00
Correct
00
Incorrect
00 : 00 : 00
Session Time
00 : 00
Average Question Time ( Mins)
  • Question 1 - A senior citizen is referred to the Emergency Department by his General Practitioner,...

    Correct

    • A senior citizen is referred to the Emergency Department by his General Practitioner, feeling generally unwell and with reduced urine output. Bloods tests show: Na+ 128 mmol/l, K+ 7.2 mmol/l, urea 42.6 mmol/l, creatinine 828 μmol/l.
      An electrocardiogram (ECG) shows widespread tenting of T-waves.
      Which of the following treatments should be given first?

      Your Answer: Calcium gluconate

      Explanation:

      Managing Hyperkalaemia: Immediate Actions and Treatment Options

      Hyperkalaemia, defined as a serum potassium level greater than 6.5 mmol/l, requires immediate attention to prevent fatal arrhythmias. The first step is to confirm the result with repeat electrolyte testing and administer calcium gluconate or chloride to stabilize cardiac membranes. ECG changes such as peaked/tented T-waves and prolonged PR interval may indicate the need for urgent intervention.

      Insulin and dextrose infusion, along with salbutamol nebulizers, can be used to lower serum potassium levels. Calcium resonium may be used for continued potassium reduction, but it is not effective in acute management.

      It is important to prioritize cardioprotection by administering calcium gluconate first, followed by insulin and dextrose and salbutamol nebulizers as needed. Intravenous saline may be useful in cases of dehydration-related acute kidney injury, but it will not have an immediate effect on significant hyperkalaemia.

      In summary, prompt recognition and management of hyperkalaemia are crucial to prevent life-threatening complications.

    • This question is part of the following fields:

      • Clinical Biochemistry
      87.7
      Seconds
  • Question 2 - A 30-year-old white man comes to his general practitioner complaining of progressive low...

    Incorrect

    • A 30-year-old white man comes to his general practitioner complaining of progressive low back pain over the past four years. The pain is worse at night when he lies down and improves as he moves around during the day, but it does not go away with rest. Upon further questioning, he reports having experienced three episodes of acute eye pain with sensitivity to light and blurry vision in the past two years. He sought treatment from an ophthalmologist, and the symptoms resolved with steroids and eye drops. X-rays reveal some inflammatory and arthritic changes in the sacroiliac joints. Despite treatment, the disease has continued to progress, and ten years later, x-rays show calcification of the anterior spinal ligament. What is the most likely positive finding in this patient?

      Your Answer: HLA-DR5

      Correct Answer: HLA-B27

      Explanation:

      Understanding HLA and Autoimmune Diseases

      HLA-B27 is a genetic marker associated with ankylosing spondylitis, an autoimmune disease that primarily affects the spine. This disease is more common in males and typically presents in the 20s and 30s. Other autoimmune manifestations, such as anterior uveitis, can also occur in individuals with HLA-B27. Additionally, young men with this genetic marker may be prone to reactive arthritis after chlamydia or gonorrhoeal urethritis.

      Rheumatoid factor, on the other hand, is not associated with HLA-B27 or ankylosing spondylitis. While stiffness that improves with exercise may be seen in rheumatoid arthritis, this disease typically affects peripheral joints and does not lead to calcification of the anterior spinal ligament.

      Other HLA markers are associated with different autoimmune diseases. HLA-DR3 is linked to type 1 diabetes mellitus, HLA-DR5 is associated with pernicious anaemia and Hashimoto’s thyroiditis, and HLA-B8 is linked to Graves’ disease. Understanding these genetic markers can aid in the diagnosis and management of autoimmune diseases.

    • This question is part of the following fields:

      • Rheumatology
      56.6
      Seconds
  • Question 3 - A 75-year-old patient with prostate cancer is initiated on goserelin therapy. After a...

    Incorrect

    • A 75-year-old patient with prostate cancer is initiated on goserelin therapy. After a week of starting the treatment, he visits a nearby emergency department with complaints of aggravated lower urinary tract symptoms and newly developed back pain. What could have been done to prevent this deterioration?

      Your Answer: Lower dose goserelin

      Correct Answer: Pretreatment with flutamide

      Explanation:

      In the initial phase of treatment, goserelin may lead to a temporary aggravation of prostatic cancer symptoms, known as the ‘flare effect’. This is due to an initial surge in luteinizing hormone production before receptor down-regulation occurs. To counteract this, flutamide, a synthetic antiandrogen, can be administered beforehand to mitigate the tumour flare by blocking androgen receptors. The sudden onset of back pain in this patient is a cause for concern and requires further examination to determine if spinal metastasis is present.

