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Question 1
Correct
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Which one of the following pathological changes favours ulcerative colitis (UC) over Crohn disease in elderly patients?
Your Answer: Crypt abscesses
Explanation:Differences between Crohn’s Disease and Ulcerative Colitis
Crohn’s disease and ulcerative colitis are both types of inflammatory bowel disease, but they differ in several aspects. One of the main differences is the presence of granulomas. While a lack of granulomas does not rule out Crohn’s disease, it is a far more likely option if they are present. Granulomas are not present in ulcerative colitis.
Another difference is the layers of the bowel affected. Crohn’s disease affects all layers of the bowel, known as transmural disease, whereas ulcerative colitis is confined to the mucosa with occasional submucosa inflammation. Only Crohn’s disease has muscularis and serosa involvement. Additionally, Crohn’s disease can affect anything from the mouth to the anus, whereas ulcerative colitis is limited to colonic lesions.
Skip lesions, or areas of discontinuity of the inflammatory process, are characteristic of Crohn’s disease. When skip lesions are present, this is suggestive of Crohn’s disease. Ulcerative colitis is a continuous disease, whereas Crohn’s disease can be present in multiple areas of the bowel with sharply demarcated areas.
In terms of histology, both diseases show intense infiltration of the mucosa and submucosa with neutrophils and lymphoid aggregates. However, in fulminant cases of ulcerative colitis, the muscularis propria may be affected. On the other hand, the histologic characteristic pattern of inflammation in Crohn’s disease is transmural involvement of the bowel wall by lymphoid infiltrates that contain non-caseating granulomas.
Therefore, it is important to differentiate between Crohn’s disease and ulcerative colitis to provide appropriate treatment. Endoscopy must be performed if ulcerative colitis is suspected.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 2
Correct
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A 16-year-old boy presents to you with complaints of excessive sweating in his hands. He reports feeling embarrassed in social situations, particularly when he has to shake hands with someone. He is also concerned about how this may impact his upcoming A-level exams.
Which of the following is the most appropriate initial management approach for this condition?Your Answer: Aluminium chloride
Explanation:Hyperhidrosis is not treated with beta blockers like propranolol or calcium channel blockers like nifedipine.
Hyperhidrosis is a condition characterized by the excessive production of sweat. To manage this condition, there are several options available. The first-line treatment is the use of topical aluminium chloride preparations, although it may cause skin irritation as a side effect. Iontophoresis is another option that is particularly useful for patients with palmar, plantar, and axillary hyperhidrosis. Botulinum toxin is also licensed for axillary symptoms. Surgery, such as Endoscopic transthoracic sympathectomy, is another option, but patients should be informed of the risk of compensatory sweating. Overall, there are various management options available for hyperhidrosis, and patients should discuss with their healthcare provider to determine the best course of action.
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This question is part of the following fields:
- Dermatology
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Question 3
Incorrect
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A 14-year-old female complains of persistent pain in her left knee. The pain usually occurs after running and is accompanied by occasional swelling and joint locking. What is the probable diagnosis?
Your Answer: Juvenile idiopathic arthritis
Correct Answer: Osteochondritis dissecans
Explanation:Common Knee Problems in Children and Young Adults
Knee problems are common in children and young adults, especially those who are active in sports.
Chondromalacia patellae is a condition that is more common in teenage girls. It is characterized by the softening of the cartilage of the patella, which can cause anterior knee pain when walking up and down stairs or rising from prolonged sitting. This condition usually responds well to physiotherapy.Osgood-Schlatter disease, also known as tibial apophysitis, is often seen in sporty teenagers. It causes pain, tenderness, and swelling over the tibial tubercle.
Osteochondritis dissecans can cause pain after exercise, as well as intermittent swelling and locking of the knee.
Patellar subluxation can cause medial knee pain due to lateral subluxation of the patella. The knee may also give way.
Patellar tendonitis is more common in athletic teenage boys. It causes chronic anterior knee pain that worsens after running. On examination, the area below the patella is tender. It is important to note that referred pain may come from hip problems such as slipped upper femoral epiphysis.
