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  • Question 1 - A 32-year-old woman presents on day 28 postpartum with burning pain in the...

    Correct

    • A 32-year-old woman presents on day 28 postpartum with burning pain in the nipples bilaterally and itching. She reports symptoms are worse after feeds.
      On examination, you notice that the nipples are erythematosus, swollen and fissured. The breasts are unremarkable. Her observations are stable, and she is apyrexial. She tells you she wants you to review her baby and that she noticed small white patches in his mouth.
      Given the likely diagnosis, which of the following is the most appropriate management?

      Your Answer: Topical antifungal cream

      Explanation:

      Management of Breast Conditions: Understanding the Different Treatment Options

      Breast conditions can present with a variety of symptoms, and it is important to understand the appropriate management for each. Here are some common breast conditions and their corresponding treatments:

      1. Fungal infection of the nipples: This is characterized by bilateral symptoms and signs of nipple thrush. Treatment involves applying a topical miconazole 2% cream to the affected nipples after every feed for two weeks. The infant should also be treated with miconazole cream in the mouth.

      2. Paget’s disease of the nipple: This is a form of in situ carcinoma that warrants urgent referral to the Breast team under the 2-week wait pathway. Symptoms include unilateral erythema, inflammation, burning pain, ulceration, and bleeding.

      3. Breast cellulitis or mastitis: This is associated with the breast itself and is characterized by unilateral engorgement, erythematosus skin, and tenderness. Treatment involves oral flucloxacillin.

      4. Eczema of the nipple: This affects both nipples and presents with a red, scaly rash that spares the base of the nipple. Treatment involves avoiding triggers and using regular emollients, with a topical steroid cream applied after feeds.

      5. Bacterial infection of the nipples: This is treated with a topical antibacterial cream, such as topical fusidic acid.

      Understanding the appropriate management for each breast condition is crucial in providing effective treatment and improving patient outcomes.

    • This question is part of the following fields:

      • Obstetrics
      2.1
      Seconds
  • Question 2 - A patient in their 60s presents to the emergency department with right-sided hemiplegia,...

    Incorrect

    • A patient in their 60s presents to the emergency department with right-sided hemiplegia, facial weakness, and difficulty with speech. A stroke is suspected. What is the recommended tool for assessing a patient in this scenario?

      Your Answer: CHA2DS2 VASC

      Correct Answer: ROSIER

      Explanation:

      ROSIER is an acronym for a tool used to assess stroke symptoms in an acute setting.

      Assessment and Investigations for Stroke

      Whilst diagnosing a stroke may be straightforward in some cases, it can be challenging when symptoms are vague. The FAST screening tool, which stands for Face/Arms/Speech/Time, is a well-known tool used by the general public to identify stroke symptoms. However, medical professionals use a validated tool called the ROSIER score, recommended by the Royal College of Physicians. The ROSIER score assesses for loss of consciousness or syncope, seizure activity, and new, acute onset of asymmetric facial, arm, or leg weakness, speech disturbance, or visual field defect. A score of greater than zero indicates a likely stroke.

      When investigating suspected stroke, a non-contrast CT head scan is the first line radiological investigation. The key question to answer is whether the stroke is ischaemic or haemorrhagic, as this determines the appropriate management. Ischaemic strokes may show areas of low density in the grey and white matter of the territory, while haemorrhagic strokes typically show areas of hyperdense material surrounded by low density. It is important to identify the type of stroke promptly, as thrombolysis and thrombectomy play an increasing role in acute stroke management. In rare cases, a third pathology such as a tumour may also be detected.

    • This question is part of the following fields:

      • Medicine
      0.9
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  • Question 3 - A 75-year-old man comes to his GP for a medication review. He has...

    Incorrect

    • A 75-year-old man comes to his GP for a medication review. He has metastatic bowel cancer and is in relatively good health, still able to move around and take care of himself. He has been eating and drinking well. Currently, he is taking modified release morphine sulphate tablets (MST) 20 mg twice daily and using oramorph 10 mg/5 ml for breakthrough pain 4-6 times a day. He has not reported any adverse effects.
      What would be the best course of action for managing his medication?

      Your Answer: Change to oxycodone

      Correct Answer: Increase the dose of modified release MST and advise him to reduce the frequency of oramorph if possible

      Explanation:

      Options for Managing Inadequate Pain Relief in a Patient on Opiates

      When a patient on opiates experiences inadequate pain relief, there are several options for managing their medication. One option is to increase the dose of modified release morphine sulphate tablets (MST) while advising the patient to reduce the frequency of breakthrough medication, such as oramorph. However, caution must be taken to avoid overdose, and the patient should be aware of the risks of continuing their current regime.

