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Question 1
Incorrect
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A 50-year-old patient on your practice list has a BMI of 52 kg/m² and is interested in bariatric surgery. There are no co-morbidities or contraindications for surgery.
What should be the next course of action?Your Answer: Orlistat trial for 6 months before referral
Correct Answer: Refer for bariatric surgery
Explanation:Bariatric Surgery as a First-Line Option for Patients with High BMI
Patients with a BMI greater than 50 kg/m² can be referred to bariatric surgery as a first-line option, provided they have no contraindications. If the patient has medical conditions that are affected by weight, surgery can be considered at a BMI greater than 35 kg/m². There are no restrictions on referral for bariatric surgery based on BMI, but the decision will involve an anaesthetic risk assessment based on multiple factors.
Referral for bariatric surgery in patients with a BMI greater than 40 kg/m² does not require them to have a medical condition affected by their weight. However, for patients with a BMI greater than 35 and up to 40 kg/m², a medical condition affected by weight is required for referral. A dietary management plan may benefit the patient, but the request for surgical consideration does not need to be delayed for a further 6 months.
While awaiting surgical assessment, Orlistat could be trialled, but this does not need to delay the referral. In summary, bariatric surgery can be considered as a first-line option for patients with a high BMI, and referral should be made without delay, taking into account the patient’s medical history and anaesthetic risk assessment.
Bariatric Surgery for Obesity Management
Bariatric surgery has become a significant option in managing obesity over the past decade. For obese patients who fail to lose weight through lifestyle changes and medication, the risks and costs of long-term obesity outweigh those of surgery. The National Institute for Health and Care Excellence (NICE) guidelines recommend early referral for bariatric surgery for very obese patients with a BMI of 40-50 kg/m^2, especially if they have other conditions such as type 2 diabetes mellitus and hypertension.
There are three types of bariatric surgery: primarily restrictive, primarily malabsorptive, and mixed operations. Laparoscopic-adjustable gastric banding (LAGB) is the first-line intervention for patients with a BMI of 30-39 kg/m^2. It produces less weight loss than other procedures but has fewer complications. Sleeve gastrectomy reduces the stomach to about 15% of its original size, while the intragastric balloon can be left in the stomach for a maximum of six months. Biliopancreatic diversion with duodenal switch is usually reserved for very obese patients with a BMI over 60 kg/m^2. Roux-en-Y gastric bypass surgery is both restrictive and malabsorptive in action.
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This question is part of the following fields:
- Surgery
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Question 2
Incorrect
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Which drugs act on calcium channels to induce relaxation of smooth muscle?
Your Answer: Enalapril
Correct Answer: Nifedipine
Explanation:Pharmacology of Commonly Used Drugs
Nifedipine is a medication that relaxes vascular muscle tone and is commonly used to treat angina and hypertension. Endothelial cells have the ability to mediate both contractile and relaxant responses, with nitric oxide (NO) being a key factor in the latter. NO is synthesized from L-arginine by nitric oxide synthases (NOS), which are calcium- and calmodulin-dependent. Calmodulin is a calcium-binding protein that regulates various cellular functions, including smooth muscle contraction and inflammation.
Amiloride is a diuretic that works by blocking the epithelial sodium channel in the kidneys, promoting the loss of sodium and water without depleting potassium. Doxazosin is an alpha-1 adrenergic receptor blocker that relaxes vascular smooth muscle tone by inhibiting the binding of norepinephrine to alpha-1 receptors. Enalapril is an angiotensin converting enzyme inhibitor that is used to treat hypertension and chronic heart failure. Finally, loperamide is an opioid-receptor agonist that is used to treat diarrhea by decreasing the activity of the myenteric plexus in the large intestine, allowing for more water absorption from fecal matter.
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This question is part of the following fields:
- Pharmacology
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Question 3
Incorrect
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A 10-year-old boy is the shortest in his class, measuring only 125 cm. His parents are worried about his growth. His last three recorded heights have been between the 0.4th and 2nd centile. His mother is 160 cm tall and his father is 175 cm tall. He has no other health issues.
