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  • Question 1 - A 58-year-old woman presents to the clinic for a follow-up on her Antihypertensive...

    Incorrect

    • A 58-year-old woman presents to the clinic for a follow-up on her Antihypertensive medication. She is currently prescribed bendroflumethiazide 2.5 mg daily and atenolol 50 mg daily for her hypertension, and atorvastatin for her dyslipidaemia. She also has a history of gout. What is a commonly known side effect of bendroflumethiazide?

      Your Answer: Hypocalcaemia

      Correct Answer: Hypoglycaemia

      Explanation:

      Thiazides: Risks and Adverse Effects

      Thiazides are a type of medication commonly used to treat high blood pressure and edema. However, they are associated with several adverse effects. One of the most common is metabolic alkalosis, which occurs when the body’s pH becomes too alkaline. Thiazides can also cause hypokalaemia, a condition where there is a low level of potassium in the blood, and hypercalcaemia, where there is too much calcium in the blood.

      Another potential risk of thiazides is an increase in insulin resistance, which can lead to type 2 diabetes. Meta-analyses have shown that combining thiazides with beta-blockers may further increase this risk. Additionally, thiazides are known to precipitate gout, a painful form of arthritis caused by the buildup of uric acid crystals in the joints.

      Hypertriglyceridaemia, a condition where there are high levels of triglycerides in the blood, is also associated with hyperuricaemia, which is an excess of uric acid in the blood. Thiazides can exacerbate this condition, leading to an increased risk of gout. It is important to be aware of these potential risks and to discuss them with a healthcare provider before starting thiazide therapy.

    • This question is part of the following fields:

      • Improving Quality, Safety And Prescribing
      21.9
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  • Question 2 - A 25-year-old man comes to his General Practitioner complaining of a painful discharging...

    Correct

    • A 25-year-old man comes to his General Practitioner complaining of a painful discharging right ear and a mild unilateral right-sided hearing loss that has been going on for 3 days. During examination, the doctor observes an intact tympanic membrane and copious purulent liquid discharge. The patient has a normal heart rate of 70 bpm and is not running a fever.
      What is the most suitable course of action for this patient?

      Your Answer: Prescribe topical antibiotics

      Explanation:

      Management Options for Otitis Externa

      Otitis externa is a common condition characterized by pain, itching, and discharge in the ear canal. Here are some management options for this condition:

      Prescribe Topical Antibiotics: Topical antibiotics are the first-line treatment for otitis externa. Neomycin or clioquinol are recommended, and they may be combined with a topical corticosteroid if there is inflammation and eczema. Aminoglycosides should be used cautiously as second line if there is perforation of the eardrum.

      Prescribe Oral Antibiotics: Oral antibiotics may be necessary if the patient is systemically unwell or there is preauricular lymphadenitis or cellulitis. Flucloxacillin or erythromycin is the drug of choice.

      Refer to Ear, Nose and Throat (ENT) for Ear Wick Insertion: If there is extensive swelling of the auditory canal, an ear wick may be used. This is impregnated with antibiotic-steroid combination and is inserted into the auditory canal. However, if the tympanic membrane is visible, topical antibiotics would be the first-line treatment.

      Prescribe Analgesia Only: Paracetamol or ibuprofen is usually sufficient for analgesia in cases of otitis externa. However, analgesia should be used in combination with antibiotics to aid in curing and preventing the worsening of symptoms.

      Do Not Prescribe Topical Antifungals: Topical antifungals are not indicated in simple cases of otitis externa. They may be necessary if there is a secondary fungal infection, but this is not described in this case.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      21.6
      Seconds
  • Question 3 - Which of the following individuals doesn't need the pneumococcal vaccine? ...

    Incorrect

    • Which of the following individuals doesn't need the pneumococcal vaccine?

      Your Answer: A 20-year-old man who has had a splenectomy

      Correct Answer: 40-year-old asthmatic using salbutamol and beclomethasone

      Explanation:

      According to the Green Book guidelines, only asthmatic patients who use oral steroids at a level that significantly weakens their immune system require the pneumococcal vaccine. However, since the angina patient is on beta-blockers, they should be given the vaccination. For more information, please refer to the provided link.

      The pneumococcal vaccine comes in two types: the pneumococcal conjugate vaccine (PCV) and the pneumococcal polysaccharide vaccine (PPV). The PCV is given to children as part of their routine immunizations at 3 and 12-13 months. On the other hand, the PPV is offered to adults over 65 years old, patients with chronic conditions such as COPD, and those who have had a splenectomy.

      The vaccine is recommended for individuals with asplenia or splenic dysfunction, chronic respiratory disease, chronic heart disease, chronic kidney disease, chronic liver disease, diabetes mellitus, immunosuppression, cochlear implants, and patients with cerebrospinal fluid leaks. However, controlled hypertension is not an indication for vaccination. Patients with any stage of HIV infection are also included in the list of those who should be vaccinated.

      Adults usually require only one dose of the vaccine, but those with asplenia, splenic dysfunction, or chronic kidney disease need a booster every five years. It is important to note that asthma is only included if it requires the use of oral steroids at a dose sufficient to act as a significant immunosuppressant.

    • This question is part of the following fields:

      • Infectious Disease And Travel Health
      7
      Seconds
  • Question 4 - A 65-year-old gentleman presents for a medication review. He is currently on sildenafil...

    Incorrect

    • A 65-year-old gentleman presents for a medication review. He is currently on sildenafil for erectile dysfunction and has a longstanding history of stable angina. Which of the following medications should be avoided in this patient?

      Your Answer: Bisoprolol

      Correct Answer: Carvedilol

      Explanation:

      Sildenafil: A Treatment for Impotence

      Sildenafil is a well-established treatment for impotence that works by inhibiting phosphodiesterase type 5, which produces cavernous venodilation and erections in appropriately stimulated patients. It is important to note that sildenafil doesn’t increase sex drive or libido.

      While sildenafil is not contraindicated in patients with ischaemic heart disease, it is contraindicated in subjects taking nitrates due to the potential for severe hypotension. Additionally, drugs like nicorandil are inadvisable due to the nitrate component.

      Common side effects of sildenafil include flushing, which develops in the majority of patients, as well as nasal congestion and blue visual discolouration. It is important to discuss any potential risks and benefits of sildenafil with a healthcare provider before starting treatment.

    • This question is part of the following fields:

      • Improving Quality, Safety And Prescribing
      16.1
      Seconds
  • Question 5 - A 35-year-old teacher complains of intense headache of 2-hours duration. The pain is...

    Incorrect

    • A 35-year-old teacher complains of intense headache of 2-hours duration. The pain is localised around the right eye and is associated with tearing and redness of the eye. The patient reported he has had similar episodes over the last year. He also admits that these episodes occurred every day for a few weeks with one to three attacks a day which last for 1-2 hours, frequently at night. After 6 weeks, the attacks stopped. She lost her job 6 months ago and has noticed an increase in the intensity of the pain since. Examination reveals drooping of the eyelid and small pupil on the right side.
      Select the single MOST likely diagnosis.

      Your Answer:

      Correct Answer: Cluster headache

      Explanation:

      Differentiating Headache Types: Cluster Headache, Intracranial Neoplasm, Acute Anterior Uveitis, Migraine, and Tension-Type Headache

      Headaches can be caused by various factors, and it is important to differentiate between different types to provide appropriate treatment. Cluster headache is a rare condition that affects mostly men and is characterized by intense pain around one eye, accompanied by nasal stuffiness and sometimes Horner syndrome. In contrast, headache is often a late symptom of an intracranial neoplasm, and a new headache or change in pattern may indicate an underlying tumor. Acute anterior uveitis presents with eye pain, redness, photophobia, excessive tearing, and decreased vision. Migraine is a common type of headache that presents with severe, often unilateral pain, accompanied by vomiting and photophobia. Tension-type headache is usually mild to moderate and described as pressure or tightness around the head. Understanding the specific features and associated symptoms of each type of headache can aid in accurate diagnosis and treatment.

    • This question is part of the following fields:

      • Neurology
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  • Question 6 - You come across a 35-year-old woman who injured her ankle while ice-skating. Despite...

    Incorrect

    • You come across a 35-year-old woman who injured her ankle while ice-skating. Despite the injury, she managed to stand up and walk off the ice with a limp. Upon examination, you notice swelling around her lateral malleolus and tenderness specifically on the anterior aspect of the distal fibula. There is no tenderness anywhere else, and she has an antalgic gait. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Anterior talofibular ligament sprain

      Explanation:

      To determine if an ankle x-ray is necessary for patients with foot or ankle pain, the Ottawa ankle rules are used. If the rules do not indicate the need for an x-ray, the likelihood of a fracture is low. The rules state that an x-ray is only necessary if the patient is unable to bear weight immediately after the injury and during assessment, or if there is tenderness along the distal 6 cm of the posterior edge of the tibia or fibula, or the distal tip of either malleoli.

      In this particular case, the patient is experiencing tenderness on the anterior aspect of the fibula, which is a common symptom of a sprain in the anterior talofibular ligament that inserts in the anterior part of the fibula.

      Ottawa Rules for Ankle Injuries

      The Ottawa Rules provide a reliable guideline for determining whether an ankle x-ray is necessary following an injury. These rules have a sensitivity approaching 100%, meaning they are highly accurate in identifying cases where an x-ray is needed. According to the Ottawa Rules for ankle injuries, an x-ray is only required if there is pain in the malleolar zone and one of the following findings: bony tenderness at the lateral malleolar zone, bony tenderness at the medial malleolar zone, or inability to walk four weight-bearing steps immediately after the injury and in the emergency department.

      By following these guidelines, healthcare professionals can avoid unnecessary x-rays and reduce radiation exposure for patients. Additionally, the Ottawa Rules are available for foot and knee injuries, providing a comprehensive approach to determining the need for imaging in these areas. Overall, the Ottawa Rules are a valuable tool for healthcare providers in making informed decisions about imaging for ankle injuries.

    • This question is part of the following fields:

      • Musculoskeletal Health
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  • Question 7 - A 5-year-old girl presents with fever, sore throat and reluctance to eat for...

    Incorrect

    • A 5-year-old girl presents with fever, sore throat and reluctance to eat for the last 48 h. On examination, you note small erosions on the buccal mucosa and tongue. Examining her body, you also find erythematous macules, some with vesicles, on the hands and feet.
      What is the most likely cause of these symptoms?

      Your Answer:

      Correct Answer: Coxsackievirus infection

      Explanation:

      Differential Diagnosis for Lesions on Hands, Feet, and Mouth

      Possible rewrite:

      Lesions on the hands, feet, and mouth can be caused by various infectious and non-infectious conditions. One possible diagnosis is hand, foot and mouth disease, which is typically caused by a coxsackievirus. This viral infection usually starts with a fever and is followed by the appearance of flat, pink spots on the hands and feet, which then turn into small, greyish blisters. The lesions may also spread to other parts of the body, such as the buttocks and arms, and may be accompanied by mild symptoms such as sore throat, cough, and malaise. The infection usually resolves within a week and confers immunity to the virus.