      Management of Prostate Cancer

      Localised prostate cancer (T1/T2) can be managed through various treatment options depending on the patient’s life expectancy and preference. Conservative approaches such as active monitoring and watchful waiting can be considered, as well as radical prostatectomy and radiotherapy (external beam and brachytherapy). On the other hand, localised advanced prostate cancer (T3/T4) may require hormonal therapy, radical prostatectomy, or radiotherapy. However, patients who undergo radiotherapy may develop proctitis and are at a higher risk of bladder, colon, and rectal cancer.

      For metastatic prostate cancer, the primary goal is to reduce androgen levels. A combination of approaches is often used, including anti-androgen therapy, synthetic GnRH agonist or antagonists, bicalutamide, cyproterone acetate, abiraterone, and bilateral orchidectomy. GnRH agonists such as Goserelin (Zoladex) may result in lower LH levels longer term by causing overstimulation, which disrupts endogenous hormonal feedback systems. This may cause a rise in testosterone initially for around 2-3 weeks before falling to castration levels. To prevent a rise in testosterone, anti-androgen therapy is often used initially. However, this may result in a tumour flare, which stimulates prostate cancer growth and may cause bone pain, bladder obstruction, and other symptoms. GnRH antagonists such as degarelix are being evaluated to suppress testosterone while avoiding the flare phenomenon. Chemotherapy with docetaxel may also be an option for the treatment of hormone-relapsed metastatic prostate cancer in patients who have no or mild symptoms after androgen deprivation therapy has failed, and before chemotherapy is indicated.

    • This question is part of the following fields:

      • Surgery
      26.4
      Seconds
  • Question 4 - A 58-year-old male presents with macrocytic anaemia and a megaloblastic bone marrow. What...

    Incorrect

    • A 58-year-old male presents with macrocytic anaemia and a megaloblastic bone marrow. What is the most probable cause of his macrocytosis?

      Your Answer: Aplastic anaemia

      Correct Answer: Folate deficiency

      Explanation:

      Megaloblastic Bone Marrow and Its Causes

      A megaloblastic bone marrow is a condition that occurs due to a deficiency in vitamin B12 or folate, as well as some cytotoxic drugs. This condition is characterized by the presence of large, immature red blood cells in the bone marrow. However, other causes of macrocytosis, which is the presence of abnormally large red blood cells in the bloodstream, do not result in a megaloblastic bone marrow appearance. It is important to identify the underlying cause of macrocytosis to determine the appropriate treatment.

    • This question is part of the following fields:

      • Haematology
      47.3
      Seconds
  • Question 5 - A 39-year-old patient with a history of peripheral vascular disease presents to the...

    Incorrect

    • A 39-year-old patient with a history of peripheral vascular disease presents to the emergency department with complaints of rest pain in their left leg. Despite being a smoker, their BMI is 25 kg/m² and they have no other medical issues. Upon examination, the patient has absent foot pulses and lower limb pallor. A CT angiogram is performed and reveals a long segmental obstruction, leading to suspicion of critical limb ischaemia. What is the best course of treatment?

      Your Answer: Angioplasty with stenting

      Correct Answer: Open bypass graft

      Explanation:

      Open surgical revascularization is more appropriate for low-risk patients with long-segment/multifocal lesions who have peripheral arterial disease with critical limb ischaemia.

      Peripheral arterial disease (PAD) is a condition that is strongly associated with smoking. Therefore, patients who still smoke should be provided with assistance to quit smoking. It is also important to treat any comorbidities that the patient may have, such as hypertension, diabetes mellitus, and obesity. All patients with established cardiovascular disease, including PAD, should be taking a statin, with Atorvastatin 80 mg being the recommended dosage. In 2010, NICE published guidance recommending the use of clopidogrel as the first-line treatment for PAD patients instead of aspirin. Exercise training has also been shown to have significant benefits, and NICE recommends a supervised exercise program for all PAD patients before other interventions.

      For severe PAD or critical limb ischaemia, there are several treatment options available. Endovascular revascularization and percutaneous transluminal angioplasty with or without stent placement are typically used for short segment stenosis, aortic iliac disease, and high-risk patients. On the other hand, surgical revascularization, surgical bypass with an autologous vein or prosthetic material, and endarterectomy are typically used for long segment lesions, multifocal lesions, lesions of the common femoral artery, and purely infrapopliteal disease. Amputation should only be considered for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty or bypass surgery.

      There are also drugs licensed for use in PAD, including naftidrofuryl oxalate, a vasodilator sometimes used for patients with a poor quality of life. Cilostazol, a phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects, is not recommended by NICE.

    • This question is part of the following fields:

      • Surgery
      27.7
      Seconds
  • Question 6 - A 25-year-old first-time mother gave birth to a healthy baby girl with an...

    Incorrect

    • A 25-year-old first-time mother gave birth to a healthy baby girl with an APGAR score of 10 at 1, 5, and 10 minutes. However, during delivery, the mother experienced a perineal tear, and the midwife has called the doctor to suture it. Upon examination, it was found that the injury affected the superficial and deep transverse perineal muscles, but the anal sphincter remained intact. What is the degree of injury?