What could be the probable reason for his short stature?Your Answer: Inadequate nutritional intake
Correct Answer: Familial short stature
Explanation:Familial Short Stature in Children
Children who have short parents and are otherwise healthy may have familial short stature. This means that their height and weight fall within the expected range based on their parents’ heights, and growth charts can be used to predict their adult height. In the case of a girl with familial short stature, her predicted adult height would be 154 cm, which falls within the mid-parental range of heights. Delayed puberty would cause a failure to gain height at the beginning of puberty and crossing of height centiles, while inadequate nutrition would cause crossing of both height and weight centiles. Low birth weight can also cause short stature in children, but in the absence of any other history, familial short stature is the most likely explanation. Precocious puberty, on the other hand, causes children to be tall for their age at the onset of puberty, not short.
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This question is part of the following fields:
- Paediatrics
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Question 4
Incorrect
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A 55-year-old diabetic man is scheduled for an elective incision and drainage of a groin abscess in the day surgery unit. He is typically well-managed on metformin. How should his diabetic control be managed during this procedure?
Your Answer: Commence variable rate insulin infusion on the day of surgery
Correct Answer: Continue her normal regimen
Explanation:It is unlikely that this patient, who is a diabetic taking oral medication, will require a sliding scale regimen for an incision and drainage procedure, unless it is a major surgery. In the case of significant surgery, the patient would typically be admitted the night before and put on a variable rate infusion. It is generally not recommended to postpone surgery unless there are significant reasons to do so. As this is likely to be a day case surgery, the patient can continue taking their regular metformin medication.
Metformin is a medication commonly used to treat type 2 diabetes mellitus. It belongs to a class of drugs called biguanides and works by activating the AMP-activated protein kinase (AMPK), which increases insulin sensitivity and reduces hepatic gluconeogenesis. Additionally, it may decrease the absorption of carbohydrates in the gastrointestinal tract. Unlike other diabetes medications, such as sulphonylureas, metformin does not cause hypoglycemia or weight gain, making it a first-line treatment option, especially for overweight patients. It is also used to treat polycystic ovarian syndrome and non-alcoholic fatty liver disease.
While metformin is generally well-tolerated, gastrointestinal side effects such as nausea, anorexia, and diarrhea are common and can be intolerable for some patients. Reduced absorption of vitamin B12 is also a potential side effect, although it rarely causes clinical problems. In rare cases, metformin can cause lactic acidosis, particularly in patients with severe liver disease or renal failure. However, it is important to note that lactic acidosis is now recognized as a rare side effect of metformin.
There are several contraindications to using metformin, including chronic kidney disease, recent myocardial infarction, sepsis, acute kidney injury, severe dehydration, and alcohol abuse. Additionally, metformin should be discontinued before and after procedures involving iodine-containing x-ray contrast media to reduce the risk of contrast nephropathy.
When starting metformin, it is important to titrate the dose slowly to reduce the incidence of gastrointestinal side effects. If patients experience intolerable side effects, modified-release metformin may be considered as an alternative.
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This question is part of the following fields:
- Pharmacology
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Question 5
Incorrect
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A 65-year-old woman visits her GP complaining of a persistent headache that has been bothering her for two weeks. The pain is more intense on the right side and is aggravated when she combs her hair. She also experiences discomfort in her jaw when eating. Her neurological and fundoscopy examinations reveal no abnormalities, and she is referred to the emergency department.
Upon admission, the patient is prescribed high-dose oral prednisolone and undergoes a temporal artery biopsy, which yields normal results. What is the next most appropriate course of action for her treatment?Your Answer: Perform an emergency computed tomography (CT) of her brain
Correct Answer: Continue high-dose prednisolone and repeat biopsy
Explanation:Performing an emergency computed tomography (CT) of the brain is not necessary for this patient. Emergency CT head scans are typically reserved for cases of head injury with symptoms such as reduced GCS, repeated vomiting, skull base fracture signs, post-traumatic seizures, or focal neurological deficits. Elderly patients may require a CT scan if they have experienced a fall with head injury or confusion.