      Another option is to switch to a different opiate, such as oxycodone, but this may not be necessary if the patient is tolerating the current medication well. In this case, the dose of MST can be titrated cautiously and reviewed regularly.

      A fentanyl patch may also be an option, but only if the patient is unable to take tablets due to eating or drinking difficulties.

      If the patient requires multiple doses of breakthrough medication, the BNF recommends reviewing the dose of longer-acting analgesia.

      Ultimately, the best course of action will depend on the individual patient’s needs and condition, and a full review of their medication and pain management plan should be performed if necessary.

    • This question is part of the following fields:

      • Palliative Care
      1.9
      Seconds
  • Question 4 - You are seeing a teenager for her 6-month follow up appointment following a...

    Correct

    • You are seeing a teenager for her 6-month follow up appointment following a normal vaginal delivery. She wishes to stop breastfeeding as her baby requires specialised formula feeds.

      Which medication can be prescribed to suppress lactation in this scenario?

      Your Answer: Cabergoline

      Explanation:

      When it is necessary to stop breastfeeding, Cabergoline is the preferred medication for suppressing lactation. This is because Cabergoline is a dopamine receptor agonist that can inhibit the production of prolactin, which in turn suppresses lactation. It should be noted that Norethisterone has no effect on lactation, Misoprostol is used to soften the cervix during labor induction, and Ursodeoxycholic acid is a bile acid chelating agent used to treat cholestasis in pregnancy.

      Techniques for Suppressing Lactation during Breastfeeding

      Breastfeeding is a natural process that provides essential nutrients to newborns. However, there may be situations where a mother needs to suppress lactation. This can be achieved by stopping the lactation reflex, which involves stopping suckling or expressing milk. Additionally, supportive measures such as wearing a well-supported bra and taking analgesia can help alleviate discomfort. In some cases, medication may be required, and cabergoline is the preferred choice. By following these techniques, lactation can be suppressed effectively and safely.

    • This question is part of the following fields:

      • Gynaecology
      1.2
      Seconds
  • Question 5 - A teenage girl has missed taking her combined contraception pill (standard strength) in...

    Incorrect

    • A teenage girl has missed taking her combined contraception pill (standard strength) in the middle of her pill pack and it has been almost 48 hours since her last pill. She is sexually active on a regular basis.
      What is the most appropriate guidance to provide her?

      Your Answer: She must continue the pill pack as usual but start the next pack without the week break

      Correct Answer: The missed pill must be taken as soon as it is remembered and the remaining pills should be taken at the correct time

      Explanation:

      How to Handle a Missed Birth Control Pill

      If you miss a birth control pill, it’s important to know what to do next. Here are some guidelines:

      1. The missed pill must be taken as soon as it is remembered and the remaining pills should be taken at the correct time.

      2. If one pill has been missed and it is 48–72 h since the last pill in the current pack or is 24–48 h late starting the new pack, the missed pill should be taken as soon as it is remembered. The remaining pills should be continued at the usual time.

      3. Emergency contraception is not usually required but may need to be considered if pills have been missed earlier in the pack or in the last week of the previous pack.

      4. If you miss a pill but remember before taking the next one, take the missed pill as soon as possible and continue the pack as normal.

      5. If you miss a pill and don’t remember until it’s time to take the next one, take the missed pill as soon as possible and use a backup method of contraception for the next seven days.

      6. If you miss two or more pills, follow the instructions on the package or talk to your healthcare provider.

      Remember, it’s important to take your birth control pills as directed to ensure their effectiveness. If you have any questions or concerns, talk to your healthcare provider.

    • This question is part of the following fields:

      • Sexual Health
      1.5
      Seconds
  • Question 6 - A 23-year-old man comes to the clinic complaining of low back pain and...

    Incorrect

    • A 23-year-old man comes to the clinic complaining of low back pain and stiffness that has persisted for over 3 months. He denies any history of injury. The patient reports that his symptoms are worse in the morning but improve with exercise. Routine blood tests were normal except for an ESR of 30 mm/hour (normal range: 0-15) and a CRP of 15 mg/L (normal range: <10). A plain x-ray of the sacroiliac joints reveals erosions, sclerosis, and joint space widening, leading to a diagnosis of ankylosing spondylitis. What is the next step in managing this patient's condition?

