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Question 1
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A 67-year-old man has been diagnosed with transitional cell carcinoma of the bladder after presenting with haematuria. Are there any recognised occupational exposures that increase the risk of developing bladder cancer?
Your Answer: Aniline dye
Explanation:Risk Factors for Bladder Cancer
Bladder cancer is a type of cancer that affects the bladder, a hollow organ in the lower abdomen that stores urine. There are several risk factors that can increase the likelihood of developing bladder cancer. One of the most significant risk factors is smoking, which can cause harmful chemicals to accumulate in the bladder and increase the risk of cancer. Exposure to aniline dyes in the printing and textile industry, as well as rubber manufacture, can also increase the risk of bladder cancer. Additionally, the use of cyclophosphamide, a chemotherapy drug, can increase the risk of bladder cancer. Schistosomiasis, a parasitic infection that is common in certain parts of the world, is also a risk factor for bladder cancer, particularly for squamous cell carcinoma of the bladder. It is important to be aware of these risk factors and take steps to reduce your risk of developing bladder cancer.
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This question is part of the following fields:
- Oncology
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Question 2
Incorrect
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A 63-year-old man presents to his primary care physician with complaints of feeling tired and dizzy upon standing up. His family members are worried because they have noticed a change in his facial appearance. Upon further investigation, the following laboratory results were obtained:
Serum:
Na+ 128 mmol/l (135–145 mmol/l)
K+ 6.1 mmol/l (3.5–5 mmol/l)
Short adrenocorticotropic hormone (ACTH) stimulation test:
Plasma cortisol:
0900 h 150 nmol/l (140–690 nmol/l)
30 min after ACTH: 155 nmol/l
60 min after ACTH: 155 nmol/l
0900 h ACTH: 6 ng/l (normal <50 ng/l)
What condition is consistent with these findings?Your Answer: Conn’s syndrome
Correct Answer: Abrupt withdrawal of corticosteroid therapy
Explanation:Causes of Adrenal Hypofunction: Understanding the Biochemistry
Adrenal hypofunction can occur due to various reasons, and understanding the underlying biochemistry can help in identifying the cause. The following are some of the common causes of adrenal hypofunction and their associated biochemical changes:
Abrupt Withdrawal of Corticosteroid Therapy: The most common cause of adrenal hypofunction is the suppression of the pituitary-adrenal axis due to therapeutic corticosteroid therapy. During therapy, patients may present with Cushing’s syndrome, which causes a moon face. However, if therapy is withdrawn abruptly or demand for cortisol increases without a concomitant dosage increase, symptoms and signs of adrenal hypofunction can occur. This results in the loss of Na+ and retention of K+. Prolonged suppression of the adrenals means that output of cortisol cannot increase in response to the ACTH stimulation test until function has recovered. Additionally, patients will classically become hypotensive.
Adrenal Metastases: Adrenal metastases cause adrenal failure through destruction of the gland tissue. So the same biochemistry will occur as in abrupt withdrawal of corticosteroid therapy, but ACTH levels would be expected to be high, owing to lack of negative feedback.
Conn’s Syndrome: In Conn’s syndrome (primary hyperaldosteronism), the high aldosterone levels result in hypernatraemia and hypokalaemia, unlike what is seen in patients with adrenal hypofunction.
Hypopituitarism: This results in secondary adrenal failure, so Na+ is lost and K+ retained.
Cushing’s Disease: Cushing’s disease resulting from overproduction of cortisol results in hypernatraemia and hypokalaemia because cortisol has some mineralocorticoid activity.
In conclusion, understanding the biochemistry of adrenal hypofunction can help in identifying the underlying cause and guiding appropriate treatment.
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This question is part of the following fields:
- Endocrinology
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Question 3
Incorrect
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A 35-year-old woman with G4P3 at 39 weeks gestation presents to the labour ward following a spontaneous rupture of membranes. She delivers a healthy baby vaginally but experiences excessive bleeding and hypotension. Despite attempts to control the bleeding, the senior doctor decides to perform a hysterectomy. Upon examination, the pathologist observes that the chorionic villi have deeply invaded the myometrium but not the perimetrium.
What is the diagnosis?Your Answer: Placenta accreta
Correct Answer: Placenta increta
Explanation:The correct answer is placenta increta, where the chorionic villi invade the myometrium but not the perimetrium. The patient’s age and history of multiple pregnancies increase the risk of this abnormal placentation, which can be diagnosed through pathological studies. Placenta accreta, percreta, and previa are incorrect answers, as they involve different levels of placental attachment and can cause different symptoms.
Understanding Placenta Accreta
Placenta accreta is a condition where the placenta attaches to the myometrium instead of the decidua basalis, which can lead to postpartum hemorrhage. This condition is caused by a defective decidua basalis. There are three types of placenta accreta, which are categorized based on the degree of invasion. The first type is accreta, where the chorionic villi attach to the myometrium. The second type is increta, where the chorionic villi invade into the myometrium. The third type is percreta, where the chorionic villi invade through the perimetrium.