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This question is part of the following fields:
- Paediatrics
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Question 4
Correct
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A 45-year-old woman reports leakage of urine, which is happening more often. She is unable to control her urine when she feels the urge to go and has had a few instances where she couldn't make it to the bathroom in time. There is no pain during urination and her urine dipstick test is negative. Which of the following is the most probable diagnosis?
Your Answer: Urge incontinence
Explanation:Urinary incontinence is a common problem that affects more women than men and increases with age. There are different types of urinary incontinence, each with its own set of symptoms. Functional incontinence occurs when a person is unable to hold urine due to reasons other than lower urinary tract dysfunction, such as delirium or impaired mobility. Mixed incontinence is a combination of stress and urge incontinence, while overflow incontinence occurs when the bladder is overdistended and urine overflows despite the absence of detrusor contraction. Stress incontinence is characterized by urine loss during periods of increased intra-abdominal pressure, while urge incontinence is associated with a sudden and intense desire to void that cannot be prevented. Symptoms of urge incontinence include urinary frequency and nocturia. Treatment is directed at the underlying cause of the incontinence.
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This question is part of the following fields:
- Reproductive Medicine
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Question 5
Correct
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A 63-year-old man visits your clinic for his regular asthma inhaler prescription. During the consultation, he mentions experiencing difficulty in sustaining his erections and requests a prescription for sildenafil. What is the most prevalent side effect of sildenafil?
Your Answer: Headaches
Explanation:Sildenafil is frequently prescribed in primary care. Adverse effects of sildenafil consist of headaches, facial flushing, indigestion, and temporary visual disturbances with a blue-green tint.
Understanding Phosphodiesterase Type V Inhibitors
Phosphodiesterase type V (PDE5) inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. These drugs work by increasing the levels of cGMP, which leads to the relaxation of smooth muscles in the blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which was the first drug of its kind. It is a short-acting medication that is usually taken one hour before sexual activity.
Other PDE5 inhibitors include tadalafil (Cialis) and vardenafil (Levitra). Tadalafil is longer-acting than sildenafil and can be taken on a regular basis, while vardenafil has a similar duration of action to sildenafil. However, these drugs are not suitable for everyone. Patients taking nitrates or related drugs, those with hypotension, and those who have had a recent stroke or myocardial infarction should not take PDE5 inhibitors.
Like all medications, PDE5 inhibitors can cause side effects. These may include visual disturbances, blue discolouration, non-arteritic anterior ischaemic neuropathy, nasal congestion, flushing, gastrointestinal side-effects, headache, and priapism. It is important to speak to a healthcare professional before taking any medication to ensure that it is safe and appropriate for you.
Overall, PDE5 inhibitors are an effective treatment for erectile dysfunction and pulmonary hypertension. However, they should only be used under the guidance of a healthcare professional and with careful consideration of the potential risks and benefits.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 6
Correct
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An 80-year-old woman arrives at the emergency department complaining of a severe headache on the right side of her head. Upon further inquiry, the doctors discover that she experiences pain while chewing. During the examination, there are no neurological impairments, and her visual fields appear normal. However, she does exhibit tenderness on her right scalp. What is the probable diagnosis?
Your Answer: Temporal arteritis
Explanation:Temporal arteritis is likely the cause of a constant throbbing headache, pain while chewing, and tenderness in the scalp. These symptoms are not typical of a migraine, which usually involves pain on one side of the head, sensitivity to light, nausea/vomiting, and sometimes an aura. A subarachnoid hemorrhage typically presents with a sudden, severe headache in the occipital region. Tension headaches are often described as a dull, band-like pain across the forehead. Cluster headaches are characterized by intense pain around the eye, accompanied by tearing, redness, and a stuffy nose.
Understanding Temporal Arteritis
Temporal arteritis is a type of large vessel vasculitis that often overlaps with polymyalgia rheumatica (PMR). It is characterized by changes in the affected artery that skip certain sections while damaging others. This condition typically affects individuals who are over 60 years old and has a rapid onset, usually occurring in less than a month. The most common symptoms include headache and jaw claudication, while vision testing is a crucial investigation for all patients.