      Your Answer: Third degree

      Correct Answer: Second degree

      Explanation:

      The patient in this case had a second degree perineal tear, which is a tear in the skin and soft tissue structures between the vagina and anus that occurs during childbirth due to excessive strain. This type of tear involves the perineal muscle but does not include the anal sphincter. Fifth degree tears do not exist, and first degree tears only involve superficial damage without muscle involvement. Fourth degree tears are severe and involve injury to the anal sphincter complex and rectal mucosa, but in this case, the anal sphincter was spared.

      Perineal tears are a common occurrence during childbirth, and the Royal College of Obstetricians and Gynaecologists (RCOG) has developed guidelines to classify them based on their severity. First-degree tears are superficial and do not require any repair, while second-degree tears involve the perineal muscle and require suturing by a midwife or clinician. Third-degree tears involve the anal sphincter complex and require repair in theatre by a trained clinician, with subcategories based on the extent of the tear. Fourth-degree tears involve the anal sphincter complex and rectal mucosa and also require repair in theatre by a trained clinician.

      There are several risk factors for perineal tears, including being a first-time mother, having a large baby, experiencing a precipitant labour, and having a shoulder dystocia or forceps delivery. It is important for healthcare providers to be aware of these risk factors and to provide appropriate care and management during childbirth to minimize the risk of perineal tears. By following the RCOG guidelines and providing timely and effective treatment, healthcare providers can help ensure the best possible outcomes for both mother and baby.

    • This question is part of the following fields:

      • Obstetrics
      54.7
      Seconds
  • Question 7 - A 20-year-old soldier has recently completed a long marching exercise and complains of...

    Incorrect

    • A 20-year-old soldier has recently completed a long marching exercise and complains of sudden and intense pain in the forefoot. Upon examination, there is tenderness along the second metatarsal. X-rays are taken and show callus formation around the shaft of the second metatarsal. What is the probable diagnosis?

      Your Answer: Mortons neuroma

      Correct Answer: Stress fracture

      Explanation:

      Based on the patient’s symptoms, physical examination, and radiological findings, it is likely that they are suffering from a stress fracture in their second metatarsal. The presence of callus indicates that immobilization may not be effective in treating the injury. Freiberg’s disease, which typically affects the head of the second metatarsal during puberty, is characterized by anterior metatarsalgia and is caused by stress microfractures at the growth plate. However, the key factor that distinguishes a stress fracture from Freiberg’s disease is the radiological evidence. In Freiberg’s disease, x-ray changes include joint space widening, bony spur formation, sclerosis, and flattening of the metatarsal head.

      Stress fractures are small hairline fractures that can occur due to repetitive activity and loading of normal bone. Although they can be painful, they are typically not displaced and do not cause surrounding soft tissue injury. In some cases, stress fractures may present late, and callus formation may be visible on radiographs. Treatment for stress fractures may vary depending on the severity of the injury. In cases where the injury is associated with severe pain and presents at an earlier stage, immobilization may be necessary. However, injuries that present later may not require formal immobilization and can be treated with tailored immobilization specific to the site of injury.

    • This question is part of the following fields:

      • Musculoskeletal
      49.6
      Seconds
  • Question 8 - As the junior doctor on the labour ward, you are summoned to attend...

    Incorrect

    • As the junior doctor on the labour ward, you are summoned to attend a first delivery of a 26-year-old patient. The patient experienced spontaneous preterm rupture of membranes at 34 weeks, and now the umbilical cord is palpable above the level of the introitus. What is the appropriate course of action for managing this patient?

      Your Answer: The cord may be pushed back into the uterus

      Correct Answer: The presenting part of the fetus may be pushed back into the uterus

      Explanation:

      In the event of cord prolapse, which occurs when the umbilical cord descends below the presenting part of the fetus after membrane rupture, fetal hypoxia and death can occur due to cord compression or spasm. To prevent compression, tocolytics should be administered and a Caesarean delivery should be performed. The patient should be advised to assume an all-fours position. It is important not to push the cord back into the uterus. The preferred method of delivery is an immediate Caesarean section.

      Understanding Umbilical Cord Prolapse

      Umbilical cord prolapse is a rare but serious complication that can occur during delivery. It happens when the umbilical cord descends ahead of the presenting part of the fetus, which can lead to compression or spasm of the cord. This can cause fetal hypoxia and potentially irreversible damage or death. Certain factors increase the risk of cord prolapse, such as prematurity, multiparity, polyhydramnios, twin pregnancy, cephalopelvic disproportion, and abnormal presentations like breech or transverse lie.