      Your Answer: Exercise and glucocorticoids

      Correct Answer: Exercise and NSAIDs

      Explanation:

      Ankylosing spondylitis is primarily managed through exercise and NSAIDs. NSAIDs are effective in relieving symptoms and preventing functional limitations, while regular exercise, including postural training, range of motion exercises, stretching, and recreational activities like swimming, can help reduce and prevent functional limitations.

      To measure disease activity, the Ankylosing Spondylitis Disease Activity Score (ASDAS) is used, which categorizes disease activity as inactive, low, high, or very high. If a patient has persistently high disease activity despite conventional treatments with NSAIDs, anti-tumor necrosis factor (TNF) therapy may be considered. However, the disease activity must be at least high (≥2.1) on ASDAS to warrant biologic therapy.

      Glucocorticoids are not recommended for patients with ankylosing spondylitis. Methotrexate may be prescribed if conventional treatment with NSAIDs does not control symptoms, specifically for persistent peripheral arthritis.

      In severe cases where the disease has progressed, surgery may be necessary. Hip and spine surgery may be beneficial for select patients with persistent pain or severe limitation in mobility, neurologic impairment, or severe flexion deformities.

      Investigating and Managing Ankylosing Spondylitis

      Ankylosing spondylitis is a type of spondyloarthropathy that is associated with HLA-B27. It is more commonly seen in males aged 20-30 years old. Inflammatory markers such as ESR and CRP are usually elevated, but normal levels do not necessarily rule out ankylosing spondylitis. HLA-B27 is not a reliable diagnostic tool as it can also be positive in normal individuals. The most effective way to diagnose ankylosing spondylitis is through a plain x-ray of the sacroiliac joints. However, if the x-ray is negative but suspicion for AS remains high, an MRI can be obtained to confirm the diagnosis.

      Management of ankylosing spondylitis involves regular exercise, such as swimming, and the use of NSAIDs as the first-line treatment. Physiotherapy can also be helpful. Disease-modifying drugs used for rheumatoid arthritis, such as sulphasalazine, are only useful if there is peripheral joint involvement. Anti-TNF therapy, such as etanercept and adalimumab, should be given to patients with persistently high disease activity despite conventional treatments, according to the 2010 EULAR guidelines. Ongoing research is being conducted to determine whether anti-TNF therapies should be used earlier in the course of the disease. Spirometry may show a restrictive defect due to a combination of pulmonary fibrosis, kyphosis, and ankylosis of the costovertebral joints.

    • This question is part of the following fields:

      • Musculoskeletal
      1.1
      Seconds
  • Question 7 - A 76-year-old retired teacher with Alzheimer’s disease is seen in the Memory Clinic...

    Incorrect

    • A 76-year-old retired teacher with Alzheimer’s disease is seen in the Memory Clinic with her son. The son believes that his mother’s Alzheimer’s dementia has worsened considerably in the last few months. He observes that his mother is becoming more forgetful and is struggling with dressing and eating regular meals. The specialist evaluates the patient and decides to initiate memantine treatment.
      What is a typical adverse effect of memantine?

      Your Answer: Hypotension

      Correct Answer: Headaches

      Explanation:

      Understanding the Side-Effects of Memantine

      Memantine is a medication commonly used for the treatment of Alzheimer’s disease. As an N-methyl-D-aspartate (NMDA) antagonist, it works by reducing levels of glutamate in the brain. While it can be effective in managing symptoms, it is important to be aware of potential side-effects.

      One common side-effect of memantine is headaches. Other possible adverse effects include constipation, abnormal gait, hypertension, and central nervous system issues such as psychosis and suicidal ideation. However, it is important to note that Parkinsonism and Mobitz type II block are not known side-effects of this medication.

      It is also worth noting that memantine can cause hypertension rather than hypotension, and may lead to constipation rather than diarrhoea. By understanding the potential side-effects of memantine, patients and healthcare providers can work together to manage symptoms and ensure the best possible outcomes.

    • This question is part of the following fields:

      • Pharmacology
      0.6
      Seconds
  • Question 8 - A 48-year-old man presents with slurred speech. Upon examination, he displays bilateral partial...

    Incorrect

    • A 48-year-old man presents with slurred speech. Upon examination, he displays bilateral partial ptosis and frontal balding. Additionally, he experiences difficulty releasing his grip after shaking hands. What is the probable diagnosis?

