in enlarged hands, feet, and jaw, as well as other symptoms. While surgery is the preferred treatment, somatostatin analogues such as octreotide and lanreotide can be used if surgery fails. Somatostatin is an inhibitory hormone that can suppress growth hormone release. However, it can also cause side effects such as bradycardia, hypothyroidism, and hypoglycemia. Cushing’s disease, caused by excess adrenocorticotropic hormone, can be treated with pituitary gland removal, radiotherapy, or cortisol-inhibiting medications. Conn syndrome, or primary aldosteronism, is usually treated with surgery. Type I diabetes is treated with insulin, while Type II diabetes is treated with insulin and oral hypoglycemic agents. Parathyroid adenomas are also treated surgically.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 35
Incorrect
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A 65-year-old man with a history of depression and lumbar spinal stenosis presents with a swollen and painful left calf. He is evaluated in the DVT clinic and a raised D-dimer is detected. A Doppler scan reveals a proximal deep vein thrombosis. Despite being active and feeling well, the patient has not undergone any recent surgeries or been immobile for an extended period. As a result, he is initiated on a direct oral anticoagulant. What is the optimal duration of treatment?
Your Answer:
Correct Answer: 6 months
Explanation:For provoked cases of venous thromboembolism, such as those following recent surgery, warfarin treatment is typically recommended for a duration of three months. However, for unprovoked cases, where the cause is unknown, a longer duration of six months is typically recommended.
NICE updated their guidelines on the investigation and management of venous thromboembolism (VTE) in 2020. The use of direct oral anticoagulants (DOACs) is recommended as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. Routine cancer screening is no longer recommended following a VTE diagnosis. The cornerstone of VTE management is anticoagulant therapy, with DOACs being the preferred choice. All patients should have anticoagulation for at least 3 months, with the length of anticoagulation being determined by whether the VTE was provoked or unprovoked.
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This question is part of the following fields:
- Haematology/Oncology
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Question 36
Incorrect
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A 31-year-old pilot comes in for his yearly physical examination. He has no significant medical history, does not take any regular medication, and reports no concerning symptoms. He maintains a healthy lifestyle and enjoys participating in ultramarathons as a runner.
During the physical examination, an ECG is conducted, which was normal during his last check-up the previous year. What would be the most worrisome ECG characteristic?Your Answer:
Correct Answer: Left bundle branch block (LBBB)
Explanation:A new left bundle branch block on an ECG is always a sign of pathology and not a normal variant. It indicates a delay in the left half of the conducting system, which can be caused by conditions such as aortic stenosis, cardiomyopathy, or ischaemia. However, other findings on an ECG, such as J-waves, left axis deviation, second-degree heart block (Mobitz I), or a short QT interval, may be normal variants in a healthy individual and not a cause for concern unless accompanied by symptoms of arrhythmias.
Left Bundle Branch Block: Causes and Diagnosis
Left bundle branch block (LBBB) is a cardiac condition that can be diagnosed through an electrocardiogram (ECG). The ECG shows typical features of LBBB, including a ‘W’ in V1 and a ‘M’ in V6. It is important to note that new LBBB is always pathological and can be caused by various factors such as myocardial infarction, hypertension, aortic stenosis, and cardiomyopathy. However, diagnosing a myocardial infarction for patients with existing LBBB can be difficult. In such cases, the Sgarbossa criteria can be used to aid in diagnosis.
Other rare causes of LBBB include idiopathic fibrosis, digoxin toxicity, and hyperkalaemia. It is crucial to identify the underlying cause of LBBB to determine the appropriate treatment plan. Therefore, patients with LBBB should undergo further evaluation and testing to determine the cause of their condition. By identifying the cause of LBBB, healthcare professionals can provide appropriate treatment and management to improve the patient’s overall health and well-being.
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This question is part of the following fields:
- Cardiovascular
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Question 37
Incorrect
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A 35-year-old man visits the clinic with complaints of decreased hearing and ringing in his right ear, which feels congested, and he experiences frequent bouts of vertigo lasting up to a few hours at a time. There are no abnormalities found during the neurological examination.
What is the most probable diagnosis?Your Answer:
Correct Answer: Ménière’s disease
Explanation:Differentiating Vertigo Conditions: Ménière’s Disease, Benign Paroxysmal Positional Vertigo, Central Vertigo, Labyrinthitis, and Vestibular Neuronitis
Vertigo is a common symptom that can be caused by various conditions. Ménière’s disease, for instance, is characterized by fluctuant hearing loss, vertigo, tinnitus, and aural fullness. Patients are advised to undergo vestibular rehabilitation and avoid risky activities. Prochlorperazine is recommended for acute attacks, while betahistine is used for preventive treatment. Benign paroxysmal positional vertigo, on the other hand, presents with brief episodes of vertigo triggered by movement, without tinnitus, hearing loss, or ear fullness. Central vertigo has a sudden onset, constant symptoms, and possible neurological abnormalities, requiring urgent hospital admission. Labyrinthitis causes acute vertigo and hearing loss, but the presence of ear fullness suggests Ménière’s disease. Vestibular neuronitis, caused by viral infection, results in isolated and prolonged episodes of vertigo without tinnitus or ear fullness. Accurate diagnosis and appropriate management are crucial in addressing vertigo and its underlying conditions.
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This question is part of the following fields:
- ENT
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Question 38
Incorrect
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A 67-year-old man presents to his Optician for a routine eye check-up. His intraocular pressure (IOP) is 30 mmHg. On examination, fundoscopy reveals cupping of the optic disc. He is referred for assessment with an Ophthalmologist; he is classed as being at high lifetime risk of visual impairment.
What is the most appropriate first-line treatment for this patient?Your Answer:
Correct Answer: Latanoprost
Explanation:Overview of Glaucoma Medications
Glaucoma is a condition that can lead to vision loss and is often associated with high intraocular pressure (IOP). The first-line treatment recommended by the National Institute for Health and Care Excellence is a prostaglandin analogue such as latanoprost. Patients must meet certain criteria to receive this treatment. Brinzolamide and brimonidine are third-line treatments that may be used if a patient cannot tolerate a prostaglandin analogue or beta-blocker. Sodium cromoglicate eye drops are used for allergic conjunctivitis and do not help manage ocular hypertension. Timolol is a beta-blocker that may be used if a patient cannot tolerate a prostaglandin analogue, but it is not a first-line treatment.
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This question is part of the following fields:
- Ophthalmology
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Question 39
Incorrect
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A 56-year-old man has been experiencing fatigue and bone pain, prompting his regular GP to conduct investigations. Blood tests revealed an elevated paraprotein level, leading to further investigations to rule out multiple myeloma as the primary differential. What other potential cause could result in a raised paraprotein level?
Your Answer:
Correct Answer: MGUS (Monoclonal gammopathy of undetermined significance)
Explanation:MGUS is a possible differential diagnosis for elevated paraproteins in the blood.
Thrombocytopenia is a characteristic feature of haemolytic uraemic syndrome.
The presence of paraproteins in the blood is an abnormal finding and not a normal variant.
While a viral infection may cause neutropenia, it would not typically result in the presence of paraproteins in the blood.
Paraproteinaemia is a medical condition characterized by the presence of abnormal proteins in the blood. There are various causes of paraproteinaemia, including myeloma, monoclonal gammopathy of uncertain significance (MGUS), benign monoclonal gammopathy, Waldenstrom’s macroglobulinaemia, amyloidosis, CLL, lymphoma, heavy chain disease, and POEMS. Benign monoclonal gammopathy can also cause paraproteinaemia, as well as non-lymphoid malignancy (such as colon or breast cancer), infections (such as CMV or hepatitis), and autoimmune disorders (such as RA or SLE).
Paraproteinaemia is a medical condition that is characterized by the presence of abnormal proteins in the blood. This condition can be caused by various factors, including myeloma, MGUS, benign monoclonal gammopathy, Waldenstrom’s macroglobulinaemia, amyloidosis, CLL, lymphoma, heavy chain disease, and POEMS. Additionally, benign monoclonal gammopathy, non-lymphoid malignancy (such as colon or breast cancer), infections (such as CMV or hepatitis), and autoimmune disorders (such as RA or SLE) can also cause paraproteinaemia. It is important to identify the underlying cause of paraproteinaemia in order to determine the appropriate treatment plan.
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This question is part of the following fields:
- Haematology/Oncology
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Question 40
Incorrect
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A 65-year-old male with COPD presents to the hospital with worsening cough, difficulty breathing, and heavy green sputum production. He is placed on a 35% venturi mask with target oxygen saturations of 88-92% due to his known hypoxic drive. Despite receiving nebulised salbutamol, nebulised ipratropium, intravenous hydrocortisone, and intravenous theophylline, there is minimal improvement. The patient is becoming fatigued and his oxygen saturations remain at 87%. An arterial blood gas is ordered and empirical intravenous antibiotics are started. What is the most appropriate next step in management?
Your Answer:
Correct Answer: BiPAP (bilevel positive airway pressure)
Explanation:When medical therapy fails to improve COPD exacerbations, patients should be given BiPAP non-invasive ventilation. Before starting non-invasive ventilation, an arterial blood gas should be taken. BiPAP delivers two different pressures for inhalation and exhalation, making it a useful tool for patients who need help with ventilation, such as those in type II respiratory failure. On the other hand, CPAP delivers one pressure setting and is more helpful in increasing oxygen saturation and intrathoracic pressure to reduce preload and cardiac workload in chronic heart failure or sleep apnea. While intravenous magnesium sulfate is part of the management for severe asthma exacerbation, there is currently insufficient evidence to support its use in COPD exacerbation. If non-invasive ventilatory support fails, intubation and ventilation may be necessary.
Acute exacerbations of COPD are a common reason for hospital visits in developed countries. The most common causes of these exacerbations are bacterial infections, with Haemophilus influenzae being the most common culprit, followed by Streptococcus pneumoniae and Moraxella catarrhalis. Respiratory viruses also account for around 30% of exacerbations, with human rhinovirus being the most important pathogen. Symptoms of an exacerbation include an increase in dyspnea, cough, and wheezing, as well as hypoxia and acute confusion in some cases.
NICE guidelines recommend increasing the frequency of bronchodilator use and giving prednisolone for five days. Antibiotics should only be given if sputum is purulent or there are clinical signs of pneumonia. Admission to the hospital is recommended for patients with severe breathlessness, acute confusion or impaired consciousness, cyanosis, oxygen saturation less than 90%, social reasons, or significant comorbidity.
For severe exacerbations requiring secondary care, oxygen therapy should be used with an initial saturation target of 88-92%. Nebulized bronchodilators such as salbutamol and ipratropium should also be administered, along with steroid therapy. IV hydrocortisone may be considered instead of oral prednisolone, and IV theophylline may be used for patients not responding to nebulized bronchodilators. Non-invasive ventilation may be used for patients with type 2 respiratory failure, with bilevel positive airway pressure being the typical method used.
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This question is part of the following fields:
- Respiratory Medicine
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Question 41
Incorrect
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A father brings his 5-year-old daughter to the clinic. Despite not getting the MMR vaccine during the recent scare, he now wants to know if it's still possible to have her immunised due to the current measles outbreak. What should be done in this situation?
Your Answer:
Correct Answer: Give MMR with repeat dose in 3 months
Explanation:According to the Green Book, it is recommended to have a 3-month gap between doses for optimal response rate. However, if the child is over 10 years old, a 1-month gap is sufficient. In case of an emergency, such as an outbreak at the child’s school, younger children can have a shorter gap of 1 month.
The MMR Vaccine: Information on Contraindications and Adverse Effects
The Measles, Mumps and Rubella (MMR) vaccine is given to children in the UK twice before they enter primary school. The first dose is administered at 12-15 months, while the second dose is given at 3-4 years old. This vaccine is part of the routine immunisation schedule.
However, there are certain contraindications to the MMR vaccine. Children with severe immunosuppression, allergies to neomycin, or those who have received another live vaccine by injection within four weeks should not receive the MMR vaccine. Pregnant women should also avoid getting vaccinated for at least one month following the MMR vaccine. Additionally, if a child has undergone immunoglobulin therapy within the past three months, there may be no immune response to the measles vaccine if antibodies are present.
While the MMR vaccine is generally safe, there are some adverse effects that may occur. After the first dose of the vaccine, some children may experience malaise, fever, and rash. These symptoms typically occur after 5-10 days and last for around 2-3 days. It is important to be aware of these potential side effects and to consult with a healthcare professional if any concerns arise.
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This question is part of the following fields:
- Paediatrics
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Question 42
Incorrect
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A 28-year-old woman visits her doctor to discuss her fertility and the possibility of conceiving. She is worried about the risk of spina bifida after a friend had a baby with the condition. The patient has no notable medical history and no family history of birth defects. What is the recommended dosage of the supplement used to prevent neural tube defects during the first 12 weeks of pregnancy?
Your Answer:
Correct Answer: 400 micrograms
Explanation:To prevent neural tube defects in the foetus, it is crucial to consume folic acid. It is advised that women who are planning to conceive should take a supplement of 400 micrograms of folic acid daily. This dose should be continued until the 12th week of pregnancy. If there is a family history or a previous pregnancy affected by neural tube defects, the recommended dose should be increased.
Folic Acid: Importance, Deficiency, and Prevention
Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.
To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.
In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.
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This question is part of the following fields:
- Reproductive Medicine
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Question 43
Incorrect
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A 45-year-old woman presents to her General Practitioner with right lower-limb pain. This is mainly localised over a red patch that has recently developed on the inner part of her thigh.
On examination, there is a well-demarcated area of erythematous skin on the patient’s thigh, which is warm and tender to touch. There are no other rashes or skin changes present in the rest of her body. Her temperature is 37.5°C and the rest of her parameters are within normal limits.
Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Cellulitis
Explanation:Differential Diagnosis for a Lower Limb Rash: Cellulitis, Atopic Dermatitis, Contact Dermatitis, Necrobiosis Lipoidica, and Pretibial Myxedema
The patient in question is most likely suffering from cellulitis, as evidenced by the presence of erythema, warmth, tenderness, and swelling in the affected area. Cellulitis typically presents as a unilateral rash in the lower limbs, with a well-defined margin and potential skin breakdown or ulceration in severe cases. Localized lymph node swelling may also occur, and systemic symptoms such as tachycardia, fever, confusion, or respiratory distress may be present in more severe cases. It is important to examine the skin carefully for potential points of entry for pathogens, such as wounds, local skin infections, or recent injection sites.
Atopic dermatitis, on the other hand, typically presents as an itchy rash in a flexural distribution, with a history of atopy and episodic flares starting from a young age. Contact dermatitis, which can be either irritant or allergic, is characterized by erythema and may present with crusting or vesicles in rare cases. Necrobiosis lipoidica is a condition that typically occurs in diabetic patients, presenting as shiny, painless areas of yellow or red skin on the shins, often with telangiectasia. Pretibial myxedema, which occurs in patients with Graves’ disease, presents as a shiny, waxy, orange-peel texture on the shins.
In summary, a lower limb rash can have various causes, and a careful examination of the skin and consideration of the patient’s medical history can help narrow down the differential diagnosis.
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This question is part of the following fields:
- Dermatology
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Question 44
Incorrect
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A 40-year-old woman presents to her General Practitioner for investigation as she and her male partner have not become pregnant after 24 months of trying to conceive. Her female partner has also had normal investigations and on examination, she has a small uncomplicated left-sided inguinal hernia. She takes fluoxetine for depression and occasionally uses acetaminophen for back pain but is not on any other medications. Her male partner's sperm count is normal.
What would be the next most appropriate step in managing this couple’s inability to conceive?Your Answer:
Correct Answer: Refer to secondary care fertility services
Explanation:Recommendations for a Couple Struggling with Infertility
When a couple is struggling to conceive, there are several recommendations that healthcare providers may suggest. Firstly, if the couple has been trying to conceive for a year without success, they should be referred to fertility services. However, if there is an underlying reason for conception difficulties, earlier investigation may be necessary. In cases where the male partner is taking non-steroidal anti-inflammatory drugs, there is no impact on his ability to conceive. A hernia repair is not indicated to improve the couple’s chances of conception. Watching and waiting is not appropriate, and referral to fertility services is recommended. Finally, while sertraline and other SSRIs are not teratogenic, they can cause sexual dysfunction, which should be explored with the patient.
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This question is part of the following fields:
- Reproductive Medicine
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Question 45
Incorrect
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A 15-year-old boy presents with a history of seasonal 'watering eyes' for the past 2 years. His symptoms have worsened this year. He complains of bilateral itchy eyes and difficulty in doing school work due to excessive tearing. There is no history of nasal symptoms, asthma or eczema. On examination, there is conjunctival redness, bulging tarsal conjunctivae and mild eyelid swelling. What is the initial management approach for this patient?
Your Answer:
Correct Answer: Topical antihistamines
Explanation:The symptoms exhibited by this patient are indicative of allergic conjunctivitis. The initial treatment approach for this condition involves the use of topical antihistamines. In case of additional symptoms like rhinosinusitis, oral antihistamines may also be prescribed.
Understanding Allergic Conjunctivitis
Allergic conjunctivitis is a condition that can occur on its own, but is often associated with hay fever. It is characterized by bilateral symptoms such as conjunctival erythema and swelling, as well as itchiness and swelling of the eyelids. Those with a history of atopy may be more prone to developing allergic conjunctivitis, which can be seasonal (due to pollen) or perennial (due to exposure to dust mites, washing powder, or other allergens).
When it comes to managing allergic conjunctivitis, first-line treatment typically involves the use of topical or systemic antihistamines. If these prove ineffective, second-line treatment options such as topical mast-cell stabilizers like Sodium cromoglicate and nedocromil may be recommended. By understanding the symptoms and treatment options for allergic conjunctivitis, individuals can take steps to manage their condition and reduce discomfort.
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This question is part of the following fields:
- Ophthalmology
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Question 46
Incorrect
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A 35-year-old woman presents with excessive sweating and weight loss. Her partner reports that she is constantly on edge and you notice a fine tremor during the consultation. A large, nontender goitre is also noted. Upon examination of her eyes, there is no evidence of exophthalmos. Her pulse rate is 96/min. The following results were obtained: Free T4 26 pmol/l, Free T3 12.2 pmol/l (3.0-7.5), and TSH < 0.05 mu/l. What is the most likely diagnosis?
Your Answer:
Correct Answer: Graves' disease
Explanation:Graves’ Disease: Common Features and Unique Signs
Graves’ disease is the most frequent cause of thyrotoxicosis, which is commonly observed in women aged 30-50 years. The condition presents typical features of thyrotoxicosis, such as weight loss, palpitations, and heat intolerance. However, Graves’ disease also exhibits specific signs that are not present in other causes of thyrotoxicosis. These include eye signs, such as exophthalmos and ophthalmoplegia, as well as pretibial myxoedema and thyroid acropachy. The latter is a triad of digital clubbing, soft tissue swelling of the hands and feet, and periosteal new bone formation.
Autoantibodies are also present in Graves’ disease, including TSH receptor stimulating antibodies in 90% of patients and anti-thyroid peroxidase antibodies in 75% of patients. Thyroid scintigraphy can also aid in the diagnosis of Graves’ disease, as it shows diffuse, homogenous, and increased uptake of radioactive iodine.
Overall, Graves’ disease presents with both typical and unique features that distinguish it from other causes of thyrotoxicosis. Early diagnosis and treatment are crucial to prevent complications and improve outcomes for patients.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 47
Incorrect
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A 65-year-old man with chronic kidney failure has been instructed by his nephrologist to adhere to a 'renal diet'. He visits you to gain further knowledge about this. What is typically recommended to individuals with chronic kidney disease?
Your Answer:
Correct Answer: Low potassium diet
Explanation:Dietary Recommendations for Chronic Kidney Disease Patients
Chronic kidney disease patients are recommended to follow a specific diet to reduce the strain on their kidneys. This diet includes low levels of protein, phosphate, sodium, and potassium. The reason for this is that these substances are typically excreted by the kidneys, and reducing their intake can help ease the burden on the kidneys. By following this diet, patients can help slow the progression of their kidney disease and improve their overall health. It is important for patients to work with a healthcare professional or registered dietitian to ensure they are meeting their nutritional needs while following these dietary restrictions.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 48
Incorrect
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A 16-year-old male is being evaluated for iron-deficiency anemia and is discovered to have multiple polyps in his jejunum. During the examination, pigmented lesions are observed on his palms and soles. What is the probable diagnosis?
Your Answer:
Correct Answer: Peutz-Jeghers syndrome
Explanation:Understanding Peutz-Jeghers Syndrome
Peutz-Jeghers syndrome is a genetic condition that is inherited in an autosomal dominant manner. It is characterized by the presence of numerous hamartomatous polyps in the gastrointestinal tract, particularly in the small bowel. These polyps are benign, but they can cause complications such as small bowel obstruction and gastrointestinal bleeding. In addition to the polyps, individuals with Peutz-Jeghers syndrome also have pigmented freckles on their lips, face, palms, and soles.
The responsible gene for Peutz-Jeghers syndrome encodes a serine threonine kinase called LKB1 or STK11. This gene is involved in regulating cell growth and division, and mutations in this gene can lead to the development of polyps in the gastrointestinal tract.
Management of Peutz-Jeghers syndrome is typically conservative, unless complications such as obstruction or bleeding develop. Regular monitoring and surveillance of the gastrointestinal tract is recommended to detect any potential malignancies, as individuals with Peutz-Jeghers syndrome have an increased risk of developing other gastrointestinal tract cancers. Overall, early detection and management of complications can improve outcomes for individuals with Peutz-Jeghers syndrome.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 49
Incorrect
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You are examining a 7-month-old infant who has a capillary haemangioma located on the right cheek that is beginning to interfere with their vision. Following a conversation with the parents, you have decided to initiate treatment for this area due to the potential impact on eyesight.
What is the primary treatment option for capillary haemangioma?Your Answer:
Correct Answer: Propranolol
Explanation:When it comes to capillary haemangiomas that require intervention, the preferred treatment is propranolol. Other options include laser therapy or systemic steroids, but topical steroids are unlikely to be effective. Surgery is generally not recommended for most cases.
Understanding Strawberry Naevus
Strawberry naevus, also known as capillary haemangioma, is a type of skin condition that usually develops in infants within the first month of life. It is characterized by raised, erythematous, and multilobed tumours that commonly appear on the face, scalp, and back. While it is not present at birth, it can grow rapidly and reach its peak size at around 6-9 months before regressing over the next few years. In fact, around 95% of cases resolve before the child reaches 10 years of age. However, there are potential complications that may arise, such as obstructing visual fields or airway, bleeding, ulceration, and thrombocytopaenia.
Capillary haemangiomas are more common in white infants, particularly in female and premature infants, as well as those whose mothers have undergone chorionic villous sampling. In cases where treatment is necessary, propranolol is now the preferred choice over systemic steroids. Topical beta-blockers like timolol may also be used. It is important to note that there is a deeper type of capillary haemangioma called cavernous haemangioma. Understanding the nature of strawberry naevus is crucial in managing its potential complications and providing appropriate treatment.
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This question is part of the following fields:
- Dermatology
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Question 50
Incorrect
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A 25-year-old female patient presents with a persistent cough and runny nose for the past 48 hours. She seeks treatment for her symptoms, but you explain that she is likely experiencing a common cold that will resolve on its own. What is the most frequent cause of the common cold?
Your Answer:
Correct Answer: Rhinovirus
Explanation:Rhinoviruses are responsible for causing the common cold, while respiratory syncytial virus is a common cause of bronchiolitis. Influenza virus is the culprit behind the flu, while Streptococcus pneumonia is the most frequent cause of community-acquired pneumonia. Parainfluenza virus is commonly associated with croup.
Respiratory Pathogens and Their Associated Conditions
Respiratory pathogens are microorganisms that cause infections in the respiratory system. The most common respiratory pathogens include respiratory syncytial virus, parainfluenza virus, rhinovirus, influenza virus, Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, Mycoplasma pneumoniae, Legionella pneumophilia, and Pneumocystis jiroveci. Each of these pathogens is associated with a specific respiratory condition.
Respiratory syncytial virus is known to cause bronchiolitis, while parainfluenza virus is associated with croup. Rhinovirus is the most common cause of the common cold, while influenza virus causes the flu. Streptococcus pneumoniae is the most common cause of community-acquired pneumonia, and Haemophilus influenzae is the most common cause of bronchiectasis exacerbations and acute epiglottitis. Staphylococcus aureus is known to cause pneumonia, particularly following influenza. Mycoplasma pneumoniae causes atypical pneumonia, which is characterized by flu-like symptoms that precede a dry cough. Legionella pneumophilia is another cause of atypical pneumonia, which is typically spread by air-conditioning systems and causes a dry cough. Pneumocystis jiroveci is a common cause of pneumonia in HIV patients, and patients typically have few chest signs and develop exertional dyspnea. Mycobacterium tuberculosis causes tuberculosis, which can present in a wide range of ways, from asymptomatic to disseminated disease. Cough, night sweats, and weight loss may be seen in patients with tuberculosis.
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This question is part of the following fields:
- Respiratory Medicine
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Question 51
Incorrect
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A 44-year-old man visits his GP with complaints of vertigo. He had a cough and sore throat last week and has been experiencing a spinning sensation since then. The vertigo can last for hours and causes significant nausea, making it difficult for him to leave the house and go to work as a teacher. During an ENT examination, the GP observes horizontal nystagmus and intact tympanic membranes with no hearing loss. What is the best course of treatment?
Your Answer:
Correct Answer: Short course of oral prochlorperazine
Explanation:In cases of vestibular neuronitis, prochlorperazine can be effective during the acute phase, but it should not be continued for an extended period as it can hinder the central compensatory mechanisms that aid in recovery. This patient’s symptoms, including recurrent vertigo attacks, nausea, and horizontal nystagmus, are consistent with vestibular neuronitis, likely triggered by a recent viral upper respiratory tract infection. A brief course of oral prochlorperazine is recommended, with the option of using buccal or intramuscular administration for more severe cases. However, it is important to discontinue prochlorperazine after a few days to avoid impeding the recovery process. Long-term use of prochlorperazine would not be appropriate in this situation.
Understanding Vestibular Neuronitis
Vestibular neuronitis is a type of vertigo that typically occurs after a viral infection. It is characterized by recurrent episodes of vertigo that can last for hours or days, accompanied by nausea and vomiting. Horizontal nystagmus, or involuntary eye movements, is a common symptom, but there is usually no hearing loss or tinnitus.
It is important to distinguish vestibular neuronitis from other conditions that can cause similar symptoms, such as viral labyrinthitis or posterior circulation stroke. The HiNTs exam can be used to differentiate between vestibular neuronitis and stroke.
Treatment for vestibular neuronitis may involve medications such as prochlorperazine or antihistamines to alleviate symptoms. However, vestibular rehabilitation exercises are often the preferred treatment for patients with chronic symptoms. These exercises can help to retrain the brain and improve balance and coordination. With proper management, most people with vestibular neuronitis can recover fully and resume their normal activities.
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This question is part of the following fields:
- ENT
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Question 52
Incorrect
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Among the drugs listed, which one is the most probable cause of diarrhoea as a side effect? Please select only one option.
Your Answer:
Correct Answer: Lansoprazole
Explanation:Gastrointestinal Side Effects of Common Medications
Lansoprazole, a proton pump inhibitor, is known to cause gastrointestinal disturbances such as abdominal pain, constipation, flatulence, nausea, vomiting, and diarrhea. This is because it reduces the acidity of the stomach, allowing bacterial flora to proliferate.
Amitriptyline, a tricyclic antidepressant, can cause abdominal pain, anorexia, constipation, increased appetite, nausea, and weight gain or loss. However, it is not associated with diarrhea.
Calcium carbonate, a calcium supplement, can commonly cause gastrointestinal disturbances but is not known to cause diarrhea.
Carbamazepine, an anticonvulsant, commonly causes nausea and vomiting, and rarely constipation and diarrhea. The rarity of diarrhea as a side effect suggests that an alternative option may be more appropriate.
Codeine phosphate, an opioid analgesic, can cause constipation, nausea, and vomiting, but is not known to cause diarrhea.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 53
Incorrect
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A 30-year-old man comes to the clinic with complaints of painful urination and left knee pain. He had experienced a severe episode of diarrhea three weeks ago. What is the probable diagnosis?
Your Answer:
Correct Answer: Reactive arthritis
Explanation:Reactive arthritis is characterized by the presence of urethritis, arthritis, and conjunctivitis, and this patient exhibits two of these classic symptoms.
Understanding Reactive Arthritis: Symptoms and Features
Reactive arthritis is a type of seronegative spondyloarthropathy that is associated with HLA-B27. It was previously known as Reiter’s syndrome, which was characterized by a triad of urethritis, conjunctivitis, and arthritis following a dysenteric illness during World War II. However, later studies revealed that patients could also develop symptoms after a sexually transmitted infection, now referred to as sexually acquired reactive arthritis (SARA).
Reactive arthritis is defined as an arthritis that develops after an infection, but the organism cannot be recovered from the joint. The symptoms typically develop within four weeks of the initial infection and last for around 4-6 months. Approximately 25% of patients experience recurrent episodes, while 10% develop chronic disease. The arthritis is usually an asymmetrical oligoarthritis of the lower limbs, and patients may also experience dactylitis.
Other symptoms of reactive arthritis include urethritis, conjunctivitis (seen in 10-30% of patients), and anterior uveitis. Skin symptoms may also occur, such as circinate balanitis (painless vesicles on the coronal margin of the prepuce) and keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles). A helpful mnemonic to remember the symptoms of reactive arthritis is Can’t see, pee, or climb a tree.
In conclusion, understanding the symptoms and features of reactive arthritis is crucial for early diagnosis and treatment. While the condition can be recurrent or chronic, prompt management can help alleviate symptoms and improve quality of life for affected individuals.
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This question is part of the following fields:
- Musculoskeletal
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Question 54
Incorrect
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A 7-year-old boy is brought to the Emergency Department with a fever, cough, coryza and conjunctivitis. He has a rash that looks like tight clusters of small red spots. He also has some grey-white spots inside his mouth. Prior to the last five days, he is normally a fit and well child who does not take any regular medications. He has not had any vaccinations. His temperature is 38 °C and his other observations are within normal limits.
What would be the next most appropriate step in this patient’s management?
Your Answer:
Correct Answer: Discharge home with advice regarding supportive care
Explanation:Supportive Care for Children with Measles: Discharge Advice
Measles is a highly contagious viral illness that can be prevented through vaccination. If a child is diagnosed with measles, they will present with symptoms such as fever, cough, and a rash. The period of contagiousness is estimated to be from five days before the appearance of the rash to four days afterwards. There is no specific treatment for uncomplicated measles, but supportive care can be provided to manage symptoms.
Discharge advice for parents of a child with measles should include information on potential complications and when to seek medical attention. It is important to monitor the child’s symptoms and provide antipyretics and fluids as needed. If a secondary bacterial infection arises, antibiotics may be required. Immunoglobulins are not given as a treatment for acute measles, but vaccination is recommended as a preventative measure. Aspirin should not be given to children with measles due to the risk of Reye syndrome. Paracetamol and ibuprofen can be given for symptomatic relief. With proper supportive care, most children with measles will recover without complications.
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This question is part of the following fields:
- Immunology/Allergy
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Question 55
Incorrect
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A 35-year-old woman and her partner visit their GP with concerns about their inability to conceive. Despite having regular unprotected intercourse for 12 months, they have not been successful in getting pregnant. The husband's semen analysis came back normal. The GP decides to order a serum progesterone test to assess ovulation.
At what point should the blood test be conducted?Your Answer:
Correct Answer: 7 days before her next expected period
Explanation:To confirm ovulation in patients struggling to conceive, a serum progesterone level should be taken 7 days prior to the expected next period. This timing coincides with ovulation and is the most accurate way to confirm it. Taking the test 14 days before the next expected period or on the first day of the next period would not be timed correctly. It is also important to note that the timing of intercourse does not affect the confirmation of ovulation through serum progesterone testing.
Infertility is a common issue that affects approximately 1 in 7 couples. It is important to note that around 84% of couples who have regular sexual intercourse will conceive within the first year, and 92% within the first two years. The causes of infertility can vary, with male factor accounting for 30%, unexplained causes accounting for 20%, ovulation failure accounting for 20%, tubal damage accounting for 15%, and other causes accounting for the remaining 15%.
When investigating infertility, there are some basic tests that can be done. These include a semen analysis and a serum progesterone test. The serum progesterone test is done 7 days prior to the expected next period, typically on day 21 for a 28-day cycle. The interpretation of the serum progesterone level is as follows: if it is less than 16 nmol/l, it should be repeated and if it remains consistently low, referral to a specialist is necessary. If the level is between 16-30 nmol/l, it should be repeated, and if it is greater than 30 nmol/l, it indicates ovulation.
It is important to counsel patients on lifestyle factors that can impact fertility. This includes taking folic acid, maintaining a healthy BMI between 20-25, and advising regular sexual intercourse every 2 to 3 days. Additionally, patients should be advised to quit smoking and limit alcohol consumption to increase their chances of conceiving.