      Around half of all cord prolapses occur when the membranes are artificially ruptured. Diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally or visible beyond the introitus. Cord prolapse is an obstetric emergency that requires immediate management. The presenting part of the fetus may be pushed back into the uterus to avoid compression, and the cord should be kept warm and moist to prevent vasospasm. The patient may be asked to go on all fours or assume the left lateral position until preparations for an immediate caesarian section have been carried out. Tocolytics may be used to reduce uterine contractions, and retrofilling the bladder with saline can help elevate the presenting part. Although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery may be possible if the cervix is fully dilated and the head is low.

      In conclusion, umbilical cord prolapse is a rare but serious complication that requires prompt recognition and management. Understanding the risk factors and appropriate interventions can help reduce the incidence of fetal mortality associated with this condition.

    • This question is part of the following fields:

      • Obstetrics
      62.9
      Seconds
  • Question 9 - A 75-year-old is brought to the Emergency Department after being found at home...

    Incorrect

    • A 75-year-old is brought to the Emergency Department after being found at home on the floor by her daughter. Her daughter tried to rouse her but had no response. She has a laceration to her head and her daughter believes she may have had a fall. You notice she has a sudden decrease in consciousness in the department. You are unable to get the patient to make any vocalisation. When you apply supraorbital pressure, she briefly opens her eyes and withdraws from the pain.
      Which one of the following is the best immediate management option for this patient?

      Your Answer: Urgent CT brain scan

      Correct Answer: Insert Guedel airway

      Explanation:

      Management of a Patient with Low Glasgow Coma Scale Score

      The Glasgow Coma Scale (GCS) is a tool used to assess the level of consciousness in patients. A patient with a GCS score below 8 requires urgent referral to critical care or the anaesthetist on-call for appropriate management. In this case, the patient has a GCS score of 7 (E2, V1, M4) and needs immediate attention.

      Airway management is the top priority in patients with a low GCS score. The patient may need invasive ventilation if they lose the capacity to maintain their own airway. Once the airway is secured, a referral to the neurosurgical registrar may be necessary, and investigations such as a CT brain scan should be carried out to determine the cause of the low GCS score.

      A neurological observation chart is also needed to detect any deteriorating central nervous system function. A medication review can be done once the patient is stabilised and an intracranial bleed has been ruled out. This will help identify medications that could cause a fall and stop unnecessary medication.

      In summary, a patient with a low GCS score requires urgent attention to secure their airway, determine the cause of the low score, and monitor for any neurological deterioration. A medication review can be done once the patient is stable.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
      34.2
      Seconds
  • Question 10 - A premature neonate is delivered via category II emergency caesarean section at 34+3...

    Correct

    • A premature neonate is delivered via category II emergency caesarean section at 34+3 weeks for fetal distress. The obstetrician notes the baby is delivered with the cord wrapped around its neck and appears floppy and 'blue'. The neonatal team immediately begins resuscitation as the initial APGAR score is 3. At 10 minutes, the score is 5 due to cyanosis, heart rate of 120 bpm, minimal response to stimulation, poor tone, slow and irregular respiratory effort with a respiratory rate of 12/min. What is the most appropriate management of this premature neonate to reduce hypoxic ischemic encephalopathy (HIE)?

      Your Answer: Therapeutic cooling

      Explanation:

      Therapeutic Cooling for Neonates with Hypoxic Brain Injury

      Therapeutic cooling, also known as therapeutic hypothermia, is a medical procedure that involves deliberately lowering a patient’s body temperature to cool the brain and prevent brain damage. This procedure has been proposed for several therapeutic uses, including neuroprotection during open-heart and neurosurgical procedures, in patients following a return of spontaneous circulation post-ventricular fibrillation arrest, in patients with trauma head injuries, in patients who have suffered acute ischemic stroke, and in neonates with moderate to severe hypoxic ischemic encephalopathy (HIE). However, the only use whose efficacy has been consistently proven in existing literature is the use of therapeutic cooling in neonates.

      The use of therapeutic cooling in carefully selected term neonates with moderate to severe HIE has been recommended as standard care by the National Institute for Health and Care Excellence (NICE). It has been shown in studies to decrease mortality and improve the neurological and neurodevelopmental outcomes of treated neonates. Hypoxic perinatal brain injury is caused by a decrease in the amount of oxygen supplied to an infant’s brain just prior to, or during the process of, labor. Neonates who survive a hypoxic brain injury can develop HIE, which occurs in an estimated 2.5/1000 term births in developed countries and 26/1000 term births in the developing world.

      Therapeutic cooling remains the only intervention shown to reduce neuronal damage caused by perinatal hypoxia. The procedure is thought to influence the extent of secondary neuronal death in a multifactorial manner, although the exact way in which it achieves this is not fully understood. The procedure involves placing the infant on a cooling blanket or mattress circulated with coolant fluid or circulating cold water in a cap fitted around the head. Temperature is continuously monitored throughout the treatment using either a rectal or nasopharyngeal thermometer. Close surveillance of infants during the cooling process is required given the risk for complications of both HIE and the process of cooling itself.