Temporal arteritis can lead to various ocular complications, with anterior ischemic optic neuropathy being the most common. This results from the occlusion of the posterior ciliary artery, leading to ischemia of the optic nerve head. Patients may experience temporary visual loss or even permanent visual loss, which is the most feared complication of this condition. Other symptoms may include diplopia, tender and palpable temporal artery, and features of PMR such as aching, morning stiffness in proximal limb muscles, lethargy, depression, low-grade fever, anorexia, and night sweats.
To diagnose temporal arteritis, doctors may look for raised inflammatory markers such as an ESR of over 50 mm/hr or elevated CRP levels. A temporal artery biopsy may also be performed to check for skip lesions. Urgent high-dose glucocorticoids should be given as soon as the diagnosis is suspected, and an ophthalmologist should review patients with visual symptoms on the same day. Treatment may also involve bone protection with bisphosphonates and low-dose aspirin, although the evidence supporting the latter is weak.
In summary, temporal arteritis is a serious condition that requires prompt diagnosis and treatment to prevent irreversible visual damage. Patients who experience symptoms such as headache, jaw claudication, and visual disturbances should seek medical attention immediately.
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This question is part of the following fields:
- Musculoskeletal
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Question 7
Correct
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A 62-year-old non-smoker with no significant medical history presents to their GP with a cough producing green sputum, fatigue, and shortness of breath that has lasted for several days. During chest examination, coarse crackles are heard in the lower right zone. The patient's observations are as follows: respiratory rate of 20 breaths per minute, oxygen saturation of 97% on air, heart rate of 80 beats per minute, blood pressure of 110/75 mmHg, temperature of 38.1ºC, and an abbreviated mental test score of 10/10. The patient is not on any regular medication and has no allergies. What is the most appropriate treatment?
Your Answer: Discharge with oral amoxicillin
Explanation:The recommended first-line antibiotic for patients with low severity community-acquired pneumonia (CAP) is oral amoxicillin. Therefore, it is appropriate to discharge this patient with oral amoxicillin as they present with symptoms of CAP, including a new cough, temperature, purulent sputum, and focal chest signs. While a chest x-ray could confirm the diagnosis, it is not usually necessary for suspected CAP managed in primary care. The patient’s CRB-65 score is 0, indicating that they can be managed in the community. Hospitalization may be required for patients with higher scores or clinical factors that increase the risk of complications, but this is not the case for this patient. Discharge with oral clarithromycin or doxycycline is not appropriate as there is no indication that amoxicillin is unsuitable as the first-line antibiotic.
Pneumonia is a serious respiratory infection that requires prompt assessment and management. In the primary care setting, the CRB65 criteria are used to stratify patients based on their risk of mortality. Patients with a score of 0 are considered low risk and may be treated at home, while those with a score of 3 or 4 are high risk and require urgent admission to hospital. The use of a point-of-care CRP test can help guide antibiotic therapy. In the secondary care setting, the CURB65 criteria are used, which includes an additional criterion of urea > 7 mmol/L. Chest x-rays and blood and sputum cultures are recommended for intermediate or high-risk patients. Treatment for low-severity community acquired pneumonia typically involves a 5-day course of amoxicillin, while moderate and high-severity cases may require dual antibiotic therapy for 7-10 days. Discharge criteria and advice post-discharge are also provided, including information on expected symptom resolution timeframes and the need for a repeat chest x-ray at 6 weeks.
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This question is part of the following fields:
- Respiratory Medicine
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Question 8
Incorrect
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A 32-year-old female patient comes in seeking emergency contraception after having unprotected sex with her ex-partner four days ago. She is determined to prevent a pregnancy. The patient has a history of ectopic pregnancy four years ago, which led to a salpingectomy. She is currently on day 14 of a 28-day cycle. What is the best course of action among the available options?
Your Answer: Prescribe a stat dose of levonorgestrel 1.5mg but explain it may not be effective
Correct Answer: Insert an intrauterine device
Explanation:Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.