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This question is part of the following fields:
- Reproductive Medicine
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Question 56
Incorrect
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A 28-year-old man presents to his General Practitioner with pallor, fatigue, weakness, palpitations and dyspnoea on exertion. His symptoms have come on quickly over the last three weeks. A full blood count is ordered and is suggestive of acute lymphoblastic myeloid leukaemia (AML).
What Is the next most appropriate investigation for this patient?
Your Answer:
Correct Answer: Bone marrow biopsy
Explanation:Diagnostic Tests for Acute Myeloid Leukaemia
Acute myeloid leukaemia (AML) is a type of blood cancer that affects the bone marrow. To diagnose AML, several diagnostic tests may be performed. The most common tests include a bone marrow biopsy, ultrasound scan of the abdomen, chest X-ray, computerised tomography (CT) scan of chest, abdomen and pelvis, and lumbar puncture.
Bone Marrow Biopsy: This is the most important test for diagnosing AML. It involves extracting cells from the bone marrow and examining them under a microscope. AML is characterised by the presence of primitive myeloblasts and Auer rods in the bone marrow.
Ultrasound Scan of the Abdomen: This test is used to check for enlarged lymph nodes in the abdomen or spleen. If any enlarged lymph nodes are found, they may be biopsied to determine the extent of the leukaemia.
Chest X-ray: This test is used to check for enlarged lymph nodes in the mediastinum.
CT Scan of Chest, Abdomen and Pelvis: This test is not usually used as a first-line investigation for AML. However, once the diagnosis is confirmed, a CT scan may be used to assess for the presence of enlarged lymph nodes or for planning purposes if radiotherapy is going to form part of the treatment.
Lumbar Puncture: This test is not usually used in the diagnosis of AML unless it is suspected that the leukaemia cells are also present in the cerebrospinal fluid.
In conclusion, a bone marrow biopsy is the most important test for diagnosing AML. Other tests may be used to determine the extent of the leukaemia or for planning purposes if radiotherapy is going to form part of the treatment.
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This question is part of the following fields:
- Haematology/Oncology
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Question 57
Incorrect
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You are reviewing an elderly patient's blood results:
K+ 6.2 mmol/l
Which medication is the most probable cause of this outcome?Your Answer:
Correct Answer: Spironolactone
Explanation:Understanding Hyperkalaemia: Causes and Symptoms
Hyperkalaemia is a condition characterized by high levels of potassium in the blood. The regulation of plasma potassium levels is influenced by various factors such as aldosterone, insulin levels, and acid-base balance. When metabolic acidosis occurs, hyperkalaemia may develop as hydrogen and potassium ions compete for exchange with sodium ions across cell membranes and in the distal tubule. ECG changes that may be observed in hyperkalaemia include tall-tented T waves, small P waves, widened QRS leading to a sinusoidal pattern, and asystole.
There are several causes of hyperkalaemia, including acute kidney injury, metabolic acidosis, Addison’s disease, rhabdomyolysis, and massive blood transfusion. Certain drugs such as potassium-sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers, spironolactone, ciclosporin, and heparin can also cause hyperkalaemia. It is important to note that beta-blockers can interfere with potassium transport into cells and potentially cause hyperkalaemia in renal failure patients. On the other hand, beta-agonists like Salbutamol are sometimes used as emergency treatment.
Foods that are high in potassium include salt substitutes, bananas, oranges, kiwi fruit, avocado, spinach, and tomatoes. It is essential to monitor potassium levels in the blood to prevent complications associated with hyperkalaemia. If left untreated, hyperkalaemia can lead to serious health problems such as cardiac arrhythmias and even death.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 58
Incorrect
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A 45-year-old man visits his General Practitioner complaining of a severely painful headache mainly around his left eye, associated with left-sided eye watering. He has had several similar episodes of pain over the past few months, each lasting about 2–3 hours.
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Cluster headache
Explanation:Distinguishing Cluster Headache from Other Headache Disorders
Cluster headache is a severe headache disorder that primarily affects men between the ages of 20 and 30. The pain is localized around one eye and can last from a few minutes up to three hours. Lacrimation and nasal congestion may occur simultaneously, and symptoms tend to occur frequently for several weeks followed by a symptom-free period lasting months or even years. It is important to distinguish cluster headache from other headache disorders, such as brain tumors, giant cell arteritis (GCA), migraine, and tension headache. Brain tumors may present with signs of raised intracranial pressure, while GCA typically affects those over 50 years old and presents with abrupt-onset headache, scalp pain/tenderness, and jaw claudication. Migraine is characterized by recurrent episodes of headache accompanied by photophobia, phonophobia, nausea, and vomiting, while tension headache is typically bilateral and described as a band-like pain across the forehead. Associated eye watering is not a feature of tension headache.
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This question is part of the following fields:
- Neurology
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Question 59
Incorrect
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A mother brings her 8-year-old daughter into surgery. She is struggling in school and the mother suspects she may have ADHD. Which of the following features is not indicative of a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)?
Your Answer:
Correct Answer: Repetitive behaviour
Explanation:In March 2018, NICE released new guidelines for identifying and managing Attention Deficit Hyperactivity Disorder (ADHD). This condition can have a significant impact on a child’s life and can continue into adulthood, making accurate diagnosis and treatment crucial. According to DSM-V, ADHD is characterized by persistent features of inattention and/or hyperactivity/impulsivity, with an element of developmental delay. Children up to the age of 16 must exhibit six of these features, while those aged 17 or over must exhibit five. ADHD has a UK prevalence of 2.4%, with a higher incidence in boys than girls, and there may be a genetic component.
NICE recommends a holistic approach to treating ADHD that is not solely reliant on medication. After presentation, a ten-week observation period should be implemented to determine if symptoms change or resolve. If symptoms persist, referral to secondary care is necessary, typically to a paediatrician with a special interest in behavioural disorders or to the local Child and Adolescent Mental Health Service (CAMHS). A tailored plan of action should be developed, taking into account the patient’s needs and wants, as well as how their condition affects their lives.
Drug therapy should be considered a last resort and is only available to those aged 5 years or older. Parents of children with mild/moderate symptoms can benefit from attending education and training programmes. For those who do not respond or have severe symptoms, pharmacotherapy may be considered. Methylphenidate is the first-line treatment for children and should be given on a six-week trial basis. It is a CNS stimulant that primarily acts as a dopamine/norepinephrine reuptake inhibitor. Side effects include abdominal pain, nausea, and dyspepsia. Weight and height should be monitored every six months in children. If there is an inadequate response, lisdexamfetamine should be considered, followed by dexamfetamine if necessary. In adults, methylphenidate or lisdexamfetamine are the first-line options, with switching between drugs if no benefit is seen after a trial of the other. All of these drugs are potentially cardiotoxic, so a baseline ECG should be performed before starting treatment, and referral to a cardiologist should be made if there is any significant past medical history or family history, or any doubt or ambiguity.
As with most psychiatric conditions, a thorough history and clinical examination are essential, particularly given the overlap of ADHD with many other psychiatric and
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This question is part of the following fields:
- Paediatrics
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Question 60
Incorrect
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A 25-year-old man with a history of bipolar disorder is scheduled for a medication review. When inquiring about his current state, he starts discussing the vast array of emotions that exist and wonders if everyone has experienced all of them. Eventually, he spontaneously mentions that he is feeling quite good.
What is the patient exhibiting in this scenario?Your Answer:
Correct Answer: Circumstantiality
Explanation:The patient’s lengthy response to the question suggests circumstantiality, which can be a symptom of anxiety disorders or hypomania. However, the patient has remained on topic and has not derailed. Their response is coherent, and there is no evidence of pressured speech in this text-based interaction. Incoherence would be demonstrated by nonsensical statements, which is not the case here.
Anxiety is a common disorder that can manifest in various ways. According to NICE, the primary feature is excessive worry about multiple events associated with heightened tension. It is crucial to consider potential physical causes when diagnosing anxiety disorders, such as hyperthyroidism, cardiac disease, and medication-induced anxiety. Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants, and caffeine.
NICE recommends a step-wise approach for managing generalised anxiety disorder (GAD). This includes education about GAD and active monitoring, low-intensity psychological interventions, high-intensity psychological interventions or drug treatment, and highly specialist input. Sertraline is the first-line SSRI for drug treatment, and if it is ineffective, an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI) such as duloxetine or venlafaxine may be offered. If the patient cannot tolerate SSRIs or SNRIs, pregabalin may be considered. For patients under 30 years old, NICE recommends warning them of the increased risk of suicidal thinking and self-harm and weekly follow-up for the first month.
The management of panic disorder also follows a stepwise approach, including recognition and diagnosis, treatment in primary care, review and consideration of alternative treatments, review and referral to specialist mental health services, and care in specialist mental health services. NICE recommends either cognitive behavioural therapy or drug treatment in primary care. SSRIs are the first-line drug treatment, and if contraindicated or no response after 12 weeks, imipramine or clomipramine should be offered.
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This question is part of the following fields:
- Psychiatry
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Question 61
Incorrect
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A 50-year-old woman presents with shiny, flat-topped papules on the palmar aspect of the wrists. She is mainly bothered by the troublesome and persistent itching.
Given the likely diagnosis, which of the following is the best management?Your Answer:
Correct Answer: Topical clobetasone butyrate
Explanation:Management of Lichen Planus: Topical Clobetasone Butyrate
Lichen planus is a skin condition that can be managed with daily potent topical steroids, such as clobetasone butyrate. As the lesions improve, the potency of the steroid can be decreased. It is important to advise patients to only treat the active, itchy lesions and not the post-inflammatory hyperpigmentation to minimize side effects. These treatments can also be used on the genital skin and scalp. Sedating antihistamines may help with itching at night, but should only be used periodically. Emollients and oral antihistamines are not first-line treatments for lichen planus. Referring for a punch biopsy is not necessary unless the presentation is atypical. The characteristic histological findings of lichen planus include irregular acanthosis of the epidermis, irregular thickening of the granular layer, and compact hyperkeratosis in the center of the papule. Topical clotrimazole and dapsone are not first-line treatments for lichen planus.
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This question is part of the following fields:
- Dermatology
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Question 62
Incorrect
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A 25-year-old Caucasian female teacher visits the clinic to inquire about preconception care. She intends to conceive and is interested in learning about the supplements she should take. She has never given birth before and is in good health. She is not on any medication and has no known allergies. She does not smoke or consume alcohol.
What supplements do you suggest she take?Your Answer:
Correct Answer: Folic acid 400 micrograms once a day and vitamin D 10 micrograms once a day
Explanation:For this patient, who has a low risk of having a baby with neural tube defects and is not at high risk of vitamin D deficiency, the standard care is recommended. This includes taking a daily supplement of 10 micrograms of vitamin D. There is no need for her to take folic acid 5mg or higher doses of vitamin D, as they exceed the recommended amount.
Antenatal care guidelines were issued by NICE in March 2008, which included specific points for the care of healthy pregnant women. Nausea and vomiting can be treated with natural remedies such as ginger and acupuncture on the ‘p6’ point, as recommended by NICE. Antihistamines, with promethazine as the first-line option according to the BNF, can also be used. Adequate vitamin D intake is crucial for the health of both the mother and baby, and women should be informed about this at their booking appointment. The Chief Medical Officer advises all pregnant and breastfeeding women to take a daily supplement containing 10 micrograms of vitamin D, with particular care taken for those at risk. In 2016, new guidelines were proposed by the Chief Medical Officer regarding alcohol consumption during pregnancy. The government now advises pregnant women not to drink any alcohol to minimize the risk of harm to the baby.
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This question is part of the following fields:
- Reproductive Medicine
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Question 63
Incorrect
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A 25-year-old man presents to the emergency department with abdominal pain and lethargy. He has areas of skin hyperpigmentation and hypopigmentation consistent with vitiligo. His blood pressure is 96/58 mmHg. Laboratory tests reveal the following results, and treatment is initiated.
Hemoglobin: 138 g/L (Male: 135-180, Female: 115-160)
Platelets: 210 * 109/L (150-400)
White blood cells: 11.5 * 109/L (4.0-11.0)
Sodium: 133 mmol/L (135-145)
Potassium: 5.8 mmol/L (3.5-5.0)
Urea: 6.5 mmol/L (2.0-7.0)
Creatinine: 95 µmol/L (55-120)
C-reactive protein: 4 mg/L (<5)
Fasting blood sugar: 4.4 mmol/L (4-7)
What is the most appropriate diagnostic test for the likely diagnosis?Your Answer:
Correct Answer: Short synacthen test
Explanation:The most likely diagnosis for this patient is Addison’s disease based on their clinical presentation of hypotension, hyperpigmentation, vitiligo, and electrolyte abnormalities. Immediate treatment with intravenous fluids and glucocorticoids is necessary. The best test to confirm the diagnosis is the short synacthen test, which measures cortisol levels after administering a stimulating hormone. The aldosterone renin ratio and overnight dexamethasone suppression test are not useful in this scenario. While the serum ACTH level can aid in the diagnosis, dynamic testing with suppression/stimulation is more accurate in endocrine conditions.
Investigating Addison’s Disease: ACTH Stimulation Test and Serum Cortisol Levels
When a patient is suspected of having Addison’s disease, the definitive investigation is an ACTH stimulation test, also known as a short Synacthen test. This involves measuring plasma cortisol levels before and 30 minutes after administering Synacthen 250ug IM. Adrenal autoantibodies, such as anti-21-hydroxylase, may also be demonstrated.
However, if an ACTH stimulation test is not readily available, a 9 am serum cortisol level can be useful. A level of over 500 nmol/l makes Addison’s disease very unlikely, while a level of less than 100 nmol/l is definitely abnormal. A level between 100-500 nmol/l should prompt an ACTH stimulation test to be performed.
It is important to note that around one-third of undiagnosed patients with Addison’s disease may also have associated electrolyte abnormalities, such as hyperkalaemia, hyponatraemia, hypoglycaemia, and metabolic acidosis. Therefore, it is crucial to investigate these patients thoroughly to ensure a proper diagnosis and appropriate treatment.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 64
Incorrect
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A 29-year-old male arrives at the Emergency Department complaining of feeling extremely sick. He reports that his GP had prescribed him antibiotics for a chest infection. Upon examination, an ECG reveals polymorphic ventricular tachycardia (torsades de pointes). What medication is he likely taking?
Your Answer:
Correct Answer: Clarithromycin
Explanation:Torsades de pointes can be caused by macrolides, particularly clarithromycin, due to its potential to prolong the QT interval and trigger polymorphic ventricular tachycardia. This risk is higher in patients with an underlying channelopathy. Long QT syndrome can be caused by genetic factors such as potassium or sodium channel mutations, as well as electrolyte imbalances like hypocalcaemia, hypomagnesaemia, and hypokalaemia. Certain drugs, including antiarrhythmics, antibiotics, and psychotropic medications, can also cause long QT syndrome.
Torsades de Pointes: A Life-Threatening Condition
Torsades de pointes is a type of ventricular tachycardia that is associated with a prolonged QT interval. This condition can lead to ventricular fibrillation, which can cause sudden death. There are several causes of a prolonged QT interval, including congenital conditions such as Jervell-Lange-Nielsen syndrome and Romano-Ward syndrome, as well as certain medications like antiarrhythmics, tricyclic antidepressants, and antipsychotics. Other causes include electrolyte imbalances, myocarditis, hypothermia, and subarachnoid hemorrhage.
The management of torsades de pointes involves the administration of intravenous magnesium sulfate. This can help to stabilize the heart rhythm and prevent further complications.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 65
Incorrect
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A 45-year-old man with known permanent AF (atrial fibrillation) on warfarin has a fast, irregularly irregular pulse. He has no other past medical history. The ECG confirms AF with a rate of 132 beats/min. He is haemodynamically stable and well. He denies any history of palpitations, shortness of breath or syncope.
Which of the following is the most appropriate intervention?Your Answer:
Correct Answer: Bisoprolol
Explanation:Treatment Options for Atrial Fibrillation: A Comprehensive Guide
Atrial fibrillation (AF) is a common cardiac arrhythmia that requires prompt and appropriate management to prevent complications. Here are some treatment options for AF:
Rate Control: This is recommended for patients who have had AF for more than 48 hours. Beta-blockers are the first-line treatment unless there is a contraindication such as asthma. Calcium channel blockers can also be used.
Digoxin: This drug can be used as rate control if the patient cannot have beta-blockers or calcium channel blockers. However, it should only be used as a third-line treatment or as an adjunct because it has been shown to increase mortality. It is also only effective in sedentary patients.
DC Cardioversion: This can be used to treat new-onset AF if the patient has had it for less than 48 hours. It can also be considered in patients who have had it for longer than that, once they have been on stable anticoagulation for at least 3 weeks.
Flecainide: This is a class Ic antiarrhythmic drug that can be used as chemical cardioversion in new AF (<48 hours) or if a patient has been anticoagulated for >3 weeks.
Rhythm Control: Nice guidelines advise that rhythm control can be used if AF onset was <48 hours ago, but should be avoided if longer ago because it can increase the risk of stroke from an atrial thrombus. In longer cases, rate control should be used, which is with beta-blockers or rate-limiting calcium channel blockers. Digoxin can be used third line or as an adjunct. In conclusion, the appropriate treatment for AF depends on the duration of the arrhythmia, the patient’s comorbidities, and other factors. It is important to consult with a healthcare professional to determine the best course of action.
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This question is part of the following fields:
- Cardiovascular
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Question 66
Incorrect
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A 26-year-old female patient arrives with a sudden onset of pain at the back of her ankle while jogging, accompanied by a cracking sound. Which medication from the following list could have played a role in causing this injury?
Your Answer:
Correct Answer: Ciprofloxacin
Explanation:The patient is displaying typical symptoms of a ruptured Achilles tendon, which can be caused by ciprofloxacin. Tendon damage is a known potential side effect of quinolone antibiotics, and it seems to be a rare reaction that can occur after just 8 days of treatment.
Understanding Quinolones: Antibiotics that Inhibit DNA Synthesis
Quinolones are a type of antibiotics that are known for their bactericidal properties. They work by inhibiting DNA synthesis, which makes them effective in treating bacterial infections. Some examples of quinolones include ciprofloxacin and levofloxacin.
The mechanism of action of quinolones involves inhibiting topoisomerase II (DNA gyrase) and topoisomerase IV. However, bacteria can develop resistance to quinolones through mutations to DNA gyrase or by using efflux pumps that reduce the concentration of quinolones inside the cell.
While quinolones are generally safe, they can have adverse effects. For instance, they can lower the seizure threshold in patients with epilepsy and cause tendon damage, including rupture, especially in patients taking steroids. Additionally, animal models have shown that quinolones can damage cartilage, which is why they are generally avoided in children. Quinolones can also lengthen the QT interval, which can be dangerous for patients with heart conditions.
Quinolones should be avoided in pregnant or breastfeeding women and in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Overall, understanding the mechanism of action, mechanism of resistance, adverse effects, and contraindications of quinolones is important for their safe and effective use in treating bacterial infections.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 67
Incorrect
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A 6-year-old girl is brought to her general practitioner by her mother, with a 3-day history of fever up to 37.8 °C. She had no history of lesions on the buccal mucosa but developed a maculopapular rash across the face and trunk. A few days before the appearance of the rash, she complained of some eye pain, sore throat and general body aches. On physical examination, she has a discrete rose-pink maculopapular rash on the face, neck and trunk, low-grade fever and enlarged posterior auricular and suboccipital lymph nodes.
What is the most likely diagnosis?Your Answer:
Correct Answer: Rubella
Explanation:Distinguishing Between Viral Diseases: Rubella, Mumps, Meningitis, Scarlet Fever, and Erythema Infectiosum
Rubella, also known as German measles, is a typically mild viral disease that often goes unnoticed, with almost half of those infected showing no symptoms. However, it can have severe consequences for pregnant women, especially in the early stages of pregnancy. Symptoms include eye pain, sore throat, low-grade fever, and a rose-pink rash that starts on the face and spreads to the trunk and extremities within 24 hours.
Mumps is another viral disease caused by rubulavirus. It typically presents with low-grade fever, malaise, headache, and myalgia, followed by painful swelling of the salivary glands and tender cervical lymphadenopathy. Mumps is highly contagious and has become less common in developing countries due to vaccination.
Meningitis is a serious condition characterized by inflammation of the meninges. Symptoms include fever, headache, and neck stiffness, and it requires urgent medical attention.
Scarlet fever is caused by group A β-hemolytic streptococci and presents with exudative pharyngitis, fever, and a bright red rash. It typically evolves from a tonsillar/pharyngeal focus and is uncommon without buccal lesions.
Erythema infectiosum, also known as fifth disease, is a mild childhood illness caused by parvovirus B19. It presents with a bright red rash on the cheeks and may have atypical rashes in adults.
It is important to distinguish between these viral diseases to ensure proper treatment and prevent complications.
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This question is part of the following fields:
- Infectious Diseases
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Question 68
Incorrect
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A middle-aged man with a history of chronic alcohol abuse presents to the Emergency Department. He appears disheveled, lethargic, and disoriented, and it is suspected that he has not had a meal in the past two days. The medical team decides to initiate chlordiazepoxide PRN and administer IV Pabrinex. Which specific vitamin, found in Pabrinex, can help halt the progression of symptoms leading to Wernicke's encephalopathy?
Your Answer:
Correct Answer: B1
Explanation:Understanding Wernicke’s Encephalopathy
Wernicke’s encephalopathy is a condition that affects the brain and is caused by a deficiency in thiamine. This condition is commonly seen in individuals who abuse alcohol, but it can also be caused by persistent vomiting, stomach cancer, or dietary deficiencies. The classic triad of symptoms associated with Wernicke’s encephalopathy includes oculomotor dysfunction, gait ataxia, and encephalopathy. Other symptoms may include peripheral sensory neuropathy and confusion.
When left untreated, Wernicke’s encephalopathy can lead to the development of Korsakoff’s syndrome. This condition is characterized by antero- and retrograde amnesia and confabulation in addition to the symptoms associated with Wernicke’s encephalopathy.
To diagnose Wernicke’s encephalopathy, doctors may perform a variety of tests, including a decreased red cell transketolase test and an MRI. Treatment for this condition involves urgent replacement of thiamine. With prompt treatment, individuals with Wernicke’s encephalopathy can recover fully.
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This question is part of the following fields:
- Neurology
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Question 69
Incorrect
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A 44-year-old woman presents to the emergency department with sudden onset abdominal pain and vomiting for the past 5 days. She feels nauseated and cannot tolerate any food and only minimal liquid. She denies diarrhoea and has not had a bowel movement for 4 days.
Her past medical history includes chronic lower back pain for which she takes regular co-codamol. The last time she was in hospital was for her cesarean section 10 years ago.
Upon examination, she appears clammy and dehydrated. Her abdomen is distended and tender throughout. Bowel sounds are inaudible.
What is the most probable underlying cause of this patient's presentation?Your Answer:
Correct Answer: Adhesions
Explanation:The most common cause of small bowel obstruction is adhesions. This patient is experiencing symptoms such as abdominal pain, distention, and constipation, which are similar to those of large bowel obstruction. However, the onset of nausea and vomiting is an early sign of small bowel obstruction, indicating a proximal lesion. Adhesions are scar tissue that can form due to inflammation or manipulation of the abdominal contents during surgery, and they are often present in patients who are asymptomatic for years before experiencing symptoms. Given the patient’s history of a previous cesarean section, adhesional small bowel obstruction is a likely diagnosis.
Large bowel obstruction is most commonly caused by colorectal cancer, and symptoms include abdominal pain, distention, and constipation. However, nausea and vomiting are later signs compared to small bowel obstruction.
Gallstone ileus is a rare complication of cholecystitis where a gallstone passes through a fistula between the gallstone and small bowel before becoming impacted, leading to small bowel obstruction.
Inguinal hernias can also cause small bowel obstruction, as they involve a protrusion of abdominal contents through a defect in the abdominal wall. However, the patient’s history of previous abdominal surgery makes adhesions a more likely cause.
While regular opioid use can lead to constipation, it is not a cause of obstruction. In this case, the patient’s bilious vomiting and positive findings of abdominal tenderness and distension suggest intestinal obstruction rather than simple constipation.
Small bowel obstruction occurs when the small intestines are blocked, preventing the passage of food, fluids, and gas. The most common cause of this condition is adhesions, which can develop after previous surgeries, followed by hernias. Symptoms of small bowel obstruction include diffuse, central abdominal pain, nausea and vomiting (often bilious), constipation, and abdominal distension. Tinkling bowel sounds may also be present in early stages of obstruction. Abdominal x-ray is typically the first-line imaging for suspected small bowel obstruction, showing distended small bowel loops with fluid levels. CT is more sensitive and considered the definitive investigation, particularly in early obstruction. Management involves initial steps such as NBM, IV fluids, and nasogastric tube with free drainage. Some patients may respond to conservative management, but others may require surgery.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 70
Incorrect
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A 28-year-old male patient visits his GP with complaints of progressive tunnel vision and difficulty seeing at night for the past year. He recalls his grandfather experiencing similar symptoms but is unsure of the cause. During fundus examination, bone-spicule pigmentation is observed in the peripheral retina. What is the probable diagnosis?
Your Answer:
Correct Answer: Retinitis pigmentosa
Explanation:The presence of black bone-spicule pigmentation on fundoscopy is a classic sign of retinitis pigmentosa, an inherited retinal disorder that causes tunnel vision and night blindness by affecting the peripheral retina.
Understanding Retinitis Pigmentosa
Retinitis pigmentosa is a condition that primarily affects the peripheral retina, leading to tunnel vision. The initial sign of this condition is often night blindness, which can progress to a loss of peripheral vision. Fundoscopy, a diagnostic test, reveals black bone spicule-shaped pigmentation in the peripheral retina and mottling of the retinal pigment epithelium. Retinitis pigmentosa is often associated with other diseases such as Refsum disease, Usher syndrome, abetalipoproteinemia, Lawrence-Moon-Biedl syndrome, Kearns-Sayre syndrome, and Alport’s syndrome.
To better understand retinitis pigmentosa, it is important to know that it is a genetic disorder that affects the retina’s ability to respond to light. This condition can lead to the death of photoreceptor cells in the retina, which are responsible for detecting light and transmitting visual information to the brain. As a result, individuals with retinitis pigmentosa may experience difficulty seeing in low light conditions, loss of peripheral vision, and, in severe cases, complete blindness.
In summary, retinitis pigmentosa is a genetic condition that primarily affects the peripheral retina, leading to tunnel vision. It is often associated with other diseases and can cause night blindness, loss of peripheral vision, and, in severe cases, complete blindness. Early diagnosis and management are crucial in preventing further vision loss.
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This question is part of the following fields:
- Ophthalmology
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Question 71
Incorrect
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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.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 72
Incorrect
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A preterm baby boy is found to have meconium ileus shortly after birth.
Which of the following conditions is most commonly associated with meconium ileus?Your Answer:
Correct Answer: Cystic fibrosis
Explanation:Common Genetic Conditions and Associated Manifestations
Cystic Fibrosis, Edward Syndrome, Down Syndrome, Myelomeningocele, and Patau Syndrome are all genetic conditions that can have various manifestations. Cystic Fibrosis affects multiple organ systems, including the lungs, liver, pancreas, and small bowel, leading to progressive organ failure. Edward Syndrome is a trisomy syndrome with a high incidence of major structural anomalies, including congenital heart disease and central nervous system abnormalities. Down Syndrome is the most common trisomy and is associated with characteristic facial features and an increased risk for congenital heart disease and gastrointestinal anomalies. Myelomeningocele is a spinal anomaly that can result in lower limb paralysis and bladder and bowel dysfunction. Patau Syndrome is the least common trisomy syndrome and is associated with congenital heart disease, central nervous system and spinal abnormalities, abnormal facies, and polydactyly. Meconium ileus is a common manifestation associated with Cystic Fibrosis in all of these conditions.
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This question is part of the following fields:
- Genetics
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Question 73
Incorrect
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A 65-year-old woman with a history of hypertension and heart failure presents with atrial fibrillation. She is stable with a ventricular rate of 70. Which of the following drug options would be the most suitable for her?
Your Answer:
Correct Answer: Warfarin or direct oral anticoagulant (DOAC)
Explanation:Treatment Options for Atrial Fibrillation: Warfarin, DOACs, Aspirin, Digoxin, Furosemide, and Lidocaine
Patients with atrial fibrillation and a CHA2DS2-VASC score of 4 require anticoagulation to reduce the risk of a CVA. The two main options are warfarin and DOACs, but the choice depends on other co-morbidities and patient preference. Before starting warfarin, patients should be referred to the Anticoagulation Clinic and screened for contraindications.
Aspirin has no benefit in atrial fibrillation, and digoxin should only be used for short-term rate control due to evidence of increased mortality with long-term use. Furosemide can help with symptoms and edema in heart failure but does not improve mortality. Lidocaine is only appropriate for ventricular arrhythmias in unstable patients and requires specialist support.
In summary, the treatment options for atrial fibrillation vary depending on the patient’s individual circumstances and should be carefully considered by healthcare professionals.
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This question is part of the following fields:
- Cardiovascular
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Question 74
Incorrect
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A 45-year old woman became pregnant unexpectedly. She had given birth to five healthy children in her 20s and 30s with her now 47-year-old husband. Chorionic villus biopsy and karyotype analysis revealed that she was carrying a fetus with trisomy 21 (Down syndrome).
What is the most likely cause of the condition?Your Answer:
Correct Answer: The mother’s age
Explanation:Down syndrome is a genetic condition that is caused by three mechanisms. The most common cause is Trisomy 21, which occurs when there is a non-separation of the homologous chromosomes during meiosis. This risk increases with advancing maternal age, with a likelihood of 1 in 1500 at age 20 and 1 in 50 at age 45 or older. Translocation, where part of chromosome 21 attaches to another chromosome, accounts for about 4% of cases. Mosaicism, where only some cells carry the extra copy of chromosome 21, is the rarest type. Paternal age is not a significant factor, but if either parent is a translocation carrier, there is a 1 in 2 chance of passing it on to their offspring. A spontaneous mutation in the fetus is not a cause of Down syndrome.
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This question is part of the following fields:
- Genetics
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Question 75
Incorrect
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You are asked by the nursing staff to review an elderly patient in recovery overnight. As you arrive, the nurse looking after the patient informs you that she is just going to get a bag of fluid for him.
On examination, the patient is unresponsive with an obstructed airway (snoring). You notice on the monitor that his heart rate is 33 beats per minute (bpm) and blood pressure 89/60 mmHg. His saturation probe has fallen off.
What is the most appropriate immediate management option?Your Answer:
Correct Answer: Call for help and maintain the airway with a jaw thrust and deliver 15 litres of high-flow oxygen
Explanation:Managing a Patient with Bradycardia and Airway Obstruction: Priorities and Interventions
When faced with a patient who is unresponsive and has both an obstructed airway and bradycardia, it is crucial to prioritize interventions based on the A-E assessment. The first priority is to maintain the airway with a jaw thrust and deliver high-flow oxygen. Once help is called, the patient’s response is monitored, and if bradycardia persists, atropine is given in 500 µg boluses IV. If the airway obstruction cannot be managed with simple measures or non-definitive airways, re-intubation may be necessary. In cases where atropine is ineffective, an isoprenaline infusion may be considered. While a second IV access line may be beneficial, it is not a priority in this situation. By following these interventions, the patient’s condition can be stabilized and managed effectively.
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This question is part of the following fields:
- Cardiovascular
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Question 76
Incorrect
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As a foundation doctor on the postnatal ward, you conduct a newborn examination on a two-day-old baby girl. She was delivered normally and in good condition. During the hip examination, you notice that the left hip can be relocated, which raises concerns. What is the next appropriate step in management?
Your Answer:
Correct Answer: Urgent referral for hip ultrasound
Explanation:The Ortolani manoeuvre was performed on a newborn to relocate the femoral head after dislocation caused by the Barlow manoeuvre. The result was abnormal, indicating a need for urgent assessment to check for potential developmental dysplasia of the hip. The best imaging option is ultrasound, which avoids radiation and provides optimal visualization of the hip’s development. Referring the child for routine assessment would cause unnecessary delay in treatment, and providing reassurance would be inappropriate given the abnormal screening result.
Developmental dysplasia of the hip (DDH) is a condition that affects 1-3% of newborns and is more common in females, firstborn children, and those with a positive family history or breech presentation. It used to be called congenital dislocation of the hip (CDH). DDH is more often found in the left hip and can be bilateral in 20% of cases. Screening for DDH is recommended for infants with certain risk factors, and all infants are screened using the Barlow and Ortolani tests at the newborn and six-week baby check. Clinical examination includes testing for leg length symmetry, restricted hip abduction, and knee level when hips and knees are flexed. Ultrasound is used to confirm the diagnosis if clinically suspected, but x-ray is the first line investigation for infants over 4.5 months. Management includes the use of a Pavlik harness for children under 4-5 months and surgery for older children with unstable hips.