    • This question is part of the following fields:

      • Paediatrics
      81.3
      Seconds
  • Question 11 - A 61-year-old man with metastatic colorectal cancer is admitted to the hospice for...

    Incorrect

    • A 61-year-old man with metastatic colorectal cancer is admitted to the hospice for end-of-life care. The patient is prescribed ondansetron for management of his nausea symptoms.
      Ondansetron acts on which of the following receptors as an antiemetic?

      Your Answer: Dopamine

      Correct Answer: Serotonin

      Explanation:

      Common Antiemetic Receptors and their Corresponding Medications

      Anti-nausea medications work by targeting specific receptors in the body. Here are some common antiemetic receptors and the medications that act on them:

      Serotonin: Ondansetron is a medication that binds strongly to the serotonin HT3 receptor. This receptor is present both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone. Ondansetron is useful for treating nausea caused by gastrointestinal irritation, GI tumors, intestinal obstruction, and genitourinary or biliary stasis.

      Acetylcholine: Acetylcholine is a neurotransmitter and not a receptor. It acts on muscarinic receptors.

      Muscarinic: Hyoscine is an antimuscarinic medication used to treat nausea. Cyclizine and metoclopramide also have antimuscarinic activity.

      Dopamine: Metoclopramide, domperidone, and prochlorperazine are dopamine receptor antagonists. Metoclopramide also acts on serotonin antagonists at high doses.

      Nicotinic: Ondansetron does not act on nicotinic receptors.

      Understanding Antiemetic Receptors and Medications

    • This question is part of the following fields:

      • Pharmacology
      22.6
      Seconds
  • Question 12 - An 80-year-old man is scheduled for a surgery to remove a cancerous growth...

    Correct

    • An 80-year-old man is scheduled for a surgery to remove a cancerous growth in his large intestine. He has been noticing a gradual decrease in weight and alteration in bowel movements for the past two months. A recent colonoscopy has revealed a mass in the lower part of his descending colon. Despite his age, he appears to be in good health and is prepared to proceed with the procedure. What is the most probable surgery he will undergo?

      Your Answer: Left hemicolectomy

      Explanation:

      The appropriate surgical procedure for a patient with distal transverse or descending colon cancer is a left hemicolectomy. This procedure involves removing the distal two-thirds of the transverse colon, the descending colon, and the sigmoid colon. The rectum is left intact and anastomosed with the proximal transverse colon, avoiding the need for a permanent stoma.

      Other surgical options, such as Hartmann’s procedure, high anterior resection, low anterior resection, and right hemicolectomy, are not suitable for this patient’s condition. Hartmann’s procedure is reserved for emergencies, while high anterior resection and low anterior resection are used for rectal tumors. Right hemicolectomy is performed for cancers in the cecum, ascending colon, or proximal third of the transverse colon.

      Colorectal cancer is typically diagnosed through CT scans and colonoscopies or CT colonography. Patients with tumors below the peritoneal reflection should also undergo MRI to evaluate their mesorectum. Once staging is complete, a treatment plan is formulated by a dedicated colorectal MDT meeting.

      For colon cancer, surgery is the primary treatment option, with resectional surgery being the only cure. The procedure is tailored to the patient and tumor location, with lymphatic chains being resected based on arterial supply. Anastomosis is the preferred method of restoring continuity, but in some cases, an end stoma may be necessary. Chemotherapy is often offered to patients with risk factors for disease recurrence.

      Rectal cancer management differs from colon cancer due to the rectum’s anatomical location. Tumors can be surgically resected with either an anterior resection or an abdominoperineal excision of rectum (APER). A meticulous dissection of the mesorectal fat and lymph nodes is integral to the procedure. Neoadjuvant radiotherapy is often offered to patients prior to resectional surgery, and those with obstructing rectal cancer should have a defunctioning loop colostomy.

      Segmental resections based on blood supply and lymphatic drainage are the primary operations for cancer. The type of resection and anastomosis depend on the site of cancer. In emergency situations where the bowel has perforated, an end colostomy is often safer. Left-sided resections are more risky, but ileocolic anastomoses are relatively safe even in the emergency setting and do not need to be defunctioned.

    • This question is part of the following fields:

      • Surgery
      101.3
      Seconds
  • Question 13 - A 32-year-old, G2P1, presents to the obstetrics assessment unit with vaginal bleeding and...

    Correct

    • A 32-year-old, G2P1, presents to the obstetrics assessment unit with vaginal bleeding and mild abdominal pain at 15 weeks gestation. What aspect of her medical history would raise concern for a possible miscarriage?

      Your Answer: Large cervical cone biopsy

      Explanation:

      There are several factors that can increase the risk of miscarriage, including age, previous miscarriages, chronic conditions, uterine or cervical problems (such as large cervical cone biopsies or Mullerian duct anomalies), smoking, alcohol and illicit drug use, and weight. Invasive prenatal tests like chorionic villus sampling and amniocentesis also carry a slight risk of miscarriage. It’s important to note that other options are not considered risk factors for 2nd-trimester miscarriage.