      Other possible diagnoses that can cause similar lesions include idiopathic thrombocytopenic purpura, Henoch–Schonlein purpura, parvovirus B19 infection, and rotavirus infection. Idiopathic thrombocytopenic purpura is a bleeding disorder that can cause purpuric rash and bruises on any part of the body, but not the specific type of lesions described in this scenario. Henoch–Schonlein purpura is a systemic vasculitis that can cause purpuric lesions on the legs, buttocks, and arms, as well as abdominal pain, joint pain, and kidney problems. Parvovirus B19 infection can cause a facial rash resembling slapped cheek syndrome, followed by a macular rash on the extremities. Rotavirus infection is a common cause of diarrhea in young children, but doesn’t typically cause skin lesions.

      Therefore, a careful history, physical examination, and laboratory tests may be needed to differentiate these conditions and guide appropriate treatment.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 8 - A 32-year-old woman presents to the clinic with sudden shortness of breath. An...

    Incorrect

    • A 32-year-old woman presents to the clinic with sudden shortness of breath. An ambulance is called and a brief medical history is obtained. She is currently taking the combined oral contraceptive pill and had a laparoscopic cholecystectomy recently. The following are her vital signs:

      - Blood pressure: 100/60 mmHg
      - Respiratory rate: 28 breaths per minute
      - Temperature: 36.8ºC
      - Oxygen saturation: 92% on room air

      While waiting for the ambulance, the patient is given oxygen through a face mask and an ECG is performed. Based on the likely diagnosis, what is the expected ECG finding?

      Your Answer:

      Correct Answer: Sinus tachycardia

      Explanation:

      Pulmonary embolism (PE) is a serious medical condition that can lead to a range of symptoms and complications. One of the most common signs of PE is an elevated heart rate, which can be caused by the increased demand on the right ventricle of the heart. This can lead to a range of other symptoms, including shortness of breath, chest pain, and coughing.

      Another common sign of PE is the presence of S1Q3T3 on an electrocardiogram (ECG). This is characterized by a deep S-wave in lead I, a Q-wave in lead III, and an inverted T-wave in lead III. While this finding is associated with PE, it is not specific to the condition and may not be present in all cases.

      T-wave inversions in leads V1-V4 can also be a sign of right ventricular strain, which can occur as a result of the increased demand on the heart caused by PE. However, this is not the most common finding in cases of PE.

      Pulmonary embolism can be difficult to diagnose as it can present with a variety of cardiorespiratory symptoms and signs depending on its location and size. The PIOPED study in 2007 found that tachypnea, crackles, tachycardia, and fever were common clinical signs in patients diagnosed with pulmonary embolism. The Well’s criteria for diagnosing a PE use tachycardia rather than tachypnea. All patients with symptoms or signs suggestive of a PE should have a history taken, examination performed, and a chest x-ray to exclude other pathology.

      To rule out a PE, the pulmonary embolism rule-out criteria (PERC) can be used. All criteria must be absent to have a negative PERC result, which reduces the probability of PE to less than 2%. If the suspicion of PE is greater than this, a 2-level PE Wells score should be performed. A score of more than 4 points indicates a likely PE, and an immediate computed tomography pulmonary angiogram (CTPA) should be arranged. If the CTPA is negative, patients do not need further investigations or treatment for PE.

      CTPA is now the recommended initial lung-imaging modality for non-massive PE. V/Q scanning may be used initially if appropriate facilities exist, the chest x-ray is normal, and there is no significant symptomatic concurrent cardiopulmonary disease. D-dimer levels should be considered for patients over 50 years old. A chest x-ray is recommended for all patients to exclude other pathology, but it is typically normal in PE. The sensitivity of V/Q scanning is around 75%, while the specificity is 97%. Peripheral emboli affecting subsegmental arteries may be missed on CTPA.

    • This question is part of the following fields:

      • Respiratory Health
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  • Question 9 - A 65-year-old man presents with new onset bilateral gynaecomastia.
    He has been diagnosed with...

    Incorrect

    • A 65-year-old man presents with new onset bilateral gynaecomastia.
      He has been diagnosed with Zollinger-Ellison syndrome and heart failure in the last year. He underwent normal puberty at age 14.

      Which of the following drugs would be most likely to cause gynaecomastia?

      Your Answer:

      Correct Answer: Rabeprazole sodium

      Explanation:

      Drugs that can cause gynaecomastia

      Research has shown that the risk of developing gynaecomastia is almost insignificant when using other drugs as part of the treatment of Zollinger-Ellison syndrome. However, there are other drugs that can cause gynaecomastia, including spironolactone, digoxin, methyldopa, gonadotrophins, and cyproterone acetate.

      Zollinger-Ellison syndrome is a condition where a gastrin-secreting pancreatic adenoma is associated with peptic ulcer, and 50-60% of cases are malignant. It is suspected in patients with multiple peptic ulcers that are resistant to drugs and occurs in approximately 0.1% of patients with duodenal ulcer disease.

      A case study into male gynaecomastia has shown that spironolactone induced gynaecomastia by blocking androgen production, blocking androgens from binding to their receptors, and increasing both total and free oestrogen levels. It is important to be aware of the potential side effects of these drugs and to discuss any concerns with a healthcare professional.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 10 - You see a 29-year-old female patient who has been trying to conceive with...

    Incorrect

    • You see a 29-year-old female patient who has been trying to conceive with her partner for 18 months. They are both typically healthy and have not previously had a successful pregnancy. She has a regular menstrual cycle and is not taking any medications. She expresses interest in being referred to a fertility clinic, but you explain that she must first undergo some blood tests and her partner must have a semen analysis. You also discuss the most common reasons for fertility problems. However, her partner is hesitant about having a semen analysis. What percentage of infertile couples experience male infertility as the cause?

      Your Answer:

      Correct Answer: 30%

      Explanation:

      Understanding Infertility: Initial Investigations and Key Counselling Points

      Infertility is a common issue that affects approximately 1 in 7 couples. However, it is important to note that around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 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%.

      To determine the cause of infertility, basic investigations are typically conducted. These include a semen analysis and a serum progesterone test, which is done 7 days prior to the expected next period. The interpretation of the serum progesterone level is as follows: if the level is less than 16 nmol/l, it should be repeated and if it consistently remains 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.

      In addition to these investigations, there are key counselling points that should be addressed. These include advising the patient to take folic acid, aiming for a BMI between 20-25, and having regular sexual intercourse every 2 to 3 days. Patients should also be advised to quit smoking and limit alcohol consumption.

      By understanding the initial investigations and key counselling points for infertility, healthcare professionals can provide their patients with the necessary information and support to help them conceive.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
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  • Question 11 - A 28-year-old woman comes in for a check-up. She started working at a...

    Incorrect

    • A 28-year-old woman comes in for a check-up. She started working at a hair salon six months ago and has been experiencing an increasing cough and wheeze during the day. She wonders if it could be related to her work as her symptoms improved during a recent two-week vacation to Hawaii. You decide to give her a peak flow meter and the average results are as follows:

      Average peak flow
      Days at work 480 l/min
      Days not at work 600 l/min

      What would be the best course of action in this situation?

      Your Answer:

      Correct Answer: Refer to respiratory

      Explanation:

      Referral to a respiratory specialist is recommended for patients who are suspected to have occupational asthma.

      Occupational Asthma: Causes and Symptoms

      Occupational asthma is a type of asthma that is caused by exposure to certain chemicals in the workplace. Patients may experience worsening asthma symptoms while at work or notice an improvement in symptoms when away from work. The most common cause of occupational asthma is exposure to isocyanates, which are found in spray painting and foam moulding using adhesives. Other chemicals associated with occupational asthma include platinum salts, soldering flux resin, glutaraldehyde, flour, epoxy resins, and proteolytic enzymes.

      To diagnose occupational asthma, it is recommended to measure peak expiratory flow at work and away from work. If there is a significant difference in peak expiratory flow, referral to a respiratory specialist is necessary. Treatment may include avoiding exposure to the triggering chemicals and using medications to manage asthma symptoms. It is important for employers to provide a safe working environment and for employees to report any concerns about potential exposure to harmful chemicals.

    • This question is part of the following fields:

      • Respiratory Health
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  • Question 12 - A 32-year-old woman visits her doctor after missing her desogestrel contraceptive pill (progestogen...

    Incorrect

    • A 32-year-old woman visits her doctor after missing her desogestrel contraceptive pill (progestogen only) this morning and is uncertain about what to do. She typically takes the pill at approximately 0900, and it is now 1430. What guidance should be provided?

      Your Answer:

      Correct Answer: Take missed pill now and no further action needed

      Explanation:

      Since desogestrel has a 12-hour window, the patient can take the pill now without requiring any additional steps.

      The progestogen only pill (POP) has simpler rules for missed pills compared to the combined oral contraceptive pill. It is important to not confuse the two. For traditional POPs such as Micronor, Noriday, Norgeston, and Femulen, as well as Cerazette (desogestrel), if a pill is less than 3 hours late, no action is required and pill taking can continue as normal. However, if a pill is more than 3 hours late (i.e. more than 27 hours since the last pill was taken), action is needed. If a pill is less than 12 hours late, no action is required. But if a pill is more than 12 hours late (i.e. more than 36 hours since the last pill was taken), action is needed.

      If action is needed, the missed pill should be taken as soon as possible. If more than one pill has been missed, only one pill should be taken. The next pill should be taken at the usual time, which may mean taking two pills in one day. Pill taking should continue with the rest of the pack. Extra precautions, such as using condoms, should be taken until pill taking has been re-established for 48 hours.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
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  • Question 13 - Which one of the following statements regarding benign rolandic epilepsy is incorrect? ...

    Incorrect

    • Which one of the following statements regarding benign rolandic epilepsy is incorrect?

      Your Answer:

      Correct Answer: Typically occurs between the age of 1 and 3 years

      Explanation:

      Understanding Benign Rolandic Epilepsy

      Benign rolandic epilepsy is a type of epilepsy that commonly affects children between the ages of 4 and 12 years. This condition is characterized by seizures that usually occur at night and are typically partial, affecting only certain parts of the body such as the face. However, in some cases, the seizures may progress to involve the entire body. Despite these symptoms, children with benign rolandic epilepsy are otherwise healthy and normal.

      One of the key diagnostic features of benign rolandic epilepsy is the presence of centrotemporal spikes on an electroencephalogram (EEG). This test measures the electrical activity in the brain and can help doctors identify the specific type of epilepsy a child may have.