Stopping high-dose prednisolone and referring the patient to a neurology clinic is not recommended. With a high suspicion of GCA, it is crucial to continue corticosteroid treatment to prevent inflammation from spreading to the eye. Any vision changes caused by GCA are typically irreversible, making it an acute problem that cannot wait for a referral to a neurology clinic.
Switching the patient to a lower dose of oral prednisolone is not advised. There is no evidence to suggest that reducing the dose of prednisolone is beneficial for GCA if the biopsy is negative. It is important to remember that a negative biopsy result may be due to skip lesions and not because the diagnosis is less likely.
Temporal arthritis, also known as giant cell arthritis, is a condition that affects medium and large-sized arteries and is of unknown cause. It typically occurs in individuals over the age of 50, with the highest incidence in those in their 70s. Early recognition and treatment are crucial to minimize the risk of complications, such as permanent loss of vision. Therefore, when temporal arthritis is suspected, urgent referral for assessment by a specialist and prompt treatment with high-dose prednisolone is necessary.
Temporal arthritis often overlaps with polymyalgia rheumatica, with around 50% of patients exhibiting features of both conditions. Symptoms of temporal arthritis include headache, jaw claudication, and tender, palpable temporal artery. Vision testing is a key investigation in all patients, as anterior ischemic optic neuropathy is the most common ocular complication. This results from occlusion of the posterior ciliary artery, leading to ischemia of the optic nerve head. Fundoscopy typically shows a swollen pale disc and blurred margins. Other symptoms may include aching, morning stiffness in proximal limb muscles, lethargy, depression, low-grade fever, anorexia, and night sweats.
Investigations for temporal arthritis include raised inflammatory markers, such as an ESR greater than 50 mm/hr and elevated CRP. A temporal artery biopsy may also be performed, and skip lesions may be present. Treatment for temporal arthritis involves urgent high-dose glucocorticoids, which should be given as soon as the diagnosis is suspected and before the temporal artery biopsy. If there is no visual loss, high-dose prednisolone is used. If there is evolving visual loss, IV methylprednisolone is usually given prior to starting high-dose prednisolone. Urgent ophthalmology review is necessary, as visual damage is often irreversible. Other treatments may include bone protection with bisphosphonates and low-dose aspirin.
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This question is part of the following fields:
- Musculoskeletal
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Question 6
Incorrect
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A 28-year-old female patient presents at the clinic for follow-up. She has been diagnosed with PCOS and is experiencing irregular and heavy menstrual cycles, excessive hair growth on her face and torso, and acne. Currently, she is taking the combined oral contraceptive pill but intends to switch to Dianette. What is the primary mechanism of action of Dianette?
Your Answer: Oestrogen receptor agonist
Correct Answer: Testosterone receptor antagonist
Explanation:Cyproterone Acetate and Ethinyloestradiol for PCOS Treatment
Cyproterone acetate and ethinyloestradiol are two active ingredients that are commonly used in the treatment of polycystic ovary syndrome (PCOS). This medication works by reducing androgen synthesis through negative feedback on the hypothalamic-pituitary-ovary axis and by inhibiting androgen-synthesising enzymes. It is effective in reducing hirsutism and acne, but it does not have a positive impact on weight in patients with PCOS.
One of the main benefits of using cyproterone acetate and ethinyloestradiol is that it can help to reduce the symptoms of PCOS. However, there are also some potential long-term adverse effects associated with its use. These include an increased risk of venous thromboembolism and oestrogen-related cancers such as breast cancer. Therefore, it is important to carefully weigh the benefits and risks of using this medication before starting treatment. Overall, cyproterone acetate and ethinyloestradiol can be an effective treatment option for PCOS, but it should be used with caution and under the guidance of a healthcare professional.