      Miscarriage: Understanding the Epidemiology

      Miscarriage, also known as abortion, refers to the expulsion of the products of conception before 24 weeks. To avoid any confusion, the term miscarriage is often used. According to epidemiological studies, approximately 15-20% of diagnosed pregnancies will end in miscarriage during early pregnancy. In fact, up to 50% of conceptions may not develop into a blastocyst within 14 days.

      Recurrent spontaneous miscarriage, which is defined as the loss of three or more consecutive pregnancies, affects approximately 1% of women. Understanding the epidemiology of miscarriage is important for healthcare providers and patients alike. It can help to identify risk factors and provide appropriate counseling and support for those who have experienced a miscarriage. By raising awareness and promoting education, we can work towards reducing the incidence of miscarriage and improving the overall health and well-being of women and their families.

    • This question is part of the following fields:

      • Obstetrics
      54.1
      Seconds
  • Question 14 - What is the most suitable time to collect blood samples for therapeutic monitoring...

    Incorrect

    • What is the most suitable time to collect blood samples for therapeutic monitoring of lithium levels?

      Your Answer: 4 hours after last dose

      Correct Answer: 12 hours after last dose

      Explanation:

      Therapeutic Drug Monitoring: Guidelines for Monitoring Lithium, Ciclosporin, Digoxin, and Phenytoin Levels

      Lithium levels should be monitored 12 hours after the last dose, with the target range being 0.4-1.0 mmol/l. Ciclosporin levels should be measured immediately before the next dose, while Digoxin levels should be checked at least 6 hours after the last dose. Phenytoin levels do not need to be monitored routinely, but trough levels should be checked before the next dose if there is a need to adjust the dose, suspected toxicity, or non-adherence to the prescribed medication.

      Therapeutic drug monitoring is an essential aspect of patient care, especially for drugs with narrow therapeutic windows. The guidelines for monitoring lithium, ciclosporin, digoxin, and phenytoin levels vary depending on the drug and the patient’s condition. It is crucial to follow these guidelines to ensure that the patient receives the optimal dose of medication and to prevent adverse effects. Proper monitoring of drug levels can also help detect non-adherence to the prescribed medication, which can affect treatment outcomes. By following these guidelines, healthcare professionals can provide safe and effective treatment to their patients.

    • This question is part of the following fields:

      • Pharmacology
      25.2
      Seconds
  • Question 15 - A 42-year-old female, 28 weeks pregnant, is referred to a nephrology consultant by...

    Incorrect

    • A 42-year-old female, 28 weeks pregnant, is referred to a nephrology consultant by her general practitioner for suspected renal stones. She has a medical history of hypertension and ischemic heart disease. A CT-KUB report reveals a 1.5 cm renal stone. What is the recommended definitive management for this patient?

      Your Answer: Diclofenac

      Correct Answer: Ureteroscopy

      Explanation:

      When it comes to removing renal stones in pregnant women, ureteroscopy is the preferred method over lithotripsy. While lithotripsy is the preferred option for stones smaller than 2 cm, it is not safe for pregnant women. Therefore, ureteroscopy is the preferred alternative. For more complex or staghorn calculi, percutaneous nephrolithotomy is the preferred option.

      The management of renal stones involves initial medication and investigations, including an NSAID for analgesia and a non-contrast CT KUB for imaging. Stones less than 5mm may pass spontaneously, but more intensive treatment is needed for ureteric obstruction or renal abnormalities. Treatment options include shockwave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy. Prevention strategies include high fluid intake, low animal protein and salt diet, and medication such as thiazides diuretics for hypercalciuria and allopurinol for uric acid stones.

    • This question is part of the following fields:

      • Surgery
      57.1
      Seconds
  • Question 16 - A 70-year-old man presents to his GP with bone pain and muscle tenderness....

    Incorrect

    • A 70-year-old man presents to his GP with bone pain and muscle tenderness. He has a past medical history of stage 3 chronic kidney disease.
      The GP decides to take some blood, and the results are shown below.
      Calcium 2.1 mmol/L (2.2-2.7)
      Phosphate 0.72 mmol/L (0.8-1.4)
      Magnesium 0.9 mmol/L (0.7-1.0)
      Thyroid stimulating hormone (TSH) 4.8 mU/L (0.5-5.5)
      Free thyroxine (T4) 10.8 pmol/L (9.0 - 18)
      What is the most appropriate initial management?