      Fortunately, the prognosis for children with benign rolandic epilepsy is excellent. Most children will outgrow their seizures by the time they reach adolescence. While the condition can be concerning for parents, it is important to remember that it is a relatively mild form of epilepsy and doesn’t typically cause any long-term complications.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 14 - A 27-year-old office secretary presents with symptoms of palpitations, restlessness, fatigue and increased...

    Incorrect

    • A 27-year-old office secretary presents with symptoms of palpitations, restlessness, fatigue and increased sweating. She also complains of infrequent periods and weight loss.

      You examine the patient and find she has tachycardia and tremors; she is hyper-reflexic. Biochemical tests on blood samples reveal hyperthyroid. Examination of neck reveals a multiple small nodular areas in a diffusely enlarged thyroid.

      What is the most appropriate initial management for this patient?

      Your Answer:

      Correct Answer: Propranolol

      Explanation:

      Treatment for Thyrotoxic Patient

      This patient is experiencing symptoms of thyrotoxicosis and requires immediate treatment to alleviate the effects of adrenergic drive. The initial therapy would involve beta blockade with propranolol to relieve her symptoms. Once her symptoms are under control, the next step would be to render her euthyroid. This can be achieved with radioiodine treatment. However, it is important to note that propranolol would still be required as the initial treatment. Proper management of thyrotoxicosis is crucial to prevent complications and improve the patient’s quality of life.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
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  • Question 15 - A 4-year-old boy has a 4-week history of loose stools. He was febrile,...

    Incorrect

    • A 4-year-old boy has a 4-week history of loose stools. He was febrile, with vomiting for the first 48 hours, but this has resolved. The diarrhoea persists. Prior to this episode of illness, he had a normal diet with no exclusions. A stool sample was sent last week, the report from which has come back, and states that there is no evidence of infection, no organisms seen and the stool is positive for reducing substances.
      What is the best course of action to take?

      Your Answer:

      Correct Answer: Recommend avoidance of lactose-containing foods for one month

      Explanation:

      The child has temporary lactose intolerance due to a deficiency in enzymes caused by viral gastroenteritis. It is recommended to avoid lactose-containing foods for two weeks to one month, after which lactose can be reintroduced to the diet. If symptoms recur, a specialist should be consulted. Antibiotics such as metronidazole and ciprofloxacin are not effective in treating this condition. Symptoms should resolve spontaneously with a lactose-free diet. Primary lactase deficiency is a common genetic condition that can be managed by determining the amount of lactose that can be tolerated and taking it in divided portions throughout the day.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 16 - A 32-year-old woman who is four months pregnant is planning to travel to...

    Incorrect

    • A 32-year-old woman who is four months pregnant is planning to travel to Africa with her husband for his business. She visits your clinic as she needs to update her vaccinations.
      Which of the following vaccines is safe to administer during pregnancy?

      Your Answer:

      Correct Answer: Hepatitis A

      Explanation:

      Live, Antigenic, and Toxoid Vaccines

      Live vaccines are those that contain a weakened or attenuated form of the virus or bacteria they protect against. Examples of live vaccines include oral polio vaccines, measles, mumps, rubella, yellow fever, and BCG. These vaccines are effective because they stimulate the immune system to produce a strong and long-lasting response.

      Antigenic vaccines, on the other hand, contain a part of the virus or bacteria that triggers an immune response. Hepatitis A and B vaccines are examples of antigenic vaccines. They are indicated in cases where there is a risk of exposure to Hepatitis A or B.

      Toxoid vaccines contain a toxin produced by the bacteria they protect against that has been inactivated or detoxified. Tetanus vaccination is an example of a toxoid vaccine. These vaccines are effective because they stimulate the immune system to produce antibodies that neutralize the toxin.

      In summary, live, antigenic, and toxoid vaccines are all important tools in preventing the spread of infectious diseases. Each type of vaccine works differently, but all are designed to stimulate the immune system to produce a protective response.

    • This question is part of the following fields:

      • Population Health
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  • Question 17 - Samantha is a 10-year-old girl who is scheduled to receive the HPV vaccine...

    Incorrect

    • Samantha is a 10-year-old girl who is scheduled to receive the HPV vaccine at her doctor's office. She is very anxious about getting shots and asks the nurse how many injections she will have to get.

      What is the correct response to Samantha's question?

      Your Answer:

      Correct Answer: Two

      Explanation:

      The NHS will provide the HPV vaccine to all 12- and 13-year-olds in school year 8 starting from September 2019. Typically, the vaccine is administered in two injections, with the second dose given 6 to 12 months after the first (during school year 8 or year 9). However, individuals who receive the vaccine after the age of 15 will require three doses, as they do not have the same response to two doses as younger individuals.

      The human papillomavirus (HPV) is a known carcinogen that infects the skin and mucous membranes. There are numerous strains of HPV, with strains 6 and 11 causing genital warts and strains 16 and 18 linked to various cancers, particularly cervical cancer. HPV infection is responsible for over 99.7% of cervical cancers, and testing for HPV is now a crucial part of cervical cancer screening. Other cancers linked to HPV include anal, vulval, vaginal, mouth, and throat cancers. While there are other risk factors for developing cervical cancer, such as smoking and contraceptive pill use, HPV vaccination is an effective preventative measure.

      The UK introduced an HPV vaccine in 2008, initially using Cervarix, which protected against HPV 16 and 18 but not 6 and 11. This decision was criticized due to the significant disease burden caused by genital warts. In 2012, Gardasil replaced Cervarix as the vaccine used, protecting against HPV 6, 11, 16, and 18. Initially given only to girls, boys were also offered the vaccine from September 2019. The vaccine is offered to all 12- and 13-year-olds in school Year 8, with the option for girls to receive a second dose between 6-24 months after the first. Men who have sex with men under the age of 45 are also recommended to receive the vaccine to protect against anal, throat, and penile cancers.

      Injection site reactions are common with HPV vaccines. It should be noted that parents may not be able to prevent their daughter from receiving the vaccine, as information given to parents and available on the NHS website makes it clear that the vaccine may be administered against parental wishes.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 18 - A 25-year-old woman presents after the birth of her second child. She complains...

    Incorrect

    • A 25-year-old woman presents after the birth of her second child. She complains of persistent fatigue and a hoarse voice that she can't seem to shake off. Despite breastfeeding her child, she is struggling to lose her pregnancy weight. Anti-thyroid peroxidase antibodies are present and the erythrocyte sedimentation rate (ESR) is normal. Her thyroid-stimulating hormone (TSH) is 12 mIU/l (normal range 0.17 - 3.2 mIU/l), with a free thyroxine (T4) of 5 pmol/l. There is no thyroid tenderness on examination, but she has a slight goitre. Her pulse is only 52 bpm.
      Which of the following diagnoses best fits with this clinical picture?

      Your Answer:

      Correct Answer: Postpartum thyroiditis

      Explanation:

      Postpartum Thyroiditis: A Self-Limiting Condition with Hypothyroidism as a Common Outcome

      Postpartum thyroiditis is a subacute lymphocytic thyroiditis that occurs within the first six months after giving birth. It is characterized by antithyroid peroxidase antibodies that mediate the condition. Symptoms may include slight painless thyroid swelling and hyperthyroidism. However, the condition is self-limiting and hyperthyroidism is commonly followed by hypothyroidism, which may become permanent in 25% of patients. The aetiology of postpartum thyroiditis is obscure, but it is associated with hypothyroidism during pregnancy and the presence of antibodies.

      Hyperthyroidism, atrophic thyroiditis, Hashimoto’s thyroiditis, and iodine deficiency are all incorrect diagnosis for postpartum thyroiditis. Hyperthyroidism is a hormonal change that is not present in postpartum thyroiditis. Atrophic thyroiditis is an autoimmune disease that occurs in elderly women and is characterized by thyroid autoantibodies, hypothyroidism, and absence of goitre. Hashimoto’s thyroiditis is an autoimmune disease that is the most common cause of goitrous hypothyroidism in non-iodine-deficient areas. Iodine deficiency is the most common cause of hypothyroidism worldwide and results in goitre, but it is still a rare cause of hypothyroidism in the UK.

      In conclusion, postpartum thyroiditis is a self-limiting condition that may result in hypothyroidism as a common outcome. It is important to diagnose and manage this condition to prevent long-term complications.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
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  • Question 19 - A 55-year-old man is brought to his General Practitioner by his daughter, who...

    Incorrect

    • A 55-year-old man is brought to his General Practitioner by his daughter, who is concerned about his memory. He has no recollection of recent or distant events, but responds to every question with a very detailed, yet incorrect, answer.

      Upon examination, he displays ataxia and nystagmus. He has not visited a doctor in over 25 years, doesn't take any regular medication, and has consumed eight pints of beer per night for the past 35 years.

      What is the most probable deficiency causing this presentation? Choose ONE option only.

      Your Answer:

      Correct Answer: Vitamin B1

      Explanation:

      The patient is suffering from Korsakoff syndrome, a condition caused by a deficiency of vitamin B1 (thiamine). This syndrome is a late manifestation of untreated Wernicke’s encephalopathy and is characterized by mental confusion, ataxia, ophthalmoplegia, anterograde and retrograde amnesia, and confabulation. It is most common in people in their fifties and sixties and is caused by alcoholism or other factors such as chronic subdural hematoma, nutritional stress, AIDS, hyperemesis gravidarum, thyrotoxicosis, long-term dialysis, or congestive heart failure. Urgent medical assessment and admission for parenteral thiamine is necessary, as it can be fatal if left untreated. Zinc deficiency, on the other hand, is characterized by symptoms such as anorexia, lethargy, diarrhea, growth restriction, impaired immune function, delayed sexual maturation, learning disability, weight loss, and macular degeneration. It is not related to memory or cognitive problems, ataxia, or nystagmus. Vitamin B2 deficiency is more common in vegetarians, vegans, pregnant women, or young children and is thought to have a role in migraines. Vitamin B12 deficiency causes symptoms such as cognitive and memory disturbance, headaches, dyspepsia, loss of appetite, palpitations, visual disturbance, weakness and lethargy, angina, optic neuropathy, symmetrical neuropathy affecting the legs more than the arms, and a megaloblastic anemia. Vitamin E deficiency is rare in healthy people and is strongly associated with conditions affecting absorption, such as Crohn’s disease or cystic fibrosis. However, this patient’s history of alcohol excess makes thiamine deficiency much more likely.

    • This question is part of the following fields:

      • Smoking, Alcohol And Substance Misuse
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  • Question 20 - A 10-year-old girl is brought in for a follow-up appointment regarding her asthma...

    Incorrect

    • A 10-year-old girl is brought in for a follow-up appointment regarding her asthma treatment. She is currently using salbutamol inhaler as needed and Symbicort 100/6 (budesonide 100 micrograms/formoterol 6 micrograms) two puffs twice a day. She has been using these inhalers for the past six months. Before that, she was using salbutamol as needed and budesonide 200 micrograms twice a day. The Symbicort was added to her regimen to include a long-acting beta2 agonist as she was using her salbutamol once or twice a day. Despite the addition of the long-acting beta2 agonist, she still experiences occasional tightness in her chest and nighttime coughing. She uses her salbutamol inhaler an average of three to four times a week. Her parents confirm that she is compliant with her inhalers and her inhaler technique is good. What is the most appropriate management plan for her current asthma treatment?