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This question is part of the following fields:
- Paediatrics
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Question 77
Incorrect
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A 26-year-old woman in her first pregnancy visits her GP at 12 weeks gestation complaining of dysuria. Apart from this, she is healthy and her pregnancy has been uneventful so far. Upon urine dip, leucocytes, nitrates, blood, and protein are detected. What is the most suitable course of treatment?
Your Answer:
Correct Answer: Nitrofurantoin
Explanation:Although UTI in pregnancy may not show any symptoms, it still needs to be treated promptly to prevent the development of pyelonephritis. The common medications used to treat UTIs are nitrofurantoin and trimethoprim. Nitrofurantoin can be used during pregnancy, but it should be avoided at term as it can cause neonatal haemolysis. Trimethoprim should be avoided in the first trimester of pregnancy. Penicillins and cephalosporins are safe to use during pregnancy, but sulfonamides (such as sulfasalazine) and quinolones (such as ciprofloxacin) should be avoided.
Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is teratogenic in the first trimester. Asymptomatic bacteriuria in pregnant women should also be treated to prevent progression to acute pyelonephritis. Men with UTIs should be offered a seven-day course of trimethoprim or nitrofurantoin unless prostatitis is suspected. A urine culture should be sent before antibiotics are started. Catheterised patients should not be treated for asymptomatic bacteria, but if symptomatic, a seven-day course of antibiotics should be given. Acute pyelonephritis requires hospital admission and treatment with a broad-spectrum cephalosporin or quinolone for 10-14 days. Referral to urology is not routinely required for men who have had one uncomplicated lower UTI.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 78
Incorrect
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A 25-year-old female presents with a history of weight loss and diarrhoea. To investigate her symptoms, she undergoes a colonoscopy and a biopsy is taken. The biopsy report indicates the presence of pigment-laden macrophages suggestive of melanosis coli. What is the probable diagnosis?
Your Answer:
Correct Answer: Laxative abuse
Explanation:Understanding Melanosis Coli
Melanosis coli is a condition that affects the pigmentation of the bowel wall. This disorder is characterized by the presence of pigment-laden macrophages, which can be observed through histology. The primary cause of melanosis coli is laxative abuse, particularly the use of anthraquinone compounds like senna.
In simpler terms, melanosis coli is a condition that causes changes in the color of the bowel wall due to the accumulation of pigments. This condition is often associated with the excessive use of laxatives, which can lead to the accumulation of pigment-laden macrophages in the bowel wall. These macrophages are responsible for the discoloration of the bowel wall, which can be observed through histology. It is important to note that melanosis coli is not a life-threatening condition, but it can be a sign of underlying health issues that need to be addressed.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 79
Incorrect
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A 25-year-old student presents to his General Practitioner with symptoms of a flu-like illness. He reports not having eaten for the past 48 hours. During examination, mild jaundice is observed, but no other significant physical findings are noted. The patient's total serum bilirubin level is elevated at 60 μmol/l (reference range < 20 μmol/l), while the other liver function tests (LFTs) are normal. Full blood count (FBC), urea and electrolytes, and haptoglobins are within normal limits. What is the most likely diagnosis for this clinical presentation?
Your Answer:
Correct Answer: Gilbert syndrome
Explanation:Differential Diagnosis: Jaundice and Abdominal Symptoms
Gilbert Syndrome:
Gilbert syndrome is an inherited condition that can manifest as jaundice on clinical examination. Patients may also experience non-specific symptoms such as abdominal cramps, fatigue, and malaise. Fasting, febrile illness, alcohol, or exercise can exacerbate jaundice in patients with Gilbert syndrome. Diagnosis is based on a thorough history and physical examination, as well as blood tests that show unconjugated hyperbilirubinaemia.Haemolytic Anaemia:
Haemolysis is the premature destruction of erythrocytes, which can lead to anaemia if bone marrow activity cannot compensate for erythrocyte loss. Mild haemolysis can be asymptomatic, while severe haemolysis can cause life-threatening symptoms such as angina and cardiopulmonary decompensation. Changes in lactate dehydrogenase and serum haptoglobin levels are the most sensitive general tests for haemolytic anaemia.Hepatitis A:
Hepatitis A is a viral infection that results almost exclusively from ingestion, typically through faecal-oral transmission. Symptoms include fatigue, anorexia, nausea, and vomiting. LFT abnormalities are common, and diagnosis is based on serologic testing for immunoglobulin M (IgM) antibody to HAV.Hepatitis B:
Hepatitis B is a viral infection that is transmitted haematogenously and sexually. Symptoms include fatigue, anorexia, nausea, and vomiting. LFT abnormalities are common, and diagnosis is based on serologic testing for hepatitis B surface antigen (HBsAg).Cholecystitis:
Cholecystitis is inflammation of the gall bladder that occurs most commonly because of an obstruction of the cystic duct by gallstones arising from the gall bladder. Symptoms include upper abdominal pain, nausea, vomiting, and fever. Signs of peritoneal irritation may also be present.Conclusion:
In summary, the differential diagnosis of jaundice and abdominal symptoms includes Gilbert syndrome, haemolytic anaemia, hepatitis A, hepatitis B, and cholecystitis. Diagnosis is based on a thorough history and physical examination, as well as blood tests and serologic testing as appropriate. Treatment -
This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 80
Incorrect
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A 22-year-old man comes to his General Practitioner complaining of frequent watery diarrhoea, abdominal pain, flatulence and nausea. Upon stool analysis, an elevated osmotic gap is detected with a pH < 6. The hydrogen breath test is positive.
What is the most probable diagnosis?Your Answer:
Correct Answer: Lactose intolerance
Explanation:Based on the patient’s symptoms and test results, it is likely that they have lactose intolerance. This diagnosis is supported by an increase in stool osmolality and a positive hydrogen breath test, which can be confirmed through dietary testing. While bowel malignancy is a possibility, additional symptoms such as rectal bleeding and weight loss would typically be present. Cows’ milk protein allergy is unlikely due to the patient’s age and the positive hydrogen breath test. Inflammatory bowel disease may have similar symptoms, but additional indicators such as weight loss, fever, and anemia would be present. Irritable bowel syndrome is not the most likely diagnosis and should only be considered after other possibilities have been ruled out.
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This question is part of the following fields:
- Immunology/Allergy
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Question 81
Incorrect
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A 32-year-old woman presents with heavy menstrual bleeding and a haemoglobin level of 102 g/L. Iron studies are ordered to investigate for iron-deficiency anaemia. What result would support this diagnosis?
Your Answer:
Correct Answer: ↓ Ferritin, ↑ total iron-binding capacity, ↓ serum iron, ↓ transferrin saturation
Explanation:In cases of iron-deficiency anemia, it is common for both the total iron-binding capacity (TIBC) and transferrin levels to be elevated. However, it should be noted that the transferrin saturation level is typically decreased.
Iron deficiency anaemia is caused by a lack of iron, which is needed to make haemoglobin in red blood cells. It is the most common type of anaemia worldwide, with preschool-age children having the highest prevalence. Causes include excessive blood loss, inadequate dietary intake, poor intestinal absorption, and increased iron requirements. Symptoms include fatigue, shortness of breath, palpitations, and nail changes. Diagnosis is made through a full blood count and serum ferritin test. Treatment involves identifying and managing the underlying cause, as well as taking oral iron supplements and consuming an iron-rich diet.
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This question is part of the following fields:
- Haematology/Oncology
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Question 82
Incorrect
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A 32-year-old man has recently returned from a backpacking trip in Southeast Asia. While there, he consumed food from various street vendors. He complained of abdominal discomfort, bloating and loose stools. Analysis of three stool samples showed cysts in two of them. The patient was treated with metronidazole and showed improvement.
What is the probable medical condition in this scenario?Your Answer:
Correct Answer: Giardiasis
Explanation:Giardiasis: A Protozoal Parasite Causing Diarrhoeal Illness
Giardiasis is a diarrhoeal disease caused by the flagellate protozoan Giardia intestinalis (previously known as G. lamblia). It is prevalent in areas with poor sanitation and can cause asymptomatic colonisation or acute or chronic diarrhoeal illness. Travellers to highly endemic areas are at high risk of infection. Ingestion of as few as ten Giardia cysts can cause infection. Diarrhoea is the most common symptom of acute Giardia infection, occurring in 90% of symptomatic subjects. The traditional basis of diagnosis is identification of G. intestinalis trophozoites or cysts in the stool of infected patients via stool ova and parasite examination. Standard treatment consists of antibiotic therapy, and metronidazole is the most commonly prescribed antibiotic for this condition. Giardia infection may occur more commonly in families with X-linked agammaglobulinaemia and in sexually active men who have sex with men (MSM).
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This question is part of the following fields:
- Infectious Diseases
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Question 83
Incorrect
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A 35-year-old man contacts his General Practitioner to discuss screening for tuberculosis (TB) for himself and his two children. His wife has recently been diagnosed with active TB and started on treatment following release from hospital. He and the children are all completely asymptomatic.
Which of the following screening options would be appropriate for the family?Your Answer:
Correct Answer: Mantoux test
Explanation:Screening and Diagnosis of Tuberculosis: Methods and Recommendations
Tuberculosis (TB) is a serious infectious disease that can be fatal if left untreated. Screening and diagnosis of TB are crucial for early detection and treatment. In this article, we will discuss the recommended methods and guidelines for screening and diagnosis of TB.
Mantoux Test
The Mantoux test is a recommended screening method for latent TB in at-risk groups, such as close contacts of patients with active pulmonary or laryngeal TB, patients with human immunodeficiency virus, or immigrants from high-risk countries. The test involves injecting tuberculin intradermally and observing a reaction 2-3 days later. A positive result is indicated by an induration of greater than 6 mm at the injection site. Further investigations are warranted to diagnose or exclude active TB infection.Chest X-Ray
Screening for latent TB is advised for all household members and close contacts of patients diagnosed with active pulmonary TB. If screening is positive, investigations for active TB are indicated, which would include a chest X-ray. Typical features of pulmonary TB on an X-ray include a cavitating lesion, upper-lobe parenchymal infiltrates, pleural effusion, or mediastinal or hilar lymphadenopathy.Heaf Test
The Heaf test was previously used to diagnose latent TB but has since been replaced by the Mantoux test. Both tests involve injecting tuberculin intradermally and observing for a reaction. The Heaf test was performed using a Heaf gun, which had six needles in a circular formation. The more severe the reaction, the more likely it is that the patient has an active infection, but previous BCG vaccine exposure can also give a reaction.Screening and Diagnosis Recommendations
According to NICE guidance, close contacts of patients with active pulmonary TB should be screened for latent TB infection with a Mantoux test. Three sputum samples (including an early morning sample) for TB microscopy and culture are indicated to diagnose active pulmonary TB infection. This investigation is not indicated for screening for latent TB but should be performed if latent screening tests are positive.In conclusion, early detection and treatment of TB are crucial for preventing the spread of the disease and improving patient outcomes. The recommended screening and diagnosis methods should be followed to ensure accurate and timely detection of TB.
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This question is part of the following fields:
- Infectious Diseases
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Question 84
Incorrect
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A 27-year-old man presents to the Emergency Department complaining of sudden shortness of breath. He recently returned from a backpacking trip in Australia and was previously healthy. He denies any other symptoms and is stable hemodynamically. He has no personal or family history of cancer, heart failure, or chronic lung disease. A D-Dimer test is performed and comes back elevated. A subsequent CTPA reveals a small pulmonary embolism without any signs of right-sided heart strain. The consultant believes that he can be managed as an outpatient with a DOAC and close monitoring. Which of the following scoring systems can aid in their decision-making process?
Your Answer:
Correct Answer: PESI
Explanation:The PESI score is suggested by BTS guidelines for identifying patients with pulmonary embolism who can be treated as outpatients. It predicts long-term morbidity and mortality in PE patients. The ABCD2 is used for triaging acute Transient Ischaemic Attack cases. The CHA2DS2-VASc score aids in deciding whether to start prophylactic anticoagulation in atrial fibrillation patients. The GRACE score estimates mortality in those who have had Acute Coronary Syndrome.
Management of Pulmonary Embolism: NICE Guidelines
Pulmonary embolism (PE) is a serious condition that requires prompt management. The National Institute for Health and Care Excellence (NICE) updated their guidelines on the management of venous thromboembolism (VTE) in 2020, with some key changes. One of the significant changes is the recommendation to use direct oral anticoagulants (DOACs) as the first-line treatment for most people with VTE, including those with active cancer. Another change is the increasing use of outpatient treatment for low-risk PE patients, determined by a validated risk stratification tool.
Anticoagulant therapy is the cornerstone of VTE management, and the guidelines recommend using apixaban or rivaroxaban as the first-line treatment following the diagnosis of a PE. If neither of these is suitable, LMWH followed by dabigatran or edoxaban or LMWH followed by a vitamin K antagonist (VKA) can be used. For patients with active cancer, DOACs are now recommended instead of LMWH. The length of anticoagulation is determined by whether the VTE was provoked or unprovoked, with treatment typically stopped after 3-6 months for provoked VTE and continued for up to 6 months for unprovoked VTE.
In cases of haemodynamic instability, thrombolysis is recommended as the first-line treatment for massive PE with circulatory failure. Patients who have repeat pulmonary embolisms, despite adequate anticoagulation, may be considered for inferior vena cava (IVC) filters. However, the evidence base for IVC filter use is weak.
Overall, the updated NICE guidelines provide clear recommendations for the management of PE, including the use of DOACs as first-line treatment and outpatient management for low-risk patients. The guidelines also emphasize the importance of individualized treatment based on risk stratification and balancing the risks of VTE recurrence and bleeding.
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This question is part of the following fields:
- Respiratory Medicine
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Question 85
Incorrect
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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.
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This question is part of the following fields:
- Psychiatry
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Question 86
Incorrect
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A 63-year-old man presents to the emergency department with sudden-onset chest pain and nausea. He is not taking any regular medications. An ECG reveals ST depression and T wave inversion in leads V2-V4, and troponin levels are elevated. The patient receives a STAT 300mg aspirin, and there are no immediate plans for primary PCI. According to the GRACE score, the 6-month mortality risk is 8.0%. The patient is stable. What is the best course of treatment going forward?
Your Answer:
Correct Answer: Fondaparinux, prasugrel or ticagrelor, and refer for coronary angiography within 72 hours
Explanation:The current treatment plan of prescribing fondaparinux, clopidogrel, and scheduling a coronary angiography in 3 months is incorrect. Clopidogrel is typically prescribed for patients with a higher risk of bleeding or those taking an oral anticoagulant. Additionally, delaying definitive treatment for a high-risk patient by scheduling a coronary angiography in 3 months could lead to increased mortality. Instead, a more appropriate treatment plan would involve prescribing prasugrel, unfractionated heparin, and a glycoprotein IIB/IIIA inhibitor, and referring the patient for urgent PCI within 2 hours. However, it should be noted that this treatment plan is specific to patients with STEMI and access to PCI facilities.
Managing Acute Coronary Syndrome: A Summary of NICE Guidelines
Acute coronary syndrome (ACS) is a common and serious medical condition that requires prompt management. The management of ACS has evolved over the years, with the development of new drugs and procedures such as percutaneous coronary intervention (PCI). The National Institute for Health and Care Excellence (NICE) has updated its guidelines on the management of ACS in 2020.
ACS can be classified into three subtypes: ST-elevation myocardial infarction (STEMI), non ST-elevation myocardial infarction (NSTEMI), and unstable angina. The management of ACS depends on the subtype. However, there are common initial drug therapies for all patients with ACS, such as aspirin and nitrates. Oxygen should only be given if the patient has oxygen saturations below 94%, and morphine should only be given for severe pain.
For patients with STEMI, the first step is to assess eligibility for coronary reperfusion therapy, which can be either PCI or fibrinolysis. Patients with NSTEMI/unstable angina require a risk assessment using the Global Registry of Acute Coronary Events (GRACE) tool to determine whether they need coronary angiography (with follow-on PCI if necessary) or conservative management.
This summary provides an overview of the NICE guidelines for managing ACS. The guidelines are complex and depend on individual patient factors, so healthcare professionals should review the full guidelines for further details. Proper management of ACS can improve patient outcomes and reduce the risk of complications.
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This question is part of the following fields:
- Cardiovascular
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Question 87
Incorrect
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A 26-year-old woman with bipolar disorder presents to the GP clinic for a medication review as she plans to conceive. She is currently prescribed lithium as a mood stabilizer. What potential fetal abnormality should be considered with this medication?
Your Answer:
Correct Answer: Ebstein's anomaly
Explanation:Cardiac foetal abnormalities, specifically Ebstein’s anomaly, can be caused by lithium. Chloramphenicol is linked to ‘Grey baby’ syndrome, while ACE inhibitors, alcohol, carbamazepine, valproate, and warfarin are associated with craniofacial abnormalities. Carbamazepine and valproate are also linked to neural tube defects.
Harmful Drugs and Medical Conditions for Developing Fetuses
During pregnancy, certain drugs and medical conditions can harm the developing fetus. These harmful substances and conditions are known as teratogens. Some of the teratogens that can cause harm to a developing fetus include ACE inhibitors, alcohol, aminoglycosides, carbamazepine, chloramphenicol, cocaine, diethylstilbesterol, lithium, maternal diabetes mellitus, smoking, tetracyclines, thalidomide, and warfarin.
ACE inhibitors can cause renal dysgenesis and craniofacial abnormalities in the fetus. Alcohol consumption during pregnancy can lead to craniofacial abnormalities. Aminoglycosides can cause ototoxicity, while carbamazepine can cause neural tube defects and craniofacial abnormalities. Chloramphenicol can cause grey baby syndrome, and cocaine can lead to intrauterine growth retardation and preterm labor.
Diethylstilbesterol can cause vaginal clear cell adenocarcinoma, while lithium can cause Ebstein’s anomaly (atrialized right ventricle). Maternal diabetes mellitus can cause macrosomia, neural tube defects, polyhydramnios, preterm labor, and caudal regression syndrome. Smoking during pregnancy can lead to preterm labor and intrauterine growth retardation. Tetracyclines can cause discolored teeth, while thalidomide can cause limb reduction defects. Finally, warfarin can cause craniofacial abnormalities in the fetus.
It is important for pregnant women to avoid exposure to these harmful substances and conditions to ensure the healthy development of their fetus.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 88
Incorrect
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A 6-year-old boy has been treated for a first urinary tract infection. There was no evidence of pyelonephritis. Urine culture demonstrated growth of Escherichia coli. He was given a course of trimethoprim and recovered well.
Which of the following is the most appropriate next step in his management?
Select the SINGLE most appropriate next step from the list below. Select ONE option only.Your Answer:
Correct Answer: No imaging required
Explanation:Imaging Guidelines for Urinary Tract Infections in Children
Urinary tract infections (UTIs) are common in children and can be divided into upper and lower UTIs. Current guidelines recommend different imaging investigations based on the type of UTI and the child’s age. For infants and children aged ≥6 months with a first-time UTI that responds to treatment, routine ultrasonography is not recommended unless the child has an atypical UTI. Micturating cystourethrography (MCUG) is indicated if renal and bladder ultrasonography reveals hydronephrosis, scarring, or other findings that suggest high-grade vesicoureteral reflux (VUR) or obstructive uropathy. Ultrasonography of the urinary tract is the imaging study of choice in children with a UTI, and it is useful in excluding obstructive uropathy and identifying renal damage caused by pyelonephritis. Technectium-99m-labelled dimercaptosuccinic acid (99mTc-DMSA) is a scintigraphic agent that can be used to assess acute pyelonephritis, renal cortical scarring, and the identification of a malpositioned kidney. However, no imaging is required for a typical, non-recurrent UTI in a child aged ≥3 years. Atypical UTI features include being seriously ill, having poor urine flow, an abdominal or bladder mass, raised creatinine, septicaemia, failure to respond to treatment with suitable antibiotics within 48 hours, or infection with non-E. coli organisms.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 89
Incorrect
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Which of the following antihypertensive agents controls blood pressure by blocking the peripheral α1 -adrenoceptor?
Your Answer:
Correct Answer: Doxazosin
Explanation:Mechanisms of Action of Antihypertensive Drugs
Doxazosin is an a1-adrenergic receptor blocker that relaxes vascular smooth muscle tone, leading to decreased peripheral vascular resistance and blood pressure.
Losartan is a selective angiotensin II receptor type 1 antagonist that reduces the end-organ response to angiotensin II, resulting in decreased total peripheral resistance and cardiac venous return.
Minoxidil is a potassium channel opener that causes vasodilatation mainly in arterial resistance vessels, with significant hypertrichosis as a side effect.
Methyldopa inhibits dopa decarboxylase, leading to reduced dopaminergic and adrenergic neurotransmission and a modest decrease in blood pressure. It also activates presynaptic central nervous system a2-adrenergic receptors, inhibiting sympathetic nervous system output.
Clonidine activates presynaptic a2-receptors in the brain stem, decreasing peripheral vascular resistance and blood pressure by inhibiting the release of noradrenaline.
Overall, these antihypertensive drugs work through different mechanisms to lower blood pressure and reduce the risk of cardiovascular disease.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 90
Incorrect
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As a foundation doctor in the endocrine department, if you were to assess a patient with hypoparathyroidism resulting in hypocalcaemia, what findings may you discover during your investigation?
Your Answer:
Correct Answer: Chvostek's sign: percussion over the facial nerve
Explanation:Hypocalcaemia: Symptoms and Signs
Hypocalcaemia is a condition characterized by low levels of calcium in the blood. Since calcium is essential for proper muscle and nerve function, many of the symptoms and signs of hypocalcaemia are related to neuromuscular excitability. The most common features of hypocalcaemia include muscle twitching, cramping, and spasms, as well as perioral paraesthesia. In chronic cases, patients may experience depression and cataracts.
An electrocardiogram (ECG) may show a prolonged QT interval, while Trousseau’s sign may be present when the brachial artery is occluded by inflating the blood pressure cuff and maintaining pressure above systolic. This causes wrist flexion and fingers to be drawn together, and is seen in around 95% of patients with hypocalcaemia and around 1% of normocalcaemic people. Chvostek’s sign, which is seen in around 70% of patients with hypocalcaemia and around 10% of normocalcaemic people, involves tapping over the parotid gland to cause facial muscles to twitch.
In summary, hypocalcaemia can cause a range of symptoms and signs related to neuromuscular excitability, including muscle twitching, cramping, and spasms, as well as perioral paraesthesia, depression, and cataracts. Trousseau’s sign and Chvostek’s sign are also commonly observed in patients with hypocalcaemia.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 91
Incorrect
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A 29-year-old woman presents to her GP with complaints of hair loss. She reports noticing that her hair has become significantly thinner and that she is shedding more hair than usual, both on her pillow and in the shower drain. She denies any other symptoms and has no significant medical history except for giving birth to her first child 6 months ago. She is not taking any medications regularly and there is no family history of hair loss. On examination, her scalp hair is uniformly thin, but there are no areas of complete hair loss. Her systemic examination is unremarkable and her vital signs are within normal limits. Blood tests, including iron studies and thyroid function, are all normal. What is the most likely diagnosis?
Your Answer:
Correct Answer: Telogen effluvium
Explanation:Telogen effluvium is characterized by hair loss and thinning as a result of experiencing significant stress. In this case, the patient’s recent physical stress from giving birth is a likely cause of her hair becoming thinner due to telogen effluvium. The hair loss patterns observed do not match those of alopecia areata or alopecia totalis, which respectively cause distinct areas of complete hair loss or complete loss of all hair on the head and face.
Input:
Alopecia may be divided into scarring (destruction of hair follicle) and non-scarring (preservation of hair follicle). Scarring alopecia can be caused by trauma, burns, radiotherapy, lichen planus, discoid lupus, and untreated tinea capitis. Non-scarring alopecia can be caused by male-pattern baldness, drugs such as cytotoxic drugs, carbimazole, heparin, oral contraceptive pill, and colchicine, nutritional deficiencies such as iron and zinc deficiency, autoimmune conditions such as alopecia areata, telogen effluvium, hair loss following a stressful period such as surgery, and trichotillomania.Output:
– Alopecia can be categorized into scarring and non-scarring types.
– Scarring alopecia is caused by trauma, burns, radiotherapy, lichen planus, discoid lupus, and untreated tinea capitis.
– Non-scarring alopecia is caused by male-pattern baldness, drugs such as cytotoxic drugs, carbimazole, heparin, oral contraceptive pill, and colchicine, nutritional deficiencies such as iron and zinc deficiency, autoimmune conditions such as alopecia areata, telogen effluvium, hair loss following a stressful period such as surgery, and trichotillomania. -
This question is part of the following fields:
- Dermatology
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Question 92
Incorrect
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A 50-year-old man presents to his primary care physician with complaints of abdominal pain, bloating, and loose stools. He recently started a new medication after being hospitalized for an upper gastrointestinal bleed and spontaneous bacterial peritonitis. Despite not reporting any blood loss, he has noticed a gradual worsening of his symptoms since his hospital discharge. The patient has a medical history of gout, type-2 diabetes, hypertension, alcoholism, and ischaemic heart disease. He quit smoking 10 years ago. Which medication is the most likely culprit for his symptoms?
Your Answer:
Correct Answer: Omeprazole
Explanation:Taking Omeprazole may heighten the possibility of experiencing severe diarrhoea, specifically Clostridium difficile infections. Omeprazole is a type of proton pump inhibitor that can lead to side effects like abdominal pain, flatulence, nausea/vomiting, and diarrhoea. The risk of contracting severe infections like clostridium difficile is higher, especially if the patient has received antibiotics, particularly broad-spectrum agents, for their spontaneous bacterial peritonitis.
Propranolol, a beta-blocker, can cause side effects such as a slow heart rate, dry eyes, tiredness, and nausea, but it may also result in abdominal discomfort with altered bowel habit.
Allopurinol is known to cause a rash or nausea and vomiting.Understanding Proton Pump Inhibitors and Their Adverse Effects
Proton pump inhibitors (PPIs) are medications that block the H+/K+ ATPase of the gastric parietal cell, leading to irreversible effects. Common examples of PPIs include omeprazole and lansoprazole. While these medications are effective in treating conditions such as gastroesophageal reflux disease (GERD) and peptic ulcers, they can also have adverse effects on the body.
One of the potential adverse effects of PPIs is hyponatremia, which is a condition characterized by low levels of sodium in the blood. PPIs can also lead to hypomagnesemia, which is a deficiency of magnesium in the blood. Additionally, long-term use of PPIs has been linked to an increased risk of osteoporosis and fractures. Another potential adverse effect is microscopic colitis, which is inflammation of the colon that can cause diarrhea and abdominal pain. Finally, PPIs have been associated with an increased risk of C. difficile infections, which can cause severe diarrhea and other gastrointestinal symptoms.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 93
Incorrect
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A 35-year-old female patient presents to the GP clinic seeking the combined oral contraceptive pill (COCP). She has a BMI of 25 kg/m2 and a history of migraine without aura. She is a smoker, consuming 20 cigarettes a day, and drinks socially. The patient gave birth to her second child 10 weeks ago and is currently breastfeeding. Her mother had a pulmonary embolism at the age of 60 years. Identify the UKMEC 4 contraindication that would make the COCP unsuitable for her.
Your Answer:
Correct Answer: 37 years-old and smoking 20 cigarettes a day
Explanation:The use of COCP is absolutely contraindicated for individuals who are over 35 years old and smoke more than 15 cigarettes per day. Migraine without aura is not a contraindication, but migraine with aura is a UKMEC 3 contraindication. A BMI of over 35 kg/m2 and a family history of thromboembolism at age less than 45 years are also UKMEC 3 contraindications, but in this case, the patient’s BMI is 25 kg/m2 and her mother had pulmonary embolism at the age of 60 years, so these are not contraindications. Breastfeeding less than 6 weeks post-partum is a UKMEC 4 contraindication, but since the patient is 10 weeks post-partum, it is a UKMEC 2.
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.
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This question is part of the following fields:
- Reproductive Medicine
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Question 94
Incorrect
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A 61-year-old Caucasian man presents for a routine health check. He has a medical history of asthma and type 2 diabetes mellitus. His most recent HbA1c is 56 mmol/mol (7.3%). During the check-up, his blood pressure is measured at 160/80 mmHg. Subsequently, ambulatory blood pressure monitoring is conducted, which shows an average daytime blood pressure of 150/90 mmHg. What is the appropriate next step in management?
Your Answer:
Correct Answer: Ramipril
Explanation:For the treatment of hypertension in diabetic patients, the first-line medication should be ACE inhibitors such as ramipril. However, this may not be suitable for individuals of Afro-Caribbean descent or women who may become pregnant. In case of a cough developing with ACE inhibitors, an angiotensin-II receptor antagonist like losartan should be prescribed. If the patient is not diabetic, calcium channel blockers like amlodipine or diuretics such as indapamide would be the preferred initial treatment. Beta blockers like propranolol are not typically the first choice for hypertension treatment, but may be considered for young patients who cannot tolerate ACE inhibitors or women attempting to conceive.
NICE released updated guidelines in 2019 for the management of hypertension, building on previous guidelines from 2011. These guidelines aimed to classify hypertension into stages and recommend the use of ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) to accurately diagnose hypertension. This is important because some patients experience white coat hypertension, where their blood pressure rises in a clinical setting, leading to potential overdiagnosis of hypertension. ABPM and HBPM allow for a more accurate assessment of a patient’s overall blood pressure and can prevent overdiagnosis.
NICE recommends measuring blood pressure in both arms when considering a diagnosis of hypertension and repeating measurements if there is a difference of more than 20 mmHg between arms. If the blood pressure is >= 140/90 mmHg, NICE suggests offering ABPM or HBPM to confirm the diagnosis. If the blood pressure is >= 180/120 mmHg, referral for specialist assessment is recommended if there are signs of retinal haemorrhage or papilloedema or life-threatening symptoms. If target organ damage is identified, antihypertensive drug treatment may be started immediately.
ABPM involves taking at least 2 measurements per hour during the person’s usual waking hours and using the average value of at least 14 measurements. If ABPM is not tolerated, HBPM should be offered. HBPM involves taking two consecutive measurements at least 1 minute apart, twice daily for at least 4 days, and using the average value of all remaining measurements.
Interpreting the results of ABPM/HBPM is important for determining treatment. If the average blood pressure is >= 135/85 mmHg (stage 1 hypertension), treatment may be considered for patients under 80 years of age with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. In 2019, NICE also recommended considering antihypertensive drug treatment for adults under 60 with stage 1 hypertension and an estimated 10-year risk below 10%. If the average blood pressure is >= 150/95 mmHg (stage 2 hypertension), drug treatment should be offered regardless of age.
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This question is part of the following fields:
- Cardiovascular
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Question 95
Incorrect
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Liam, 35, is admitted to the Emergency Department after a fall down the stairs at home. Upon examination, it is observed that he has bruising around the eyes and behind the ears. What does this indicate?
Your Answer:
Correct Answer: Basilar skull fracture
Explanation:The classic signs associated with basilar skull fractures are periorbital bruising, which is bruising around the eye also known as Raccoon eyes, and post-auricular bruising, which is bruising of the mastoid also known as Battle’s sign. Therefore, the correct answer for this question is basilar skull fracture.
NICE Guidelines for Investigating Head Injuries in Adults
Head injuries can be serious and require prompt medical attention. The National Institute for Health and Care Excellence (NICE) has provided clear guidelines for healthcare professionals to determine which adult patients need further investigation with a CT head scan. Patients who require immediate CT head scans include those with a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment, suspected open or depressed skull fractures, signs of basal skull fractures, post-traumatic seizures, focal neurological deficits, and more than one episode of vomiting.
For patients with any loss of consciousness or amnesia since the injury, a CT head scan within 8 hours is recommended for those who are 65 years or older, have a history of bleeding or clotting disorders, experienced a dangerous mechanism of injury, or have more than 30 minutes of retrograde amnesia of events immediately before the head injury. Additionally, patients on warfarin who have sustained a head injury with no other indications for a CT head scan should also receive a scan within 8 hours of the injury.
It is important for healthcare professionals to follow these guidelines to ensure that patients receive appropriate and timely care for their head injuries. By identifying those who require further investigation, healthcare professionals can provide the necessary treatment and support to prevent further complications and improve patient outcomes.
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This question is part of the following fields:
- Neurology
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Question 96
Incorrect
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What is the pathophysiological mechanism of hyperacute allograft rejection, which is one of the significant risks associated with transplantation and can potentially endanger the patient's life?
Your Answer:
Correct Answer: Class I HLA antibody activation, granulocyte adhesion and thrombosis
Explanation:Misconceptions about the Pathophysiology of Allograft Rejection
There are several misconceptions about the pathophysiology of allograft rejection. One of them is that hyper-acute allograft rejection is solely caused by class I HLA antibody activation, granulocyte adhesion, and thrombosis. While these factors do play a role, the ultimate result of hyper-acute rejection is thrombosis of the vessels and graft ischaemia, which presents itself as graft swelling once perfusion is reinstated.
Another misconception is that donor MHC I antigens react with host CD8 resulting in direct cytotoxic damage, which is a sequence in the pathophysiology of acute rejection response, not hyper-acute rejection.
Class II HLA antibodies are often thought to be the primary source of activation of the coagulation cascade, but this is not the case. Monocytes are also not activated in this process.