      Your Answer: Oral bisphosphonates

      Correct Answer: Vitamin D supplements

      Explanation:

      The appropriate management for osteomalacia, which is likely caused by chronic kidney disease, involves vitamin D supplementation with an initial loading dose regime. Blood tests for osteomalacia typically reveal low levels of calcium and phosphate, as well as high levels of alkaline phosphatase. Calcium supplementation may also be prescribed if the patient’s dietary intake is insufficient. Intravenous fluids and bisphosphonates are not recommended for the treatment of hypocalcaemia, while levothyroxine is used to manage hypothyroidism and oral bisphosphonates are used for osteoporosis.

      Understanding Osteomalacia

      Osteomalacia is a condition that occurs when the bones become soft due to low levels of vitamin D, which leads to a decrease in bone mineral content. This condition is commonly seen in adults, while in growing children, it is referred to as rickets. The causes of osteomalacia include vitamin D deficiency, malabsorption, lack of sunlight, chronic kidney disease, drug-induced factors, inherited conditions, liver disease, and coeliac disease.

      The symptoms of osteomalacia include bone pain, muscle tenderness, fractures, especially in the femoral neck, and proximal myopathy, which may lead to a waddling gait. To diagnose osteomalacia, blood tests are conducted to check for low vitamin D levels, low calcium and phosphate levels, and raised alkaline phosphatase levels. X-rays may also show translucent bands known as Looser’s zones or pseudofractures.

      The treatment for osteomalacia involves vitamin D supplementation, with a loading dose often needed initially. Calcium supplementation may also be necessary if dietary calcium intake is inadequate. Understanding the causes, symptoms, and treatment options for osteomalacia is crucial in managing this condition effectively.

    • This question is part of the following fields:

      • Musculoskeletal
      44.7
      Seconds
  • Question 17 - A 29-year-old woman who is 39-weeks pregnant presents to the labour suite with...

    Correct

    • A 29-year-old woman who is 39-weeks pregnant presents to the labour suite with sporadic contractions. She had noticed a mucous plug in her underwear earlier in the day. Upon examination, she appears to be breathing heavily and experiencing some discomfort. The cardiotocography is normal and progressing smoothly. During a vaginal examination, her cervix is estimated to be dilated at 2 cm. What phase of labour is she currently in?

      Your Answer: Latent 1st stage

      Explanation:

      The correct stage of labour for a woman with a cervix that is just beginning to ripen and dilate is the latent phase of the 1st stage. This stage is characterized by a cervix dilation of 0-3 cm. The active phase of the 1st stage, which is characterized by a cervix dilation of 3-10 cm and more regular contractions, is not applicable in this scenario. The active 2nd stage is also not a descriptive stage of labour, as it only refers to the general stage that ends with the expulsion of the foetus.

      Labour is divided into three stages, with the first stage beginning from the onset of true labour until the cervix is fully dilated. This stage is further divided into two phases: the latent phase and the active phase. The latent phase involves dilation of the cervix from 0-3 cm and typically lasts around 6 hours. The active phase involves dilation from 3-10 cm and progresses at a rate of approximately 1 cm per hour. In primigravidas, this stage can last between 10-16 hours.

      During this stage, the baby’s presentation is important to note. Approximately 90% of babies present in the vertex position, with the head entering the pelvis in an occipito-lateral position. The head typically delivers in an occipito-anterior position.

    • This question is part of the following fields:

      • Obstetrics
      21.4
      Seconds
  • Question 18 - A 64-year-old postmenopausal woman visits her General Practitioner (GP) complaining of dyspareunia, increased...

    Incorrect

    • A 64-year-old postmenopausal woman visits her General Practitioner (GP) complaining of dyspareunia, increased urinary frequency, and vaginal dryness. She reports no vaginal bleeding, discharge, or haematuria, and there are no signs of vasomotor or psychological menopausal symptoms. What is the accurate statement about treating vaginal atrophy in postmenopausal women?

      Your Answer: Vaginal oestrogens improve vaginal, but not urinary, symptoms associated with vaginal atrophy

      Correct Answer: Following cessation of treatment, symptoms recur

      Explanation:

      Management of Vaginal Atrophy in Menopausal Women

      Menopausal women often experience vaginal atrophy due to oestrogen deficiency, leading to a variety of symptoms such as dyspareunia, burning, irritation, vaginal discharge, and bleeding. It is crucial to rule out urinary and sexually transmitted infections and perform a speculum examination to exclude malignancy in the presence of vaginal bleeding. Topical therapy is the first-line management for vaginal atrophy, which can be either hormonal or non-hormonal. Hormonal treatments are more effective but have more side-effects, while non-hormonal treatments provide symptom relief to a number of patients. A combination of both therapies is also an option for maximal symptom relief. Systemic hormonal replacement therapy is offered to women who have both vaginal and systemic menopausal symptoms. Vaginal bleeding is a common side-effect of hormonal treatment and requires further investigation if it persists after the first six months of therapy.

    • This question is part of the following fields:

      • Gynaecology
      31
      Seconds
  • Question 19 - A 14-year-old girl is brought to the Emergency Department by her mother, who...