      Your Answer:

      Correct Answer: Add in a leukotriene receptor antagonist to her current treatment

      Explanation:

      Treatment Ladder for Asthma in a 9-Year-Old Child

      Here we have a 9-year-old child with asthma who is currently on a regular inhaled corticosteroid (ICS) + long acting beta2 agonist (LABA) combination inhaler and salbutamol as needed. Despite some improvement with the regular inhaled ICS+LABA, the child is still requiring salbutamol quite frequently.

      To guide treatment titration, the British Thoracic Society treatment ladder is the best recognized guideline in the UK. Based on this, the next step would be to trial a leukotriene receptor antagonist. If the addition of the LABA had not yielded any clinical benefit, then it should be stopped. However, since it has proved to be somewhat helpful, it should be continued.

      In summary, the treatment ladder for asthma in a 9-year-old child involves gradually increasing the level of medication until symptoms are controlled. The addition of a leukotriene receptor antagonist may be the next step in this process.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 21 - A 25-year-old man presented with bloody discolouration of his urine over the past...

    Incorrect

    • A 25-year-old man presented with bloody discolouration of his urine over the past few days, following a recent respiratory tract infection. Urine testing confirmed haematuria and proteinuria, which had also been noted on two previous occasions after respiratory tract infections. He was referred for renal opinion and a biopsy revealed a focal proliferative glomerulonephritis. What is the most likely underlying diagnosis based on this clinical presentation?

      Your Answer:

      Correct Answer: IgA nephropathy

      Explanation:

      IgA nephropathy is a common type of glomerulonephritis that is characterized by the presence of mesangial IgA deposits. This condition is often triggered by an abnormal immune response to viral or other antigens, resulting in the formation of macromolecular aggregates that accumulate in the glomerular mesangium. IgA nephropathy typically presents with macroscopic hematuria and may be associated with upper respiratory or other infections. It is more common in men and tends to affect children over 10 years of age and young adults. Treatment may involve high-dose prednisolone or immunosuppressive drugs, but some patients may eventually develop end-stage renal failure.

      Goodpasture’s syndrome is an autoimmune disease that can cause diffuse pulmonary hemorrhage, glomerulonephritis, acute kidney injury, and chronic kidney disease. With aggressive treatment, the prognosis has improved, with a one-year survival rate of 70-90%.

      Henoch-Schönlein purpura is a condition that shares similarities with IgA nephropathy and may be a variant of the same disease. About 20% of patients with IgA nephropathy develop impaired renal function, and 5% develop end-stage renal failure.

      Membranous glomerulonephritis is the most common cause of nephrotic syndrome in adults and may present as nephritic syndrome or hypertension. It is characterized by widespread thickening of the glomerular basement membrane and may be idiopathic or due to systemic lupus erythematosus, hepatitis B, malignancy, or the use of certain medications. About 30-50% of patients with membranous glomerulonephritis progress to end-stage kidney disease.

      Minimal change nephropathy is responsible for most cases of nephrotic syndrome in children under 5 years of age and can also occur in adults. It is called minimal change because the only detectable abnormality is fusion and deformity of the foot processes under the electron microscope. Prognosis is generally good for the majority of patients.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 22 - A 35-year-old patient who is on methotrexate for psoriasis presents because her 6-year-old...

    Incorrect

    • A 35-year-old patient who is on methotrexate for psoriasis presents because her 6-year-old son has been suffering from Chickenpox and she is concerned about developing it. She has not previously had Chickenpox herself and is currently well, with no symptoms or rash.

      What advice should be given to this patient?

      Your Answer:

      Correct Answer: Test for varicella antibodies and give varicella-zoster immunoglobulin

      Explanation:

      Patients who are on long-term steroids or methotrexate and have weakened immune systems should be given VZIG if they come into contact with Chickenpox and have no antibodies to varicella. Although Chickenpox is usually a mild illness, it can be dangerous for those who are immunosuppressed or pregnant.

      If a patient has been exposed to varicella, they should be offered active post-exposure prophylaxis with varicella-zoster immunoglobulin. It is important to test people who have had significant exposure to Chickenpox and are immunocompromised for varicella-zoster antibody, regardless of their history of Chickenpox.

      It is inappropriate to wait for up to 21 days to see if symptoms appear or take no action because this patient is immunosuppressed and is at risk of severe varicella infection. Similarly, stopping her methotrexate would not be appropriate as the immunosuppressive effects would take time to wear off.

      Managing Chickenpox Exposure in At-Risk Groups

      Whilst Chickenpox is usually a mild condition in children with normal immune systems, it can cause serious systemic disease in at-risk groups. Pregnant women and their developing fetuses are particularly vulnerable. Therefore, it is crucial to know how to manage varicella exposure in these special groups.

      To determine who would benefit from active post-exposure prophylaxis, the following criteria should be met: significant exposure to Chickenpox or herpes zoster, a clinical condition that increases the risk of severe varicella (such as immunosuppression), and no antibodies to the varicella virus. Ideally, all at-risk exposed patients should have a blood test for varicella antibodies. However, post-exposure prophylaxis should not be delayed past 7 days after initial contact.

      Patients who meet the above criteria should be given varicella-zoster immunoglobulin (VZIG). The management of Chickenpox exposure in pregnancy is an important topic that is covered in more detail in a separate entry to the textbook.

    • This question is part of the following fields:

      • Infectious Disease And Travel Health
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  • Question 23 - A 55-year-old woman presents to the diabetes clinic following a recent diagnosis of...

    Incorrect

    • A 55-year-old woman presents to the diabetes clinic following a recent diagnosis of type 2 diabetes. Her HbA1c levels were 59 mmol/mol and 61 mmol/mol on repeat testing. She has a medical history of stable angina and essential hypertension. Her renal function results show an eGFR of 72 ml/min/1.73m² and a urine ACR of 2.3 mg/mmol.

      What would be the best initial treatment option for this patient?

      Your Answer:

      Correct Answer: Start metformin first and titrate upwards as tolerated, add an SGLT-2 inhibitor regardless of glycaemic control

      Explanation:

      To properly manage a patient with type 2 diabetes mellitus (T2DM) who has a history of angina, it is important to start with metformin and titrate upwards as tolerated. Additionally, an SGLT-2 inhibitor should be added regardless of glycaemic control, as it is indicated for organ protection. Once metformin tolerability is confirmed, the SGLT-2 inhibitor can be added. Starting with an SGLT-2 inhibitor first or starting both medications immediately and titrating metformin upwards as tolerated is incorrect. Adding a DPP 4 inhibitor, pioglitazone, or sulfonylurea only if adequate glycaemic control is not achieved is also not the recommended approach for this patient.

      NICE has updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022 to reflect advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. For the average patient taking metformin for T2DM, lifestyle changes and titrating up metformin to aim for a HbA1c of 48 mmol/mol (6.5%) is recommended. A second drug should only be added if the HbA1c rises to 58 mmol/mol (7.5%). Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates, controlling intake of saturated fats and trans fatty acids, and initial target weight loss of 5-10% in overweight individuals.

      Individual HbA1c targets should be agreed upon with patients to encourage motivation, and HbA1c should be checked every 3-6 months until stable, then 6 monthly. Targets should be relaxed on a case-by-case basis, with particular consideration for older or frail adults with type 2 diabetes. Metformin remains the first-line drug of choice, and SGLT-2 inhibitors should be given in addition to metformin if the patient has a high risk of developing cardiovascular disease (CVD), established CVD, or chronic heart failure. If metformin is contraindicated, SGLT-2 monotherapy or a DPP-4 inhibitor, pioglitazone, or sulfonylurea may be used.

      Further drug therapy options depend on individual clinical circumstances and patient preference. Dual therapy options include adding a DPP-4 inhibitor, pioglitazone, sulfonylurea, or SGLT-2 inhibitor (if NICE criteria are met). If a patient doesn’t achieve control on dual therapy, triple therapy options include adding a sulfonylurea or GLP-1 mimetic. GLP-1 mimetics should only be added to insulin under specialist care. Blood pressure targets are the same as for patients without type 2 diabetes, and ACE inhibitors or ARBs are first-line for hypertension. Antiplatelets should not be offered unless a patient has existing cardiovascular disease, and only patients with a 10-year cardiovascular risk > 10% should be offered a statin.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
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  • Question 24 - As part of a community health initiative, you are tasked with developing a...

    Incorrect

    • As part of a community health initiative, you are tasked with developing a program to enhance the well-being of infants in the area. What is the leading cause of mortality among infants aged over one month but under 12 months?

      Your Answer:

      Correct Answer: Sudden infant death syndrome

      Explanation:

      Accidents become the leading cause of death in children after they turn one year old.

      Sudden infant death syndrome (SIDS) is the leading cause of death in infants during their first year of life, with the highest incidence occurring at three months of age. There are several major risk factors associated with SIDS, including placing the baby to sleep on their stomach, parental smoking, prematurity, bed sharing, and hyperthermia or head covering. These risk factors are additive, meaning that the more risk factors present, the higher the likelihood of SIDS. Other risk factors include male sex, multiple births, lower social classes, and maternal drug use. SIDS incidence also tends to increase during the winter months. However, there are protective factors that can reduce the risk of SIDS, such as breastfeeding, room sharing (but not bed sharing), and the use of pacifiers. In the event of a SIDS case, it is important to screen siblings for potential sepsis and inborn errors of metabolism.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 25 - A 5-year-old girl presents with a six-month history of constant snoring and seems...

    Incorrect

    • A 5-year-old girl presents with a six-month history of constant snoring and seems to ‘talk through her nose.’ Her nose seems clear on anterior examination.
      What is the most appropriate management intervention?

      Your Answer:

      Correct Answer: A period of watchful waiting

      Explanation:

      Management of Enlarged Adenoids in Children

      Explanation:
      Enlarged adenoids are a common condition in children, which usually resolve on their own by the age of eight years. In cases where there is no history of sleep apnea or significant impairment of hearing or speech, a period of watchful waiting for six months or longer is appropriate. Nasal corticosteroids are not effective in treating enlarged adenoids as they do not affect the postnasal space. Adenoidectomy may be considered if the problem persists despite the waiting period. Tonsillectomy is not necessary unless there are frequent throat infections. The use of an albuterol inhaler is not recommended as there is no indication of asthma in the child. Overall, careful monitoring and appropriate intervention can effectively manage enlarged adenoids in children.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 26 - During a home visit to a 58-year-old patient with a lower respiratory tract...