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This question is part of the following fields:
- Reproductive Medicine
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Question 9
Incorrect
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A 50-year-old man with a persistent chest infection visits the clinic for evaluation. Despite two rounds of antibiotics, there has been no significant improvement. The medical team decides to conduct a chest x-ray and screening blood tests. When analyzing the blood tests, which of the following markers is typically not elevated in response to an acute infection?
Your Answer: Platelets
Correct Answer: Albumin
Explanation:A decrease in albumin levels is frequently observed after an acute phase response.
Acute phase proteins are a group of proteins that are produced by the liver in response to inflammation or infection. These proteins are involved in various physiological processes such as immune response, blood clotting, and iron metabolism. Examples of acute phase proteins include CRP, procalcitonin, ferritin, fibrinogen, alpha-1 antitrypsin, caeruloplasmin, serum amyloid A, serum amyloid P component, haptoglobin, and complement.
During the acute phase response, the liver decreases the production of other proteins known as negative acute phase proteins. These proteins include albumin, transthyretin, transferrin, retinol binding protein, and cortisol binding protein. The levels of acute phase proteins, particularly CRP, are commonly measured in acutely unwell patients. Elevated levels of CRP are indicative of inflammation or infection, and levels greater than 150 at 48 hours post-surgery suggest the development of complications.
It is important to note that while acute phase proteins play a significant role in humans, some of these proteins, such as serum amyloid P component, have a more significant role in other mammals like mice. Overall, the production of acute phase proteins is a crucial part of the body’s response to inflammation or infection, and monitoring their levels can aid in the diagnosis and management of various medical conditions.
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This question is part of the following fields:
- Infectious Diseases
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Question 10
Correct
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A 56-year-old woman with COPD has been recommended an inhaled corticosteroid. What is the primary advantage of using inhaled corticosteroids for treating COPD patients?
Your Answer: Reduced frequency of exacerbations
Explanation:Inhaled corticosteroids are used to decrease the frequency of exacerbations in patients with COPD.
NICE guidelines recommend smoking cessation advice, annual influenza and one-off pneumococcal vaccinations, and pulmonary rehabilitation for COPD patients. Bronchodilator therapy is first-line treatment, with the addition of LABA and LAMA for patients without asthmatic features and LABA, ICS, and LAMA for those with asthmatic features. Theophylline is recommended after trials of bronchodilators or for patients who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients. Mucolytics should be considered for patients with a chronic productive cough. Loop diuretics and long-term oxygen therapy may be used for cor pulmonale. Smoking cessation and long-term oxygen therapy may improve survival in stable COPD patients. Lung volume reduction surgery may be considered in selected patients.
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This question is part of the following fields:
- Respiratory Medicine
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Question 11
Correct
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A 35-year-old female patient complains of recurring episodes of vertigo accompanied by a sensation of 'fullness' and 'pressure' in her ears. She believes her hearing is impaired during these episodes. Physical examination reveals no abnormalities. What is the probable diagnosis?
Your Answer: Meniere's disease
Explanation:Understanding Meniere’s Disease
Meniere’s disease is a condition that affects the inner ear and its cause is still unknown. It is more commonly seen in middle-aged adults but can occur at any age and affects both men and women equally. The condition is characterized by excessive pressure and progressive dilation of the endolymphatic system. The most prominent symptoms of Meniere’s disease are recurrent episodes of vertigo, tinnitus, and sensorineural hearing loss. Other symptoms include a sensation of aural fullness or pressure, nystagmus, and a positive Romberg test. These episodes can last from minutes to hours and are typically unilateral, but bilateral symptoms may develop over time.
The natural history of Meniere’s disease shows that symptoms usually resolve in the majority of patients after 5-10 years. However, most patients are left with some degree of hearing loss, and psychological distress is common. To manage the condition, an ENT assessment is required to confirm the diagnosis. Patients should inform the DVLA, and the current advice is to cease driving until satisfactory control of symptoms is achieved. During acute attacks, buccal or intramuscular prochlorperazine may be administered, and admission to the hospital may be required. To prevent future attacks, betahistine and vestibular rehabilitation exercises may be of benefit.