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This question is part of the following fields:
- Pharmacology
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Question 7
Correct
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A frail 82-year-old woman with metastatic renal cell carcinoma is admitted with acute confusion. She takes paracetamol and codeine for pain and has been on bendroflumethiazide for several years to treat hypertension. On examination, she is disorientated in time and place. She is clinically hypovolaemic but her blood pressure and heart rate are normal. Chest, cardiovascular, abdominal and neurological examinations are otherwise normal. There is no evidence of infection. Her blood results are as follows:
Creatinine 140 μmol/l
Urea 18.0 mmol/l
Sodium 129 mmol/l
Potassium 4.0 mmol/l
Corrected calcium 3.2 mmol/l
What is the most appropriate next step in management?Your Answer: Administer 2 l of 0.9% sodium chloride over 24 hours
Explanation:Managing Malignant Hypercalcaemia: Urgent Treatment Required
Malignant hypercalcaemia is a serious oncological and palliative care emergency that requires urgent treatment. In this patient, bony metastases are the most likely cause, but hypercalcaemia can also arise as a paraneoplastic phenomenon. A calcium level of >2.8 mmol/l will usually require treatment.
Administering 2 l of 0.9% sodium chloride over 24 hours is a crucial first step in managing hypercalcaemia. However, it is important to note that renal dialysis would not be the first choice of management. Instead, the mainstay of treatment is rehydration followed by a bisphosphonate infusion. Therefore, it is not advisable to commence an infusion of pamidronate before the patient is rehydrated, as this can reduce the efficacy of the bisphosphonate and cause or exacerbate renal failure.
It is also important to stop any medications that may inhibit renal excretion of calcium, such as bendroflumethiazide. However, stopping this medication alone would not acutely resolve the hypercalcaemia present in this patient or resolve her confusion.
Encouraging oral fluids and reassessing in 24 hours is not a suitable option for this patient, as she is already confused and has a high calcium level that requires urgent treatment. Ignoring the issue could potentially worsen the hypercalcaemia and put the patient at a severely increased risk of coma and death.
In summary, managing malignant hypercalcaemia requires urgent treatment, including rehydration and bisphosphonate infusion, while also stopping any medications that may inhibit renal excretion of calcium.
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This question is part of the following fields:
- Clinical Biochemistry
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Question 8
Incorrect
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A 65-year-old man presents for a medication review after being discharged from the hospital three months ago following a cholecystectomy. He was started on new medications for hypertension and atrial fibrillation. Despite feeling well, he has noticed ankle swelling and suspects it may be a side effect of one of the new medications. During examination, his blood pressure is 124/82 mmHg, and his heart rate is 68/min irregularly irregular. Which medication is most likely causing this side effect?
Your Answer: Bisoprolol
Correct Answer: Felodipine
Explanation:Felodipine is the correct answer as it is a calcium channel blocker commonly used as a first-line treatment for hypertension in patients over 55. One of the common side effects of calcium channel blockers is peripheral edema. Dihydropyridines, such as amlodipine, are more likely to cause ankle swelling as they work on calcium receptors located on the vascular smooth muscle, causing muscle relaxation and vasodilation. This leads to increased capillary pressure, fluid leakage, and ankle edema. On the other hand, non-dihydropyridines, such as verapamil, are more selective for myocardial calcium receptors, resulting in reduced cardiac contraction and heart rate.
Understanding Calcium Channel Blockers
Calcium channel blockers are medications primarily used to manage cardiovascular diseases. These blockers target voltage-gated calcium channels present in myocardial cells, cells of the conduction system, and vascular smooth muscle cells. The different types of calcium channel blockers have varying effects on these three areas, making it crucial to differentiate their uses and actions.
Verapamil is an example of a calcium channel blocker used to manage angina, hypertension, and arrhythmias. However, it is highly negatively inotropic and should not be given with beta-blockers as it may cause heart block. Verapamil may also cause side effects such as heart failure, constipation, hypotension, bradycardia, and flushing.
Diltiazem is another calcium channel blocker used to manage angina and hypertension. It is less negatively inotropic than verapamil, but caution should still be exercised when patients have heart failure or are taking beta-blockers. Diltiazem may cause side effects such as hypotension, bradycardia, heart failure, and ankle swelling.
On the other hand, dihydropyridines such as nifedipine, amlodipine, and felodipine are calcium channel blockers used to manage hypertension, angina, and Raynaud’s. These blockers affect the peripheral vascular smooth muscle more than the myocardium, resulting in no worsening of heart failure but may cause ankle swelling. Shorter-acting dihydropyridines such as nifedipine may cause peripheral vasodilation, resulting in reflex tachycardia and side effects such as flushing, headache, and ankle swelling.