    Incorrect

    • During a home visit to a 58-year-old patient with a lower respiratory tract infection, who is also housebound due to motor neurone disease, you review her medications. What regular medication/s should you consider initiating?

      Your Answer:

      Correct Answer: Vitamin D

      Explanation:

      It is recommended to provide daily vitamin D supplements to all patients who are confined to their homes.

      Vitamin D supplementation has been a topic of interest for several years, and recent releases have provided some clarity on the matter. The Chief Medical Officer’s 2012 letter and the National Osteoporosis Society’s 2013 UK Vitamin D guideline recommend that certain groups take vitamin D supplements. These groups include pregnant and breastfeeding women, children aged 6 months to 5 years, adults over 65 years, and individuals who are not exposed to much sun, such as housebound patients.

      Testing for vitamin D deficiency is not necessary for most people. The NOS guidelines suggest that testing may be appropriate for patients with bone diseases that may be improved with vitamin D treatment, such as osteomalacia or Paget’s disease, and for patients with musculoskeletal symptoms that could be attributed to vitamin D deficiency, such as bone pain. However, patients with osteoporosis should always be given calcium/vitamin D supplements, and individuals at higher risk of vitamin D deficiency should be treated regardless of testing. Overall, vitamin D supplementation is recommended for certain groups, while testing for deficiency is only necessary in specific situations.

    • This question is part of the following fields:

      • Respiratory Health
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  • Question 27 - A 35-year-old asthmatic woman presents with a history of amenorrhoea and galactorrhoea. She...

    Incorrect

    • A 35-year-old asthmatic woman presents with a history of amenorrhoea and galactorrhoea. She is eager to get pregnant and has been attempting to conceive for six months, but has not been successful. What is the most probable reason for this patient's symptoms? Choose ONE option only.

      Your Answer:

      Correct Answer: Pituitary microadenoma

      Explanation:

      Causes of hyperprolactinaemia and galactorrhoea: differential diagnosis

      Hyperprolactinaemia and galactorrhoea are two related conditions that can have various underlying causes. One common cause is a prolactin-secreting pituitary tumour, which can be either a microadenoma (more common) or a macroadenoma (less common). Another possible cause is the use of certain drugs, such as dopamine receptor antagonists and some antidepressants. Hyperthyroidism is not a likely cause, but hypothyroidism can sometimes lead to hyperprolactinaemia. Finally, while hepatic impairment can cause hyperprolactinaemia, it is not a frequent finding in patients with liver cirrhosis. Therefore, a careful differential diagnosis is needed to identify the specific cause of hyperprolactinaemia and galactorrhoea in each patient.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
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  • Question 28 - A parent is concerned about her 9-month-old child’s prominent ears. ...

    Incorrect

    • A parent is concerned about her 9-month-old child’s prominent ears.

      Your Answer:

      Correct Answer: Delay operation until the age of 8

      Explanation:

      Prominent Ears: Causes, Diagnosis, and Treatment Options

      Prominent ears affect a small percentage of the population and are usually inherited. This condition arises due to the lack or malformation of cartilage during ear development in the womb, resulting in abnormal helical folds or lateral growth. While some babies are born with normal-looking ears, the problem may arise within the first three months of life.

      Before six months of age, the ear cartilage is soft and can be molded and splinted. However, after this age, surgical correction is the only option. Pinnaplasty or otoplasty can be performed on children from the age of five, but the ideal age for the procedure is around eight years old. This allows enough time to see if the child perceives the condition as a problem, while also avoiding potential teasing or bullying at school.

      While some prominent ears may become less visible over time, it is best not to delay corrective procedures. Younger ears tend to produce better results after surgery, and waiting too long may increase the risk of bullying at school. Overall, understanding the causes, diagnosis, and treatment options for prominent ears can help individuals make informed decisions about their care.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 29 - If you were looking at evidence about which age group is most susceptible...

    Incorrect

    • If you were looking at evidence about which age group is most susceptible to psychiatric disturbance in patients taking Tamiflu, in what type of study would you be most likely to find it?

      Your Answer:

      Correct Answer: Nested case-control study

      Explanation:

      Investigating Rare Case Reports of Psychiatric Disturbance and Drug Safety

      By definition, rare case reports cannot be adequately addressed in a standard clinical development program that typically involves studies in up to 5,000 patients. Therefore, conducting another randomized controlled trial (RCT) is unlikely to provide significant data. Managed healthcare databases may not offer sufficient detailed information to establish causality, and a cohort study may not have a large enough number of index events to draw conclusions about drug safety. In this scenario, a nested case-control study is the most appropriate approach to investigate any potential link between psychiatric disturbance and the drug. This type of study compares a collection of cases with control patients to identify any differences and draw conclusions about drug safety.

    • This question is part of the following fields:

      • Evidence Based Practice, Research And Sharing Knowledge
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  • Question 30 - A 50-year-old man has had intermittent heartburn and acid regurgitation over the past...

    Incorrect

    • A 50-year-old man has had intermittent heartburn and acid regurgitation over the past 10 years. He has previously had an H2 receptor antagonist and a proton pump inhibitor with good effect. He occasionally has bought preparations from the pharmacy with good effect. His body mass index (BMI) is 29 kg/m2 and he smokes 15 cigarettes per day. His symptoms have been worse recently and are waking him at night.
      Select from the list the single management option that is likely to be most effective in bringing about a QUICK resolution of his symptoms.

      Your Answer:

      Correct Answer: Proton pump inhibitor (PPI)

      Explanation:

      Management of Gastro-Oesophageal Reflux Disease-Like Symptoms

      Explanation:

      When a patient presents with symptoms suggestive of gastro-oesophageal reflux disease (GORD), it is recommended to manage it as uninvestigated dyspepsia, according to NICE guidelines. This is because an endoscopy has not been carried out, and there are no red flag symptoms that require immediate referral for endoscopy.

      The first step in managing GORD-like symptoms is to advise the patient on lifestyle modifications such as weight loss, dietary changes, smoking cessation, and alcohol reduction. These changes may lead to a reduction in symptoms.

      In the short term, a full dose of a proton pump inhibitor (PPI) for one month is the most effective treatment to bring about a quick resolution of symptoms. If the patient has responded well to PPI in the past, it is likely to be effective again. Testing for H. pylori may also be an option if it has not been done previously.

      After the initial treatment, a low-dose PPI as required may be appropriate for the patient. Other drugs such as H2 receptor antagonists, antacids, and prokinetics can also be used in the management of uninvestigated dyspepsia. However, they are not the first choice according to the guidelines and are less likely to be as effective as a PPI.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 31 - A 42-year-old man visits his GP with concerns about decreased libido and erectile...

    Incorrect

    • A 42-year-old man visits his GP with concerns about decreased libido and erectile dysfunction. His wife notes that he has a constant tan and lacks energy. He also reports experiencing hand pains. What investigation is most likely to uncover the diagnosis?

      Your Answer:

      Correct Answer: Ferritin

      Explanation:

      To screen for haemochromatosis in the general population, a transferrin saturation level higher than ferritin is used. For family members, HFE genetic testing is recommended. It is important to note that while the patient in question is experiencing symptoms associated with haemochromatosis, diabetes mellitus alone would not typically result in decreased libido.

      Understanding Haemochromatosis: Investigation and Management

      Haemochromatosis is a genetic disorder that causes iron accumulation in the body due to mutations in the HFE gene. The best investigation to screen for haemochromatosis is still a topic of debate. For the general population, transferrin saturation is considered the most useful marker, while genetic testing for HFE mutation is recommended for testing family members. Diagnostic tests include molecular genetic testing for the C282Y and H63D mutations and liver biopsy using Perl’s stain.

      A typical iron study profile in patients with haemochromatosis includes high transferrin saturation levels, raised ferritin and iron, and low TIBC. The first-line treatment for haemochromatosis is venesection, which involves removing blood from the body to reduce iron levels. Transferrin saturation should be kept below 50%, and the serum ferritin concentration should be below 50 ug/l to monitor the adequacy of venesection. If venesection is not effective, desferrioxamine may be used as a second-line treatment. Joint x-rays may also show chondrocalcinosis, which is a characteristic feature of haemochromatosis.

      It is important to note that there are rare cases of families with classic features of genetic haemochromatosis but no mutation in the HFE gene. As HFE gene analysis becomes less expensive, guidelines for investigating and managing haemochromatosis may change.

    • This question is part of the following fields:

      • Haematology
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  • Question 32 - A 29-year-old woman who is 11 weeks pregnant contacts her General Practitioner to...

    Incorrect

    • A 29-year-old woman who is 11 weeks pregnant contacts her General Practitioner to discuss screening for Down syndrome. She is very anxious, as her sister has Down syndrome and is keen to ensure she has the most reliable test.
      What is the most appropriate screening test to offer at this stage?

      Your Answer:

      Correct Answer: Combined test

      Explanation:

      Prenatal Screening Tests: Overview and Differences

      Prenatal screening tests are offered to pregnant women to assess the risk of chromosomal abnormalities in the fetus. There are several types of tests available, each with its own advantages and limitations.

      Combined Test: This test is offered to all pregnant women between ten and 14 weeks gestation. It involves the measurement of nuchal translucency on ultrasound, serum beta-human chorionic gonadotropin (B-HCG), and pregnancy-associated plasma protein-A. The test allows risk stratification of the likelihood of the baby having Down, Patau, or Edward’s syndrome.

      Amniocentesis: This invasive test is usually offered to women who are found to be at higher risk of carrying a baby with a chromosomal abnormality. It carries a 1% risk of miscarriage and is not offered routinely to all pregnant women.

      Nuchal Translucency: This measurement is part of the combined test and is routinely offered to all pregnant women. However, if performed alone, it cannot be used as a reliable screening test.

      Quadruple Test: This blood test for alpha fetaprotein (AFP), HCG, unconjugated oestriol (uE3), and inhibin A can be offered to women at 15–20 weeks gestation who have missed the chance for the combined test.

      Triple Test: This blood test for AFP, HCG, and uE3 can also be offered to women at 15–20 weeks gestation who have missed the chance for the combined test. However, for a patient who is only 11 weeks pregnant, the combined test is indicated instead of the triple test.

      In summary, prenatal screening tests can help identify the risk of chromosomal abnormalities in the fetus. The choice of test depends on the gestational age and individual risk factors of the patient.

    • This question is part of the following fields:

      • Neurodevelopmental Disorders, Intellectual And Social Disability
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  • Question 33 - A 20-year-old woman presents to the clinic with complaints of breakthrough bleeding while...

    Incorrect

    • A 20-year-old woman presents to the clinic with complaints of breakthrough bleeding while taking her combined oral contraceptive pill containing 30 mcg ethinylestradiol with levonorgestrel. She started the pill two cycles ago and takes 21 active pills with a seven day pill-free interval. Although she is not currently sexually active, she plans to be in the near future. She reports no missed pills, recent illnesses, or other medication use. What is the probable cause of her breakthrough bleeding?