In summary, Meniere’s disease is a condition that affects the inner ear and can cause recurrent episodes of vertigo, tinnitus, and hearing loss. While the cause is unknown, there are management strategies available to help control symptoms and prevent future attacks. It is important for patients to seek medical attention and inform the DVLA to ensure their safety and well-being.
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This question is part of the following fields:
- ENT
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Question 12
Incorrect
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A 35-year-old woman presents to you with concerns about her migraine prophylaxis medication and its potential effects on her unborn child. She reports that her migraines used to occur 1-2 times per week, but since starting the medication, they have decreased to 1-2 times per month. Which medication commonly used for migraine prophylaxis is associated with congenital abnormalities, specifically cleft lip and palate?
Your Answer: Propranolol
Correct Answer: Topiramate
Explanation:If a person experiences more than 2 migraine attacks a month, they should be offered migraine prophylaxis. Propranolol and topiramate are both options for this, but propranolol is preferred for women of child-bearing age due to the risk of cleft lip/cleft palate in infants if topiramate is used during the first trimester of pregnancy. The combined oral contraceptive pill is not typically prescribed for migraines, and if a patient using it becomes pregnant, it will not harm the fetus. Triptan medications like sumatriptan and zolmitriptan are used for acute migraine treatment and should be taken as soon as a migraine starts. They may also be used for menstrual migraine prophylaxis, but should be avoided during pregnancy due to limited safety data.
Managing Migraines: Guidelines and Treatment Options
Migraines can be debilitating and affect a significant portion of the population. To manage migraines, it is important to understand the different treatment options available. According to the National Institute for Health and Care Excellence (NICE) guidelines, acute treatment for migraines involves a combination of an oral triptan and an NSAID or paracetamol. For young people aged 12-17 years, a nasal triptan may be preferred. If these measures are not effective, non-oral preparations of metoclopramide or prochlorperazine may be considered, along with a non-oral NSAID or triptan.
Prophylaxis should be given if patients are experiencing two or more attacks per month. NICE recommends topiramate or propranolol, depending on the patient’s preference, comorbidities, and risk of adverse events. Propranolol is preferred in women of childbearing age as topiramate may be teratogenic and reduce the effectiveness of hormonal contraceptives. Acupuncture and riboflavin may also be effective in reducing migraine frequency and intensity for some people. For women with predictable menstrual migraines, frovatriptan or zolmitriptan may be recommended as a type of mini-prophylaxis.
Specialists may consider other treatment options, such as candesartan or monoclonal antibodies directed against the calcitonin gene-related peptide (CGRP) receptor, like erenumab. However, pizotifen is no longer recommended due to common adverse effects like weight gain and drowsiness. It is important to exercise caution with young patients as acute dystonic reactions may develop. By following these guidelines and considering various treatment options, migraines can be effectively managed.
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This question is part of the following fields:
- Reproductive Medicine
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Question 13
Correct
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A 25-year-old female patient complains of red, itchy, and sore eyelids with crusts on the eyelashes and a gritty feeling in both eyes. What is the primary treatment for this condition?
Your Answer: Eyelid hygiene with warm compresses, lid massage and lid margin cleaning
Explanation:The initial step in treating blepharitis is to apply hot compresses to the affected area. This is followed by eyelid hygiene, which involves cleaning the lid margins and massaging them. If this does not work, chloramphenicol eye drops and oral antibiotics may be prescribed. Oily tear eye drops can be used to prevent rapid evaporation of tears caused by blepharitis. While an omega-3 rich diet may help improve the condition, it is not considered a first-line treatment.
Blepharitis is a condition where the eyelid margins become inflamed. This can be caused by dysfunction of the meibomian glands (posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (anterior blepharitis). It is more common in patients with rosacea. The meibomian glands secrete oil to prevent rapid evaporation of the tear film, so any problem affecting these glands can cause dryness and irritation of the eyes. Symptoms of blepharitis are usually bilateral and include grittiness, discomfort around the eyelid margins, sticky eyes in the morning, and redness of the eyelid margins. Styes and chalazions are also more common in patients with blepharitis, and secondary conjunctivitis may occur.