      Your Answer: Eaton-Lambert syndrome

      Correct Answer: Myotonia dystrophica

      Explanation:

      Myotonic Dystrophy: A Progressive Multi-System Disorder

      Myotonic dystrophy is a genetic disorder that affects multiple systems in the body. It is caused by a mutation in the DMPK gene on chromosome 19, which leads to a CTG repeat. The length of this repeat determines the age of onset and severity of symptoms. Myotonic dystrophy can affect skeletal muscles, the heart, gastrointestinal and uterine smooth muscles, the eyes, and the endocrine and central nervous systems.

      Symptoms of myotonic dystrophy include ptosis, frontal balding, cataracts, cardiomyopathy, impaired intellect, testicular atrophy, diabetes mellitus, and dysarthria. The age of onset can range from birth to old age, with some patients presenting with symptoms in late adulthood. There is no cure for the weakness that is the main cause of disability, but medications such as phenytoin, quinine, or procainamide may be helpful for myotonia.

      It is important to differentiate myotonic dystrophy from other conditions that present with similar symptoms. Myotonia congenita, for example, presents in childhood with myotonia but does not have the other features associated with myotonic dystrophy. Duchenne muscular dystrophy also presents in childhood and has a much shorter life expectancy. Eaton-Lambert syndrome and myasthenia gravis are other conditions that can cause weakness but do not have the characteristic features of myotonic dystrophy.

    • This question is part of the following fields:

      • Neurology
      0.9
      Seconds
  • Question 9 - You are requested to attend to a 65-year-old male patient who has just...

    Correct

    • You are requested to attend to a 65-year-old male patient who has just returned from surgery in the high dependency unit. He underwent a left hemicolectomy to remove colon cancer. Your task is to prescribe the appropriate intravenous fluids for him.

      What is the most effective way to determine the infusion rate for the fluids?

      Your Answer: Measure his urine output and adjust accordingly

      Explanation:

      Importance of Adequate Hydration in Monitoring Organ Perfusion

      Hourly urine output is a reliable indicator of organ perfusion, which is directly linked to hydration levels. However, if there is a urological obstruction, this measure may not be accurate. While a trend in central venous pressure (CVP) can be helpful, a single reading is not a reliable indicator of hydration status. Late signs of hypovolemia include dry mucous membranes and hypotension. Therefore, it is crucial to maintain adequate hydration levels to ensure proper organ perfusion and prevent hypovolemia.

    • This question is part of the following fields:

      • Anaesthetics & ITU
      1.2
      Seconds
  • Question 10 - A 35-year-old businesswoman comes to the GP complaining of persistent pain and swelling...

    Incorrect

    • A 35-year-old businesswoman comes to the GP complaining of persistent pain and swelling in her forefoot. She reports that she recently relocated to London for a new job and spends a lot of time on her feet, often wearing high heels. The pain is exacerbated when she bears weight on her foot, and squeezing the area reproduces the discomfort. Based on these symptoms, which bone is most likely affected by a stress fracture?

      Your Answer:

      Correct Answer: 2nd metatarsal

      Explanation:

      Metatarsal fractures are a common occurrence, with the potential to affect one or multiple metatarsals. These fractures can result from direct trauma or repeated mechanical stress, known as stress fractures. The metatarsals are particularly susceptible to stress fractures, with the second metatarsal shaft being the most common site. The proximal 5th metatarsal is the most commonly fractured metatarsal, while the 1st metatarsal is the least commonly fractured.

      Fractures of the proximal 5th metatarsal can be classified as either proximal avulsion fractures or Jones fractures. Proximal avulsion fractures occur at the proximal tuberosity and are often associated with lateral ankle sprains. Jones fractures, on the other hand, are transverse fractures at the metaphyseal-diaphyseal junction and are much less common.

      Symptoms of metatarsal fractures include pain, bony tenderness, swelling, and an antalgic gait. X-rays are typically used to distinguish between displaced and non-displaced fractures, which guides subsequent management options. However, stress fractures may not appear on X-rays and may require an isotope bone scan or MRI to establish their presence. Overall, metatarsal fractures are a common injury that can result from a variety of causes and require prompt diagnosis and management.

    • This question is part of the following fields:

      • Musculoskeletal
      0
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SESSION STATS - PERFORMANCE PER SPECIALTY

Obstetrics (1/1) 100%
Medicine (0/1) 0%
Palliative Care (0/1) 0%
Gynaecology (1/1) 100%
Sexual Health (0/1) 0%
Musculoskeletal (0/1) 0%
Pharmacology (0/1) 0%
Neurology (0/1) 0%
Anaesthetics & ITU (1/1) 100%
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