      Your Answer:

      Correct Answer: Chlamydia infection

      Explanation:

      Breakthrough Bleeding and the Combined Pill

      Breakthrough bleeding is a common issue that can occur when taking the combined pill. It is important to first check compliance with pill usage, as missed pills or erratic usage can lead to bleeding problems. Other factors such as intercurrent illness or the use of other medications should also be considered. Pregnancy should be ruled out with a test, especially if any pills have been missed or pill efficacy has been compromised. Additionally, sexually transmitted infections should be considered and appropriate tests performed.

      For women who have recently started using the combined pill, breakthrough bleeding is a common occurrence in the first few months of use. It is important to discuss this with a healthcare provider and be reassured that it usually settles with time. If breakthrough bleeding persists, a change in approach may be necessary. Lower dose pills (20 mcg ethinyloestradiol) are more likely to cause breakthrough bleeding, and switching to a higher dose pill (30 mcg) may be an option. Overall, it is important to address breakthrough bleeding promptly to ensure the effectiveness and safety of the combined pill.

    • This question is part of the following fields:

      • Gynaecology And Breast
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  • Question 34 - A 47-year-old woman presents with a complaint of a lump in her left...

    Incorrect

    • A 47-year-old woman presents with a complaint of a lump in her left breast.

      On questioning, she says she first noticed this lump eight weeks ago. There is no change in size in relation to the menstrual cycle. There is no family history of breast cancer.

      On examination, the lump measures 3 × 4 cm and it is firm, but not tender and not mobile. The other breast is normal.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Fibroadenosis

      Explanation:

      Breast Lump Characteristics and Possible Diagnoses

      The characteristics of a breast lump can provide clues to its possible diagnosis. A firm, non-mobile lump in a woman with a history of it raises the suspicion of breast carcinoma. On the other hand, breast cysts are usually tender and their symptoms are related to the menstrual cycle. Fat necrosis, which is the death of fat cells, is preceded by a history of trauma. Lastly, a fibroadenoma is non-tender and highly mobile. It is important to note that these characteristics are not definitive and a proper diagnosis can only be made through medical examination and testing.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
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  • Question 35 - 32-year-old Sarah is on methadone 60mg once a day to manage her symptoms...

    Incorrect

    • 32-year-old Sarah is on methadone 60mg once a day to manage her symptoms from heroin withdrawal. She collects her methadone daily from the pharmacy and is supervised consuming it. One Friday morning Sarah fails to turn up to the pharmacy. What should the pharmacist do in this situation?

      Your Answer:

      Correct Answer: Give him his usual 60mg methadone when he turns up the next day on Thursday and forfeit the dose from the day before

      Explanation:

      Understanding Opioid Misuse and its Management

      Opioid misuse is a serious problem that can lead to various complications and health risks. Opioids are substances that bind to opioid receptors, including natural opiates like morphine and synthetic opioids like buprenorphine and methadone. Signs of opioid misuse include rhinorrhoea, needle track marks, pinpoint pupils, drowsiness, watering eyes, and yawning.

      Complications of opioid misuse can range from viral and bacterial infections to venous thromboembolism and overdose, which can lead to respiratory depression and death. Psychological and social problems such as craving, crime, prostitution, and homelessness can also arise.

      In case of an opioid overdose, emergency management involves administering IV or IM naloxone, which has a rapid onset and relatively short duration of action. Harm reduction interventions such as needle exchange and testing for HIV, hepatitis B & C may also be offered.

      Patients with opioid dependence are usually managed by specialist drug dependence clinics or GPs with a specialist interest. Treatment options may include maintenance therapy or detoxification, with methadone or buprenorphine recommended as the first-line treatment by NICE. Compliance is monitored using urinalysis, and detoxification can last up to 4 weeks in an inpatient/residential setting and up to 12 weeks in the community. Understanding opioid misuse and its management is crucial in addressing this growing public health concern.

    • This question is part of the following fields:

      • Smoking, Alcohol And Substance Misuse
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  • Question 36 - A new medication for reducing joint pain in elderly patients is being tested...

    Incorrect

    • A new medication for reducing joint pain in elderly patients is being tested compared to a standard pain medication. A total of 1500 elderly patients were enrolled in the trial with 750 taking the new medication and 750 taking the standard pain medication.

      After completing the same treatment period, 50 patients within the new medication group reported experiencing joint pain, giving an experimental event rate (EER) of 0.067, compared to 150 patients within the standard pain medication group, giving a control event rate (CER) of 0.2.

      What is the numbers needed to treat (NNT) for this new medication in reducing joint pain in elderly patients?

      Your Answer:

      Correct Answer: 5

      Explanation:

      The NNT (number needed to treat) is a measure of how many patients need to receive an intervention or medication to reduce the expected number of outcomes by one. In this case, we want to determine the NNT for the new antiemetic to reduce the number of individuals who suffer from travel sickness. The formula for NNT is 1/absolute risk reduction (ARR), which can be calculated by subtracting the experimental event rate (EER) from the control event rate (CER).

      Using the data from the experiment, we can calculate the NNT as follows:

      NNT = 1/ARR
      NNT = 1/(CER – EER)
      NNT = 1/(0.3 – 0.1)
      NNT = 5

      This means that for every 5 patients who receive the new antiemetic, one patient will be prevented from experiencing travel sickness.

      If we wanted the NNT to be 1, the ARR would need to be 1, which is not the case in this experiment. If we wanted the NNT to be 10, the ARR would need to be 0.1. However, the ARR in this experiment is 0.2. To achieve an NNT of 2, the ARR would need to be 0.5.

      Numbers needed to treat (NNT) is a measure that determines how many patients need to receive a particular intervention to reduce the expected number of outcomes by one. To calculate NNT, you divide 1 by the absolute risk reduction (ARR) and round up to the nearest whole number. ARR can be calculated by finding the absolute difference between the control event rate (CER) and the experimental event rate (EER). There are two ways to calculate ARR, depending on whether the outcome of the study is desirable or undesirable. If the outcome is undesirable, then ARR equals CER minus EER. If the outcome is desirable, then ARR is equal to EER minus CER. It is important to note that ARR may also be referred to as absolute benefit increase.

    • This question is part of the following fields:

      • Evidence Based Practice, Research And Sharing Knowledge
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  • Question 37 - A 35-year-old multiparous woman underwent an ultrasound pelvis to investigate menorrhagia. The report...

    Incorrect

    • A 35-year-old multiparous woman underwent an ultrasound pelvis to investigate menorrhagia. The report revealed a 2 cm fibroid with no distortion of the uterine cavity. What is the MOST SUITABLE course of action to take next?

      Your Answer:

      Correct Answer: Levonorgestrel-releasing intrauterine system

      Explanation:

      First-Line Treatment for Menorrhagia

      When it comes to treating menorrhagia, the levonorgestrel-releasing intrauterine system (LNG-IUS) is considered the first-line option by NICE. This is especially true for women with no identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis. While the combined oral contraceptive pill is also an option, it is not the preferred choice.

      It is important to note that a repeat ultrasound may not be the next step in management, as the history of menorrhagia is the crucial point to consider. If menorrhagia is not present, the treatment plan may differ. Ulipristal acetate may be used for larger fibroids, but it is typically started in secondary care. Referral for surgical treatment should not be the first-line option, as more conservative measures should be tried initially.

    • This question is part of the following fields:

      • Gynaecology And Breast
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  • Question 38 - A 4-month-old boy presents with a temperature of 39oC. He attends a morning...

    Incorrect

    • A 4-month-old boy presents with a temperature of 39oC. He attends a morning surgery. The mother reports improvement with paracetamol, but this has worn off and he is miserable again. He looks flushed, but there are no focal symptoms or signs. He is not dehydrated, and there are no other worrying features.
      What is the most appropriate management option at this time?

      Your Answer:

      Correct Answer: Antipyretic drugs and review at the evening surgery

      Explanation:

      Antipyretic Drugs and Safety-Netting for Fever in Children: A Review at the Evening Surgery

      Fever in children can be a cause for concern, and it is important to provide appropriate safety-netting to parents or carers. The National Institute for Health and Care Excellence (NICE) recommends that a temperature of 39°C or more in a child aged 3–6 months is an amber (intermediate) risk sign, and in a child aged 0–3 months, 38°C or more is red (high risk). If any ‘amber’ features are present and no diagnosis has been reached, it is important to provide a safety net or refer the child to specialist paediatric care for further assessment.

      Reviewing the child later in the day is appropriate safety-netting and is preferred to immediate admission. The cause of the fever may be viral and self-limiting, and antipyretic drugs such as paracetamol and ibuprofen may be the only treatment needed. It is also important to provide advice on the most likely course of the illness and symptoms to look out for if the child’s condition worsens.

      However, admitting the child to the hospital is only necessary if there is any suggestion of an immediately life-threatening illness or if the child had any ‘red flag’ features. Intramuscular penicillin and admission to the hospital are not indicated unless there are symptoms or signs to suggest meningococcal disease in the patient.

      Prescribing amoxicillin is also not necessary unless a bacterial cause for the infection has been found on examination. Instead, it is important to provide appropriate safety-netting and review the child in a timely manner to ensure their well-being.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 39 - A 32-year-old woman who delivered a baby a week ago comes in for...

    Incorrect

    • A 32-year-old woman who delivered a baby a week ago comes in for a follow-up appointment with her spouse. The husband expresses concern about her mood as she appears to be depressed and is not bonding well with the newborn. He recalls her behavior three days ago when she was speaking rapidly and incoherently about the future. The patient denies experiencing any hallucinations but mentions that she feels like her child has been born into a terrible world. What is the best course of action for managing this situation?

      Your Answer:

      Correct Answer: Arrange urgent admission

      Explanation:

      The mother’s behavior suggests that she may be experiencing puerperal psychosis and requires immediate admission for psychiatric assessment.

      Although not all psychotic symptoms are present, there are several indications of significant mental health issues, such as the mother’s unusual lack of interaction with her baby, incoherent speech about the future, and expressing concern that the baby has been born into a troubled world.

      Therefore, it is crucial that the mother receives prompt psychiatric evaluation.

      Understanding Postpartum Mental Health Problems

      Postpartum mental health problems can range from mild ‘baby-blues’ to severe puerperal psychosis. To screen for depression, healthcare professionals may use the Edinburgh Postnatal Depression Scale, which is a 10-item questionnaire that indicates how the mother has felt over the previous week. A score of over 13 indicates a ‘depressive illness of varying severity’, and the questionnaire includes a question about self-harm. The sensitivity and specificity of this screening tool are over 90%.

      ‘Baby-blues’ are seen in around 60-70% of women and typically occur 3-7 days following birth. This condition is more common in primips, and mothers are characteristically anxious, tearful, and irritable. Postnatal depression affects around 10% of women, with most cases starting within a month and typically peaking at 3 months. The features of postnatal depression are similar to depression seen in other circumstances.