There are certain risk factors that increase the likelihood of developing placenta accreta, such as having a previous caesarean section or placenta previa. It is important for healthcare providers to be aware of these risk factors and monitor patients closely during pregnancy and delivery. Early detection and management of placenta accreta can help prevent complications and ensure the best possible outcome for both the mother and baby.
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This question is part of the following fields:
- Obstetrics
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Question 4
Correct
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A 45-year-old man with a history of schizophrenia no longer reports hallucinations or delusions. However, he spends many hours doing nothing, has trouble reading a book or watching a film and rarely speaks spontaneously or fluently. His grooming is poor and he is socially withdrawn.
What is a positron emission tomography (PET) scan most likely to show?Your Answer: Hypoactivity of the prefrontal lobes, enlarged cerebral ventricles
Explanation:Brain Function and Psychiatric Disorders: PET Scan Findings
Major psychiatric syndromes, such as schizophrenia, mania, and depression, involve alterations in sensory processing, volitional behavior, environmental adaptation, and regulation of strong emotions. PET scans have shown that hypoactivity of the prefrontal lobes and enlarged cerebral ventricles are most likely to be associated with schizophrenia. On the other hand, hyperactivity of the prefrontal lobes is linked to obsessive-compulsive disorder (OCD). The prefrontal cortex plays a crucial role in planning, temporal sequencing, abstract thought, problem-solving, motility, attention, and the modulation of emotion. Lesions of these pathways impair pursuit of goal-oriented activity. PET scans have also revealed decreased metabolic activity in the temporal lobes in some patients with schizophrenia. However, increased occipital lobe activity is not likely to be seen on PET scans. Additionally, symmetrical enlargement of cerebral ventricles is a well-validated finding in patients suffering from schizophrenia.
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This question is part of the following fields:
- Psychiatry
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Question 5
Correct
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You are asked to see a patient on the high dependency unit following an elective repair of her abdominal aortic aneurysm. Her last haemoglobin was 75 g/L (130-180) and your consultant has told you to give her four units of blood urgently.
The nurse informs you that the patient's date of birth is incorrect on the blood she is about to give, although all other details are correct. The patient mentions that this has happened before. She has previously received six units of blood in theatre without any issues.
What course of action should you take?Your Answer: Stop the blood transfusion
Explanation:Importance of Correct Patient Identification in Transfusions
Transfusions are a crucial aspect of medical treatment, but incorrect patient identification of samples and blood products can lead to fatal consequences. In fact, it is the most common cause of death following transfusion. Therefore, it is essential to ensure that patient identification is accurate and consistent throughout the process.
If there are any inconsistencies or doubts about the patient’s identity, it is crucial to stop the transfusion immediately and inform the laboratory. This step can prevent serious harm or even death. It is better to err on the side of caution and take the necessary steps to ensure that the patient receives the correct blood product.
In emergency situations where blood is needed immediately, and there is uncertainty about the patient’s identity, group O negative blood may be used. However, this should only be a temporary solution until the patient’s identity is confirmed, and the appropriate blood product can be administered.
In conclusion, patient identification is a critical aspect of transfusions, and any errors or inconsistencies should be addressed immediately to prevent harm to the patient. It is better to take the necessary precautions and ensure that the patient receives the correct blood product, even if it means delaying the transfusion.
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This question is part of the following fields:
- Anaesthetics & ITU
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Question 6
Correct
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A 50-year-old homeless individual is brought to the emergency department after being found vomiting. Upon examination, the patient appears confused and disoriented, with unkempt appearance and slurred speech. However, the patient has a Glasgow Coma Scale score of 14. Vital signs include a pulse of 108 bpm, oxygen saturation of 94% on air, and blood pressure of 124/78 mmHg. Cardiovascular and respiratory exams are normal, with mild epigastric tenderness on abdominal exam. The patient has a broad-based gait and bilateral nystagmus with weakness of abduction of the eyes. Reflexes, power, and tone are generally normal with flexor plantar responses. What is the likely diagnosis?
Your Answer: Wernicke’s encephalopathy
Explanation:Wernicke’s Encephalopathy: A Medical Emergency
Wernicke’s encephalopathy is a condition caused by thiamine deficiency, which can be life-threatening if not treated urgently. This condition is often seen in alcoholics or malnourished individuals and can even occur during pregnancy due to hyperemesis gravidarum. The classic triad of symptoms includes ataxia, confusion, and ophthalmoplegia.
It is crucial to differentiate Wernicke’s encephalopathy from alcohol intoxication as the former requires immediate thiamine replacement. The recommended treatment is either oral thiamine 300 mg/24h or, preferably, intravenous Pabrinex. If left untreated, the condition can rapidly progress to irreversible Korsakoff’s psychosis due to haemorrhage into the mamillary bodies.