Management of blepharitis involves softening the lid margin with hot compresses twice a day and practicing lid hygiene to remove debris from the lid margins. This can be done using cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo or sodium bicarbonate in cooled boiled water. Artificial tears may also be given for symptom relief in people with dry eyes or an abnormal tear film.
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This question is part of the following fields:
- Ophthalmology
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Question 14
Incorrect
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A 65-year-old man comes to the clinic with a blistering rash around his left eye that is causing him pain. Upon examination, a vesicular rash is observed covering the left trigeminal nerve dermatome. The patient reports no current eye symptoms or signs. What factor is most likely to indicate future eye involvement?
Your Answer: Presence of the rash in the ear canal
Correct Answer: Presence of the rash on the tip of his nose
Explanation:Hutchinson’s sign is a reliable indicator of potential ocular involvement.
Herpes Zoster Ophthalmicus: Symptoms, Treatment, and Complications
Herpes zoster ophthalmicus (HZO) is a condition that occurs when the varicella-zoster virus reactivates in the area supplied by the ophthalmic division of the trigeminal nerve. It is responsible for approximately 10% of shingles cases. The main symptom of HZO is a vesicular rash around the eye, which may or may not involve the eye itself. Hutchinson’s sign, a rash on the tip or side of the nose, is a strong indicator of nasociliary involvement and increases the risk of ocular involvement.
Treatment for HZO involves oral antiviral medication for 7-10 days, ideally started within 72 hours of symptom onset. Intravenous antivirals may be necessary for severe infections or immunocompromised patients. Topical antiviral treatment is not recommended for HZO, but topical corticosteroids may be used to treat any secondary inflammation of the eye. Ocular involvement requires urgent ophthalmology review to prevent complications such as conjunctivitis, keratitis, episcleritis, anterior uveitis, ptosis, and post-herpetic neuralgia.
In summary, HZO is a condition caused by the reactivation of the varicella-zoster virus in the ophthalmic division of the trigeminal nerve. It presents with a vesicular rash around the eye and may involve the eye itself. Treatment involves oral antiviral medication and urgent ophthalmology review is necessary for ocular involvement. Complications of HZO include various eye conditions, ptosis, and post-herpetic neuralgia.
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This question is part of the following fields:
- Ophthalmology
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Question 15
Incorrect
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A 50-year-old woman comes to the clinic complaining of an itchy papular rash on her palms and forearms. The rash has white lines visible across its surface and scratching has worsened it. Additionally, she has noticed thinning of her nails with longitudinal ridges visible. What is the most appropriate first-line treatment?
Your Answer: Topical calcipotriol
Correct Answer: Potent topical steroids
Explanation:The primary treatment for lichen planus is potent topical steroids. Emollients are not effective for this condition, and oral steroids may only be necessary in severe or resistant cases. Calcipotriol, a synthetic vitamin D derivative, is used for psoriasis and not lichen planus. Fusidic acid is an antibiotic used for staphylococcal skin infections, such as impetigo, and is not indicated for lichen planus.
Understanding Lichen Planus
Lichen planus is a skin condition that is believed to be caused by an immune response, although the exact cause is unknown. It is characterized by an itchy, papular rash that typically appears on the palms, soles, genitalia, and flexor surfaces of the arms. The rash often has a polygonal shape and a distinctive white-lines pattern on the surface, known as Wickham’s striae. In some cases, new skin lesions may appear at the site of trauma, a phenomenon known as the Koebner phenomenon.
Oral involvement is common in around 50% of patients, with a white-lace pattern often appearing on the buccal mucosa. Nail changes may also occur, including thinning of the nail plate and longitudinal ridging. Lichenoid drug eruptions can be caused by certain medications, such as gold, quinine, and thiazides.
The main treatment for lichen planus is potent topical steroids. For oral lichen planus, benzydamine mouthwash or spray is recommended. In more extensive cases, oral steroids or immunosuppression may be necessary.