Interstitial fibrosis is often thought to be a mechanism of acute rejection, but it is actually the end-stage mechanism of chronic graft rejection.
Lastly, lymphocyte, killer T-cell, and cytokine activation are often thought to be part of the mechanism of hyper-acute allograft rejection, but they are actually part of the mechanism of action in acute allograft rejection.
It is important to have a clear understanding of the pathophysiology of allograft rejection to properly diagnose and treat patients.
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This question is part of the following fields:
- Immunology/Allergy
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Question 97
Incorrect
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A 27-year-old man with a history of treatment resistant schizophrenia presents to the emergency department with complaints of chest pain and general malaise over the past few days. He appears uncomfortable and sweaty while lying on the bed. Which medication is the most probable cause of these symptoms?
Your Answer:
Correct Answer: Clozapine
Explanation:Schizophrenia that is resistant to treatment can be very challenging to manage. Clozapine, an atypical antipsychotic, is one of the most effective drugs for this condition. However, it should only be used as a second or third line medication after trying at least two other antipsychotics for 6-8 weeks, with one of them being from the atypical class. Although clozapine is highly effective, it can cause serious side effects such as weight gain, excessive salivation, agranulocytosis, neutropenia, myocarditis, and arrhythmias. In this patient’s case, there is concern that he may be experiencing myocarditis due to his underlying psychiatric condition and potential use of clozapine.
Management of Schizophrenia: NICE Guidelines
Schizophrenia is a complex mental disorder that requires careful management. In 2009, the National Institute for Health and Care Excellence (NICE) published guidelines on the management of schizophrenia. According to these guidelines, oral atypical antipsychotics should be the first-line treatment for patients with schizophrenia. Additionally, cognitive behavioural therapy should be offered to all patients to help them manage their symptoms and improve their quality of life.
It is also important to pay close attention to cardiovascular risk-factor modification in patients with schizophrenia. This is because schizophrenic patients have high rates of cardiovascular disease, which is linked to antipsychotic medication and high smoking rates. Therefore, healthcare providers should work with patients to modify their lifestyle habits and reduce their risk of developing cardiovascular disease.
Overall, the NICE guidelines provide a comprehensive approach to managing schizophrenia. By following these guidelines, healthcare providers can help patients with schizophrenia achieve better outcomes and improve their overall health and well-being.
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This question is part of the following fields:
- Psychiatry
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Question 98
Incorrect
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A 50-year-old man presents to the emergency department with a 24-hour history of worsening right knee pain and limited mobility. He reports falling off his bike a few days ago but did not experience any knee pain until yesterday. Upon examination, the right knee appears red and hot with only 20º of flexion and a small effusion. The patient has a history of a conservatively treated ACL rupture in the other knee.
The patient's vital signs are as follows: heart rate 100 beats/min, respiratory rate 18/min, saturations 98% on room air, blood pressure 102/67 mmHg, and temperature 37.9ºC. Blood tests reveal a hemoglobin level of 145 g/L, platelets of 500 * 109/L, a white cell count of 13.6 * 109/L, a sodium level of 142 mmol/L, a potassium level of 5.0 mmol/L, a urea level of 4.0 mmol/L, a creatinine level of 110 µmol/L, and a CRP level of 130 mg/L. X-ray results show no obvious bony injury.
What is the most appropriate next step in managing this patient?Your Answer:
Correct Answer: Urgent orthopaedic review
Explanation:Septic arthritis is most commonly observed in adults’ knees, which presents as sudden joint pain and immobility, accompanied by fever and elevated inflammatory markers. Urgent orthopaedic evaluation is necessary for aspiration and potential washout, as untreated septic arthritis can lead to joint destruction within hours to days. Discharging the patient with oral antibiotics or physiotherapy is not recommended. Administering colchicine is not appropriate as there is no history of gout or pseudogout, and X-ray results do not indicate chondrocalcinosis. Ordering an MRI knee scan may delay appropriate treatment and will not impact management.
Septic Arthritis in Adults: Causes, Symptoms, and Treatment
Septic arthritis is a condition that occurs when bacteria infect a joint, leading to inflammation and pain. The most common organism that causes septic arthritis in adults is Staphylococcus aureus, but in young adults who are sexually active, Neisseria gonorrhoeae is the most common organism. The infection usually spreads through the bloodstream from a distant bacterial infection, such as an abscess. The knee is the most common location for septic arthritis in adults. Symptoms include an acute, swollen joint, restricted movement, warmth to the touch, and fever.
To diagnose septic arthritis, synovial fluid sampling is necessary and should be done before administering antibiotics if necessary. Blood cultures may also be taken to identify the cause of the infection. Joint imaging may also be used to confirm the diagnosis.
Treatment for septic arthritis involves intravenous antibiotics that cover Gram-positive cocci. Flucloxacillin or clindamycin is recommended if the patient is allergic to penicillin. Antibiotic treatment is typically given for several weeks, and patients are usually switched to oral antibiotics after two weeks. Needle aspiration may be used to decompress the joint, and arthroscopic lavage may be required in some cases.
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This question is part of the following fields:
- Musculoskeletal
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Question 99
Incorrect
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A 6-year-old girl is diagnosed with haemolytic uraemic syndrome (HUS), after a recent Salmonella infection. She is admitted to the hospital and blood tests demonstrate a platelet count of 85 × 109/l as well as a haemoglobin of 9 g/dl. She is maintaining good oral intake and her observations are normal.
What would be the next most appropriate step in this patient’s management?
Your Answer:
Correct Answer: Supportive treatment with intravenous fluids
Explanation:Treatment Options for Haemolytic Uraemic Syndrome
Haemolytic uraemic syndrome (HUS) is a condition that can lead to acute renal failure and even chronic renal failure if left untreated. The main treatment for HUS is supportive care, which often involves intravenous fluids to prevent renal damage and decline in renal function. Oral rehydration medications may be useful for patients with ongoing diarrhoea, but intravenous fluids are preferred for inpatients. Intravenous immunoglobulins are not used in the acute treatment of HUS, and transfusion of red blood cells and platelets is only necessary if the patient’s levels are significantly low. Intravenous steroids are not a viable treatment option for HUS.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 100
Incorrect
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A 60-year-old man with no significant medical history presents to the Emergency Department with an ECG indicative of an anterior myocardial infarction. Tragically, he experiences cardiac arrest shortly after arrival. What is the leading cause of mortality in patients following a heart attack?
Your Answer:
Correct Answer: Ventricular fibrillation
Explanation:Complications of Myocardial Infarction
Myocardial infarction (MI) can lead to various complications, which can occur immediately, early, or late after the event. Cardiac arrest is the most common cause of death following MI, usually due to ventricular fibrillation. Patients are treated with defibrillation as per the ALS protocol. Cardiogenic shock may occur if a significant portion of the ventricular myocardium is damaged, leading to a decrease in ejection fraction. This condition is challenging to treat and may require inotropic support and/or an intra-aortic balloon pump. Chronic heart failure may develop if the patient survives the acute phase, and loop diuretics such as furosemide can help decrease fluid overload. Tachyarrhythmias, such as ventricular fibrillation and ventricular tachycardia, are common complications of MI. Bradyarrhythmias, such as atrioventricular block, are more common following inferior MI.
Pericarditis is a common complication of MI in the first 48 hours, characterized by typical pericarditis pain, a pericardial rub, and a pericardial effusion. Dressler’s syndrome, which occurs 2-6 weeks after MI, is an autoimmune reaction against antigenic proteins formed during myocardial recovery. It is treated with NSAIDs. Left ventricular aneurysm may form due to weakened myocardium, leading to persistent ST elevation and left ventricular failure. Patients are anticoagulated due to the increased risk of thrombus formation and stroke. Left ventricular free wall rupture and ventricular septal defect are rare but serious complications that require urgent surgical correction. Acute mitral regurgitation may occur due to ischaemia or rupture of the papillary muscle, leading to acute hypotension and pulmonary oedema. Vasodilator therapy and emergency surgical repair may be necessary.
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This question is part of the following fields:
- Cardiovascular
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Question 101
Incorrect
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A 55-year-old rancher presents to the ER with his spouse. He is experiencing a high fever and excessive sweating. During the examination, multiple black blisters are observed, which are producing a malodorous discharge. What is the typical microorganism linked to this ailment?
Your Answer:
Correct Answer: Clostridium perfringens
Explanation:Gas gangrene is a severe bacterial infection that can lead to muscle necrosis, sepsis, gas production, and ultimately, death. The infection can occur in two ways: through traumatic or surgical inoculation of a wound with bacteria, or spontaneously, which is often observed in immunocompromised patients. While there are multiple causes of gas gangrene, clostridium perfringens, a type of clostridia species, is frequently implicated. The condition typically begins with pain and progresses to systemic symptoms such as fever and dehydration. Skin changes, including blisters that can burst and produce a foul-smelling discharge, are also common. Movement may produce a crackling sound known as crepitus.
Clostridia: Gram-Positive Anaerobic Bacilli
Clostridia are a group of gram-positive, obligate anaerobic bacilli. There are several species of Clostridia, each with their own unique features and pathologies. C. perfringens produces α-toxin, a lecithinase, which can cause gas gangrene and haemolysis. Symptoms of gas gangrene include tender, oedematous skin with haemorrhagic blebs and bullae, and crepitus may be present on palpation. C. botulinum is typically found in canned foods and honey and can cause flaccid paralysis by preventing the release of acetylcholine. C. difficile is known for causing pseudomembranous colitis, which is often seen after the use of broad-spectrum antibiotics. This species produces both an exotoxin and a cytotoxin. Finally, C. tetani produces an exotoxin called tetanospasmin, which prevents the release of glycine from Renshaw cells in the spinal cord, leading to spastic paralysis.
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This question is part of the following fields:
- Infectious Diseases
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Question 102
Incorrect
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A 42-year-old-woman, who rarely visits the clinic, complains of heartburn and acid reflux for the past 3 weeks. She comes back after taking a PPI for 1 week with some relief. Her BMI is 27 kg/m2. What is the most suitable next step in her treatment?
Your Answer:
Correct Answer: Continue the PPI and review in 2 weeks
Explanation:Management of New-Onset Dyspepsia in a Middle-Aged Patient
When a middle-aged patient presents with new-onset dyspepsia, it is important to take a thorough clinical history to rule out more serious conditions such as malignancy. A 4-week course of full-dose PPI is typically recommended, although there is no clear evidence on whether this or Helicobacter pylori testing should be done first. If PPIs are used, a 2-week washout period is necessary before testing for H. pylori to avoid false-negative results.
While alginate preparations like Gaviscon® can be used to inhibit gastric acid reflux, it may be more appropriate to increase the PPI dose if the patient has already experienced some improvement with this medication. However, if the patient exhibits ‘red flag’ symptoms like gastrointestinal bleeding, anorexia, weight loss, dysphagia, or the presence of an epigastric mass, urgent endoscopy is necessary. Endoscopy is also recommended for patients over 55 with persistent, unexplained dyspepsia that has not responded well to PPIs.
Finally, while this patient’s BMI is on the higher end of the healthy range, referral to a dietician is unlikely to be necessary unless there are specific concerns about weight loss measures. Overall, a comprehensive approach to managing new-onset dyspepsia in middle-aged patients involves careful consideration of symptoms, medication options, and potential underlying conditions.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 103
Incorrect
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A 28-year-old woman has a Mirena intrauterine device inserted for birth control on day 10 of her menstrual cycle. She has not engaged in sexual activity since her last period. What is the duration required before it can be considered a reliable contraceptive method?
Your Answer:
Correct Answer: Immediately
Explanation:Contraceptives – Time to become effective (if not used on the first day of period):
Immediate: IUD
2 days: Progestin-only pill (POP)
7 days: Combined oral contraceptive (COC), injection, implant, intrauterine system (IUS)Intrauterine contraceptive devices include copper IUDs and levonorgestrel-releasing IUS. Both are over 99% effective. The IUD prevents fertilization by decreasing sperm motility, while the IUS prevents endometrial proliferation and thickens cervical mucus. Potential problems include heavier periods with IUDs and initial bleeding with the IUS. There is a small risk of uterine perforation, ectopic pregnancy, and infection. New IUS systems, such as Jaydess® and Kyleena®, have smaller frames and less levonorgestrel, resulting in lower serum levels and different rates of amenorrhea.
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This question is part of the following fields:
- Reproductive Medicine
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Question 104
Incorrect
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A mother who refused regular prenatal check-ups delivers a male infant. During delivery, a defect is observed on the side of the belly button, revealing the intestines.
What could be the possible diagnosis?Your Answer:
Correct Answer: Gastroschisis
Explanation:Gastroschisis is a bowel condition where the intestines are exposed and not encased by a sac. It is not associated with cardiac and kidney diseases, unlike exomphalos. It can be diagnosed through routine ultrasound, but may be missed if the mother does not engage in antenatal care. It is not a normal variant and is not necessarily associated with prematurity.
Gastroschisis and exomphalos are both types of congenital visceral malformations. Gastroschisis refers to a defect in the anterior abdominal wall located just beside the umbilical cord. In contrast, exomphalos, also known as omphalocoele, involves the protrusion of abdominal contents through the anterior abdominal wall, which are covered by an amniotic sac formed by amniotic membrane and peritoneum.
When it comes to managing gastroschisis, vaginal delivery may be attempted, but newborns should be taken to the operating theatre as soon as possible after delivery, ideally within four hours. As for exomphalos, a caesarean section is recommended to reduce the risk of sac rupture. In cases where primary closure is difficult due to lack of space or high intra-abdominal pressure, a staged repair may be undertaken. This involves allowing the sac to granulate and epithelialise over several weeks or months, forming a shell. As the infant grows, the sac contents will eventually fit within the abdominal cavity, at which point the shell can be removed and the abdomen closed.
Overall, both gastroschisis and exomphalos require careful management to ensure the best possible outcome for the newborn. By understanding the differences between these two conditions and the appropriate steps to take, healthcare professionals can provide effective care and support to both the infant and their family.
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This question is part of the following fields:
- Paediatrics
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Question 105
Incorrect
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You are scheduled to evaluate a 56-year-old patient in clinic who was initiated on cholesterol treatment with ezetimibe during his last clinic visit.
Which of the following statements is accurate regarding ezetimibe?Your Answer:
Correct Answer: Its principal action is to reduce intestinal cholesterol absorption
Explanation:Understanding the Mechanism of Action of Ezetimibe: Effects on Cholesterol Absorption, Cytochrome P450 Enzyme System, and Drug Interactions
Ezetimibe is a medication commonly used to lower cholesterol levels in patients with primary cholesterolaemia. Its principal action is to reduce intestinal cholesterol absorption by selectively inhibiting the uptake of cholesterol through the Niemann-Pick C1-like 1 (NPC1L1) protein mediator on small intestine epithelial cells. This mechanism of action also reduces intracellular hepatic cholesterol levels, leading to an upregulation of hepatic low-density lipoprotein receptors (LDLRs) and ultimately lowering plasma cholesterol levels.
Unlike ion-exchange resins, ezetimibe does not decrease the absorption of anionic drugs or fat-soluble vitamins. Additionally, ezetimibe lacks inhibitor or inducer effects on cytochrome P450 isoenzymes, which explains its limited number of drug interactions. However, it is important to note that if used in combination with a statin, there is an increased risk of rhabdomyolysis, which is not seen in ezetimibe monotherapy.
Overall, while ezetimibe has a modest effect on lowering low-density lipoprotein (LDL)-cholesterol, it is most commonly used as an adjunct to dietary measures and statin treatment in primary cholesterolaemia. Understanding its mechanism of action and potential effects on drug interactions and vitamin absorption is crucial for safe and effective use in clinical practice.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 106
Incorrect
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A 27-year-old woman who has never given birth presents to your clinic seeking contraception. She complains of experiencing extremely heavy menstrual periods and desires a long-term contraceptive option that can alleviate her heavy bleeding. What is the most appropriate contraceptive method for this patient?
Your Answer:
Correct Answer: Intrauterine system
Explanation:The Mirena coil is a contraceptive method that reduces the duration and intensity of periods and can be used for an extended period.
Intrauterine contraceptive devices include copper IUDs and levonorgestrel-releasing IUS. Both are over 99% effective. The IUD prevents fertilization by decreasing sperm motility, while the IUS prevents endometrial proliferation and thickens cervical mucus. Potential problems include heavier periods with IUDs and initial bleeding with the IUS. There is a small risk of uterine perforation, ectopic pregnancy, and infection. New IUS systems, such as Jaydess® and Kyleena®, have smaller frames and less levonorgestrel, resulting in lower serum levels and different rates of amenorrhea.
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This question is part of the following fields:
- Reproductive Medicine
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Question 107
Incorrect
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An elderly woman of 74 years old comes in with a vesicular rash surrounding her left eye. The eye appears red and she is experiencing some sensitivity to light. The initial diagnosis is herpes zoster ophthalmicus and an immediate referral to ophthalmology is arranged. What is the probable treatment she will receive?
Your Answer:
Correct Answer: Oral aciclovir
Explanation:If systemic therapy is administered, topical antivirals are unnecessary. However, secondary inflammation may be treated with topical corticosteroids.
Herpes Zoster Ophthalmicus: Symptoms, Treatment, and Complications
Herpes zoster ophthalmicus (HZO) is a condition that occurs when the varicella-zoster virus reactivates in the area supplied by the ophthalmic division of the trigeminal nerve. It is responsible for approximately 10% of shingles cases. The main symptom of HZO is a vesicular rash around the eye, which may or may not involve the eye itself. Hutchinson’s sign, a rash on the tip or side of the nose, is a strong indicator of nasociliary involvement and increases the risk of ocular involvement.
Treatment for HZO involves oral antiviral medication for 7-10 days, ideally started within 72 hours of symptom onset. Intravenous antivirals may be necessary for severe infections or immunocompromised patients. Topical antiviral treatment is not recommended for HZO, but topical corticosteroids may be used to treat any secondary inflammation of the eye. Ocular involvement requires urgent ophthalmology review to prevent complications such as conjunctivitis, keratitis, episcleritis, anterior uveitis, ptosis, and post-herpetic neuralgia.
In summary, HZO is a condition caused by the reactivation of the varicella-zoster virus in the ophthalmic division of the trigeminal nerve. It presents with a vesicular rash around the eye and may involve the eye itself. Treatment involves oral antiviral medication and urgent ophthalmology review is necessary for ocular involvement. Complications of HZO include various eye conditions, ptosis, and post-herpetic neuralgia.
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This question is part of the following fields:
- Ophthalmology
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Question 108
Incorrect
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A 45 year-old-woman of African origin is diagnosed with type II diabetes by her General Practitioner. Her haemoglobin A1c was found to be 58 mmol/mol (normal range < 48 mmol/mol) on routine bloods for her annual hypertension review. Her body mass index (BMI) is 30 kg/m2.
Along with Metformin (an oral hypoglycaemic agent), which of the following is the most appropriate dietary recommendation for this patient?Your Answer:
Correct Answer: Low-fat dairy and oily fish
Explanation:Dietary Recommendations for Type II Diabetes Management
Managing type II diabetes requires a comprehensive approach that includes lifestyle modifications and medication. One crucial aspect of diabetes management is a healthy, balanced diet. The National Institute for Health and Care Excellence (NICE) provides guidelines on dietary recommendations for people with type II diabetes.
Low-fat dairy and oily fish are recommended to control the intake of saturated and trans fatty acids. Oily fish contains Omega-3 fatty acids, which are cardio-protective. High-fibre foods with carbohydrates with a low glycaemic index, such as fruits, vegetables, whole grains, and pulses, are also recommended.
Sucrose-containing foods should be limited, and care should be taken to avoid excess energy intake. NICE discourages the use of foods marketed specifically for people with type II diabetes, as they are often higher in calories.
Weight loss is an essential aspect of diabetes management, particularly for overweight individuals. NICE recommends a weight loss target of 5-10% for overweight adults with type II diabetes. Those who achieve a weight loss of 10% or more in the first five years after diagnosis have the greatest chance of seeing their disease go into remission.
In summary, a healthy, balanced diet that includes low-fat dairy, oily fish, high-fibre foods with low glycaemic index carbohydrates, and limited sucrose-containing foods is crucial for managing type II diabetes. Weight loss is also an essential aspect of diabetes management, particularly for overweight individuals.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 109
Incorrect
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Which of the following is most commonly linked to male infertility?
Your Answer:
Correct Answer: Varicoceles
Explanation:Infertility may be linked to varicoceles.
Understanding Varicocele: Symptoms, Diagnosis, and Management
Varicocele is a medical condition characterized by the abnormal enlargement of the veins in the testicles. Although it is often asymptomatic, it can lead to infertility, making it an important condition to address. Varicoceles are more commonly found on the left side of the testicles, with over 80% of cases occurring on this side. The condition is often described as a bag of worms due to the appearance of the affected veins.
Diagnosis of varicocele is typically done through ultrasound with Doppler studies. This allows doctors to visualize the affected veins and determine the extent of the condition. While conservative management is often recommended, surgery may be necessary if the patient experiences pain or discomfort. However, there is ongoing debate regarding the effectiveness of surgery in treating infertility associated with varicocele.
Overall, understanding varicocele is important for men who may be experiencing infertility or other symptoms related to the condition. With proper diagnosis and management, it is possible to address the issue and improve overall reproductive health.
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This question is part of the following fields:
- Reproductive Medicine
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Question 110
Incorrect
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A 75-year-old man visits the doctor's office accompanied by his wife, who is worried about his well-being. The man has been experiencing episodes of confusion and drowsiness that appear to occur unpredictably for the past five years. Additionally, he has developed a tremor in his right hand on one side of his body. The man's wife reveals that she has slept in a different bed from her husband for the past three decades due to his frequent nightmares. What is the probable diagnosis?
Your Answer:
Correct Answer: Dementia with Lewy bodies
Explanation:The correct answer is Dementia with Lewy bodies, which is a type of dementia that is characterized by fluctuating cognition. This can be confusing as there are different types of dementia, especially non-Alzheimer’s disease dementia. In this case, the man’s symptoms and the classification of dementias point towards DLB. Parkinson’s disease dementia is also a type of dementia that falls under the category of Lewy body dementia, but it is characterized by tremors, bradykinesia, and rigidity that develop before dementia. DLB, on the other hand, presents with dementia before these motor symptoms. Other clues that suggest DLB include the man’s periods of confusion and sleepiness that come and go randomly, as well as his wife’s report of him suffering from bad nightmares, which is a distinctive feature of DLB. In contrast, Alzheimer’s disease dementia typically presents with slowly worsening memory loss and forgetfulness, while frontal lobe dementia primarily presents with behavioural changes and reckless behaviour.
Understanding Lewy Body Dementia
Lewy body dementia is a type of dementia that is becoming more recognized as a cause of cognitive impairment, accounting for up to 20% of cases. It is characterized by the presence of alpha-synuclein cytoplasmic inclusions, known as Lewy bodies, in certain areas of the brain. While there is a complicated relationship between Parkinson’s disease and Lewy body dementia, with dementia often seen in Parkinson’s disease, the two conditions are distinct. Additionally, up to 40% of patients with Alzheimer’s disease have Lewy bodies.
The features of Lewy body dementia include progressive cognitive impairment, which typically occurs before parkinsonism, but both features usually occur within a year of each other. Unlike other forms of dementia, cognition may fluctuate, and early impairments in attention and executive function are more common than memory loss. Other features include parkinsonism, visual hallucinations, and sometimes delusions and non-visual hallucinations.
Diagnosis of Lewy body dementia is usually clinical, but single-photon emission computed tomography (SPECT) can be used to confirm the diagnosis. Management of Lewy body dementia involves the use of acetylcholinesterase inhibitors and memantine, similar to Alzheimer’s disease. However, neuroleptics should be avoided as patients with Lewy body dementia are extremely sensitive and may develop irreversible parkinsonism. It is important to carefully consider the use of medication in these patients to avoid worsening their condition.
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This question is part of the following fields:
- Neurology
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Question 111
Incorrect
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A 7-year-old boy is brought to the Emergency Department in December because, for the past three days, he has had a high fever (up to 40 °C), vomiting and night sweats. For the last four weeks, he has been lethargic and has sweated through his pyjamas almost every night. He has had several nosebleeds in this time period, which his parents attributed to dry air from the heater. He has also been complaining that his back hurts.
On examination, his temperature is 39.5 °C, his heart rate 140 beats per minute, his blood pressure is 80/60 mmHg and his respiratory rate 20 breaths per minute. He appears acutely ill, and you notice small petechiae on his abdomen.
Which one of the following would an examination of peripheral lymphocytes most likely show?Your Answer:
Correct Answer: A clonal population of immature cells expressing terminal deoxynucleotidyl transferase (TdT)
Explanation:Acute lymphoblastic leukemia (ALL) is a common pediatric cancer that occurs due to the clonal expansion of immature T lymphocytes expressing terminal deoxynucleotidyl transferase (TdT). This protein is involved in gene rearrangements during T-cell receptor and immunoglobulin development and is no longer expressed after maturation. Symptoms include hepatosplenomegaly, lymphadenopathy, bruising, fatigue, joint and bone pain, bleeding, and infections. Diagnosis is made through bone marrow aspirate and biopsy, and treatment involves pegaspargase, which interferes with malignant cell growth. Hairy cell leukemia is characterized by lymphocytes with thin cytoplasmic projections and is mostly seen in middle-aged men. Chronic myeloid leukemia is caused by a chromosomal translocation leading to a constitutively active tyrosine kinase, treated with imatinib. Promyelocytic leukemia is an aggressive form of acute myeloid leukemia with a clonal population of immature cells containing Auer rods. Chronic lymphocytic leukemia is characterized by a clonal population of mature B cells, often seen in the elderly population and referred to as smudge cells on peripheral smear.
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This question is part of the following fields:
- Haematology/Oncology
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Question 112
Incorrect
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A 1-year-old child is diagnosed with multiple congenital abnormalities such as an extra finger on each hand, microphthalmia, microcephaly, and cleft palate and lip. Which chromosome is most likely to be affected in this case?
Your Answer:
Correct Answer: 13
Explanation:A newborn has been diagnosed with Patau syndrome, which is caused by an extra full copy of chromosome 13 (trisomy 13). This chromosomal abnormality often results in physical and mental disabilities, with distinguishing features including polydactyly, cleft lips and palates, microcephaly, and microphthalmia. Unfortunately, many infants with Patau syndrome do not survive beyond their first year of life. Those who do survive often experience intellectual and motor disabilities.
Childhood syndromes are a group of medical conditions that affect children and are characterized by a set of common features. Patau syndrome, also known as trisomy 13, is a syndrome that is characterized by microcephaly, small eyes, cleft lip/palate, polydactyly, and scalp lesions. Edward’s syndrome, also known as trisomy 18, is characterized by micrognathia, low-set ears, rocker bottom feet, and overlapping of fingers. Fragile X syndrome is characterized by learning difficulties, macrocephaly, long face, large ears, and macro-orchidism. Noonan syndrome is characterized by a webbed neck, pectus excavatum, short stature, and pulmonary stenosis. Pierre-Robin syndrome is characterized by micrognathia, posterior displacement of the tongue, and cleft palate. Prader-Willi syndrome is characterized by hypotonia, hypogonadism, and obesity. William’s syndrome is characterized by short stature, learning difficulties, friendly, extrovert personality, and transient neonatal hypercalcaemia. Cri du chat syndrome, also known as chromosome 5p deletion syndrome, is characterized by a characteristic cry, feeding difficulties and poor weight gain, learning difficulties, microcephaly and micrognathism, and hypertelorism. It is important to note that Treacher-Collins syndrome is similar to Pierre-Robin syndrome, but it is autosomal dominant and usually has a family history of similar problems.
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This question is part of the following fields:
- Paediatrics
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Question 113
Incorrect
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A 25-year-old actress visits your clinic seeking advice on contraception. She expresses concern about weight gain as she needs to maintain her figure for her profession. Which contraceptive method has been linked to weight gain?
Your Answer:
Correct Answer: Depo Provera (Medroxyprogesterone acetate)
Explanation:Weight gain is a known side effect of the Depo Provera contraceptive method. Additionally, it may take up to a year for fertility to return after discontinuing use, and there is an increased risk of osteoporosis and irregular bleeding. Other contraceptive methods such as the combined pill, progesterone only pill, and subdermal implant do not have a proven link to weight gain.
Injectable Contraceptives: Depo Provera
Injectable contraceptives are a popular form of birth control in the UK, with Depo Provera being the main option available. This contraceptive contains 150mg of medroxyprogesterone acetate and is administered via intramuscular injection every 12 weeks. It can be given up to 14 weeks after the last dose without the need for extra precautions. The primary method of action is by inhibiting ovulation, while secondary effects include cervical mucus thickening and endometrial thinning.
However, there are some disadvantages to using Depo Provera. Once the injection is given, it cannot be reversed, and there may be a delayed return to fertility of up to 12 months. Adverse effects may include irregular bleeding and weight gain, and there is a potential increased risk of osteoporosis. It should only be used in adolescents if no other method of contraception is suitable.
It is important to note that there are contraindications to using Depo Provera, such as current breast cancer (UKMEC 4) or past breast cancer (UKMEC 3). While Noristerat is another injectable contraceptive licensed in the UK, it is rarely used in clinical practice and is given every 8 weeks. Overall, injectable contraceptives can be an effective form of birth control, but it is important to weigh the potential risks and benefits before deciding on this method.
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This question is part of the following fields:
- Reproductive Medicine
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Question 114
Incorrect
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As a foundation doctor in general practice, you assess a thirty-three-year-old woman who presents with muscle weakness and erythematous, keratotic macules on her interphalangeal joints. She reports a family history of osteoarthritis. Can you describe the changes observed on her hands?
Your Answer:
Correct Answer: Gottron's papules
Explanation:The presence of roughened red papules over the knuckles, known as Gottron’s papules, is indicative of dermatomyositis. This patient’s description of muscle weakness and associated skin changes suggests that she may have this condition. Bouchard’s and Heberden’s nodes, on the other hand, are associated with osteoarthritis and present as painless swellings of the proximal and distal interphalangeal joints, respectively. Macular lesions on the palms, such as Osler nodes and janeway lesions, are linked to endocarditis. Osler nodes are painful and caused by immune complex deposition, while janeway lesions are painless and caused by septic emboli.
Dermatomyositis is a condition that causes inflammation and muscle weakness, as well as distinct skin lesions. It can occur on its own or be associated with other connective tissue disorders or underlying cancers, particularly ovarian, breast, and lung cancer. Screening for cancer is often done after a diagnosis of dermatomyositis. Polymyositis is a variant of the disease that does not have prominent skin manifestations.
The skin features of dermatomyositis include a photosensitive macular rash on the back and shoulders, a heliotrope rash around the eyes, roughened red papules on the fingers’ extensor surfaces (known as Gottron’s papules), extremely dry and scaly hands with linear cracks on the fingers’ palmar and lateral aspects (known as mechanic’s hands), and nail fold capillary dilatation. Other symptoms may include proximal muscle weakness with tenderness, Raynaud’s phenomenon, respiratory muscle weakness, interstitial lung disease (such as fibrosing alveolitis or organizing pneumonia), dysphagia, and dysphonia.
Investigations for dermatomyositis typically involve testing for ANA antibodies, which are positive in around 80% of patients. Approximately 30% of patients have antibodies to aminoacyl-tRNA synthetases, including antibodies against histidine-tRNA ligase (also called Jo-1), antibodies to signal recognition particle (SRP), and anti-Mi-2 antibodies.
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This question is part of the following fields:
- Musculoskeletal
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Question 115
Incorrect
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A 40-year-old man complains of pain in his right eye that worsens with movement. Upon examination, a relative afferent pupillary defect is observed. What is the most probable reason for his symptoms?
Your Answer:
Correct Answer: Multiple sclerosis
Explanation:Optic neuritis is a condition that can be caused by multiple sclerosis, diabetes, or syphilis. It is characterized by a decrease in visual acuity in one eye over a period of hours or days, as well as poor color discrimination and pain that worsens with eye movement. Other symptoms include a relative afferent pupillary defect and a central scotoma. The condition can be diagnosed through an MRI of the brain and orbits with gadolinium contrast. Treatment typically involves high-dose steroids, and recovery usually takes 4-6 weeks. If an MRI shows more than three white-matter lesions, the risk of developing multiple sclerosis within five years is approximately 50%.
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This question is part of the following fields:
- Ophthalmology
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Question 116
Incorrect
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As the GPST1 in the emergency department, you are requested to assess a 34-year-old woman who fell and struck her head while drinking three hours ago. Your consultant instructs you to confirm the absence of any clinical indications of a base of skull fracture. Which of the following is not linked to a base of skull injury?
Your Answer:
Correct Answer: Stellwag's sign
Explanation:The base of the skull is made up of three bony fossae: the anterior, middle, and posterior. These structures provide support for various internal structures within the cranium. If these bones are fractured, it can result in damage to associated neurovascular structures, which can have external manifestations in areas such as the nasal cavity or auditory canal. Bleeding from ruptured vessels can lead to haemotympanum or Battle’s sign in the mastoid area, while ruptured CSF spaces can cause CSF rhinorrhoea and otorrhoea. Stellwag’s sign, on the other hand, is not related to base of skull trauma and refers to reduced blinking.