In summary, Wernicke’s encephalopathy is a medical emergency that requires prompt recognition and treatment to prevent irreversible neurological damage. It is essential to be aware of the classic triad of symptoms and to differentiate it from alcohol intoxication to ensure appropriate management.
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This question is part of the following fields:
- Neurology
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Question 7
Incorrect
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A 30-year-old female presents with menorrhagia that has not responded to treatment with non-steroidal anti-inflammatory drugs.
She underwent sterilisation two years ago.
What would be the most suitable treatment for her?Your Answer: Mefenamic acid
Correct Answer: Intrauterine system (Mirena)
Explanation:Treatment Options for Menorrhagia
Menorrhagia, or heavy menstrual bleeding, can be a distressing condition for women. Current guidelines recommend the use of Mirena (IUS) as the first line of treatment, even for women who do not require contraception. Patient preference is important in the decision-making process, but IUS is still the preferred option.
If IUS is not suitable or preferred, there are several other treatment options available. Tranexamic acid, a medication that prevents the breakdown of blood clots, is a second-line option. Non-steroidal anti-inflammatory drugs (NSAIDs) and combined oral contraceptive pills can also be used to prevent the proliferation of the endometrium.
If these options are not effective, oral or injected progestogens can be used to prevent endometrial proliferation. Gonadotrophin-releasing hormone (GnRH) agonists, such as Goserelin, are also available as a last resort.
It is important for women to discuss their options with their healthcare provider and choose the treatment that is best for them. With the variety of options available, there is likely a treatment that can effectively manage menorrhagia and improve quality of life.
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This question is part of the following fields:
- Gynaecology
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Question 8
Correct
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A 3-month-old baby girl has just been registered with the surgery. Her parents have recently arrived in the UK from Syria, seeking refuge. She received a Hepatitis B vaccination before leaving Syria.
What other vaccinations should she be provided with now?Your Answer: Diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type b, hepatitis B, rotavirus and meningitis B
Explanation:Paediatric Vaccination Schedule for 2-Month-Old Babies in the UK
The correct vaccination regime for a 2-month-old baby in the UK includes diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type b, hepatitis B, rotavirus and meningitis B. However, the guidelines have been updated since 2015, and now include pneumococcus (PCV) vaccination at 12 weeks. Meningitis B is vaccinated against at 8 weeks, 16 weeks, and one year, while meningitis C and PCV are vaccinated against at 12 months. Rotavirus and meningitis B are also recommended in the vaccination schedule at 8 weeks old, but meningitis C is not included in this particular regime.
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This question is part of the following fields:
- Paediatrics
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Question 9
Incorrect
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A 65-year-old woman comes to the clinic complaining of sudden pain in her right groin. She mentions that she had noticed a swelling in the area on and off for a few years, but it never bothered her before. She denies any nausea, vomiting, changes in bowel habits, or weight loss.
Upon examination, the abdomen appears normal, but there is a tender and irreducible swelling below and to the side of the pubic tubercle.
What is the probable diagnosis?Your Answer: Direct inguinal hernia
Correct Answer: Femoral hernia
Explanation:Diagnosis and Treatment of Femoral Hernia
The patient’s hernia is located in the typical position of a femoral hernia, which is below and to the side of the pubic tubercle. The patient has reported an intermittent swelling that has become irreducible. Based on these symptoms, it is likely that the femoral canal has been blocked by omentum, rather than a loop of bowel becoming trapped. Since the patient has no other concerning signs, it is safe for them to undergo hernia repair on the next available CEPOD list.
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This question is part of the following fields:
- Surgery
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Question 10
Correct
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A 20-year-old male has been referred by his doctor due to experiencing severe bloody diarrhoea on and off for the past three months. After undergoing a barium enema, it was discovered that he has multiple ulcers and signs of inflammation that extend from his rectum to the mid transverse colon. A colonoscopy was performed and biopsies were taken from various sites, revealing acute and chronic inflammation that is limited to the mucosa. What is the most probable diagnosis for this patient?
Your Answer: Ulcerative colitis
Explanation:Differences between Ulcerative Colitis and Crohn’s Disease
Ulcerative colitis (UC) and Crohn’s disease are both types of inflammatory bowel disease that can cause bloody diarrhoea. However, UC is more likely to result in the passage of blood. The onset of UC usually begins in the distal part of the colon and progresses towards the proximal end. On the other hand, Crohn’s disease can affect any part of the gastrointestinal tract and can skip areas, resulting in disease occurring at different sites.
Histologically, Crohn’s disease affects the entire thickness of the bowel wall, while UC typically only affects the mucosa. This means that Crohn’s disease can cause more severe damage to the bowel wall and lead to complications such as strictures and fistulas. In contrast, UC is more likely to cause inflammation and ulceration of the mucosa, which can lead to symptoms such as abdominal pain and diarrhoea.
In summary, while both UC and Crohn’s disease can cause similar symptoms, there are important differences in their presentation and histological features. these differences is crucial for accurate diagnosis and appropriate management of these conditions.
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This question is part of the following fields:
- Gastroenterology
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