      Puerperal psychosis affects approximately 0.2% of women and usually occurs within the first 2-3 weeks following birth. The features of this condition include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations). Reassurance and support are important for all these conditions, but admission to hospital is usually required for puerperal psychosis, ideally in a Mother & Baby Unit. Cognitive behavioural therapy may be beneficial, and certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe. While these medications are secreted in breast milk, they are not thought to be harmful to the infant. However, fluoxetine is best avoided due to its long half-life. There is around a 25-50% risk of recurrence following future pregnancies.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
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  • Question 40 - You are assessing a 28-year-old woman who has chronic plaque psoriasis. Despite trying...

    Incorrect

    • You are assessing a 28-year-old woman who has chronic plaque psoriasis. Despite trying various combinations of potent corticosteroids, vitamin D analogues, coal tar and dithranol over the past two years, she has seen limited improvement. Light therapy was attempted last year but the psoriasis returned within a month. The patient is feeling increasingly discouraged, especially after a recent relationship breakdown. As per NICE guidelines, what is a necessary requirement before considering systemic therapy for this patient?

      Your Answer:

      Correct Answer: It has a significant impact on physical, psychological or social wellbeing

      Explanation:

      Referral Criteria for Psoriasis Patients

      Psoriasis is a chronic skin condition that affects a significant number of people. According to NICE guidelines, around 60% of psoriasis patients will require referral to secondary care at some point. The guidance provides some general criteria for referral, including diagnostic uncertainty, severe or extensive psoriasis, inability to control psoriasis with topical therapy, and major functional or cosmetic impact on nail disease. Additionally, any type of psoriasis that has a significant impact on a person’s physical, psychological, or social wellbeing should also be referred to a specialist. Children and young people with any type of psoriasis should be referred to a specialist at presentation.

      For patients with erythroderma or generalised pustular psoriasis, same-day referral is recommended. erythroderma is characterized by a generalised erythematous rash, while generalised pustular psoriasis is marked by extensive exfoliation. These conditions require immediate attention due to their severity. Overall, it is important for healthcare professionals to be aware of the referral criteria for psoriasis patients to ensure that they receive appropriate care and management.

    • This question is part of the following fields:

      • Dermatology
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  • Question 41 - A 29-year-old woman comes to her General Practitioner for a check-up. She has...

    Incorrect

    • A 29-year-old woman comes to her General Practitioner for a check-up. She has been diagnosed with type I diabetes mellitus since she was 20 years old. Her diabetes is currently well managed, and she has no other medical conditions. There is no family history of diabetes.
      Which of the following conditions is this patient most likely to develop? Choose ONE option only.

      Your Answer:

      Correct Answer: Thyroid disease

      Explanation:

      The Link Between Diabetes and Other Medical Conditions

      Diabetes, a chronic metabolic disorder, is often associated with other medical conditions. Autoimmune diseases such as Hashimoto’s thyroiditis and Graves’ disease, which affect the thyroid gland, have a higher prevalence in women with diabetes. However, diabetes doesn’t increase the risk of developing giant cell arteritis (GCA) or polymyalgia rheumatica (PMR), but the high-dose steroids used to treat these conditions can increase the risk of developing type II diabetes (T2DM). Anaphylaxis, a severe allergic reaction, is not linked to diabetes, but increased steroid use in asthmatic patients, a chronic respiratory condition, is a risk factor for developing T2DM. Systemic lupus erythematosus (SLE), an autoimmune condition that causes widespread inflammation, doesn’t have a significant increased risk in diabetic patients, but steroid treatments used to treat SLE can increase the risk of developing T2DM. Understanding the link between diabetes and other medical conditions is crucial for effective management and treatment.

    • This question is part of the following fields:

      • Allergy And Immunology
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  • Question 42 - A 19-year-old man is concerned about blood-borne viruses after getting a tattoo while...

    Incorrect

    • A 19-year-old man is concerned about blood-borne viruses after getting a tattoo while backpacking abroad. He wants to get tested for HIV and hepatitis B and C, but you advise him that the tests may not show any infection yet. When should he return for an HIV blood test?

      Your Answer:

      Correct Answer: 4 weeks

      Explanation:

      It is recommended to conduct HIV testing in asymptomatic patients 4 weeks after a potential exposure. This is the optimal time frame for detecting most infections through tests for antibodies and p24 antigen. Additionally, it may be beneficial to perform an HIV test upon presentation in case of a prior infection (although 1 week may be too soon for detection), and a follow-up test at 12 weeks should be offered to confirm the absence of infection.

      HIV seroconversion is a process where the body develops antibodies against the virus. This process is symptomatic in 60-80% of patients and usually presents as a glandular fever type illness. The severity of symptoms is associated with a poorer long-term prognosis. The symptoms typically occur 3-12 weeks after infection and include a sore throat, lymphadenopathy, malaise, myalgia, arthralgia, diarrhea, maculopapular rash, mouth ulcers, and rarely meningoencephalitis.

      Diagnosing HIV involves testing for HIV antibodies, which may not be present in early infection. However, most people develop antibodies to HIV at 4-6 weeks, and 99% do so by 3 months. The diagnosis usually involves both a screening ELISA test and a confirmatory Western Blot Assay. Additionally, a p24 antigen test can be used to detect a viral core protein that appears early in the blood as the viral RNA levels rise. Combination tests that test for both HIV p24 antigen and HIV antibody are now standard for the diagnosis and screening of HIV. If the combined test is positive, it should be repeated to confirm the diagnosis. Some centers may also test the viral load (HIV RNA levels) if HIV is suspected at the same time. Testing for HIV in asymptomatic patients should be done at 4 weeks after possible exposure, and after an initial negative result, a repeat test should be offered at 12 weeks.

    • This question is part of the following fields:

      • Infectious Disease And Travel Health
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  • Question 43 - A 4-week-old boy is brought in for a routine check-up. He was born...

    Incorrect

    • A 4-week-old boy is brought in for a routine check-up. He was born at 35 weeks gestation via normal vaginal delivery and spent a few days in the neonatal intensive care unit due to low birth weight. During the examination, it is noted that only one testicle can be felt.

      What is the recommended course of action in this situation?

      Your Answer:

      Correct Answer: Review at 3 months

      Explanation:

      Undescended testicles are more common in premature infants, such as the patient in this case. According to new guidelines, it is recommended to review the patient at 3 months and refer them for consideration of orchidopexy before they reach 6 months of age if the condition persists.

      While a referral to a pediatrician is not necessary at this stage, it can be arranged if the parents are concerned. However, if the patient has bilateral undescended testes, an urgent referral is required to rule out any genetic abnormalities.

      Similarly, a referral to a pediatric urologist is not needed yet. A review at 3 months may show that the testes have descended normally, and parents should be reassured that observation is useful in preventing unnecessary surgeries.

      By 6 months of age, the testis should have descended, and if it hasn’t, it is definitely abnormal. Delaying referral until 12 months of age is not ideal, as surgical procedures are typically planned for this age group, and undescended testes can lead to complications such as infertility, torsion, and testicular cancer. Therefore, earlier review and referral are crucial.

      Undescended testis is a condition that affects approximately 2-3% of male infants born at term, but is more common in premature babies. Bilateral undescended testes occur in about 25% of cases. This condition can lead to complications such as infertility, torsion, testicular cancer, and psychological issues.

      To manage unilateral undescended testis, it is recommended to consider referral from around 3 months of age, with the baby ideally seeing a urological surgeon before 6 months of age. Orchidopexy, a surgical procedure, is typically performed at around 1 year of age, although surgical practices may vary.

      For bilateral undescended testes, it is important to have the child reviewed by a senior paediatrician within 24 hours as they may require urgent endocrine or genetic investigation.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 44 - A 75-year-old woman is being evaluated in surgery. She has a medical history...

    Incorrect

    • A 75-year-old woman is being evaluated in surgery. She has a medical history of vertebral fractures caused by osteoporosis. However, she cannot tolerate bisphosphonates, so her doctor has initiated raloxifene. What condition would make it inappropriate to prescribe raloxifene?

      Your Answer:

      Correct Answer: A history of venous thromboembolism

      Explanation:

      The use of Raloxifene is associated with an elevated risk of venous thromboembolism.

      Therapeutic Management of Osteoporosis According to NICE Guidelines

      Osteoporosis is a condition that affects bone density and increases the risk of fractures. The National Institute for Health and Care Excellence (NICE) has released guidelines on the therapeutic management of osteoporosis. The first-line treatment recommended by NICE is oral alendronate, taken once weekly at a dose of 70mg. If oral alendronate is not tolerated, NICE recommends the use of risk tables to determine whether it is worth trying another treatment. The tables display a minimum T score based on a patient’s age and number of clinical risk factors. If another treatment is indicated, alternative oral bisphosphonates such as risedronate or etidronate are recommended as the second-line treatment.

      If bisphosphonates are not tolerated, NICE recommends reviewing risk tables again to see if further treatment is indicated. Strontium ranelate or raloxifene are recommended as alternative treatments. Strontium ranelate is a ‘dual action bone agent’ that increases the deposition of new bone by osteoblasts and reduces the resorption of bone by inhibiting osteoclasts. However, concerns regarding its safety profile have been raised recently, and it should only be prescribed by a specialist in secondary care. Raloxifene is a selective oestrogen receptor modulator (SERM) that has been shown to prevent bone loss and reduce the risk of vertebral fractures. It may worsen menopausal symptoms and increase the risk of thromboembolic events.

      In summary, NICE guidelines recommend oral alendronate as the first-line treatment for osteoporosis, followed by alternative oral bisphosphonates if necessary. Strontium ranelate or raloxifene may be considered if bisphosphonates are not tolerated, but their use should be carefully monitored due to safety concerns. Clinical judgement may be required when determining the best course of action for individual patients.

    • This question is part of the following fields:

      • Musculoskeletal Health
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  • Question 45 - Which of the following drugs doesn't inhibit cytochrome P450? ...

    Incorrect

    • Which of the following drugs doesn't inhibit cytochrome P450?

      Your Answer:

      Correct Answer: Clopidogrel

      Explanation:

      P450 Enzyme System and its Inducers and Inhibitors

      The P450 enzyme system is responsible for metabolizing many drugs in the body. Induction of this system occurs when a drug or substance causes an increase in the activity of the P450 enzymes. This process usually requires prolonged exposure to the inducing drug. On the other hand, P450 inhibitors decrease the activity of the enzymes and their effects are often seen rapidly.

      Some common inducers of the P450 system include antiepileptics like phenytoin and carbamazepine, barbiturates such as phenobarbitone, rifampicin, St John’s Wort, chronic alcohol intake, griseofulvin, and smoking. Smoking affects CYP1A2, which is the reason why smokers require more aminophylline.