Patients with head injuries should be managed according to ATLS principles and extracranial injuries should be managed alongside cranial trauma. There are different types of traumatic brain injuries, including extradural hematoma, subdural hematoma, and subarachnoid hemorrhage. Primary brain injury may be focal or diffuse, and secondary brain injury can occur due to cerebral edema, ischemia, infection, or herniation. Management may include IV mannitol/frusemide, decompressive craniotomy, and ICP monitoring. Pupillary findings can provide information on the location and severity of the injury.
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This question is part of the following fields:
- ENT
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Question 117
Incorrect
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A 72-year-old male presents to the emergency department with complaints of new-onset pain in his left groin. Upon examination, a large, warm, non-reducible mass located inferolateral to the pubic tubercle is observed, accompanied by erythema of the overlying skin. The patient reports vomiting twice and passing stools with blood mixed in them once. He appears to be in pain and is sweating profusely. His medical history includes peptic ulcer disease, which is managed with omeprazole. What is the most likely diagnosis?
Your Answer:
Correct Answer: Strangulated femoral hernia
Explanation:A femoral hernia can lead to the serious complication of strangulation. In this case, the patient has a non-reducible mass located below the pubic tubercle, which is typical of a femoral hernia. However, the accompanying symptoms of vomiting, bloody stools, and a toxic appearance suggest that the hernia has become strangulated, meaning that the blood supply to the herniated tissue has been compromised and may lead to tissue death.
An incarcerated femoral hernia would also present as a non-reducible mass below the pubic tubercle, but without the symptoms of strangulation.
In contrast, an incarcerated inguinal hernia would present as a non-reducible mass above and towards the middle of the pubic tubercle, and would not cause symptoms of strangulation.
A perforated peptic ulcer would cause pain in the upper abdomen, syncope, and possibly vomiting blood, which is different from the patient’s symptoms.
Similarly, a strangulated inguinal hernia would cause similar symptoms, but the mass would be located above and towards the middle of the pubic tubercle, rather than below it.
Understanding Femoral Hernias
Femoral hernias occur when a part of the bowel or other abdominal organs pass through the femoral canal, which is a potential space in the anterior thigh. This can result in a lump in the groin area that is mildly painful and typically non-reducible. Femoral hernias are less common than inguinal hernias, accounting for only 5% of abdominal hernias, and are more prevalent in women, especially those who have had multiple pregnancies. Diagnosis is usually clinical, but ultrasound may be used to confirm the presence of a femoral hernia and exclude other possible causes of a lump in the groin area.
Complications of femoral hernias include incarceration, where the herniated tissue cannot be reduced, and strangulation, which is a surgical emergency. The risk of strangulation is higher with femoral hernias than with inguinal hernias and increases over time. Bowel obstruction and bowel ischaemia may also occur, leading to significant morbidity and mortality for the patient.
Surgical repair is necessary for femoral hernias, and it can be done laparoscopically or via a laparotomy. Hernia support belts or trusses should not be used for femoral hernias due to the risk of strangulation. In an emergency situation, a laparotomy may be the only option. It is essential to distinguish femoral hernias from inguinal hernias, as they have different locations and require different management approaches.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 118
Incorrect
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A 79-year-old man presents to the emergency department with persistent left-sided epistaxis following a fall and hitting his nose on a door. He has a medical history of hypertension managed with amlodipine, atrial fibrillation managed with apixaban, stroke, and type 2 diabetes managed with metformin. On examination, he has active bleeding from the left anterior nasal septum and is spitting blood. Despite attempting to control the bleeding by squeezing his nose for 30 minutes and inserting a Rapid Rhino, the bleeding persists. What is an indication for surgical intervention in this case?
Your Answer:
Correct Answer: Failure of nasal packing
Explanation:If all emergency measures fail to stop epistaxis, sphenopalatine ligation in a surgical setting may be necessary.
To manage epistaxis in an emergency, it is important to provide adequate first aid for at least 20 minutes by firmly squeezing both nasal ala and sitting forward. Ice in the mouth can also be helpful. Topical adrenaline and local anaesthetic, as well as topical tranexamic acid, can be applied. If these measures are unsuccessful, nasal packing with devices such as Rapid Rhino may be necessary. If the bleeding persists, a posterior pack or Foley catheter may be used. In cases where all of these measures fail, surgical intervention such as sphenopalatine artery ligation may be required.
Understanding Epistaxis: Causes and Management
Epistaxis, commonly known as nosebleeds, can be categorized into anterior and posterior bleeds. Anterior bleeds usually have a visible source of bleeding and occur due to an injury to the network of capillaries that form Kiesselbach’s plexus. On the other hand, posterior haemorrhages tend to be more severe and originate from deeper structures. They are more common in older patients and pose a higher risk of aspiration and airway obstruction.
Most cases of epistaxis are benign and self-limiting. However, certain factors can exacerbate the condition, such as nose picking, nose blowing, trauma to the nose, insertion of foreign bodies, bleeding disorders, and immune thrombocytopenia. Other causes include the use of cocaine, hereditary haemorrhagic telangiectasia, and granulomatosis with polyangiitis.
If the patient is haemodynamically stable, bleeding can be controlled with first aid measures. This involves asking the patient to sit with their torso forward and their mouth open, pinching the cartilaginous area of the nose firmly for at least 20 minutes, and using a topical antiseptic to reduce crusting and the risk of vestibulitis. If bleeding persists, cautery or packing may be necessary. Patients should be advised to avoid activities that increase the risk of re-bleeding.
In cases where emergency management fails, sphenopalatine ligation in theatre may be required. Patients with unknown or posterior sources of bleeding should be admitted to the hospital for observation and review. Overall, understanding the causes and management of epistaxis is crucial in providing effective care for patients experiencing this condition.
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This question is part of the following fields:
- ENT
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Question 119
Incorrect
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A 55-year-old man presents to the respiratory clinic for a follow-up on his chronic obstructive pulmonary disease. He has a history of chronic CO2 retention and his oxygen saturation goals are between 88-92%. Upon examination, his chest sounds are quiet throughout, with equal air expansion, and a hyper-expanded chest. His oxygen saturation levels are at 91% on air. The clinic performs an arterial blood gas test.
What would be the most likely blood gas results for this patient?Your Answer:
Correct Answer: pH = 7.37, pO2 = 9.1 kPa, pCO2 = 6.1 kPa, HCO3- = 30 mmol/l
Explanation:Arterial Blood Gas Interpretation Made Easy
Arterial blood gas interpretation can be a daunting task for healthcare professionals. However, the Resuscitation Council (UK) has provided a simple 5-step approach to make it easier. The first step is to assess the patient’s overall condition. The second step is to determine if the patient is hypoxaemic, which is indicated by a PaO2 level of less than 10 kPa on air. The third step is to check if the patient is acidaemic or alkalaemic, which is determined by the pH level. A pH level of less than 7.35 indicates acidaemia, while a pH level of more than 7.45 indicates alkalaemia.
The fourth step is to assess the respiratory component by checking the PaCO2 level. A PaCO2 level of more than 6.0 kPa suggests respiratory acidosis, while a PaCO2 level of less than 4.7 kPa suggests respiratory alkalosis. The fifth and final step is to evaluate the metabolic component by checking the bicarbonate level or base excess. A bicarbonate level of less than 22 mmol/l or a base excess of less than -2mmol/l indicates metabolic acidosis, while a bicarbonate level of more than 26 mmol/l or a base excess of more than +2mmol/l indicates metabolic alkalosis.
To make it easier to remember, healthcare professionals can use the ROME acronym. Respiratory is opposite, which means that low pH and high PaCO2 indicate acidosis, while high pH and low PaCO2 indicate alkalosis. Metabolic is equal, which means that low pH and low bicarbonate indicate acidosis, while high pH and high bicarbonate indicate alkalosis. By following this simple approach, healthcare professionals can easily interpret arterial blood gas results and provide appropriate treatment for their patients.
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This question is part of the following fields:
- Respiratory Medicine
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Question 120
Incorrect
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A 68-year-old psychiatric patient is brought to the Emergency Room, complaining of excessive thirst. He is carrying multiple shopping bags and has spent a significant amount of money. Blood tests reveal a urea level of 20.5 mmol/l (reference range 2.5–7.1 mmol/l), a creatinine level of 190 μmol/l (reference range 53–106 μmol/l) and a sodium level of 144 mmol/l (reference range 135–145 mmol/l). Urinary osmolality is low.
What is the most likely diagnosis based on this clinical presentation?Your Answer:
Correct Answer: Nephrogenic diabetes insipidus (DI)
Explanation:Medical Conditions Explained: Nephrogenic Diabetes Insipidus, Cranial Diabetes Insipidus, Chronic Reflux Nephropathy, Syndrome of Inappropriate Antidiuretic Hormone Secretion, and Psychogenic Polydipsia
Nephrogenic Diabetes Insipidus (DI)
Nephrogenic DI is a condition where the kidneys are unable to concentrate urine due to resistance to the action of antidiuretic hormone (ADH). This can be caused by lithium toxicity, which is commonly used to treat bipolar affective disorder. Symptoms include passing large volumes of dilute urine and a urinary specific gravity of 1.005 or less. Treatment involves replacing fluid losses with dextrose and water or hypo-osmolar intravenous fluids, as well as a low-protein, low-sodium diet. Alternative medication to lithium may be considered after consultation with a psychiatrist.Cranial Diabetes Insipidus
Cranial DI, also known as central or neurogenic DI, is caused by decreased secretion of ADH, resulting in polyuria and polydipsia. Urine osmolality will be less than 300 mOsm/kg after a water deprivation test, and will rise to over 750 mOsm/kg after ADH administration.Chronic Reflux Nephropathy
Reflux nephropathy is a condition where urine flows back from the bladder to the kidneys, causing renal damage. It is typically seen in children with urinary tract abnormalities, but can also occur with conditions that obstruct urine flow. Symptoms include those of nephrotic syndrome and urinary tract infections, but this diagnosis is not consistent with the clinical presentation in this scenario.Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)
SIADH is characterized by hyponatremia and hypo-osmolality due to excessive secretion or action of ADH, resulting in impaired water excretion. However, the patient in this scenario is presenting with hypernatremia, which is not consistent with SIADH.Psychogenic Polydipsia
Psychogenic polydipsia is excessive fluid intake without physiological stimuli, often caused by psychiatric disorders such as schizophrenia or bipolar affective disorder. It is accompanied by the sensation of dry mouth. -
This question is part of the following fields:
- Renal Medicine/Urology
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Question 121
Incorrect
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A 38-year-old, atopic, healthcare worker presents with red wheals and itchy hands within 20 minutes of wearing latex gloves.
Which of the following is the most appropriate investigation to perform to establish a diagnosis?Your Answer:
Correct Answer: Radioallergosorbent test (RAST)
Explanation:Diagnosis of Latex Allergy: Tests and Considerations
Latex allergy is an immediate hypersensitivity reaction that is IgE-mediated. The diagnosis of latex allergy involves various tests and considerations. The first choice test for results on latex-specific IgE is the Radioallergosorbent test (RAST). Skin-prick testing with latex extracts is sensitive, specific, and rapid, but carries the risk of anaphylaxis. Skin-patch testing is useful in identifying specific allergens in patients with type IV hypersensitivity to latex products. A gluten exclusion diet would not be the most appropriate investigation if latex allergy were suspected. Complement-mediated and immune complex reactions typically produce vascular damage, so bullae and petechiae would predominate in the skin. In summary, the diagnosis of latex allergy requires careful consideration of the type of hypersensitivity reaction and appropriate testing.
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This question is part of the following fields:
- Immunology/Allergy
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Question 122
Incorrect
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A 70-year-old patient was discovered to have an abdominal aortic aneurysm during a routine medical check-up. The patient is currently receiving treatment for hypertension and high cholesterol but is otherwise healthy and medically capable. The aneurysm was infra-renal and had a diameter of 4.9 cm.
What is the best course of action for managing this patient?Your Answer:
Correct Answer: Ultrasound scan every three months
Explanation:Screening and Management of Abdominal Aortic Aneurysms
Abdominal aortic aneurysms (AAAs) are screened for initially by an ultrasound scan of the abdomen. Men are invited for an initial ultrasound during the year of their 65th birthday, while women are not routinely screened as AAA is predominantly found in men.
If the initial scan shows an AAA of less than 3 cm, patients are discharged. If it is between 3 and 4.4 cm, they are invited back for yearly screening. If it is between 4.5 and 5.4 cm, patients receive an ultrasound scan every three months. If the aneurysm is above 5.5 cm, patients are referred to a vascular surgeon for consideration for repair.
Elective surgery is recommended for aneurysms larger than 5.5 cm in diameter or those that are growing rapidly, as clinical trials have shown that the risk of rupture is increased when the aneurysm is larger than 5.5 cm. Immediate surgery is only performed on those aneurysms that are leaking or ruptured.
Surveillance is required to ensure the aneurysm remains below 5.5 cm. Patients with an aneurysm over 4.5 cm require an ultrasound scan every three months. Once the aneurysm reaches 5.5 cm, patients are referred for consideration of elective surgery.
Managing Abdominal Aortic Aneurysms: Screening and Treatment Guidelines
Abdominal aortic aneurysms (AAAs) are a serious health concern that require careful management. This article outlines the screening and treatment guidelines for AAAs.
Screening for AAAs is done initially by an ultrasound scan of the abdomen. Men are invited for an initial ultrasound during the year of their 65th birthday, while women are not routinely screened. Patients with an AAA less than 3 cm are discharged, while those with an AAA between 3 and 4.4 cm are invited back for yearly screening. Patients with an AAA between 4.5 and 5.4 cm require an ultrasound scan every three months, while those with an AAA over 5.5 cm are referred to a vascular surgeon for consideration of elective surgery.
Elective surgery is recommended for aneurysms larger than 5.5 cm in diameter or those that are growing rapidly.
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This question is part of the following fields:
- Cardiovascular
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Question 123
Incorrect
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A 50-year-old woman with a history of multiple sclerosis for a few years has been struggling with increased muscle stiffness and trouble with fluid movements. Despite taking baclofen for a year, there has been no improvement. What medication should be considered next to alleviate these symptoms?
Your Answer:
Correct Answer: Gabapentin
Explanation:Spasticity in multiple sclerosis is caused by demyelination along the nerves that control movement, resulting in stiffness that can sometimes be helpful but can also become painful. Physiotherapy exercises are the simplest and most effective treatment, but first-line medications such as baclofen and gabapentin are also recommended. Gabapentin is an anticonvulsant that can be effective against muscle spasms, while diazepam is a muscle relaxant that may be more useful at night due to side effects at higher doses. Botulinum toxin and dantrolene sodium can be considered if conventional treatments prove ineffective, but are not used as first-line for spasticity. The NICE multiple sclerosis guideline recommends gabapentin as one of the first drugs to try in the treatment of spasms and spasticity.
Multiple sclerosis is a condition that cannot be cured, but its treatment aims to reduce the frequency and duration of relapses. In the case of an acute relapse, high-dose steroids may be administered for five days to shorten its length. However, it is important to note that steroids do not affect the degree of recovery. Disease-modifying drugs are used to reduce the risk of relapse in patients with MS. These drugs are typically indicated for patients with relapsing-remitting disease or secondary progressive disease who have had two relapses in the past two years and are able to walk a certain distance unaided. Natalizumab, ocrelizumab, fingolimod, beta-interferon, and glatiramer acetate are some of the drugs used to reduce the risk of relapse in MS.
Fatigue is a common problem in MS patients, and amantadine is recommended by NICE after excluding other potential causes such as anaemia, thyroid problems, or depression. Mindfulness training and CBT are other options for managing fatigue. Spasticity is another issue that can be addressed with first-line drugs such as baclofen and gabapentin, as well as physiotherapy. Cannabis and botox are currently being evaluated for their effectiveness in managing spasticity. Bladder dysfunction is also a common problem in MS patients, and anticholinergics may worsen symptoms in some patients. Ultrasound is recommended to assess bladder emptying, and intermittent self-catheterisation may be necessary if there is significant residual volume. Gabapentin is the first-line treatment for oscillopsia, which is a condition where visual fields appear to oscillate.
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This question is part of the following fields:
- Neurology
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Question 124
Incorrect
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Which of the following is a side-effect of lithium therapy?
Your Answer:
Correct Answer: Hypothyroidism
Explanation:Understanding the Side-Effects of Lithium Maintenance Therapy
Lithium maintenance therapy is a common treatment for bipolar disorder, but it can also cause a range of side-effects. One of the most common is hypothyroidism, which affects up to 5% of patients on lithium and requires regular thyroid function tests. Weight gain, acne, tremors, and polydipsia are also common, as well as ankle edema and a metallic taste in the mouth. Lithium can also cause renal toxicity, so regular urea and electrolyte tests are necessary. However, lithium does not cause abnormal liver function or fever, and actually causes leukocytosis rather than leucopenia. Cystitis is also not a typical side-effect of lithium. Overall, understanding the potential side-effects of lithium maintenance therapy is crucial for managing bipolar disorder effectively.
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This question is part of the following fields:
- Psychiatry
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Question 125
Incorrect
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A 28-year-old professional basketball player presents with complaints of feeling lightheaded during exercise. Upon physical examination, a laterally displaced apical impulse is noted. Auscultation reveals a 2/6 mid-systolic murmur in the mitral area that increases upon sudden standing. The ECG shows LVH and Q waves in V1–4 leads.
What is the most probable diagnosis?Your Answer:
Correct Answer: Hypertrophic cardiomyopathy
Explanation:Differential Diagnosis for a Patient with Dyspnoea and a Murmur: Hypertrophic Cardiomyopathy
Hypertrophic cardiomyopathy is a condition that can lead to sudden death in young athletes and is characterized by dyspnoea, LVH, and a loud S4. The systolic murmur associated with hypertrophic cardiomyopathy does not radiate to the carotids and can be differentiated from aortic stenosis, which causes a crescendo-decrescendo murmur that does radiate to the carotids. Young-onset hypertension is unlikely to cause a murmur, and acute myocardial infarction would show ST elevation or depression on ECG, but not LVH. Atrial septal defect is usually picked up in newborn checks and presents with a brief murmur in early systole and early diastole, while hypertrophic cardiomyopathy presents with a double or triple apical impulse and a characteristic jerky carotid pulse. It is important to recognize the symptoms and signs of hypertrophic cardiomyopathy to prevent sudden death in young athletes.
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This question is part of the following fields:
- Cardiovascular
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Question 126
Incorrect
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A 32-year-old patient with a history of psoriasis complains of redness in the groin and genital region, as well as in the axilla. The patient has previously mentioned a distaste for creams that are messy or difficult to use. What is the best course of treatment?
Your Answer:
Correct Answer: Topical steroid
Explanation:Topical steroids are effective in treating flexural psoriasis in this patient.
NICE recommends a step-wise approach for chronic plaque psoriasis, starting with regular emollients and then using a potent corticosteroid and vitamin D analogue separately, followed by a vitamin D analogue twice daily, and then a potent corticosteroid or coal tar preparation if there is no improvement. Phototherapy, systemic therapy, and topical treatments are also options for management. Topical steroids should be used cautiously and vitamin D analogues may be used long-term. Dithranol and coal tar have adverse effects but can be effective.
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This question is part of the following fields:
- Dermatology
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Question 127
Incorrect
-
A 68-year-old man complains of a burning sensation around his left eye. Upon examination, a rash with erythematous blisters is visible in the left trigeminal distribution. What is the probable diagnosis?
Your Answer:
Correct Answer: Herpes zoster ophthalmicus
Explanation:Herpes Zoster Ophthalmicus: Symptoms, Treatment, and Complications
Herpes zoster ophthalmicus (HZO) is a condition that occurs when the varicella-zoster virus reactivates in the area supplied by the ophthalmic division of the trigeminal nerve. It is responsible for approximately 10% of shingles cases. The main symptom of HZO is a vesicular rash around the eye, which may or may not involve the eye itself. Hutchinson’s sign, a rash on the tip or side of the nose, is a strong indicator of nasociliary involvement and increases the risk of ocular involvement.
Treatment for HZO involves oral antiviral medication for 7-10 days, ideally started within 72 hours of symptom onset. Intravenous antivirals may be necessary for severe infections or immunocompromised patients. Topical antiviral treatment is not recommended for HZO, but topical corticosteroids may be used to treat any secondary inflammation of the eye. Ocular involvement requires urgent ophthalmology review to prevent complications such as conjunctivitis, keratitis, episcleritis, anterior uveitis, ptosis, and post-herpetic neuralgia.
In summary, HZO is a condition caused by the reactivation of the varicella-zoster virus in the ophthalmic division of the trigeminal nerve. It presents with a vesicular rash around the eye and may involve the eye itself. Treatment involves oral antiviral medication and urgent ophthalmology review is necessary for ocular involvement. Complications of HZO include various eye conditions, ptosis, and post-herpetic neuralgia.
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This question is part of the following fields:
- Ophthalmology
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Question 128
Incorrect
-
Each one of the following is a recognised complication of gastro-oesophageal reflux disease, except:
Your Answer:
Correct Answer: Achalasia
Explanation:Managing Gastro-Oesophageal Reflux Disease
Gastro-oesophageal reflux disease (GORD) is a condition where gastric contents cause symptoms of oesophagitis. If GORD has not been investigated with endoscopy, it should be treated according to dyspepsia guidelines. However, if oesophagitis is confirmed through endoscopy, a full dose proton pump inhibitor (PPI) should be given for 1-2 months. If there is a positive response, low dose treatment may be given as required. If there is no response, double-dose PPI should be given for 1 month.
On the other hand, if endoscopy shows negative reflux disease, a full dose PPI should be given for 1 month. If there is a positive response, low dose treatment may be given on an as-required basis with a limited number of repeat prescriptions. If there is no response, H2RA or prokinetic should be given for one month.
Complications of GORD include oesophagitis, ulcers, anaemia, benign strictures, Barrett’s oesophagus, and oesophageal carcinoma. Therefore, it is important to manage GORD effectively to prevent these complications.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 129
Incorrect
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A 65-year-old female presents to her GP with a 4-week history of bilateral shoulder pain. She also experiences stiffness in her shoulders in the morning which improves throughout the day. She reports feeling generally fatigued. No other joints are affected. The patient has a history of osteoarthritis in her left knee.
During examination, the patient's observations are normal. There is no swelling or redness in the shoulders, and she has a full range of motion bilaterally. Upper limb power is 5/5 bilaterally with normal sensation.
Based on the patient's history and examination, what is the most likely diagnosis?Your Answer:
Correct Answer: Polymyalgia rheumatica
Explanation:The patient’s symptoms are suggestive of polymyalgia rheumatica (PMR), which is a common inflammatory condition in older adults. The sudden onset of pain and stiffness in the shoulders and hips, along with systemic symptoms such as fatigue and anorexia, are typical of PMR. Osteoarthritis, fibromyalgia, hypothyroidism, and adhesive capsulitis are less likely diagnoses, as they do not typically present with acute onset of symptoms or systemic involvement. However, it is important to rule out hypothyroidism by checking thyroid function. Frozen shoulder may cause shoulder pain and stiffness, but it is usually associated with restricted range of motion and does not typically cause systemic symptoms.
Polymyalgia Rheumatica: A Condition of Muscle Stiffness in Older People
Polymyalgia rheumatica (PMR) is a common condition that affects older people. It is characterized by muscle stiffness and elevated inflammatory markers. Although it is closely related to temporal arteritis, the underlying cause is not fully understood, and it does not appear to be a vasculitic process. PMR typically affects patients over the age of 60 and has a rapid onset, usually within a month. Patients experience aching and morning stiffness in proximal limb muscles, along with mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, and night sweats.
To diagnose PMR, doctors look for raised inflammatory markers, such as an ESR of over 40 mm/hr. Creatine kinase and EMG are normal. Treatment for PMR involves prednisolone, usually at a dose of 15mg/od. Patients typically respond dramatically to steroids, and failure to do so should prompt consideration of an alternative diagnosis.
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This question is part of the following fields:
- Musculoskeletal
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Question 130
Incorrect
-
In an adult patient with Marfan syndrome, what is the most frequently observed cardiovascular abnormality?
Your Answer:
Correct Answer: Aortic root dilatation
Explanation:Marfan Syndrome: A Connective Tissue Disorder with Cardiovascular Manifestations
Marfan syndrome is an autosomal dominant connective tissue disorder that presents with a wide range of clinical manifestations. The ocular, skeletal, and cardiovascular systems are characteristically involved. Aortic root dilatation, occurring in 70-80% of cases, is the most common cardiovascular manifestation, followed by mitral valve prolapse at 60-70%. Mitral annular calcification is less common, occurring in 8-15% of cases. Aortic dissection, accounting for around 5% of all cases, is more likely in patients with Marfan syndrome, especially those with severe aortic root dilatation.
The weakening of the aortic media leads to a fusiform ascending aortic aneurysm, which may be complicated by aortic regurgitation and aortic dissection. Mitral regurgitation can result from mitral valve prolapse, dilatation of a mitral valve annulus, or mitral annular calcification. Pregnancy is particularly hazardous for patients with Marfan syndrome. Treatment with β blockers can reduce the rate of aortic dilatation and the risk of rupture.
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This question is part of the following fields:
- Cardiovascular
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Question 131
Incorrect
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Which one of the following is true regarding anti-tuberculous therapy?
Your Answer:
Correct Answer: Visual acuity should be checked before starting ethambutol
Explanation:Rifampicin has a strong ability to induce liver enzymes. During the initial two months of treatment, Pyrazinamide should be administered, but it may cause hepatitis and gout as side effects. Isoniazid may cause peripheral neuropathy as a side effect.
Managing Tuberculosis: Treatment and Complications
Tuberculosis is a serious infectious disease that requires prompt and effective treatment. The standard therapy for active tuberculosis involves an initial phase of two months, during which patients are given a combination of four drugs: rifampicin, isoniazid, pyrazinamide, and ethambutol. The continuation phase lasts for four months and involves the use of rifampicin and isoniazid. Patients with latent tuberculosis are typically treated with a combination of isoniazid and rifampicin for three or six months, depending on the severity of the infection.
In some cases, patients may require prolonged treatment, particularly if they have meningeal tuberculosis. Steroids may be added to the treatment regimen in these cases. Directly observed therapy may also be necessary for certain groups, such as homeless individuals, prisoners, and patients who are likely to have poor concordance.
While tuberculosis treatment is generally effective, there are some potential complications to be aware of. Immune reconstitution disease can occur several weeks after starting treatment and may present with enlarging lymph nodes. Drug adverse effects are also possible, with rifampicin being a potent liver enzyme inducer and isoniazid causing peripheral neuropathy. Pyrazinamide can cause hyperuricaemia and ethambutol may lead to optic neuritis, so it is important to monitor patients closely for any signs of adverse effects. Overall, with proper management and monitoring, tuberculosis can be successfully treated.
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This question is part of the following fields:
- Infectious Diseases
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Question 132
Incorrect
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At the 4-month check, you observe bilateral hydroceles in a male infant. The swelling is limited to the scrotum and the testis can be felt in the scrotal sac. The infant is otherwise healthy and thriving. The mother expresses concern about the potential impact of the swelling on her son's fertility.
What is the best course of action for managing this situation?Your Answer:
Correct Answer: Reassure mum that hydroceles are common in infants and often self resolve
Explanation:It is common for newborn males to have communicating hydroceles, which usually resolve on their own. This is due to the processus vaginalis remaining open. Parents should be reassured that the hydroceles typically disappear within a few months. However, if the hydrocele persists beyond one year, it is recommended to refer the child to a urologist for possible repair. Ultrasound is not necessary to confirm the diagnosis. It is important to note that hydroceles do not impact fertility, but undescended testes can affect fertility if not treated.
Common Scrotal Problems and Their Features
Epididymal cysts, hydroceles, and varicoceles are the most common scrotal problems seen in primary care. Epididymal cysts are usually found posterior to the testicle and are separate from the body of the testicle. They may be associated with conditions such as polycystic kidney disease, cystic fibrosis, and von Hippel-Lindau syndrome. Diagnosis is confirmed by ultrasound, and management is usually supportive, although surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts.
Hydroceles, on the other hand, describe the accumulation of fluid within the tunica vaginalis. They may be communicating or non-communicating, and may develop secondary to conditions such as epididymo-orchitis, testicular torsion, or testicular tumors. Hydroceles are usually soft, non-tender swellings of the hemi-scrotum that transilluminate with a pen torch. Diagnosis may be clinical, but ultrasound is required if there is any doubt about the diagnosis or if the underlying testis cannot be palpated. Management depends on the severity of the presentation, with infantile hydroceles generally repaired if they do not resolve spontaneously by the age of 1-2 years.
Varicoceles, on the other hand, are abnormal enlargements of the testicular veins that are usually asymptomatic but may be associated with subfertility. They are much more common on the left side and are classically described as a bag of worms. Diagnosis is confirmed by ultrasound with Doppler studies, and management is usually conservative, although surgery may be required if the patient is troubled by pain. There is ongoing debate regarding the effectiveness of surgery to treat infertility.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 133
Incorrect
-
An 18-year-old woman presents to her GP with painful lumps in her neck that appeared two days ago. She also reports a sore throat and fever. Upon examination, she has tender, enlarged, smooth masses on both sides. What is the most probable diagnosis?
Your Answer:
Correct Answer: Reactive lymphadenopathy
Explanation:Differentiating Neck Lumps: Causes and Characteristics
When a patient presents with a neck lump, it is important to consider the possible causes and characteristics to determine the appropriate course of action. In this case, the patient’s sore throat and fever suggest a throat infection, which has resulted in reactive lymphadenopathy. This is a common cause of neck lump presentations in primary care.
Other possible causes of neck lumps include goitre, which is a painless mass in the midline of the throat that is not associated with fever and may be functional if accompanied by hyperthyroidism. An abscess could also present as a painful neck lump, but the history of a sore throat and bilateral swelling make this less likely.
Branchial cysts are smooth, soft masses in the lateral neck that are usually benign and congenital in origin. Lipomas, on the other hand, are lumps caused by the accumulation of soft, fatty deposits under the skin and do not typically present with systemic features.
In summary, understanding the characteristics and possible causes of neck lumps can aid in the diagnosis and management of patients presenting with this symptom.
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This question is part of the following fields:
- ENT
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Question 134
Incorrect
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A 57-year-old man presents with papilloedema during examination. What could be the possible cause?
Your Answer:
Correct Answer: Hypercapnia
Explanation:In emergency situations, inducing hypocapnia through hyperventilation may be employed as a means to decrease intracranial pressure.
Understanding Papilloedema: Optic Disc Swelling Caused by Increased Intracranial Pressure
Papilloedema is a condition characterized by swelling of the optic disc due to increased pressure within the skull. This condition is typically bilateral and can be identified through fundoscopy. During this examination, venous engorgement is usually the first sign observed, followed by loss of venous pulsation, blurring of the optic disc margin, elevation of the optic disc, loss of the optic cup, and the presence of Paton’s lines, which are concentric or radial retinal lines cascading from the optic disc.
There are several potential causes of papilloedema, including space-occupying lesions such as tumors or vascular abnormalities, malignant hypertension, idiopathic intracranial hypertension, hydrocephalus, and hypercapnia. In rare cases, papilloedema may also be caused by hypoparathyroidism and hypocalcaemia, or vitamin A toxicity.
Overall, understanding papilloedema is important for identifying potential underlying conditions and providing appropriate treatment to prevent further complications.
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This question is part of the following fields:
- Ophthalmology
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Question 135
Incorrect
-
A 35-year-old man complains of pain in his left ear. He was using cotton buds to clean his ears earlier today and experienced a sharp pain during the process. He now has slightly reduced hearing in his left ear. The patient reports no discharge and is in good health otherwise.
All of the patient's vital signs are normal. Upon examination of the left ear, a small perforation in the tympanic membrane is observed. There is no discharge or redness in the ear, and the ear canal is dry. The cranial nerve examination is unremarkable.
What is the next best course of action for managing this patient's condition?Your Answer:
Correct Answer: Reassure patient and review in 4 weeks
Explanation:If a patient has an uncomplicated tympanic membrane perforation that is dry, they can be managed with watchful waiting for a month without needing to see an ENT specialist. These perforations can occur due to various reasons such as blunt trauma, penetrating injuries, or barotrauma. Typically, the perforation will heal on its own within 4-8 weeks. However, patients should schedule a follow-up appointment after 4 weeks to ensure that the perforation is healing properly. If the patient experiences increasing ear pain, discharge, or worsening hearing loss, they should see their GP. During the examination, the patient should undergo a full examination, including otoscopy, cranial nerve examination, and Rinne/Weber tests. If there are any cranial nerve deficits, the patient should discuss them with an ENT specialist. Patients should keep their ears clean and dry, and topical antibiotics are not recommended for clean, dry perforations. If there are any signs of infection or contamination, topical antibiotics may be given. In cases where the patient has more complex issues such as temporal bone fractures or slowly healing perforations, they may need to be reviewed by an ENT specialist in an emergency clinic. If the perforation does not heal, surgical intervention may be necessary.