    Incorrect

    • A 14-year-old girl is brought to the Emergency Department by her mother, who found her on the bathroom floor. She is ataxic, appears confused and her speech is slurred, however she does not smell of alcohol. She says she 'took something' because she wanted to end her life. She has vomited twice.

      On the blood gas, there is a metabolic acidosis.

      What is the most appropriate treatment for this situation?

      Your Answer: Glucagon

      Correct Answer: Fomepizole

      Explanation:

      Fomepizole is an effective treatment for ethylene glycol toxicity as it inhibits alcohol dehydrogenase, slowing down the production of toxic metabolites. Ethanol can also be used if fomepizole is not available. Symptoms of ethylene glycol poisoning include ataxia, vomiting, dysarthria, and metabolic acidosis with a raised anion gap. In severe cases, convulsions and coma can occur. Atropine is used to treat organophosphate poisoning, which can cause anxiety, restlessness, headache, muscle weakness, respiratory failure, and bronchospasm with bronchial secretions. Flumazenil is used to treat benzodiazepine overdose, which can cause drowsiness, dizziness, ataxia, coma, and respiratory depression. Glucagon is used to treat beta blocker overdose, which can cause sinus bradycardia, hypotension, and coma.

      Understanding Ethylene Glycol Toxicity and Its Management

      Ethylene glycol is a type of alcohol commonly used as a coolant or antifreeze. Its toxicity is characterized by three stages of symptoms. The first stage is similar to alcohol intoxication, with confusion, slurred speech, and dizziness. The second stage involves metabolic acidosis with high anion gap and high osmolar gap, as well as tachycardia and hypertension. The third stage is acute kidney injury.

      In the past, ethanol was the primary treatment for ethylene glycol toxicity. It works by competing with ethylene glycol for the enzyme alcohol dehydrogenase, which limits the formation of toxic metabolites responsible for the haemodynamic and metabolic features of poisoning. However, in recent times, fomepizole, an inhibitor of alcohol dehydrogenase, has become the first-line treatment preference over ethanol. Haemodialysis also has a role in refractory cases.

      Overall, understanding the stages of ethylene glycol toxicity and the changing management options is crucial for healthcare professionals to provide effective treatment and prevent further harm to patients.

    • This question is part of the following fields:

      • Pharmacology
      40.8
      Seconds
  • Question 20 - A 26-year-old female student presents to the Emergency Department with severe abdominal pain...

    Correct

    • A 26-year-old female student presents to the Emergency Department with severe abdominal pain that started suddenly while she was shopping 3 hours ago. She reports not having her periods for 8 weeks and being sexually active. She also has a history of pelvic inflammatory disease 4 years ago. On examination, there is generalised guarding and signs of peritonism. An urgent ultrasound scan reveals free fluid in the pouch of Douglas with an empty uterine cavity, and a positive urine βhCG. Basic bloods are sent. Suddenly, her condition deteriorates, and her vital signs are BP 85/50 mmHg, HR 122/min, RR 20/min, and O2 saturation 94%.

      What is the most appropriate next step?

      Your Answer: Resuscitate and arrange for emergency laparotomy

      Explanation:

      There is a strong indication of a ruptured ectopic pregnancy based on the clinical presentation. The patient’s condition has deteriorated significantly, with symptoms of shock and a systolic blood pressure below 90 mmHg. Due to her unstable cardiovascular state, urgent consideration must be given to performing an emergency laparotomy.

      Understanding Ectopic Pregnancy

      Ectopic pregnancy occurs when a fertilized egg implants outside the uterus. This condition is characterized by lower abdominal pain and vaginal bleeding, typically occurring 6-8 weeks after the start of the last period. The pain is usually constant and may be felt on one side of the abdomen due to tubal spasm. Vaginal bleeding is usually less than a normal period and may be dark brown in color. Other symptoms may include shoulder tip pain, pain on defecation/urination, dizziness, fainting, or syncope. Breast tenderness may also be reported.

      During examination, abdominal tenderness and cervical excitation may be observed. However, it is not recommended to examine for an adnexal mass due to the risk of rupturing the pregnancy. Instead, a pelvic examination to check for cervical excitation is recommended. In cases of pregnancy of unknown location, serum bHCG levels >1,500 may indicate an ectopic pregnancy. It is important to seek medical attention immediately if ectopic pregnancy is suspected as it can be life-threatening.

    • This question is part of the following fields:

      • Obstetrics
      36.9
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Clinical Biochemistry (1/1) 100%
Rheumatology (0/1) 0%
Surgery (1/4) 25%
Haematology (0/1) 0%
Obstetrics (3/5) 60%
Musculoskeletal (0/2) 0%
Acute Medicine And Intensive Care (0/1) 0%
Paediatrics (1/1) 100%
Pharmacology (0/3) 0%
Gynaecology (0/1) 0%
Passmed