In summary, understanding the different types of calcium channel blockers and their effects on the body is crucial in managing cardiovascular diseases. It is also important to note the potential side effects and cautions when prescribing these medications.
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This question is part of the following fields:
- Pharmacology
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Question 9
Incorrect
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A young child develops an eczematous, weeping rash on their wrist after receiving a new bracelet. In the Gell and Coombs classification of hypersensitivity reactions, what type of reaction is this an example of?
Your Answer: Type V reaction
Correct Answer: Type IV reaction
Explanation:Allergic contact dermatitis, which is often caused by nickel, is the type IV hypersensitivity reaction observed in this patient.
Classification of Hypersensitivity Reactions
Hypersensitivity reactions are classified into four types according to the Gell and Coombs classification. Type I, also known as anaphylactic hypersensitivity, occurs when an antigen reacts with IgE bound to mast cells. This type of reaction is responsible for anaphylaxis and atopy, such as asthma, eczema, and hay fever. Type II, or cytotoxic hypersensitivity, happens when cell-bound IgG or IgM binds to an antigen on the cell surface. This type of reaction is associated with autoimmune hemolytic anemia, ITP, Goodpasture’s syndrome, and other conditions. Type III, or immune complex hypersensitivity, occurs when free antigen and antibody (IgG, IgA) combine to form immune complexes. This type of reaction is responsible for serum sickness, systemic lupus erythematosus, post-streptococcal glomerulonephritis, and extrinsic allergic alveolitis. Type IV, or delayed hypersensitivity, is T-cell mediated and is responsible for tuberculosis, graft versus host disease, allergic contact dermatitis, and other conditions.
In recent times, a fifth category has been added to the classification of hypersensitivity reactions. Type V hypersensitivity occurs when antibodies recognize and bind to cell surface receptors, either stimulating them or blocking ligand binding. This type of reaction is associated with Graves’ disease and myasthenia gravis. Understanding the different types of hypersensitivity reactions is important in diagnosing and treating various conditions. Proper identification of the type of reaction can help healthcare professionals provide appropriate treatment and management strategies.
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This question is part of the following fields:
- Musculoskeletal
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Question 10
Incorrect
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As a paediatrician, you are reviewing a 1-month-old who was delivered at 39+2 weeks vaginally and without any complications. The parents of the child have a concern that their child might have achondroplasia as the child's father has been diagnosed with this condition. Apart from measuring the child's length, what other physical characteristic should you look for to determine if the child has achondroplasia?
Your Answer: Single palmar crease
Correct Answer: Trident hand deformity
Explanation:Identifying physical features of congenital conditions is crucial for exam purposes and diagnosis. One such feature of achondroplasia is trident hands, characterized by short, stubby fingers with a gap between the middle and ring fingers. Other physical features include short limbs (rhizomelia), lumbar lordosis, and midface hypoplasia. Fragile X syndrome is associated with low set ears, while Down’s syndrome is characterized by saddle-gap deformity and a single palmar crease. It is important to note that achondroplasia is characterized by macrocephaly with frontal bossing, not microcephaly.
Understanding Achondroplasia
Achondroplasia is a genetic disorder that is inherited in an autosomal dominant manner. It is caused by a mutation in the fibroblast growth factor receptor 3 (FGFR-3) gene, which leads to abnormal cartilage development. This results in short stature, with affected individuals having short limbs (rhizomelia) and shortened fingers (brachydactyly). They also have a large head with frontal bossing and a narrow foramen magnum, midface hypoplasia with a flattened nasal bridge, ‘trident’ hands, and lumbar lordosis.
In most cases, achondroplasia occurs as a sporadic mutation, with advancing parental age at the time of conception being a risk factor. There is no specific therapy for achondroplasia, but some individuals may benefit from limb lengthening procedures. These procedures involve the application of Ilizarov frames and targeted bone fractures, with a clearly defined need and endpoint being essential for success.
Overall, understanding achondroplasia is important for individuals and families affected by this condition. While there is no cure, there are treatment options available that can improve quality of life for those living with achondroplasia.
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This question is part of the following fields:
- Paediatrics
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