Perforated Tympanic Membrane: Causes and Management
A perforated tympanic membrane, also known as a ruptured eardrum, is a condition where there is a tear or hole in the thin tissue that separates the ear canal from the middle ear. The most common cause of this condition is an infection, but it can also be caused by barotrauma or direct trauma. When left untreated, a perforated tympanic membrane can lead to hearing loss and increase the risk of otitis media.
In most cases, no treatment is needed as the tympanic membrane will usually heal on its own within 6-8 weeks. During this time, it is important to avoid getting water in the ear. However, if the perforation occurs following an episode of acute otitis media, antibiotics may be prescribed. This approach is supported by the 2008 Respiratory tract infection guidelines from the National Institute for Health and Care Excellence (NICE).
If the tympanic membrane does not heal by itself, myringoplasty may be performed. This is a surgical procedure where a graft is used to repair the hole in the eardrum.
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This question is part of the following fields:
- ENT
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Question 136
Incorrect
-
Which of the following characteristics is least commonly associated with rosacea?
Your Answer:
Correct Answer: Pruritus
Explanation:It is uncommon for pruritus to be present in cases of acne rosacea.
Understanding Rosacea: Symptoms and Management
Rosacea, also known as acne rosacea, is a chronic skin condition that has no known cause. It typically affects the nose, cheeks, and forehead, and the first symptom is often flushing. Over time, telangiectasia (visible blood vessels) may appear, followed by persistent redness with papules and pustules. In some cases, rhinophyma (enlarged nose) may develop, and there may be ocular involvement, such as blepharitis. Sunlight can exacerbate symptoms.
Mild cases of rosacea may be treated with topical metronidazole, while topical brimonidine gel may be used for patients with predominant flushing but limited telangiectasia. More severe cases may require systemic antibiotics like oxytetracycline. Patients are advised to apply high-factor sunscreen daily and use camouflage creams to conceal redness. Laser therapy may be appropriate for those with prominent telangiectasia, and patients with rhinophyma should be referred to a dermatologist.
Overall, understanding the symptoms and management of rosacea can help individuals manage their condition and improve their quality of life.
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This question is part of the following fields:
- Dermatology
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Question 137
Incorrect
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A 50-year-old woman started treatment for tuberculosis infection 3 months ago and now complains of a burning sensation at the base of her feet. Which medication could be responsible for this new symptom?
Your Answer:
Correct Answer: Isoniazid
Explanation:Isoniazid treatment may lead to a deficiency of vitamin B6, which can result in peripheral neuropathy. This is a well-known side effect of TB medications that is often tested in medical school exams. The patient’s symptoms suggest the possibility of peripheral neuropathy caused by a lack of vitamin B6 due to Isoniazid therapy. Typically, pyridoxine hydrochloride is prescribed concurrently with Isoniazid to prevent peripheral neuropathy.
The Importance of Vitamin B6 in the Body
Vitamin B6 is a type of water-soluble vitamin that belongs to the B complex group. Once it enters the body, it is converted into pyridoxal phosphate (PLP), which acts as a cofactor for various reactions such as transamination, deamination, and decarboxylation. These reactions are essential for the proper functioning of the body.
One of the primary causes of vitamin B6 deficiency is isoniazid therapy, which is a medication used to treat tuberculosis. When the body lacks vitamin B6, it can lead to peripheral neuropathy, which is a condition that affects the nerves outside the brain and spinal cord. It can also cause sideroblastic anemia, which is a type of anemia that affects the production of red blood cells.
Overall, vitamin B6 plays a crucial role in the body, and its deficiency can have severe consequences. It is essential to ensure that the body receives an adequate amount of this vitamin through a balanced diet or supplements.
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This question is part of the following fields:
- Infectious Diseases
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Question 138
Incorrect
-
A 6-year-old boy is brought to see his General Practitioner by his father, who is concerned as his son has a 4-day history of abdominal pain and fever. He seems to have lost his appetite and has been waking in the night with night sweats for the last week.
On examination, there is a large palpable abdominal mass and hepatomegaly. A urine dipstick is negative for blood, protein, leukocytes and nitrates.
What is the most likely diagnosis?Your Answer:
Correct Answer: Burkitt’s lymphoma
Explanation:Pediatric Abdominal Mass: Possible Causes and Symptoms
When a child presents with an abdominal mass, it can be a sign of various conditions, including malignancies. Here are some possible causes and symptoms to consider:
1. Burkitt’s lymphoma: This aggressive non-Hodgkin’s lymphoma commonly affects children and presents with abdominal pain, an abdominal mass, splenomegaly, and B symptoms such as fever and weight loss.
2. Wilms’ tumour: This malignant kidney tumour usually affects young children and presents with an asymptomatic abdominal mass, hypertension, haematuria, or urinary tract infection. Splenomegaly is not expected.
3. Hepatoblastoma: This rare malignant liver tumour usually presents with an asymptomatic abdominal mass in the right upper quadrant. However, if the child has symptoms and splenomegaly, it may suggest a haematological malignancy.
4. Neuroblastoma: This rare malignancy commonly affects children under five and presents with an abdominal mass. Symptoms are rare in early disease, but if present, may suggest a haematological malignancy.
5. Phaeochromocytoma: This rare tumour releases excessive amounts of catecholamines and commonly arises in the adrenal glands. It presents with headache, palpitations, tremor, and hyperhidrosis, but not with splenomegaly or a palpable abdominal mass.
In summary, a pediatric abdominal mass can be a sign of various conditions, including malignancies. It is important to consider the child’s symptoms and other clinical findings to determine the appropriate diagnosis and management.
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This question is part of the following fields:
- Haematology/Oncology
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Question 139
Incorrect
-
A 68-year-old complains of tingling and numbness in his left little and ring finger. He states that the pain used to be intermittent but is now persistent. The pain intensifies when he puts pressure on his elbow, and he remembers fracturing his elbow as a child. Based on the provided medical history, what is the probable cause of his symptoms?
Your Answer:
Correct Answer: Cubital tunnel syndrome
Explanation:Cubital tunnel syndrome results from the ulnar nerve being compressed, leading to tingling and numbness in the 4th and 5th fingers. This condition is often aggravated by leaning on the affected elbow and may be associated with osteoarthritis or prior injury. Medial epicondylitis causes pain in the medial elbow, not distal hand symptoms. Radial tunnel syndrome causes aching and paraesthesia in the hand and forearm distal to the lateral epicondyle. Carpal tunnel syndrome, on the other hand, is caused by compression of the median nerve and presents with pain and tingling in the thumb, index, middle, and medial half of the ring finger. De Quervain’s tenosynovitis typically affects the base of the thumb.
Understanding Cubital Tunnel Syndrome
Cubital tunnel syndrome is a condition that occurs when the ulnar nerve is compressed as it passes through the cubital tunnel. This can cause a range of symptoms, including tingling and numbness in the fourth and fifth fingers, which may start off intermittent but eventually become constant. Over time, patients may also experience weakness and muscle wasting. Pain is often worse when leaning on the affected elbow, and there may be a history of osteoarthritis or prior trauma to the area.
Diagnosis of cubital tunnel syndrome is usually made based on clinical features, although nerve conduction studies may be used in selected cases. Management of the condition typically involves avoiding aggravating activities, undergoing physiotherapy, and receiving steroid injections. In cases where these measures are not effective, surgery may be necessary. By understanding the symptoms and treatment options for cubital tunnel syndrome, patients can take steps to manage their condition and improve their quality of life.
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This question is part of the following fields:
- Musculoskeletal
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Question 140
Incorrect
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A 35-year-old man is brought to the Accident and Emergency Department after having a blackout. He was walking down the street when he felt nauseated, dizzy and sweaty. He collapsed and lost consciousness for one minute. A friend says that he was pale and had some jerking of his limbs for 10 seconds, but he did not bite his tongue and there was no history of urinary incontinence. He recovered immediately, with no confusion or disorientation. Examination and the electrocardiogram (ECG) are normal. He is otherwise usually fit and well and on no regular medications.
What further investigation is required to make a diagnosis?Your Answer:
Correct Answer: No investigation
Explanation:When to Investigate Transient Loss of Consciousness: A Guide for Clinicians
Transient loss of consciousness (LOC) can be a concerning symptom for patients and clinicians alike. However, not all cases require extensive investigation. According to the National Institute for Health and Care Excellence (NICE) guidelines, patients presenting with a transient LOC should undergo a thorough history, examination, and electrocardiogram (ECG). If these are normal and the patient meets certain criteria, further work-up may not be necessary.
For example, uncomplicated vasovagal syncope can be diagnosed if there are no features suggesting an alternative diagnosis and if the patient experiences the 3 Ps of posture-prolonged standing, provoking factors, and prodromal symptoms. Doppler ultrasonography of the carotids would only be indicated if there was suspicion of carotid artery stenosis, while a single syncopal episode is not an indication for a computed tomography (CT) scan of the brain.
Electroencephalogram (EEG) may be considered if the history is suggestive of epilepsy, but it should not be routinely used in the work-up for transient LOC. Features strongly suggestive of epilepsy include a bitten tongue, head turning to one side during transient LOC, no memory of abnormal behavior witnessed by someone else, unusual posturing, prolonged limb jerking, confusion following the event, and prodromal déjà vu or jamais vu. If any of these are present, the patient should be reviewed by a specialist within 2 weeks, who would then make a decision regarding EEG.
In summary, a thorough evaluation is necessary for all patients presenting with a transient LOC. However, if the patient meets certain criteria and there are no features suggesting an alternative diagnosis, further investigation may not be required.
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This question is part of the following fields:
- Neurology
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Question 141
Incorrect
-
As a junior doctor on a night shift in the emergency department of a district general hospital, you receive a 59-year-old man via ambulance who is complaining of chest pain and shortness of breath. After performing an A-E assessment, you find that his airway is patent, he is tachypnoeic with equal chest expansion, he is tachycardic with a blood pressure of 100/70 mmHg, he is alert with normal blood glucose and apyrexial. An ECG reveals ST-segment elevation in the anterior chest leads. Due to the nearest PCI center being over 3 hours away, it is decided that he will receive fibrinolysis.
What is the medication that should be administered before this treatment?Your Answer:
Correct Answer: Fondaparinux
Explanation:When treating ST-elevation myocardial infarctions with fibrinolysis, it is recommended to also administer an antithrombin drug. This is especially important when percutaneous coronary intervention cannot be performed within 120 minutes, which is often the case in district general hospitals. Ramipril, an ACE inhibitor, is not used in the acute management of acute coronary syndrome, but rather for hypertension, heart failure, and secondary prevention following a myocardial infarction. Low-dose aspirin (75mg) is not indicated for acute myocardial infarction, but rather for primary and secondary prevention. The recommended dose for STEMI management is 300 mg. Fondaparinux, an antithrombin medication, is used to prevent the clot from getting bigger by activating antithrombin 3, which causes the inactivation of factor Xa. It should be administered before fibrinolysis. Morphine, historically used for pain control in ACS, has been found to increase mortality and should only be used for severe pain control.
Managing Acute Coronary Syndrome: A Summary of NICE Guidelines
Acute coronary syndrome (ACS) is a common and serious medical condition that requires prompt management. The management of ACS has evolved over the years, with the development of new drugs and procedures such as percutaneous coronary intervention (PCI). The National Institute for Health and Care Excellence (NICE) has updated its guidelines on the management of ACS in 2020.
ACS can be classified into three subtypes: ST-elevation myocardial infarction (STEMI), non ST-elevation myocardial infarction (NSTEMI), and unstable angina. The management of ACS depends on the subtype. However, there are common initial drug therapies for all patients with ACS, such as aspirin and nitrates. Oxygen should only be given if the patient has oxygen saturations below 94%, and morphine should only be given for severe pain.
For patients with STEMI, the first step is to assess eligibility for coronary reperfusion therapy, which can be either PCI or fibrinolysis. Patients with NSTEMI/unstable angina require a risk assessment using the Global Registry of Acute Coronary Events (GRACE) tool to determine whether they need coronary angiography (with follow-on PCI if necessary) or conservative management.
This summary provides an overview of the NICE guidelines for managing ACS. The guidelines are complex and depend on individual patient factors, so healthcare professionals should review the full guidelines for further details. Proper management of ACS can improve patient outcomes and reduce the risk of complications.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 142
Incorrect
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A 30-year-old woman comes to her General Practitioner complaining of fatigue and sudden shortness of breath. An urgent full blood count is performed and the patient is diagnosed with acute lymphoblastic leukemia (ALL).
What is the most probable first-line treatment option for this patient's leukemia?Your Answer:
Correct Answer: Chemotherapy
Explanation:Treatment Options for Acute Leukaemia: Chemotherapy, Stem-Cell Transplant, Blood Transfusion, Intravenous Immunoglobulins, and Radiotherapy
Acute leukaemias, such as acute lymphoblastic leukaemia (ALL), are characterized by an increase in primitive undifferentiated blast cells in the bone marrow and blood, leading to marrow failure. The traditional treatment for ALL involves four components: induction, consolidation, maintenance, and central nervous system (CNS) prophylaxis. The first-line therapy for ALL is combination chemotherapy, which aims to eradicate the blast cells. Once remission is induced, maintenance chemotherapy is given to eliminate the disease that cannot be detected under the microscope.
Stem-cell transplants can be used to treat ALL once remission is induced using chemotherapy. This treatment can be allogeneic (the patient receives stem cells from a matched or partially mismatched related or unrelated donor) or autologous (the patient receives their own stem cells). The goal of a stem-cell transplant is to restore the body’s ability to produce normal blood cells. While it can be a curative treatment for patients with this disease, it is not used as a first-line treatment.
Blood transfusions are not a treatment for acute leukaemia, but they may be necessary to treat anaemia or platelet deficiency. Patients with leukaemia are at risk of graft-versus-host disease, so they are typically given irradiated blood components. Intravenous immunoglobulins are not used to treat acute leukaemia but may be used prophylactically against infection in patients with hypogammaglobulinaemia due to cancer treatment.
Radiotherapy is not a first-line treatment for acute leukaemia, but it may be used to treat the brain or spinal cord if the disease has spread there. Total body radiotherapy may also be used before a stem-cell transplant to suppress the immune system and reduce the risk of transplant rejection.
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This question is part of the following fields:
- Haematology/Oncology
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Question 143
Incorrect
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An 80-year-old man is admitted to the orthogeriatric ward following a femoral fracture from a fall. He has a medical history of diabetes mellitus type 2, benign prostate hyperplasia, and severe hay fever. After a few days, the patient reports experiencing suprapubic discomfort and difficulty urinating. Which medication is the most probable cause of his symptoms?
Your Answer:
Correct Answer: Codeine
Explanation:Urinary retention is a common side effect of opioid analgesia, including the use of codeine. Other medications that can cause this issue include tricyclic antidepressants, anticholinergics, and NSAIDs. Doxazosin, an alpha-blocker, is often prescribed to improve symptoms of benign prostatic hyperplasia and reduce resistance to bladder outflow. Duloxetine, an SSRI used to treat diabetic neuropathy, does not typically cause urinary retention. Finasteride, a 5-alpha reductase inhibitor, is a second-line treatment for benign prostatic hyperplasia when alpha-blockers are not effective, as it reduces prostatic bulk.
Drugs that can cause urinary retention
Urinary retention is a condition where a person is unable to empty their bladder completely. This can be caused by various factors, including certain medications. Some drugs that may lead to urinary retention include tricyclic antidepressants like amitriptyline, anticholinergics such as antipsychotics and antihistamines, opioids, NSAIDs, and disopyramide. These drugs can affect the muscles that control the bladder, making it difficult to urinate.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 144
Incorrect
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You assess a 27-year-old female patient who experiences intense, one-sided, pulsating headaches. These occur approximately once a month and are not associated with her menstrual cycle. Prior to the onset of the headache, she occasionally experiences momentary 'zig-zags' in her vision. She has no specific preference for treatment and seeks your guidance on the most effective approach to managing acute episodes. Which of the following options would be the most suitable initial treatment?
Your Answer:
Correct Answer: Oral triptan + oral NSAID
Explanation:Managing Migraines: Guidelines and Treatment Options
Migraines can be debilitating and affect a significant portion of the population. To manage migraines, it is important to understand the different treatment options available. According to the National Institute for Health and Care Excellence (NICE) guidelines, acute treatment for migraines involves a combination of an oral triptan and an NSAID or paracetamol. For young people aged 12-17 years, a nasal triptan may be preferred. If these measures are not effective, non-oral preparations of metoclopramide or prochlorperazine may be considered, along with a non-oral NSAID or triptan.
Prophylaxis should be given if patients are experiencing two or more attacks per month. NICE recommends topiramate or propranolol, depending on the patient’s preference, comorbidities, and risk of adverse events. Propranolol is preferred in women of childbearing age as topiramate may be teratogenic and reduce the effectiveness of hormonal contraceptives. Acupuncture and riboflavin may also be effective in reducing migraine frequency and intensity for some people. For women with predictable menstrual migraines, frovatriptan or zolmitriptan may be recommended as a type of mini-prophylaxis.
Specialists may consider other treatment options, such as candesartan or monoclonal antibodies directed against the calcitonin gene-related peptide (CGRP) receptor, like erenumab. However, pizotifen is no longer recommended due to common adverse effects like weight gain and drowsiness. It is important to exercise caution with young patients as acute dystonic reactions may develop. By following these guidelines and considering various treatment options, migraines can be effectively managed.
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This question is part of the following fields:
- Neurology
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Question 145
Incorrect
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A 45-year-old patient was referred with a 2-year history of persistent cough productive of yellowish sputum throughout the year. He has been treated by his GP for frequent chest infections.
Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Bronchiectasis
Explanation:Bronchiectasis: Causes, Symptoms, and Treatment
Bronchiectasis is a condition characterized by permanent and irreversible dilatations of the bronchial walls. It can be caused by various factors, including cystic fibrosis, immune system deficiencies, lung infections, foreign body aspiration, and smoking. Common symptoms of bronchiectasis include high sputum production, recurrent chest infections, and frequent but usually not severe haemoptysis. Patients may also experience postnasal drip, chronic sinusitis, and undue tiredness. A high-resolution computed tomography (HR-CT) scan is usually used to diagnose bronchiectasis. Treatment involves a multidisciplinary approach, including chest physiotherapy, patient education on airway-clearing techniques, antibiotic treatment during infective exacerbations, and bronchodilators in case of airflow obstruction. While treatment of the underlying cause may be necessary, it does not provide reversal of the existing bronchiectasis. Other conditions, such as sarcoidosis, fibrosing alveolitis, lung cancer, and asthma, are unlikely to produce the same clinical picture as bronchiectasis.
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This question is part of the following fields:
- Respiratory Medicine
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Question 146
Incorrect
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A father brings his 4-year-old daughter to your clinic with worsening eczema despite regular use of emollient creams. On examination, the child has dry, scaly skin on the flexor surfaces of her arms and legs without any signs of infection or weeping. What is the most suitable next step in managing her condition?
Your Answer:
Correct Answer: Continue using emollients and use hydrocortisone 1% ointment to be applied thinly twice a day
Explanation:Eczema in Children: Symptoms and Management
Eczema is a common skin condition that affects around 15-20% of children and is becoming more prevalent. It usually appears before the age of 2 and clears up in around 50% of children by the age of 5 and in 75% of children by the age of 10. The symptoms of eczema include an itchy, red rash that can worsen with repeated scratching. In infants, the face and trunk are often affected, while in younger children, it typically occurs on the extensor surfaces. In older children, the rash is more commonly seen on the flexor surfaces and in the creases of the face and neck.
To manage eczema in children, it is important to avoid irritants and use simple emollients. Large quantities of emollients should be prescribed, roughly in a ratio of 10:1 with topical steroids. If a topical steroid is also being used, the emollient should be applied first, followed by waiting at least 30 minutes before applying the topical steroid. Creams are absorbed into the skin faster than ointments, and emollients can become contaminated with bacteria, so fingers should not be inserted into pots. Many brands have pump dispensers to prevent contamination.
In severe cases, wet wrapping may be used, which involves applying large amounts of emollient (and sometimes topical steroids) under wet bandages. Oral ciclosporin may also be used in severe cases. Overall, managing eczema in children involves a combination of avoiding irritants, using emollients, and potentially using topical steroids or other medications in severe cases.
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This question is part of the following fields:
- Paediatrics
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Question 147
Incorrect
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A 9-week-old girl is seen by a surgeon for a general evaluation. During the assessment, her head circumference is observed to be between the 0.4th and 2nd percentile. Which of the following options would NOT account for this observation?
Your Answer:
Correct Answer: Fragile X syndrome
Explanation:Although not a typical reason for macrocephaly, children diagnosed with Fragile X syndrome often exhibit an enlarged head size.
Understanding Microcephaly: Causes and Definitions
Microcephaly is a condition characterized by a smaller than average head circumference, with measurements falling below the 2nd percentile. While some cases may be attributed to normal variation or familial traits, other causes include congenital infections, perinatal brain injury, fetal alcohol syndrome, and syndromes such as Patau and craniosynostosis.
In some cases, microcephaly may simply be a variation of normal development, with no underlying medical concerns. However, when it is caused by other factors, it can lead to developmental delays, intellectual disability, and other neurological issues.
It is important to note that microcephaly is not a disease in and of itself, but rather a symptom of an underlying condition. As such, it is crucial to identify and address the root cause of microcephaly in order to provide appropriate treatment and support for affected individuals.
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This question is part of the following fields:
- Paediatrics
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Question 148
Incorrect
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A 75-year-old man presents to the ambulatory care unit with complaints of tenderness in his calf. His GP referred him for evaluation. Upon examination, there is no visible swelling, and the leg appears symmetrical to the other leg. However, he experiences tenderness when the deep veins of the calf are palpated. The patient has no significant medical history. What is the initial management option recommended for this patient?
Your Answer:
Correct Answer: Arrange a D dimer test with results available within 4 hours
Explanation:If a patient has a Wells’ score of 1 or less for a suspected DVT, the first step is to arrange a D dimer test with results available within 4 hours, according to NICE guidelines. In this case, the score of 1 is due to localized tenderness along the deep venous system, with no other risk factors present. A proximal leg vein ultrasound scan is not the first-line investigation option for a Wells’ score of 1 or less, and anticoagulant treatment should not be started without a D dimer test. If the D dimer results cannot be obtained within 4 hours, low molecular weight heparin injection may be considered, but therapeutic dose apixaban should not be started without a D dimer test.
NICE updated their guidelines on the investigation and management of venous thromboembolism (VTE) in 2020. The use of direct oral anticoagulants (DOACs) is recommended as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. Routine cancer screening is no longer recommended following a VTE diagnosis. The cornerstone of VTE management is anticoagulant therapy, with DOACs being the preferred choice. All patients should have anticoagulation for at least 3 months, with the length of anticoagulation being determined by whether the VTE was provoked or unprovoked.
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This question is part of the following fields:
- Cardiovascular
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Question 149
Incorrect
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A 21-year-old man visits his General Practitioner (GP) with a lump on his eyelid that he has noticed for two days. The GP diagnoses it as a chalazion. What is the most suitable course of action?
Your Answer:
Correct Answer: Apply heat and massage daily
Explanation:Managing Chalazion: Options and Recommendations
Chalazion, also known as meibomian cyst, is a painless inflammatory lesion of the eyelid that contains meibomian secretions. While it is a self-limiting condition, it may become infected and require medical attention. Here are some management options and recommendations for chalazion:
Apply Heat and Massage Daily: The best way to manage chalazion is to apply heat and massage daily to release the oil. This treatment option is effective and usually improves the condition without the need for antibiotics.
Refer to Ophthalmology Urgently: While GPs can manage chalazion, referrals to ophthalmology should be made if the lesion does not improve with treatment or if the GP feels the lesion might be suspicious.
Surgical Incision: If medical management has been unsuccessful, chalazions can be removed surgically by incision and curettage.
Topical Antibiotics: There is no indication for the use of antibiotics in the treatment of chalazion.
Watch and Wait: While chalazions can sometimes resolve with time without treatment, they usually require medical attention. As such, watch and wait is not an appropriate management option.
In summary, applying heat and massage daily is the best way to manage chalazion. Referrals to ophthalmology should be made if necessary, and surgical incision may be required if medical management is unsuccessful. Topical antibiotics are not recommended, and watch and wait is not an appropriate management option.
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This question is part of the following fields:
- Ophthalmology
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Question 150
Incorrect
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An obese 28-year-old female visits her GP with concerns about acne and difficulty conceiving after trying to get pregnant for two years. What is the most probable reason for her symptoms?
Your Answer:
Correct Answer: Polycystic ovarian syndrome (PCOS)
Explanation:Differential Diagnosis of a Woman with Acne and Infertility
Polycystic ovarian syndrome (PCOS), endogenous Cushing’s syndrome, Addison’s disease, congenital adrenal hyperplasia (CAH), and primary hypoparathyroidism are all potential differential diagnoses for a woman presenting with acne and infertility. PCOS is the most likely diagnosis, as it presents with menstrual dysfunction, anovulation, and signs of hyperandrogenism, including excess terminal body hair in a male distribution pattern, acne, and male-pattern hair loss. Endogenous Cushing’s syndrome and primary hypoparathyroidism are less likely, as they do not present with acne and infertility. Addison’s disease is characterized by hyperpigmentation, weakness, fatigue, poor appetite, and weight loss, while CAH may present with oligomenorrhoea, hirsutism, and/or infertility.
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This question is part of the following fields:
- Reproductive Medicine
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Question 151
Incorrect
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A 4-year-old boy presents to the emergency department with stridor and drooling. He is sitting forward and appears to be struggling to breathe. The clinician suspects acute epiglottitis. What is the causative organism of this condition?
Your Answer:
Correct Answer: Haemophilus influenzae type B
Explanation:Haemophilus influenzae type B is the cause of acute epiglottitis. Fortunately, this disease is now rare due to the inclusion of Hib in the childhood vaccination program since 1992. Hib can also lead to other severe infections like meningitis and septicaemia. Haemophilus influenzae type A is an uncommon illness. Staphylococcus aureus is known for causing skin infections like abscesses, respiratory infections such as sinusitis, and food poisoning. Streptococcus pneumoniae is a common cause of bronchitis, otitis media, and sinusitis.
Acute epiglottitis is a rare but serious infection caused by Haemophilus influenzae type B. It is important to recognize and treat it promptly as it can lead to airway obstruction. Although it was once considered a disease of childhood, it is now more common in adults in the UK due to the immunization program. The incidence of epiglottitis has decreased since the introduction of the Hib vaccine. Symptoms include a rapid onset, high temperature, stridor, drooling of saliva, and a tripod position where the patient leans forward and extends their neck to breathe easier. Diagnosis is made by direct visualization, but x-rays may be done to rule out a foreign body.
Immediate senior involvement is necessary, including those who can provide emergency airway support such as anaesthetics or ENT. Endotracheal intubation may be necessary to protect the airway. It is important not to examine the throat if epiglottitis is suspected due to the risk of acute airway obstruction. The diagnosis is made by direct visualization, but only senior staff who are able to intubate if necessary should perform this. Treatment includes oxygen and intravenous antibiotics.
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This question is part of the following fields:
- Paediatrics
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Question 152
Incorrect
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A 56-year-old man comes to the clinic with a continuous tremor. During the examination, it is observed that his arms have a tremor of 6-8 Hz, which worsens when he stretches them out. His father also had a similar condition. What is the most appropriate initial treatment option?
Your Answer:
Correct Answer: Propranolol
Explanation:The patient’s symptoms are consistent with essential tremor, an autosomal dominant condition that worsens with outstretched arms but improves with alcohol and propranolol. Propranolol is typically the initial treatment option.
Understanding Essential Tremor
Essential tremor, also known as benign essential tremor, is a genetic condition that typically affects both upper limbs. The most common symptom is a postural tremor, which worsens when the arms are outstretched. However, the tremor can be improved by rest and alcohol consumption. Essential tremor is also the leading cause of head tremors, known as titubation.
When it comes to managing essential tremor, the first-line treatment is propranolol. This medication can help reduce the severity of the tremors. In some cases, primidone may also be used to manage the condition. It’s important to note that essential tremor is a lifelong condition, but with proper management, individuals can lead a normal life. By understanding the symptoms and treatment options, those with essential tremor can take control of their condition and improve their quality of life.
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This question is part of the following fields:
- Neurology
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Question 153
Incorrect
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A 67-year-old man presents to you with progressive numbness in his right hand and entire right side, indicating a possible stroke. You promptly arrange for an ambulance and he returns 6 weeks later to express his gratitude and discuss medication. If there are no contraindications, what antiplatelet regimen is recommended after an acute ischemic stroke?
Your Answer:
Correct Answer: Aspirin 300 mg daily for 2 weeks then clopidogrel 75 mg daily long-term
Explanation:When a patient shows symptoms of acute stroke, it is crucial to immediately send them to the nearest stroke center. Treatment should not be administered until a diagnosis of ischemic stroke is confirmed. Once confirmed, the patient should be prescribed aspirin 300 mg daily for two weeks, followed by long-term use of clopidogrel 75 mg daily. Additionally, if the patient is not already taking a statin, it should be offered as a treatment option.
The Royal College of Physicians (RCP) and NICE have published guidelines on the diagnosis and management of patients following a stroke. The management of acute stroke includes maintaining normal levels of blood glucose, hydration, oxygen saturation, and temperature. Blood pressure should not be lowered in the acute phase unless there are complications. Aspirin should be given as soon as possible if a haemorrhagic stroke has been excluded. Anticoagulants should not be started until brain imaging has excluded haemorrhage. Thrombolysis with alteplase should only be given if administered within 4.5 hours of onset of stroke symptoms and haemorrhage has been definitively excluded. Mechanical thrombectomy is a new treatment option for patients with an acute ischaemic stroke. NICE recommends thrombectomy for people who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography or magnetic resonance angiography. Secondary prevention includes the use of clopidogrel and dipyridamole. Carotid artery endarterectomy should only be considered if carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.
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This question is part of the following fields:
- Neurology
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Question 154
Incorrect
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A 32-year-old female presents with a purpuric rash on the back of her legs, frequent nose bleeds, and menorrhagia. She is currently taking Microgynon 30. A full blood count reveals Hb of 11.7 g/dl, platelets of 62 * 109/l, and WCC of 5.3 * 109/l. What is the probable diagnosis?
Your Answer:
Correct Answer: Idiopathic thrombocytopenic purpura
Explanation:A diagnosis of ITP is suggested by the presence of isolated thrombocytopenia in a healthy patient. Blood dyscrasias are not typically caused by the use of combined oral contraceptive pills.
Understanding Immune Thrombocytopenia (ITP) in Adults
Immune thrombocytopenia (ITP) is a condition where the immune system attacks and reduces the number of platelets in the blood. This is caused by antibodies targeting the glycoprotein IIb/IIIa or Ib-V-IX complex. While children with ITP usually experience acute thrombocytopenia after an infection or vaccination, adults tend to have a more chronic form of the condition. ITP is more common in older females and may be detected incidentally during routine blood tests. Symptoms may include petechiae, purpura, and bleeding, but catastrophic bleeding is not a common presentation.
To diagnose ITP, a full blood count and blood film are typically performed. While a bone marrow examination is no longer routinely used, antiplatelet antibody testing may be done, although it has poor sensitivity and does not affect clinical management. The first-line treatment for ITP is oral prednisolone, but pooled normal human immunoglobulin (IVIG) may also be used if active bleeding or an urgent invasive procedure is required. Splenectomy is now less commonly used as a treatment option.
In some cases, ITP may be associated with autoimmune haemolytic anaemia (AIHA), which is known as Evan’s syndrome. It is important for individuals with ITP to work closely with their healthcare provider to manage their condition and prevent complications.
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This question is part of the following fields:
- Haematology/Oncology
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Question 155
Incorrect
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A 32-year-old male presents to his GP with a complaint of rectal bleeding and black stool. He reports experiencing this issue more than six times in the past four months. The patient denies any other symptoms such as weight loss, abdominal pain, or changes in bowel habits. During the examination, no masses or apparent causes of bleeding are found in his abdomen or rectum. However, the GP notices some red spots on the patient's lips and tongue. When questioned about them, the patient dismisses them as insignificant and claims that everyone in his family has them. What is the most probable reason for the bleeding?
Your Answer:
Correct Answer: Hereditary haemorrhagic telangiectasia
Explanation:Rectal bleeding can have various causes, and it is crucial to differentiate between them as the treatments and prognosis can differ significantly. By utilizing signs and examinations, one can eliminate possibilities. If there are no masses, weight loss, or changes in bowel habits, rectal or colon cancer is less probable. Similarly, if there are no changes in bowel habits, abdominal pain, or weight loss, Crohn’s disease is less likely. This narrows down the possibilities to Louis-Bar syndrome and hereditary haemorrhagic telangiectasia. Louis-Bar syndrome, also known as ataxia telangiectasia, is a rare neurodegenerative disorder that typically manifests in early childhood with severe ataxia and other neurological symptoms.