      In contrast, some common inhibitors of the P450 system include antibiotics like ciprofloxacin and erythromycin, isoniazid, cimetidine, omeprazole, amiodarone, allopurinol, imidazoles such as ketoconazole and fluconazole, SSRIs like fluoxetine and sertraline, ritonavir, sodium valproate, acute alcohol intake, and quinupristin.

      It is important to be aware of the potential for drug interactions when taking medications that affect the P450 enzyme system. Patients should always inform their healthcare provider of all medications and supplements they are taking to avoid any adverse effects.

    • This question is part of the following fields:

      • Improving Quality, Safety And Prescribing
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  • Question 46 - A 65-year-old gentleman with a long history of depression is brought to see...

    Incorrect

    • A 65-year-old gentleman with a long history of depression is brought to see you by his neighbour. He is distressed and tells you that he feels he has nothing to live for. He is single and is recently unemployed. His neighbour happened to call to his house earlier and found him in a 'terrible state' and persuaded him to come to the clinic. He shows you a suicide note he wrote earlier today and says that he feels his life is hopeless and that he has no reason to live. He tells you that he has been feeling increasingly low over the last few months and today has been at home all day drinking whiskey alone. He also tells you that last week he went to see his solicitor and made a will leaving his possessions to his niece. Which of the following factors suggests the greatest risk of suicidal intent?

      Your Answer:

      Correct Answer: He visited his solicitor last week and made a will

      Explanation:

      Assessing Suicide Risk in Patients:

      Assessing the risk of suicide in a patient can be a challenging task. However, a sensitive and thorough enquiry into the details can help in identifying and managing the risk. It is crucial to ask all patients who present with low mood or anxiety about suicidal thoughts.

      In this case, the patient has consumed large quantities of alcohol, which may affect his impulsivity but is not a reliable indicator of current or future intent. The patient’s unemployment, unmarried status, and living alone are important considerations as they indicate a lack of social support and potential financial difficulties.

      The presence of a suicide note would show a certain amount of forethought and is a marker of serious intent and ongoing risk. It is important to determine whether the note was written under the influence of alcohol or not. Either way, it demonstrates significant persistent consideration of suicide.

      However, the most critical sign of suicidal intent is that the patient visited his solicitor last week to put his affairs in order. This act shows considerable planning far in advance and demonstrates the highest risk of suicide. It is not impulsive or acutely reactive but measured and requires arrangement and planning.

      Sources such as the Oxford Centre for Suicide Research and the Royal College of Psychiatrists provide guidance on assessing suicide risk using structured professional judgement. By conducting a sensitive and thorough enquiry, healthcare professionals can identify and manage the risk of suicide in their patients.

    • This question is part of the following fields:

      • Mental Health
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  • Question 47 - A 42-year-old pregnant woman is curious about why she has been recommended to...

    Incorrect

    • A 42-year-old pregnant woman is curious about why she has been recommended to undergo an oral glucose tolerance test. She has had four previous pregnancies, and her babies' birth weights have ranged from 3.4-4.6kg. She has no history of diabetes, but both her parents have hypertension, and her grandfather has diabetes. She is of white British ethnicity and has a BMI of 29.6kg/m². What makes her eligible for an oral glucose tolerance test?

      Your Answer:

      Correct Answer: Previous macrosomia

      Explanation:

      It is recommended that pregnant women with a family history of diabetes undergo an oral glucose tolerance test (OGTT) for gestational diabetes between 24 and 28 weeks of pregnancy.

      Gestational diabetes is a common medical disorder that affects around 4% of pregnancies. It can develop during pregnancy or be a pre-existing condition. According to NICE, 87.5% of cases are gestational diabetes, 7.5% are type 1 diabetes, and 5% are type 2 diabetes. Risk factors for gestational diabetes include a BMI of > 30 kg/m², previous gestational diabetes, a family history of diabetes, and family origin with a high prevalence of diabetes. Screening for gestational diabetes involves an oral glucose tolerance test (OGTT), which should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal.

      To diagnose gestational diabetes, NICE recommends using the following thresholds: fasting glucose is >= 5.6 mmol/L or 2-hour glucose is >= 7.8 mmol/L. Newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week and taught about self-monitoring of blood glucose. Advice about diet and exercise should be given, and if glucose targets are not met within 1-2 weeks of altering diet/exercise, metformin should be started. If glucose targets are still not met, insulin should be added to the treatment plan.

      For women with pre-existing diabetes, weight loss is recommended for those with a BMI of > 27 kg/m^2. Oral hypoglycaemic agents, apart from metformin, should be stopped, and insulin should be commenced. Folic acid 5 mg/day should be taken from preconception to 12 weeks gestation, and a detailed anomaly scan at 20 weeks, including four-chamber view of the heart and outflow tracts, should be performed. Tight glycaemic control reduces complication rates, and retinopathy should be treated as it can worsen during pregnancy.

      Targets for self-monitoring of pregnant women with diabetes include a fasting glucose level of 5.3 mmol/l and a 1-hour or 2-hour glucose level after meals of 7.8 mmol/l or 6.4 mmol/l, respectively. It is important to manage gestational diabetes and pre-existing diabetes during pregnancy to reduce the risk of complications for both the mother and baby.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
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  • Question 48 - A 44-year-old woman presents with complaints of lethargy. Routine blood testing reveals hypochromic...

    Incorrect

    • A 44-year-old woman presents with complaints of lethargy. Routine blood testing reveals hypochromic microcytic anaemia with a low ferritin. Her haemoglobin level is 100 g/l. She has had no symptoms of abnormal bleeding, indigestion or change in bowel habit and there is no medication use of note. She is still menstruating and regards her menstrual loss as normal. She has a normal diet and there have been no recent foreign trips. Faecal occult blood tests are negative. There is no family history of colorectal cancer. Abdominal examination is normal.
      What is most appropriate for this stage in her management?

      Your Answer:

      Correct Answer: Measure tissue transglutaminase antibody

      Explanation:

      Recommended Actions for Patients with Iron Deficiency Anaemia

      Iron deficiency anaemia is a common condition that requires prompt diagnosis and treatment. Here are some recommended actions for patients with this condition:

      Screen for Coeliac Disease: All patients with iron deficiency anaemia should be screened for coeliac disease using coeliac serology, which involves measuring the presence of anti-endomysial antibody or tissue transglutaminase antibody.

      Refer for Gastrointestinal Investigations: Men of any age with unexplained iron deficiency anaemia and a haemoglobin level of 110 g/l or below, as well as women who are not menstruating with a haemoglobin level of 100 g/l or below, should be urgently referred for upper and lower gastrointestinal investigations. For other patients, referral for gastrointestinal investigation will depend on the haemoglobin level and clinical findings.

      Prescribe Iron Supplements: Treatment for iron deficiency anaemia should begin with oral ferrous sulphate 200 mg tablets two or three times a day. Doctors should not wait for investigations to be carried out before prescribing iron supplements.

      Check Vitamin B12 and Folate Levels: Vitamin B12 and folate levels should be checked if the anaemia is normocytic with a low or normal ferritin level, there is an inadequate response to iron supplements, vitamin B12 or folate deficiency is suspected, or the patient is in an older age bracket.

      Avoid Inappropriate Tests: Pelvic ultrasound examination is not necessary for patients with iron deficiency anaemia unless they have gynaecological symptoms.

      By following these recommended actions, patients with iron deficiency anaemia can receive timely and appropriate care.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 49 - You are asked to see a 4-month-old baby girl as an emergency.
    Her parents...

    Incorrect

    • You are asked to see a 4-month-old baby girl as an emergency.
      Her parents are increasingly concerned about her, she has a four day history of runny nose, and increasing difficulty in breathing, and has worsened over the past 24 hours.
      She was born at 35/40 weighing 2.2 kg and bottle feeds. There were no neonatal problems. She has received the first two routine immunisations. Both parents are heavy smokers.
      On examination she has a temperature of 38.3°C, with respiratory rate of 65/min and a heart rate of 150/min. She has nasal flaring, grunting and marked recession and scattered wheeze and crackles throughout both lung fields. You cannot hear any heart mumurs.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Virus-induced wheeze

      Explanation:

      Bronchiolitis: A Common Respiratory Infection in Infants

      Bronchiolitis is a respiratory infection that commonly affects infants, with symptoms ranging from mild upper respiratory tract infection to severe lower respiratory tract symptoms. The infection is typically caused by respiratory syncytial virus (RSV), which leads to epidemics during the winter season. The severity of the infection is influenced by both baby and maternal factors.

      Baby factors that increase the risk of severe bronchiolitis include chronic lung disease, congenital heart disease, immunodeficiency, and gastro-oesophageal reflux. On the other hand, maternal factors such as smoking and bottle feeding can also contribute to the severity of the infection. Breastfeeding, however, has been found to be partly protective against bronchiolitis.

      In summary, bronchiolitis is a common respiratory infection in infants that can range from mild to severe. It is important for parents and caregivers to be aware of the risk factors that can increase the severity of the infection and take appropriate measures to prevent and manage it.

    • This question is part of the following fields:

      • Urgent And Unscheduled Care
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  • Question 50 - You design a clinical trial to test a new shingles vaccine. You begin...

    Incorrect

    • You design a clinical trial to test a new shingles vaccine. You begin by collecting data on the age shingles was contracted by members of your local population. You notice this data set is positively skewed.

      What does that mean?

      Your Answer:

      Correct Answer: Mean > median > mode

      Explanation:

      When data is positively skewed, the mean is greater than the median, which is also greater than the mode. Skewness refers to how much a dataset deviates from a symmetrical bell curve, which is seen in normally distributed data. In positively skewed data, the tail is longer on the positive side of the peak. This is in contrast to normally distributed data, where the median, mode, and mean are all equal. To remember the order of these values, write them in alphabetical order and use ‘>’ to indicate greater than for positively skewed data. For negatively skewed data, use ‘<' to indicate less than. The mean is the average of all the numbers, the mode is the most frequently occurring number, and the median is the middle number in a sequential list of the data. Skewed Data: Understanding the Relationship between Mean, Median, and Mode Skewness is a measure of the degree of asymmetry of a distribution. In a negatively skewed data set, the bulk of data is concentrated to the right of the figure, and the left tail is longer. Conversely, in a positively skewed data set, the bulk of data is concentrated to the left of the figure, and the right tail is longer. In such cases, the median is always positioned between the mode and the mean, as it represents the halfway point. The mode corresponds to the peak of the distribution, representing the most common value. However, the mean moves away from the median in the direction of the tail, as it is affected by extreme values or outliers. In contrast, in a normally distributed data set, a bell-shaped curve is seen that is symmetrical. In such cases, the median, mode, and mean are all equal. Understanding the relationship between mean, median, and mode is crucial in analyzing skewed data sets. For positively skewed data, the mean is greater than the median, which is greater than the mode. Conversely, for negatively skewed data, the mode is greater than the median, which is greater than the mean.

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