Understanding Hereditary Haemorrhagic Telangiectasia
Hereditary haemorrhagic telangiectasia, also known as Osler-Weber-Rendu syndrome, is a genetic condition that is inherited in an autosomal dominant manner. It is characterized by the presence of multiple telangiectasia on the skin and mucous membranes. While 80% of cases have a family history, 20% occur spontaneously without prior family history.
There are four main diagnostic criteria for HHT. If a patient has two of these criteria, they are said to have a possible diagnosis of HHT. If they meet three or more of the criteria, they are said to have a definite diagnosis of HHT. These criteria include spontaneous, recurrent nosebleeds (epistaxis), multiple telangiectases at characteristic sites such as the lips, oral cavity, fingers, and nose, visceral lesions such as gastrointestinal telangiectasia (with or without bleeding), pulmonary arteriovenous malformations (AVM), hepatic AVM, cerebral AVM, and spinal AVM, and a first-degree relative with HHT.
In summary, HHT is a genetic condition that is characterized by multiple telangiectasia on the skin and mucous membranes. It can be diagnosed based on the presence of certain criteria, including nosebleeds, telangiectases, visceral lesions, and family history.
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This question is part of the following fields:
- Dermatology
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Question 156
Incorrect
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A 68-year-old woman with chronic osteoarthritis to multiple joints has been managed on morphine modified-release for several months. She currently takes 30 mg morphine modified-release twice daily. She has also been using Oramorph 10 mg four times daily for the past week because the twice-daily, 30-mg morphine modified-release has not been helping. You decide to increase the total dose of modified-release morphine.
Which of the following is the most appropriate dose of morphine modified-release?
Select the SINGLE most appropriate dose from the list below. Select ONE option only.Your Answer:
Correct Answer: Morphine modified-release 50 mg twice daily
Explanation:Understanding Opioid Conversion and Dosage Adjustments
When managing pain in patients with advanced and progressive disease, strong opioids such as morphine are often used. However, as the patient’s condition changes, adjustments to the dosage and type of opioid may be necessary.
For example, if a patient is using a total of 100 mg of morphine in 24 hours and requires increased use of Oramorph PRN, it may be appropriate to increase the total daily dose of morphine modified-release. To calculate the new dose, simply add the total amount of morphine used in 24 hours and divide by 2, which gives a twice-daily dose for morphine modified-release.
It is important to note that transdermal patch formulations should not be routinely offered to patients for whom oral opioids are suitable. If a patient requires additional pain relief, other options such as adding a fentanyl patch may be considered.
When converting between different opioids, it is important to consult the BNF or local guidance for equi-analgesic potencies. For example, 10 mg of oral morphine is equivalent to 100 mg of codeine phosphate or dihydrocodeine, 1.3 mg of hydromorphone, 5 mg of oxycodone, 25 mg of tapentadol, or 67 mg of tramadol.
Dosage adjustments should always be undertaken with specialist advice, especially when converting to or from methadone. Transdermal opioids also require careful consideration, with buprenorphine and fentanyl patches available in various strengths and corresponding oral morphine equivalents.
In summary, understanding opioid conversion and dosage adjustments is crucial for effective pain management in patients with advanced and progressive disease.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 157
Incorrect
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A 12-year-old overweight boy attends surgery with his father. He complains of left knee pain for several weeks, worse when having to participate in sports at school. Examination reveals a normal left knee with good range of motion; left hip flexion causes obligatory external rotation.
Which of the following is the likely diagnosis?Your Answer:
Correct Answer: Slipped upper femoral epiphysis (SUFE)
Explanation:Slipped upper femoral epiphysis (SUFE) is a common hip disorder in adolescence that occurs when the proximal femoral growth plate weakens, causing displacement of the femoral epiphysis. This can be caused by various factors, with obesity being the most common risk factor. Patients often present with knee or groin pain, and the affected leg may be externally rotated with limited internal rotation and abduction. Chondromalacia patellae, Osgood-Schlatter disease, osteochondritis dissecans, and patellar subluxation are other possible causes of knee pain, but hip examination would be expected to be normal in these conditions. It is important to examine the hip joint in children presenting with knee pain, as it could be due to hip pathology such as SUFE.
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This question is part of the following fields:
- Musculoskeletal
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Question 158
Incorrect
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A 67-year-old woman comes to her General Practitioner complaining of severe mucosal ulceration and blistering lesions on her torso and arms. Upon examination, the blisters are flaccid and rupture easily upon contact. What is the most appropriate course of action for this likely diagnosis? Choose the BEST management option from the list below.
Your Answer:
Correct Answer: Refer urgently to dermatology
Explanation:Urgent Referral to Dermatology for Pemphigus Vulgaris Treatment
Pemphigus vulgaris requires urgent referral to the Dermatology Team for investigation and treatment. Supportive measures include wound care and antiseptic regimens to reduce the risk of secondary infection. Patients should also avoid activities that may traumatize the skin and mucous membranes during active phases. Topical steroids are used in milder cases, while systemic corticosteroids with topical treatments are preferred in advanced cases. Emollients and oral antihistamines are not first-line treatments. Topical clobetasone butyrate can be used in mild cases, but referral to Dermatology is still necessary. Topical clotrimazole is not a first-line treatment, and topical dapsone should not be started immediately without further investigation and treatment from Dermatology.
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This question is part of the following fields:
- Dermatology
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Question 159
Incorrect
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A 75-year-old woman with age-related macular degeneration (AMD) presented to the emergency department with a painless bloodshot right eye. She was very worried about her condition. The previous day, she had received an intravitreal injection for the treatment of AMD. Upon examination, her visual acuity had not decreased further, but there was bleeding under the conjunctiva around the injection site. What is the probable diagnosis?
Your Answer:
Correct Answer: Subconjunctival haemorrhage
Explanation:It is important to inform patients about the possibility of developing subconjunctival haemorrhage after receiving intravitreal injections, as it is a common iatrogenic complication. This condition causes a red eye but is not painful and typically resolves within a couple of weeks.
Understanding Subconjunctival Haemorrhage
Subconjunctival haemorrhage occurs when blood vessels bleed into the subconjunctival space, usually those that supply the conjunctiva or episclera. Trauma is the most common cause, followed by spontaneous idiopathic cases, Valsalva manoeuvres, and several systemic diseases. Although subconjunctival haemorrhages can look alarming, they are rarely an indicator of anything sinister.
Subconjunctival haemorrhages are more common in women than in men when there has been no history of trauma. The annual incidence of non-traumatic subconjunctival haemorrhages is 0.6%, and the risk increases with age as the risk factors are more common in elderly patients. Newborns are also more susceptible. The incidence of both traumatic and non-traumatic subconjunctival haemorrhages is 2.6%.
The most common causes of subconjunctival haemorrhages are trauma and contact lens usage, which are often the sole risk factor in younger patients. Other risk factors include idiopathic causes, Valsalva manoeuvre, hypertension, bleeding disorders, drugs such as aspirin, NSAIDs and anticoagulants, diabetes, arterial disease, and hyperlipidaemia.
Subconjunctival haemorrhages are mostly asymptomatic, but patients may experience mild irritation. The main sign is a flat, red patch on the conjunctiva with well-defined edges and normal conjunctiva surrounding it. 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 a clinical one. 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. Recurrent or spontaneous, bilateral subconjunctival haemorrhages warrant investigations for bleeding disorders or other pathology.
Reassure the patient that subconjunctival haemorrhage is a benign condition that will resolve on its own in 2 to
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This question is part of the following fields:
- Ophthalmology
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Question 160
Incorrect
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A 32-year-old woman presents with dizziness to her General Practitioner. She reports a similar episode six months ago, which was also accompanied by some discomfort in her chest lasting for a short period. Upon further questioning, she admits to feeling her heart beating rapidly in her chest. She is currently stable, with a blood pressure of 120/80 mmHg, oxygen saturation of 99%, and a heart rate of 110 bpm. What is the best investigation to guide further management?
Your Answer:
Correct Answer: Electrocardiogram (ECG)
Explanation:Diagnostic Tests for Arrhythmias: An Overview
Arrhythmias can cause symptoms such as palpitations and light-headedness. An electrocardiogram (ECG) is the first-line investigation to determine the type of arrhythmia present. However, if the arrhythmia resolves prior to presentation, a Holter ECG monitor may be required. Tachyarrhythmias are classified according to the QRS complexes as narrow or broad and whether the rhythm is regular or irregular. A chest X-ray is not indicated unless there are other signs and symptoms of pneumonia. A D-dimer is not indicated unless there are risk factors for pulmonary embolus (PE) or deep-vein thrombosis (DVT). An echocardiogram is not indicated as a first-line investigation but may be performed in future workup. Troponin levels can increase in some arrhythmias, but the prognostic significance of this elevation is yet to be determined.
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This question is part of the following fields:
- Cardiovascular
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Question 161
Incorrect
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Which one of the following clinical features would be least consistent with a diagnosis of severe pre-eclampsia?
Your Answer:
Correct Answer: Reflexes difficult to elicit
Explanation:Hyperreflexia and clonus are commonly observed in patients with severe pre-eclampsia, while a decrease in platelet count may indicate the onset of HELLP syndrome.
Pre-eclampsia is a condition that occurs during pregnancy and is characterized by high blood pressure, proteinuria, and edema. It can lead to complications such as eclampsia, neurological issues, fetal growth problems, liver involvement, and cardiac failure. Severe pre-eclampsia is marked by hypertension, proteinuria, headache, visual disturbances, and other symptoms. Risk factors for pre-eclampsia include hypertension in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension, first pregnancy, and age over 40. Aspirin may be recommended for women with high or moderate risk factors. Treatment involves emergency assessment, admission for observation, and medication such as labetalol, nifedipine, or hydralazine. Delivery of the baby is the most important step in management, with timing depending on the individual case.
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This question is part of the following fields:
- Reproductive Medicine
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Question 162
Incorrect
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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:
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.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 163
Incorrect
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An 80-year-old man with a history of hypertension and ischaemic heart disease comes in for a check-up. He had a heart attack two decades ago but has been symptom-free since. His current medications include bisoprolol, ramipril, atorvastatin, and clopidogrel. He has been experiencing dizziness lately, and an ECG reveals that he has atrial fibrillation. What is the appropriate antithrombotic medication for him now?
Your Answer:
Correct Answer: Switch to an oral anticoagulant
Explanation:Patients who have AF and stable CVD are typically prescribed anticoagulants while antiplatelets are discontinued. This is because such patients are at risk of stroke, as indicated by their CHADS-VASC score, which takes into account factors such as age, hypertension, and cardiovascular disease. Therefore, the patient in question needs to be treated accordingly. In this case, the patient should discontinue their antiplatelet medication and switch to oral anticoagulant monotherapy.
Managing Combination Antiplatelet and Anticoagulant Therapy
With the rise of comorbidity, it is becoming increasingly common for patients to require both antiplatelet and anticoagulant therapy. However, this combination increases the risk of bleeding and may not be necessary in all cases. While there are no guidelines to cover every scenario, a recent review in the BMJ offers expert opinion on how to manage this situation.
For patients with stable cardiovascular disease who require an anticoagulant, it is recommended that they receive antiplatelet therapy as well. However, if the patient has an indication for an anticoagulant, such as atrial fibrillation, it is best to prescribe anticoagulant monotherapy without the addition of antiplatelets.
In patients who have experienced an acute coronary syndrome or undergone percutaneous coronary intervention, there is a stronger indication for antiplatelet therapy. Typically, patients are given triple therapy (two antiplatelets and one anticoagulant) for four to six months after the event, followed by dual therapy (one antiplatelet and one anticoagulant) for the remaining 12 months. However, the stroke risk in atrial fibrillation varies according to risk factors, so there may be variation in treatment from patient to patient.
For patients who develop venous thromboembolism while on antiplatelets, they will likely be prescribed anticoagulants for three to six months. An ORBIT score should be calculated to determine the risk of bleeding. Patients with a low risk of bleeding may continue taking antiplatelets, while those with an intermediate or high risk of bleeding should consider stopping them.
Overall, managing combination antiplatelet and anticoagulant therapy requires careful consideration of the patient’s individual circumstances and risk factors.
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This question is part of the following fields:
- Cardiovascular
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Question 164
Incorrect
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A 68-year-old man visits his GP after being urged by his son. He reports experiencing left-sided facial drooping four days ago, which he observed in the mirror. He did not seek medical attention at the time and was relieved to see that it disappeared on its own after approximately 40 minutes. He has not had any additional symptoms since then. Besides an immediate referral to specialist services, what should be done about drug treatment?
Your Answer:
Correct Answer: Aspirin 300mg
Explanation:If a patient is suspected of having a TIA and visits their GP within 7 days, they should receive immediate treatment with 300 mg aspirin and be referred to a specialist for review within 24 hours. NICE guidelines also suggest considering gastric protection with a PPI if necessary.
A transient ischaemic attack (TIA) is a brief period of neurological deficit caused by a vascular issue, lasting less than an hour. The original definition of a TIA was based on time, but it is now recognized that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new ’tissue-based’ definition is now used. The clinical features of a TIA are similar to those of a stroke, but the symptoms resolve within an hour. Possible features include unilateral weakness or sensory loss, aphasia or dysarthria, ataxia, vertigo, or loss of balance, visual problems, and sudden transient loss of vision in one eye (amaurosis fugax).
NICE recommends immediate antithrombotic therapy with aspirin 300 mg unless the patient has a bleeding disorder or is taking an anticoagulant. If the patient has had more than one TIA or has a suspected cardioembolic source or severe carotid stenosis, specialist review is necessary. Urgent assessment is required within 24 hours for patients who have had a suspected TIA in the last 7 days. Referral for specialist assessment is necessary as soon as possible within 7 days for patients who have had a suspected TIA more than a week previously. Neuroimaging and carotid imaging are recommended, and antithrombotic therapy is necessary. Carotid artery endarterectomy should only be considered if the carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.
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This question is part of the following fields:
- Neurology
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Question 165
Incorrect
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A nurse updates you on a 32-year-old woman who is 38 weeks pregnant. The patient's blood pressure reading is 155/90 mmHg, up from 152/85 mmHg two days ago. A 24-hour urine collection shows a urinary protein excretion of 0.7g / 24 hours. The patient was previously healthy before pregnancy. Following oral labetalol administration, what is the next step in managing this situation?
Your Answer:
Correct Answer: Plan delivery of the foetus within 48 hours
Explanation:Pregnant women who have mild or moderate gestational hypertension, are beyond 37 weeks of pregnancy, and exhibit pre-eclampsia symptoms, should be advised to deliver their baby within 24 to 48 hours as per the existing recommendations.
Hypertension during pregnancy is a common occurrence that requires careful management. In normal pregnancies, blood pressure tends to decrease in the first trimester and then gradually increase to pre-pregnancy levels by term. However, in cases of hypertension during pregnancy, the systolic blood pressure is usually above 140 mmHg or the diastolic blood pressure is above 90 mmHg. Additionally, an increase of more than 30 mmHg systolic or 15 mmHg diastolic from the initial readings may also indicate hypertension.
There are three categories of hypertension during pregnancy: pre-existing hypertension, pregnancy-induced hypertension (PIH), and pre-eclampsia. Pre-existing hypertension refers to a history of hypertension before pregnancy or elevated blood pressure before 20 weeks gestation. PIH occurs in the second half of pregnancy and resolves after birth. Pre-eclampsia is characterized by hypertension and proteinuria, and may also involve edema.
The management of hypertension during pregnancy involves the use of antihypertensive medications such as labetalol, nifedipine, and hydralazine. In cases of pre-existing hypertension, ACE inhibitors and angiotensin II receptor blockers should be stopped immediately and alternative medications should be prescribed. Women who are at high risk of developing pre-eclampsia should take aspirin from 12 weeks until the birth of the baby. It is important to carefully monitor blood pressure and proteinuria levels during pregnancy to ensure the health of both the mother and the baby.
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This question is part of the following fields:
- Reproductive Medicine
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Question 166
Incorrect
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A 45-year-old man presents to the Emergency Department feeling very sick. He reports having flu-like symptoms for the past few days and is having difficulty keeping anything down. He feels weak, drowsy, and disoriented. He experiences dizziness when he stands up. Upon observation, he is found to be tachycardic and hypotensive with a fever. He reports taking only hydrocortisone 10 mg PO bidaily for Addison's disease. What is the most crucial management step in this case?
Your Answer:
Correct Answer: Give 100 mg hydrocortisone intravenous (IV) STAT
Explanation:Managing Addisonian Crisis: Treatment Options and Considerations
Addisonian crisis is a life-threatening condition that requires prompt intervention. Patients with Addison’s disease are at risk of developing an Addisonian crisis if they forget to take their steroids or if steroids have not been increased appropriately during an accompanying illness. In such cases, the first-line treatment is to administer 100 mg hydrocortisone intravenously (IV) STAT. This should be followed by fluid resuscitation and IV glucose if hypoglycemia is present.
It is important to note that treatment should be initiated before biochemical results are obtained. Patients with Addison’s disease should carry an IM autoinjector in case of an emergency. If an Addisonian crisis is suspected, hydrocortisone should be administered immediately, and blood tests for cortisol, ACTH, urea and electrolytes, and glucose should be carried out urgently.
Oral hydrocortisone is not recommended in cases where the patient is vomiting. In such cases, IM hydrocortisone injection is the preferred treatment option. Additionally, glucose gel sublingually may be given for hypoglycemia, but the primary focus should be on restoring cortisol levels.
Fludrocortisone may be of use if the cause of the Addisonian crisis is adrenal disease. However, it should be noted that hydrocortisone is the first-line treatment as it acts mainly on glucocorticoid receptors to increase blood sugar levels and counteract insulin. Fludrocortisone, on the other hand, acts mainly at mineralocorticoid receptors.
In conclusion, managing Addisonian crisis requires prompt intervention and careful consideration of treatment options. Administering hydrocortisone, fluid resuscitation, and IV glucose if necessary should be the primary focus, with fludrocortisone being considered only if the cause is adrenal disease.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 167
Incorrect
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A 55-year-old woman with a history of diabetes complains of left-sided ear pain and discharge. During examination, her temperature is recorded at 37.9ºC and there is red discharge in the ear canal. The tympanic membrane is partially visible and appears normal. Despite visiting the out of hours clinic twice and using different ear drops for two weeks, her symptoms persist. What course of treatment should be recommended?
Your Answer:
Correct Answer: Referral to secondary care
Explanation:It is probable that the patient is suffering from malignant otitis externa, a condition that affects individuals with weakened immune systems like those with diabetes. This condition is characterized by osteomyelitis of the temporal bone. Despite receiving several rounds of antibiotic drops, the patient’s symptoms have not improved. It is recommended that the patient be referred to an ENT specialist for a CT scan of the temporal bones and treated with an extended course of intravenous antibiotics.
Understanding Otitis Externa: Causes, Features, and Management
Otitis externa is a common condition that often prompts patients to seek medical attention. It is characterized by ear pain, itch, and discharge, and is caused by various factors such as infection, seborrhoeic dermatitis, and contact dermatitis. Swimming is also a common trigger of otitis externa. Upon examination, the ear canal appears red, swollen, or eczematous.
The recommended initial management of otitis externa involves the use of topical antibiotics or a combination of topical antibiotics with a steroid. However, if the tympanic membrane is perforated, aminoglycosides are traditionally not used. In cases where there is canal debris, removal may be necessary, while an ear wick may be inserted if the canal is extensively swollen. Second-line options include oral antibiotics, taking a swab inside the ear canal, and empirical use of an antifungal agent.
It is important to note that if a patient fails to respond to topical antibiotics, referral to an ENT specialist may be necessary. Malignant otitis externa is a more serious condition that is more common in elderly diabetics. It involves the extension of infection into the bony ear canal and the soft tissues deep to the bony canal, and may require intravenous antibiotics.
Overall, understanding the causes, features, and management of otitis externa is crucial in providing appropriate care and preventing complications.
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This question is part of the following fields:
- ENT
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Question 168
Incorrect
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A 35-year-old woman comes to the clinic with patchy hair loss on her scalp, which is well-defined. The hair loss is affecting approximately 25% of her scalp, and she is experiencing significant emotional distress. The doctor suspects alopecia areata. What would be an appropriate course of action for management?
Your Answer:
Correct Answer: Topical corticosteroid + referral to dermatologist
Explanation:In this clinical scenario, the patient presents with well-defined patchy hair loss on the scalp, which is characteristic of alopecia areata. This autoimmune condition can lead to significant psychological distress, making effective management crucial. The most appropriate management strategy involves the use of topical corticosteroids, which are anti-inflammatory agents that can help reduce the immune response in the affected areas, promoting hair regrowth.
Additionally, referring the patient to a dermatologist is advisable for further evaluation and potential advanced treatment options, especially if the condition is extensive or does not respond to initial therapy. Other options presented are less suitable for this case. For instance, topical 5-fluorouracil (5-FU) is primarily used for actinic keratosis and superficial basal cell carcinoma, not for alopecia areata. An autoimmune screen may be considered in certain cases, but it is not routinely necessary for alopecia areata unless there are other clinical indications. Topical ketoconazole is an antifungal treatment and is not indicated for alopecia areata.
Key Takeaways: – Alopecia areata is an autoimmune condition that can cause significant emotional distress. – Topical corticosteroids are effective in managing localized alopecia areata. – Referral to a dermatologist is important for comprehensive care and management options. – Other treatments like 5-FU and ketoconazole are not appropriate for this condition.
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This question is part of the following fields:
- Dermatology
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Question 169
Incorrect
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A 45-year-old man visits his doctor complaining of difficulty lifting heavy objects and describes a feeling of weakness when climbing stairs. He has noticed occasional muscle twitches and spasms that seem to be increasing in frequency.
Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Polymyositis
Explanation:Based on the patient’s symptoms, the most likely diagnosis is polymyositis. This is a connective tissue disease that affects the striated muscles, causing symmetrical weakness in the proximal muscles. Patients may have difficulty rising from chairs and experience muscle tenderness. Creatine kinase levels are elevated, and a muscle biopsy can confirm the diagnosis. This presentation is not suggestive of Guillain-Barré syndrome, which typically presents with distal weakness that progresses proximally. Mononeuritis multiplex, which involves neuropathy of multiple peripheral and/or cranial nerves, is unlikely given the symmetrical distribution of symptoms affecting proximal muscles. Multiple sclerosis is also unlikely, as it tends to present with distal rather than proximal limb weakness or paraesthesia. Myasthenia gravis, which is associated with antibodies to acetylcholine receptors and causes fatigability, is not suggested by the patient’s symptoms.
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This question is part of the following fields:
- Neurology
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Question 170
Incorrect
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A 32-year-old taxi driver presents with a frontal headache that has been ongoing for the past 2 weeks. After taking 3 blood pressure readings, the lowest of which is 168/98 mmHg, a 24-hour tape reveals an average blood pressure reading of 158/88mmHg. The patient is open to starting medication for hypertension but expresses concern about how this diagnosis will affect his job. What advice would you give him?
Your Answer:
Correct Answer: Advise him that he may continue driving as long as is blood pressure is not consistently above 180mmHg systolic or above 100mmHg diastolic
Explanation:Drivers of cars and motorcycles are not required to inform the DVLA of their hypertension, but they must refrain from driving if their symptoms would impair their ability to drive safely. The same guidelines apply to bus and lorry drivers, but if their resting blood pressure consistently exceeds 180 mmHg systolic or 100mmHg diastolic, they must cease driving and notify the DVLA.
DVLA Guidelines for Cardiovascular Disorders and Driving
The DVLA has specific guidelines for individuals with cardiovascular disorders who wish to drive a car or motorcycle. For those with hypertension, driving is permitted unless the treatment causes unacceptable side effects, and there is no need to notify the DVLA. However, for those with Group 2 Entitlement, a resting blood pressure consistently at 180 mmHg systolic or more and/or 100 mm Hg diastolic or more disqualifies them from driving.
Individuals who have undergone elective angioplasty must refrain from driving for one week, while those who have undergone CABG or acute coronary syndrome must refrain from driving for four weeks. However, if successfully treated by angioplasty, driving is permitted after one week. Those with angina must cease driving if symptoms occur at rest or while driving.
For individuals who have undergone pacemaker insertion, they must refrain from driving for one week. If they have an implantable cardioverter-defibrillator (ICD) for sustained ventricular arrhythmia, they must cease driving for six months. If the ICD is implanted prophylactically, they must cease driving for one month, and having an ICD results in a permanent bar for Group 2 drivers. Successful catheter ablation for an arrhythmia requires two days off driving.
Individuals with an aortic aneurysm of 6cm or more must notify the DVLA, and licensing will be permitted subject to annual review. However, an aortic diameter of 6.5 cm or more disqualifies patients from driving. Those who have undergone a heart transplant must refrain from driving for six weeks, but there is no need to notify the DVLA.
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This question is part of the following fields:
- Cardiovascular
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Question 171
Incorrect
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A 32-year-old woman is brought to the Emergency Department by ambulance having ingested 12 g of paracetamol over the past three hours. She weighs 70 kg. Her observations are within normal limits and she feels well.
Which of the following is the most appropriate management option?Your Answer:
Correct Answer: Give intravenous acetylcysteine immediately
Explanation:Treatment and Management of Paracetamol Overdose
Paracetamol overdose is a serious medical emergency that requires prompt treatment and management. Here are some important steps to take:
Give intravenous acetylcysteine immediately for patients who have taken a staggered overdose, which is defined as ingesting a potentially toxic dose of paracetamol over a period of over one hour. Patients who have taken a dose of paracetamol > 150 mg/kg are at risk of serious toxicity.
Observe the patient for 24 hours after treatment.
Measure serum paracetamol level and give acetylcysteine if the level is above the treatment line. Patients who have ingested > 75 mg/kg of paracetamol over a period of less than one hour should have their serum paracetamol levels measured four hours after ingestion. If this level is above the treatment line, they should be treated with intravenous acetylcysteine. If blood tests reveal an alanine aminotransferase above the upper limit of normal, patients should be started on acetylcysteine regardless of serum paracetamol levels.
Start haemodialysis if patients have an exceedingly high serum paracetamol concentration (> 700 mg/l) associated with an elevated blood lactate and coma.
Take bloods including a coagulation screen and start acetylcysteine if clotting is deranged. In patients where a serum paracetamol level is indicated (patients who have ingested > 75 mg/kg of paracetamol over a period of less than one hour), deranged liver function tests are an indication to start acetylcysteine regardless of serum paracetamol levels.
In summary, prompt treatment with intravenous acetylcysteine is crucial for patients who have taken a staggered overdose of paracetamol. Monitoring of serum paracetamol levels, liver function tests, and clotting factors can help guide further management. Haemodialysis may be necessary in severe cases.
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This question is part of the following fields:
- Musculoskeletal
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Question 172
Incorrect
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A 28-year-old female presents to the gynaecology clinic with symptoms of endometriosis and severe dysmenorrhoea. Despite taking paracetamol and ibuprofen, she has not experienced much relief. She has no immediate plans to start a family. What is the initial recommended treatment option, assuming there are no contraindications?
Your Answer:
Correct Answer: Combined oral contraceptive pill (COCP)
Explanation:Understanding Endometriosis
Endometriosis is a common condition where endometrial tissue grows outside of the uterus. It affects around 10% of women of reproductive age and can cause chronic pelvic pain, painful periods, painful intercourse, and subfertility. Other symptoms may include urinary problems and painful bowel movements. Diagnosis is typically made through laparoscopy, and treatment options depend on the severity of symptoms.
First-line treatments for symptomatic relief include NSAIDs and/or paracetamol. If these do not help, hormonal treatments such as the combined oral contraceptive pill or progestogens may be tried. If symptoms persist or fertility is a priority, referral to secondary care may be necessary. Secondary treatments may include GnRH analogues or surgery. For women trying to conceive, laparoscopic excision or ablation of endometriosis plus adhesiolysis is recommended, as well as ovarian cystectomy for endometriomas.
It is important to note that there is poor correlation between laparoscopic findings and severity of symptoms, and that there is little role for investigation in primary care. If symptoms are significant, referral for a definitive diagnosis is recommended.
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This question is part of the following fields:
- Reproductive Medicine
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Question 173
Incorrect
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A 56-year-old man who comes to see you concerned about prostate cancer. You perform a digital rectal exam which reveals an enlarged, firm and irregular prostate. What would be the best course of action for management?
Your Answer:
Correct Answer: Refer to urology as 2 week wait referral
Explanation:The appropriate way to address the patient is as a 2-week wait referral. According to the NICE Guidelines for suspected cancer referrals, if a hard, irregular prostate indicative of prostate carcinoma is detected during rectal examination, urgent referral is necessary. Along with the referral, the PSA test result should also be included. It is important to note that the PSA test is not always reliable in detecting prostate cancer, as around 1 in 50 men with fast-growing prostate cancer have a normal PSA level.
Prostate specific antigen (PSA) is an enzyme produced by both normal and cancerous prostate cells. It is commonly used as a marker for prostate cancer, but its effectiveness as a screening tool is still debated. The NHS Prostate Cancer Risk Management Programme (PCRMP) has released guidelines for handling requests for PSA testing in asymptomatic men. While a recent European trial showed a reduction in prostate cancer deaths, it also revealed a high risk of over-diagnosis and over-treatment. As a result, the National Screening Committee has decided not to introduce a screening programme, but rather allow men to make an informed decision. The PCRMP recommends age-adjusted upper limits for PSA levels, while NICE Clinical Knowledge Summaries suggest a lower threshold for referral. PSA levels can also be raised by factors such as benign prostatic hyperplasia, prostatitis, and urinary tract infections.
The specificity and sensitivity of PSA testing are poor, with a significant number of men with elevated PSA levels not having prostate cancer, and some with normal PSA levels having the disease. Various methods are used to add meaning to PSA levels, including age-adjusted upper limits and monitoring changes in PSA levels over time. It is also debated whether digital rectal examination causes a rise in PSA levels. It is important to note that PSA testing should be postponed after certain events, such as ejaculation or instrumentation of the urinary tract.
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This question is part of the following fields:
- Haematology/Oncology
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Question 174
Incorrect
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A 42-year-old man is being evaluated for possible diabetes mellitus and undergoes an oral glucose tolerance test using the standard WHO protocol. The results are as follows:
Time (hours) Blood glucose (mmol/l)
0 5.9
2 8.2
What is the interpretation of these findings?Your Answer:
Correct Answer: Normal
Explanation:Type 2 diabetes mellitus can be diagnosed through a plasma glucose or HbA1c sample. The diagnostic criteria vary depending on whether the patient is experiencing symptoms or not. If the patient is symptomatic, a fasting glucose level of 7.0 mmol/l or higher or a random glucose level of 11.1 mmol/l or higher (or after a 75g oral glucose tolerance test) indicates diabetes. If the patient is asymptomatic, the same criteria apply but must be demonstrated on two separate occasions.
In 2011, the World Health Organization released supplementary guidance on the use of HbA1c for diagnosing diabetes. A HbA1c level of 48 mmol/mol (6.5%) or higher is diagnostic of diabetes mellitus. However, a HbA1c value of less than 48 mmol/mol (6.5%) does not exclude diabetes and may not be as sensitive as fasting samples for detecting diabetes. For patients without symptoms, the test must be repeated to confirm the diagnosis. It is important to note that increased red cell turnover can cause misleading HbA1c results.
There are certain conditions where HbA1c cannot be used for diagnosis, such as haemoglobinopathies, haemolytic anaemia, untreated iron deficiency anaemia, suspected gestational diabetes, children, HIV, chronic kidney disease, and people taking medication that may cause hyperglycaemia (such as corticosteroids).
Impaired fasting glucose (IFG) is defined as a fasting glucose level of 6.1 mmol/l or higher but less than 7.0 mmol/l. Impaired glucose tolerance (IGT) is defined as a fasting plasma glucose level less than 7.0 mmol/l and an OGTT 2-hour value of 7.8 mmol/l or higher but less than 11.1 mmol/l. People with IFG should be offered an oral glucose tolerance test to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person does not have diabetes but does have IGT.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 175
Incorrect
-
A 6-year-old girl's normal heart rate is which of the following?
Your Answer:
Correct Answer: 80 – 120 bpm
Explanation:Normal Heart Rate Range for Children
The normal heart rate for a 6-year-old child would be between 80-120 beats per minute (bpm). It’s important to note that the normal heart rate range varies depending on the child’s age. For instance, a heart rate of 110-160 bpm would be normal for a child aged less than 1 year, while a heart rate of 60-100 bpm would be normal for a child aged over 12 years. For children aged between 1 and 2 years, a heart rate of 100-150 bpm is considered normal, while for those aged between 2 and 5 years, a heart rate of 95-140 bpm is normal. For children aged between 5 and 12 years, a heart rate of 80-120 bpm is normal. Knowing the normal heart rate range for children is essential in monitoring their health and detecting any abnormalities.
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This question is part of the following fields:
- Paediatrics
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Question 176
Incorrect
-
Which of the following complications is most commonly associated with PUVA therapy in elderly patients?
Your Answer:
Correct Answer: Squamous cell cancer
Explanation:Squamous cell skin cancer is the most notable adverse effect of PUVA therapy in treating psoriasis.
NICE recommends a step-wise approach for chronic plaque psoriasis, starting with regular emollients and then using a potent corticosteroid and vitamin D analogue separately, followed by a vitamin D analogue twice daily, and then a potent corticosteroid or coal tar preparation if there is no improvement. Phototherapy, systemic therapy, and topical treatments are also options for management. Topical steroids should be used cautiously and vitamin D analogues may be used long-term. Dithranol and coal tar have adverse effects but can be effective.
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This question is part of the following fields:
- Dermatology
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Question 177
Incorrect
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A 56-year-old male patient arrives at the emergency department complaining of back pain and fever that have persisted for two weeks. During the examination, it is discovered that he has weakness in his right lower limb. The patient has a history of stroke and type 2 diabetes mellitus. Although he has not traveled recently, discitis is suspected. What is the probable organism responsible for this condition?
Your Answer:
Correct Answer: Staphylococcus aureus
Explanation:Understanding Discitis: Causes, Symptoms, Diagnosis, and Treatment
Discitis is a condition characterized by an infection in the intervertebral disc space, which can lead to serious complications such as sepsis or an epidural abscess. The most common cause of discitis is bacterial, with Staphylococcus aureus being the most frequent culprit. However, it can also be caused by viral or aseptic factors. The symptoms of discitis include back pain, pyrexia, rigors, and sepsis. In some cases, neurological features such as changing lower limb neurology may occur if an epidural abscess develops.
To diagnose discitis, imaging tests such as MRI are used due to their high sensitivity. A CT-guided biopsy may also be required to guide antimicrobial treatment. The standard therapy for discitis involves six to eight weeks of intravenous antibiotic therapy. The choice of antibiotic depends on various factors, with the most important being the identification of the organism through a positive culture, such as a blood culture or CT-guided biopsy.
Complications of discitis include sepsis and epidural abscess. Therefore, it is essential to assess the patient for endocarditis, which can be done through transthoracic echo or transesophageal echo. Discitis is usually due to haematogenous seeding of the vertebrae, which implies that the patient has had a bacteraemia, and seeding could have occurred elsewhere. Understanding the causes, symptoms, diagnosis, and treatment of discitis is crucial in managing this condition and preventing its complications.
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This question is part of the following fields:
- Musculoskeletal
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Question 178
Incorrect
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A 4-year-old boy is brought to the doctor's office because of a rash on his upper arm. During the examination, the doctor observes several raised lesions that are approximately 2 mm in diameter. Upon closer inspection, a central dimple is visible in most of the lesions. What is the probable diagnosis?
Your Answer:
Correct Answer: Molluscum contagiosum
Explanation:Understanding Molluscum Contagiosum
Molluscum contagiosum is a viral skin infection that is commonly seen in children, particularly those with atopic eczema. It is caused by the molluscum contagiosum virus and can be transmitted through direct contact or contaminated surfaces. The infection presents as pinkish or pearly white papules with a central umbilication, which can appear anywhere on the body except for the palms of the hands and soles of the feet. In children, lesions are commonly seen on the trunk and in flexures, while in adults, sexual contact may lead to lesions developing on the genitalia, pubis, thighs, and lower abdomen.
While molluscum contagiosum is a self-limiting condition that usually resolves within 18 months, it is important to avoid sharing towels, clothing, and baths with uninfected individuals to prevent transmission. Scratching the lesions should also be avoided, and treatment may be considered if the itch is problematic. However, treatment is not usually recommended, and if necessary, simple trauma or cryotherapy may be used. In some cases, referral may be necessary, such as for individuals who are HIV-positive with extensive lesions or those with eyelid-margin or ocular lesions and associated red eye.
Overall, understanding molluscum contagiosum and taking appropriate precautions can help prevent transmission and alleviate symptoms.
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This question is part of the following fields:
- Dermatology
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Question 179
Incorrect
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A 42-year-old woman with chronic upper gastrointestinal (GI) symptoms has recently been diagnosed as having a gastric ulcer at endoscopy. No evidence of oesophageal or duodenal pathology was found. Helicobacter pylori testing was positive. She is not allergic to penicillin.
Which of the following treatment regimens would be best suited to her case?Your Answer:
Correct Answer: A proton pump inhibitor (PPI), amoxicillin and either clarithromycin or metronidazole, followed by a PPI for 4-8 weeks
Explanation:Treatment Options for Helicobacter pylori Infection
Helicobacter pylori is a common bacterial infection that can cause dyspepsia and gastro-oesophageal reflux disease (GORD). There are several treatment options available for patients who test positive for H. pylori.
One option is a 7-day course of a proton pump inhibitor (PPI), amoxicillin, and either clarithromycin or metronidazole. This should be followed by a PPI for 4-8 weeks. Patients who are allergic to penicillin and have had previous exposure to clarithromycin should be offered a 7-day course of a PPI, bismuth, metronidazole, and tetracycline.
Long-term PPI and dietary advice alone will not eradicate H. pylori. If symptoms return after initial care strategies for dyspepsia, step down PPI therapy to the lowest dose needed to control symptoms. Patients with GORD should be offered full-dose PPI.
It is important to consult the British National Formulary (BNF) for appropriate doses of each drug, as they may vary. Sucralfate has no role in the eradication of H. pylori.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 180
Incorrect
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A 30-year-old man with a history of schizophrenia presents to the Emergency Department with drowsiness. Upon examination, he appears rigid. The medical team suspects neuroleptic malignant syndrome. Which of the following is not a feature of this condition?
Your Answer:
Correct Answer: Usually occurs after prolonged treatment
Explanation:Patients who have recently started treatment are commonly affected by neuroleptic malignant syndrome, which can lead to renal failure due to rhabdomyolysis.
Understanding Neuroleptic Malignant Syndrome
Neuroleptic malignant syndrome is a rare but serious condition that can occur in patients taking antipsychotic medication. It can also happen with dopaminergic drugs used for Parkinson’s disease. The exact cause of this condition is unknown, but it is believed that dopamine blockade induced by antipsychotics triggers massive glutamate release, leading to neurotoxicity and muscle damage. Symptoms of neuroleptic malignant syndrome typically appear within hours to days of starting an antipsychotic and include fever, muscle rigidity, autonomic lability, and agitated delirium with confusion.
A raised creatine kinase is present in most cases, and acute kidney injury may develop in severe cases. Management of neuroleptic malignant syndrome involves stopping the antipsychotic medication and transferring the patient to a medical ward or intensive care unit. Intravenous fluids may be given to prevent renal failure, and dantrolene or bromocriptine may be used in selected cases. It is important to differentiate neuroleptic malignant syndrome from serotonin syndrome, which has similar symptoms but is caused by excessive serotonin activity.
In summary, neuroleptic malignant syndrome is a rare but potentially life-threatening condition that can occur in patients taking antipsychotic medication or dopaminergic drugs. Early recognition and management are crucial to prevent complications and improve outcomes.
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This question is part of the following fields:
- Psychiatry
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Question 181
Incorrect
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A 65-year-old woman with atrial fibrillation and hypertension is prescribed amiodarone.
Which of the following blood tests is crucial for monitoring amiodarone use?Your Answer:
Correct Answer: LFTs, TFTs (6-monthly)
Explanation:Drug Monitoring in Primary Care
Drug monitoring is an essential aspect of patient care, particularly for medications with potential side effects. In primary care, drug monitoring is becoming increasingly common, especially for patients managed through shared-care with specialty care.
Amiodarone is a medication that requires ongoing monitoring for potential side effects, including pulmonary toxicity, thyroid dysfunction, abnormal liver function, and corneal microdeposits. Monitoring includes checking LFTs and TFTs every six months, a chest radiograph and ECG every 12 months, and an annual ophthalmological examination.
Azathioprine requires monitoring of FBC and LFTs every three months, while lithium requires monitoring of U&Es, TFTs, and lithium plasma levels every six months. Methotrexate requires monitoring of FBC, U&Es, and LFTs every two to three months.
In conclusion, drug monitoring is crucial in primary care to ensure patient safety and prevent potential adverse effects. Regular monitoring of blood tests can help detect any changes in a patient’s health and allow for timely intervention.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 182
Incorrect
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A 75 year old man with congestive cardiac failure is seen in cardiology clinic. He reports persistent shortness of breath with minimal activity. His current medications consist of furosemide, ramipril, bisoprolol, and spironolactone. An ECHO reveals an ejection fraction of 30%, while an ECG shows sinus rhythm with a QRS duration of 150ms. What is the optimal approach to enhance mortality?
Your Answer:
Correct Answer: Cardiac resynchronisation therapy
Explanation:Heart failure patients with a left ventricular ejection fraction of less than or equal to 40% and symptoms no more severe than class III according to the New York Heart Association functional classification may benefit from digoxin in terms of reducing hospitalization. However, it does not have an impact on mortality. While increasing the dosage of furosemide may provide relief from fluid overload symptoms, it does not affect mortality.
Non-Drug Management for Chronic Heart Failure
Chronic heart failure is a condition that requires long-term management to improve symptoms and reduce hospitalization. While medication is often the first line of treatment, non-drug management options are also available. Two such options are cardiac resynchronization therapy and exercise training.
Cardiac resynchronization therapy involves biventricular pacing for patients with heart failure and wide QRS. This therapy has been shown to improve symptoms and reduce hospitalization in patients with NYHA class III heart failure. By synchronizing the heart’s contractions, this therapy can improve the heart’s pumping ability and reduce symptoms such as shortness of breath and fatigue.
Exercise training is another non-drug management option for chronic heart failure. While it may not reduce hospitalization or mortality rates, it has been shown to improve symptoms. Exercise can help improve the heart’s ability to pump blood and increase overall fitness levels. This can lead to a reduction in symptoms such as fatigue and shortness of breath, allowing patients to engage in daily activities with greater ease.
Overall, non-drug management options such as cardiac resynchronization therapy and exercise training can be effective in managing chronic heart failure. These options can improve symptoms and quality of life for patients, reducing the need for hospitalization and improving overall health outcomes.
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This question is part of the following fields:
- Cardiovascular
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Question 183
Incorrect
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A 25-year-old woman presents to the Emergency Department with blurred vision. She mentions that she has been having recurrent painful ulcers in her mouth and genital area for the past four months. Her blood tests reveal elevated inflammatory markers.
Which of the following features points towards a diagnosis of Behçet’s disease?
Select the SINGLE best answer from the list below.
Your Answer:
Correct Answer: Positive pathergy test
Explanation:Clinical Signs and Tests for Behçet’s Disease: Understanding the Differences
Behçet’s disease is a rare autoimmune disorder that can be difficult to diagnose due to its non-specific symptoms. However, there are several clinical signs and tests that can help differentiate it from other conditions. Here are some of the key differences:
Positive Pathergy Test
The pathergy test involves inserting a needle into the skin and observing the site for the formation of a papule after 24-48 hours. A positive result is suggestive of Behçet’s disease. This is different from the Koebner phenomenon, which involves the appearance of new lesions on previously unaffected skin that are identical to the patient’s existing skin condition.
Auspitz Sign
The Auspitz sign is the presence of small bleeding points when layers of scales are removed. This is a hallmark of psoriasis, but not Behçet’s disease.
Koebner Phenomenon
As mentioned, the Koebner phenomenon involves the appearance of new lesions on previously unaffected skin that are identical to the patient’s existing skin condition. This is seen in psoriasis, vitiligo, and lichen planus, but not typically in Behçet’s disease.
Nikolsky Sign
The Nikolsky sign is used to differentiate between intra-epidermal and subepidermal blisters. It is a hallmark of certain skin conditions, such as pemphigus, toxic epidermal necrolysis, and staphylococcal scalded skin syndrome, but not Behçet’s disease.
Positive Mantoux Test
The Mantoux test is used to detect past infection with Mycobacterium tuberculosis. A positive result is not indicative of Behçet’s disease.
In summary, while there are some similarities between Behçet’s disease and other skin conditions, these clinical signs and tests can help differentiate it from other diagnoses.
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This question is part of the following fields:
- Musculoskeletal
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Question 184
Incorrect
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An 8-year-old girl is brought in by her father, who reports that the child experiences constant urinary dribbling and dampness. A urine dipstick was negative.
Which of the following is the most appropriate drug to prescribe?Your Answer:
Correct Answer: Oxybutynin
Explanation:Medications for Urinary and Bowel Issues in Children
Overactive bladder and nocturnal enuresis are common urinary issues in children. Here are some medications that can be used to treat these conditions:
1. Oxybutynin: This medication relaxes the urinary smooth muscle and is used to treat overactive bladder in children over 5 years old.
2. Imipramine: A tricyclic antidepressant that is used as a second-line treatment for nocturnal enuresis.
3. Desmopressin: A vasopressin analogue that can be used to treat nocturnal enuresis in children.
4. Duloxetine: A serotonin and noradrenaline reuptake inhibitor (SNRI) used to treat stress urinary incontinence in women. It is not licensed for use in individuals under 18 years old.
In addition, loperamide is an opioid antimotility drug that can be used to treat diarrhoea caused by gastroenteritis or inflammatory bowel disease.
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This question is part of the following fields:
- Paediatrics
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Question 185
Incorrect
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A mother brings her 10-month-old baby to the doctor because of a diaper rash. During the examination, the doctor observes a red rash with flexural sparing. What is the probable reason for this?
Your Answer:
Correct Answer: Irritant dermatitis
Explanation:Understanding Napkin Rashes and How to Manage Them
Napkin rashes, also known as nappy rashes, are common skin irritations that affect babies and young children. The most common cause of napkin rash is irritant dermatitis, which is caused by the irritant effect of urinary ammonia and faeces. This type of rash typically spares the creases. Other causes of napkin rash include candida dermatitis, seborrhoeic dermatitis, psoriasis, and atopic eczema.
To manage napkin rash, it is recommended to use disposable nappies instead of towel nappies and to expose the napkin area to air when possible. Applying a barrier cream, such as Zinc and castor oil, can also help. In severe cases, a mild steroid cream like 1% hydrocortisone may be necessary. If the rash is suspected to be candidal nappy rash, a topical imidazole should be used instead of a barrier cream until the candida has settled.
Understanding the different types of napkin rashes and their causes is important in managing them effectively. By following these general management points, parents and caregivers can help prevent and alleviate napkin rashes in babies and young children.
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This question is part of the following fields:
- Paediatrics
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Question 186
Incorrect
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A 32-year-old woman reports experiencing a cough and tightness in her chest a few days a week, but feels better on weekends. She mentions that she works at a hair salon.
What is the most appropriate initial investigation for occupational asthma?Your Answer:
Correct Answer: Serial peak expiratory flow rates at home and at work
Explanation:The recommended initial investigation for suspected occupational asthma is serial peak expiratory flow rates at home and at work, according to SIGN (Scottish Intercollegiate Guidelines Network) referenced by NICE. CT of the thorax is inappropriate due to high radiation doses and chest radiograph is not part of the initial work-up for occupational asthma as it is unlikely to show specific evidence. Skin-prick testing is only recommended for high-molecular-weight agents and spirometry is not recommended as an initial investigation for occupational asthma, but may be appropriate for surveillance in industries with risk of the condition.
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This question is part of the following fields:
- Respiratory Medicine
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Question 187
Incorrect
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Migraine can be a debilitating condition that affects many people, but there is no one-size-fits-all solution for managing it. Which of the following is the best statement about migraine.
Your Answer:
Correct Answer: Over half of all patients have their first attack before the age of 20
Explanation:Understanding Migraines: Facts and Diagnostic Criteria
Migraines are a common neurological disorder that affects people of all ages. Here are some important facts to know about migraines:
– The first attack of migraine often occurs in childhood or teenage years, with over half of all patients experiencing their first attack before the age of 20.
– Migraine attacks can last for a few hours to several days, with the International Headache Society diagnostic criteria requiring at least five episodes of headache lasting 4-72 hours.
– While aura is estimated to accompany headache in only a quarter to a third of patients, over half of all patients experience aura before the headache.
– Migraine is classically described as a unilateral, pulsating headache, but subsequent migraines can affect the same side or be bilateral.
– The release of vasogenic amines from blood vessel walls, accompanied by pulsatile distension, is believed to be responsible for migrainous attacks.
– A good history is important in diagnosing migraines, as patients may self-diagnose and overlook other factors such as combined oral contraception.In summary, migraines are a complex neurological disorder that can have a significant impact on a person’s quality of life. Understanding the facts and diagnostic criteria can help with proper diagnosis and management of this condition.
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This question is part of the following fields:
- Neurology
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Question 188
Incorrect
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A 54-year-old Caucasian man with a history of hypertension visits his GP clinic seeking advice on controlling his blood pressure. He has been monitoring his blood pressure at home for the past week and has consistently recorded high readings, with an average of 147/85 mmHg. He is asymptomatic and denies any chest discomfort. He is a non-smoker and non-alcoholic. His current medications include perindopril 10 mg once daily and indapamide 2.5mg once daily. What is the most appropriate course of action for managing his hypertension?
Your Answer:
Correct Answer: Amlodipine
Explanation:To improve poorly controlled hypertension despite taking an ACE inhibitor and a thiazide diuretic, a calcium channel blocker such as amlodipine should be added according to NICE guidelines. Loop diuretics may be considered in cases of resistant hypertension. Aldosterone antagonists and alpha-blockers are only recommended if blood pressure remains uncontrolled despite taking a combination of an ACE inhibitor or angiotensin II receptor blocker, a calcium-channel blocker, and a thiazide-like diuretic. It is important to note that ACE inhibitors should not be used in combination with angiotensin receptor blockers for hypertension management.
NICE Guidelines for Managing Hypertension
Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.
The guidelines also provide a flow chart for the diagnosis and management of hypertension. Lifestyle advice, such as reducing salt intake, caffeine intake, and alcohol consumption, as well as exercising more and losing weight, should not be forgotten and is frequently tested in exams. Treatment options depend on the patient’s age, ethnicity, and other factors, and may involve a combination of drugs.
NICE recommends treating stage 1 hypertension in patients under 80 years old if they have target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For patients with stage 2 hypertension, drug treatment should be offered regardless of age. The guidelines also provide step-by-step treatment options, including adding a third or fourth drug if necessary.
New drugs, such as direct renin inhibitors like Aliskiren, may have a role in patients who are intolerant of more established antihypertensive drugs. However, trials have only investigated the fall in blood pressure and no mortality data is available yet. Patients who fail to respond to step 4 measures should be referred to a specialist. The guidelines also provide blood pressure targets for different age groups.
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This question is part of the following fields:
- Cardiovascular
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Question 189
Incorrect
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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.
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This question is part of the following fields:
- Reproductive Medicine
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Question 190
Incorrect
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A 25-year-old man visits his General Practitioner with a complaint of a sore throat that has been bothering him for the past three weeks. He reports feeling significantly fatigued, which is affecting his academic performance. On examination, he appears healthy and has tender cervical lymphadenopathy; his tonsils are enlarged but no exudate is present, and he has tender splenomegaly.
Which of the following investigation findings is most likely to be associated with this condition?
Select the SINGLE most appropriate result from the list below.Your Answer:
Correct Answer: Raised liver transaminases (aspartate transaminase and alanine aminotransferase)
Explanation:The patient has raised liver transaminases, thrombocytosis, neutrophilia, raised antistreptolysin titres, and a reduced estimated glomerular filtration rate (eGFR). The most probable diagnosis is glandular fever/infectious mononucleosis caused by the Epstein-Barr virus (EBV). This infection is common in adolescents and presents with a prolonged sore throat, lethargy, and flu-like symptoms. Splenomegaly or hepatosplenomegaly, along with lymphadenopathy, are often observed. Liver function tests, especially the transaminases, are commonly elevated during active infection. Thrombocytopenia is commonly associated with glandular fever due to splenic involvement. Neutrophilia is less likely in this case than lymphocytosis, which is common with glandular fever. Antistreptolysin titres rise after a streptococcal infection, but glandular fever is a more likely diagnosis than streptococcal infection. Reduced eGFR associated with a sore throat should raise suspicion of dehydration or glomerulonephritis caused by a streptococcal infection, but neither of these diagnoses is as likely as glandular fever. The diagnostic investigation of choice for glandular fever is the Monospot test, which tests for heterophile antibodies to EBV.
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This question is part of the following fields:
- Infectious Diseases
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Question 191
Incorrect
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A 45-year-old man visits his GP with a lump on the side of his head. During the examination, the GP suspects that the lump may be a basal cell carcinoma. What characteristic is most indicative of this diagnosis?
Your Answer:
Correct Answer: Telangiectasia
Explanation:Understanding Basal Cell Carcinomas: Symptoms and Diagnosis
Basal cell carcinomas are the most common type of non-melanocytic skin carcinoma, typically found in sun-exposed areas of the skin such as the face and neck. They can be familial and associated with certain syndromes. Symptoms of basal cell carcinomas include a slow-growing, skin-colored, pearly nodule with surface telangiectasia, an ulcerated lesion with rolled edges, and crusted edges. Pigmentation is not a predominant feature, but bleeding may occur. Size is not a specific feature of malignancy, but sudden changes in size should be referred to a dermatologist for further assessment and investigation. Diagnosis is confirmed with a biopsy, and treatment involves excision with a clear margin. Recurrence is possible, but basal cell carcinomas rarely metastasize.
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This question is part of the following fields:
- Dermatology
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Question 192
Incorrect
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A 67-year-old male presents to an urgent care centre with concerns about decreased frequency of urination. He reports only urinating once in the past 12 hours and feels unable to urinate despite the urge to do so. The patient has a medical history of diabetes mellitus managed with metformin and chronic back pain managed with ibuprofen and PPI cover. He has no known allergies. Blood tests reveal the following results: Na+ 139 mmol/L (135 - 145), K+ 4.8 mmol/L (3.5 - 5.0), Bicarbonate 22 mmol/L (22 - 29), Urea 7.1 mmol/L (2.0 - 7.0), and Creatinine 200 µmol/L (55 - 120). The patient's previous creatinine level was 119 µmol/L. The general practitioner refers the patient to the emergency department for further investigation. What is the correct classification?
Your Answer:
Correct Answer: Acute Kidney Injury stage 1
Explanation:The patient in this vignette meets the criteria for AKI Stage 1, which is characterized by a moderate increase in serum creatinine (1.5-1.9 times the baseline) or reduced urine output (<0.5 mL/kg/hr) for at least 6 hours. The patient has risk factors such as age, diabetes mellitus, and NSAID use for back pain, which can contribute to AKI. It is important to note that AKI is a classification and not a diagnosis. AKI Stage 2 is characterized by a more significant increase in serum creatinine (2-2.9 times the baseline) or reduced urine output for at least 12 hours. The vignette does not show renal function that is severe enough to meet this classification. AKI Stage 3 is the most severe stage, with a serum creatinine increase of 3 times or more from baseline or reduced urine output for at least 24 hours. Again, the patient’s renal function is not severe enough to meet this classification. There is no AKI Stage 4 or 5. Chronic kidney disease is classified from stages 1-5 based on the patient’s estimated glomerular filtration rate (eGFR). A patient with CKD Stage 4 would have an eGFR of 15-29 ml/min/1.73m², while a patient with CKD Stage 5 would have end-stage renal disease with an eGFR <15 ml/min/1.73m² or be receiving renal replacement therapy. The NICE guidelines for acute kidney injury (AKI) identify risk factors such as emergency surgery, CKD, diabetes, and use of nephrotoxic drugs. Diagnostic criteria include a rise in creatinine, fall in urine output, or fall in eGFR. The KDIGO criteria are used to stage AKI, with stage 3 indicating the most severe cases. Referral to a nephrologist is recommended for certain cases, such as AKI with no known cause or inadequate response to treatment. Complications of AKI include CKD, hyperkalaemia, metabolic acidosis, and fluid overload.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 193
Incorrect
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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.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 194
Incorrect
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A 35-year-old footballer presents with persistent pain in his left knee that began abruptly during a game. During the physical examination, you instruct the patient to lie down and flex his knee. As you internally rotate his foot, he experiences discomfort and you detect a clicking sensation. The patient inquires about the procedure, and you clarify that you are performing McMurray's test, a specialized examination for knee joint issues. What is the probable reason for his knee pain?
Your Answer:
Correct Answer: Meniscal tear
Explanation:A positive McMurray test is indicative of a meniscal tear, which is typically caused by twisting of the knee. During the test, the knee is flexed while the sole of the foot is held, and one hand is placed on the medial side of the knee to pull it towards a varus position. The other hand is used to internally rotate the leg while extending the knee. If the patient experiences pain or a clicking sensation, the test is considered positive. On the other hand, a positive draw test is a sign of an anterior cruciate ligament tear, which is also commonly caused by twisting of the knee.
Knee problems are common among older adults, and it is important to be aware of the key features of each condition. Osteoarthritis of the knee is often seen in patients over 50 years of age who are overweight. This condition can cause severe pain, intermittent swelling, crepitus, and limited movement. Infrapatellar bursitis, also known as Clergyman’s knee, is associated with kneeling, while prepatellar bursitis, or Housemaid’s knee, is associated with more upright kneeling. Anterior cruciate ligament injuries may be caused by twisting of the knee, and patients may have heard a popping noise. Rapid onset of knee effusion and a positive draw test are also common features. Posterior cruciate ligament injuries may be caused by anterior force applied to the proximal tibia, such as during a car accident. Collateral ligament injuries can cause tenderness over the affected ligament and knee effusion. Meniscal lesions may be caused by twisting of the knee and can cause locking and giving-way, as well as tenderness along the joint line.
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This question is part of the following fields:
- Musculoskeletal
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Question 195
Incorrect
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A 25-year-old woman comes to her General Practitioner complaining of urinary frequency, dysuria, suprapubic pain and back pain. The symptoms have been getting worse over the past 48 hours. During examination, she is febrile and tachycardic. She has no history of urinary infections.
What is the most suitable investigation to arrange for this patient next?
Choose ONE option only.Your Answer:
Correct Answer: Urinary microscopy and culture
Explanation:The most appropriate investigation to arrange for a patient presenting with symptoms suggestive of a urinary tract infection or pyelonephritis is urinary microscopy and culture. It is important to obtain a sample before starting empirical antibiotics to guide subsequent antibiotic choice if the initial course is ineffective. While genital swabs may be useful if there is a history of sexually transmitted infection, they are not as important as urine culture in this situation. Cystoscopy and ultrasound scans of the abdomen may be useful in other situations, but are not urgently indicated in this case. Similarly, a CTKUB would not be useful in investigating the cause of the infection, which can be determined through urine culture.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 196
Incorrect
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A 67-year-old male visits his primary care clinic complaining of progressive dyspnea on exertion and a dry cough. He has a smoking history of 35 pack-years. He denies chest pain, weight loss, or hemoptysis. In the past, he was prescribed bronchodilators for COPD, but they did not alleviate his symptoms.
During the examination, the physician detects fine crackles at the lung bases bilaterally, and the patient has significant finger clubbing. The physician orders a chest X-ray, pulmonary function tests, and refers him urgently to a respiratory clinic.
What pulmonary function test pattern would you expect to see based on the most likely underlying diagnosis?Your Answer:
Correct Answer: FEV1:FVC normal or increased, TLCO reduced
Explanation:In cases of IPF, the TLCO (gas transfer test) is reduced, indicating a restrictive lung disease that results in a reduced FEV1 and reduced FVC. This leads to a normal or increased FEV1:FVC ratio, which is a distinguishing factor from obstructive lung diseases like COPD or asthma. Therefore, the correct statement is that in IPF, the FEV1:FVC ratio is normal or increased, while the TLCO is reduced.
Understanding Idiopathic Pulmonary Fibrosis
Idiopathic pulmonary fibrosis (IPF) is a chronic lung condition that causes progressive fibrosis of the interstitium of the lungs. Unlike other causes of lung fibrosis, IPF has no underlying cause. It is typically seen in patients aged 50-70 years and is more common in men.
The symptoms of IPF include progressive exertional dyspnoea, dry cough, clubbing, and bibasal fine end-inspiratory crepitations on auscultation. Diagnosis is made through spirometry, impaired gas exchange tests, and imaging such as chest x-rays and high-resolution CT scans.
Management of IPF includes pulmonary rehabilitation, but very few medications have been shown to be effective. Some evidence suggests that pirfenidone, an antifibrotic agent, may be useful in selected patients. Many patients will eventually require supplementary oxygen and a lung transplant.
The prognosis for IPF is poor, with an average life expectancy of around 3-4 years. CT scans can show advanced pulmonary fibrosis, including honeycombing. While there is no cure for IPF, early diagnosis and management can help improve quality of life and potentially prolong survival.
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This question is part of the following fields:
- Respiratory Medicine
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Question 197
Incorrect
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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:
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.
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This question is part of the following fields:
- Haematology/Oncology
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Question 198
Incorrect
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A 32-year-old woman presents with worries about hair loss. She reports experiencing hair loss in small patches on her scalp. During examination, you observe distinct patches of hair loss with some ‘broken exclamation mark’ hairs at the edges.
What is the most probable diagnosis?Your Answer:
Correct Answer: Alopecia areata
Explanation:Understanding Hair Loss: Causes and Symptoms
Hair loss is a common concern for many individuals, causing anxiety and worry. There are various causes of hair loss, each with their own unique symptoms. Alopecia areata is a chronic inflammatory disease that affects the hair follicles, resulting in patchy, non-scarring hair loss on the scalp. Androgenic alopecia, on the other hand, is more common in men and causes a receding hairline and loss of hair from the top and front of the head. Fungal infections, such as tinea capitis, can also cause hair loss accompanied by scaling, itching, and pain. Scalp psoriasis can range from mild scaling to severe crusted plaques covering the entire scalp, while erosive pustular dermatosis of the scalp affects elderly individuals with scarring and yellow-brown crusts. It is important to understand the various causes and symptoms of hair loss in order to properly diagnose and treat the condition.
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This question is part of the following fields:
- Dermatology
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Question 199
Incorrect
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Which of the following contraceptives may lead to a decrease in bone mineral density among women?
Your Answer:
Correct Answer: Depo Provera (injectable contraceptive)
Explanation:Injectable Contraceptives: Depo Provera
Injectable contraceptives are a popular form of birth control in the UK, with Depo Provera being the main option available. This contraceptive contains 150mg of medroxyprogesterone acetate and is administered via intramuscular injection every 12 weeks. It can be given up to 14 weeks after the last dose without the need for extra precautions. The primary method of action is by inhibiting ovulation, while secondary effects include cervical mucus thickening and endometrial thinning.
However, there are some disadvantages to using Depo Provera. Once the injection is given, it cannot be reversed, and there may be a delayed return to fertility of up to 12 months. Adverse effects may include irregular bleeding and weight gain, and there is a potential increased risk of osteoporosis. It should only be used in adolescents if no other method of contraception is suitable.
It is important to note that there are contraindications to using Depo Provera, such as current breast cancer (UKMEC 4) or past breast cancer (UKMEC 3). While Noristerat is another injectable contraceptive licensed in the UK, it is rarely used in clinical practice and is given every 8 weeks. Overall, injectable contraceptives can be an effective form of birth control, but it is important to weigh the potential risks and benefits before deciding on this method.
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This question is part of the following fields:
- Reproductive Medicine
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Question 200
Incorrect
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A 45-year-old woman presents after an episode of confusion. She had just finished cooking dinner when she started to behave in a manner that worried her husband. When he questioned her about what was the matter, she appeared not to know where she was, what day it was or indeed who her husband was. She did, however, have knowledge of her own identity. Her husband mentioned that she also complained of feeling tired, so went to sleep and woke the next day feeling well and having returned to normal, but she was unable to recall exactly what had happened the previous day. She is a non-smoker. On examination there are no abnormalities.
Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Transient global amnesia (TGA)
Explanation:Transient Global Amnesia: A Temporary Disorder of Memory
Transient global amnesia (TGA) is a temporary and isolated disorder of memory that typically affects patients aged over 50. It is characterized by a sudden onset of anterograde amnesia, which can last for several hours. The patient retains remote memories and immediate recall, but has no memory of the event after recovery. TGA can be triggered by various factors, such as sexual intercourse, heavy exercise, and exposure to hot or cold water.
To diagnose TGA, all of the following criteria must be met: the attack was witnessed and reported, there was obvious anterograde amnesia during the attack, there was no clouding of consciousness, there were no focal neurological signs or deficits during or after the attack, there were no features of epilepsy, the attack resolved within 24 hours, and the patient did not have any recent head injury or active epilepsy.
Although there is a correlation between TGA and migraine, it is not associated with cerebrovascular disease. The condition usually resolves spontaneously, and there is a small risk of recurrence.
Other conditions that can cause memory loss or confusion include subarachnoid hemorrhage, right caudate hemorrhage, cerebral venous thrombosis, and right hemisphere TIA. However, these conditions have different clinical presentations and require different diagnostic criteria.
In conclusion, TGA is a benign condition that can cause temporary memory loss and confusion. It is important to recognize the characteristic features of TGA and differentiate it from other conditions that can cause similar symptoms.
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This question is part of the following fields:
- Neurology
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