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This question is part of the following fields:
- Dermatology
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Question 16
Correct
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An anxious, 30-year-old saleswoman presents with mild shortness of breath on exertion, which had come on gradually over several months. The symptom was intermittent and seemed to get worse in the evening. She has also been on treatment for depression over the last two months. On examination, she has minimal weakness of shoulder abductors and slight weakness of eye closure bilaterally. Deep tendon reflexes are present and symmetrical throughout and plantar responses are flexor. You now have the results of the investigations: FBC, U&E, LFT, TFT - normal; chest radiograph and lung function tests - normal; ECG - normal.
Which of the following is the most likely diagnosis?
Select the SINGLE most likely diagnosis.Your Answer: Myasthenia gravis
Explanation:Understanding Myasthenia Gravis: Symptoms, Diagnosis, and Treatment
Myasthenia gravis (MG) is a neuromuscular disorder that occurs when the body produces autoantibodies against the nicotinic acetylcholine receptor at the neuromuscular junction. This results in muscular weakness that is characterized by fatigability, meaning that the muscles become increasingly weaker during their use. MG primarily affects the muscles of the face, the extrinsic ocular muscles (causing diplopia), and the muscles involved in deglutition. Respiratory and proximal lower limb muscles may also be involved early in the disease, which can cause breathlessness and even sudden death.
Diagnosing MG can be challenging, as weakness may not be apparent on a single examination. However, electrodiagnostic tests and detecting the autoantibodies can confirm the diagnosis. The Tensilon test, which involves injecting edrophonium chloride to reverse the symptoms of MG, is now used only when other tests are negative and clinical suspicion of MG is still high.
Treatment of MG involves anticholinesterase medications, but many patients also benefit from thymectomy. It is important to note that a thymoma may be present in up to 15% of patients with MG.
Other conditions, such as transient ischaemic attacks, angina, multiple sclerosis, and somatisation disorder, may cause weakness, but they do not typically present with the same symptoms as MG. Therefore, it is crucial to consider MG as a potential diagnosis when a patient presents with fatigable muscular weakness.
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This question is part of the following fields:
- Respiratory Medicine
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Question 17
Correct
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A 43-year-old man, David, visits you after his 72-year-old father passed away due to a heart attack. David has a history of asthma, which he occasionally manages with his salbutamol inhaler, and was diagnosed with type 1 diabetes at the age of 20. His diabetes is well-controlled, and his last cholesterol test, conducted three months ago, was within the normal range. David has been reading about the connection between cholesterol and heart attacks in the news and is curious if he should take medication to lower his cholesterol levels.
Which of the following options is the most appropriate?Your Answer: Start atorvastatin 20mg today
Explanation:For primary prevention of cardiovascular disease, individuals with type 1 diabetes who do not have established risk factors should be prescribed atorvastatin 20mg if they are over 40 years old, have had diabetes for more than 10 years, have established nephropathy, or have other risk factors such as obesity and hypertension. As this patient has had type 1 diabetes for over 10 years, they should be offered statins.
Statins are drugs that inhibit the action of an enzyme called HMG-CoA reductase, which is responsible for producing cholesterol in the liver. However, they can cause some adverse effects such as myopathy, which includes muscle pain, weakness, and damage, and liver impairment. Myopathy is more common in lipophilic statins than in hydrophilic ones. Statins may also increase the risk of intracerebral hemorrhage in patients who have had a stroke before. Therefore, they should be avoided in these patients. Statins should not be taken during pregnancy and should be stopped if the patient is taking macrolides.
Statins are recommended for people with established cardiovascular disease, those with a 10-year cardiovascular risk of 10% or more, and patients with type 2 diabetes mellitus. Patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago, are over 40 years old, or have established nephropathy should also take statins. It is recommended to take statins at night as this is when cholesterol synthesis takes place. Atorvastatin 20mg is recommended for primary prevention, and the dose should be increased if non-HDL has not reduced for 40% or more. Atorvastatin 80 mg is recommended for secondary prevention. The graphic shows the different types of statins available.
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This question is part of the following fields:
- Cardiovascular
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Question 18
Correct
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A 55-year-old woman is brought into the Emergency Department with a sudden onset of severe back pain lasting 30 minutes. The pain is constant and not exacerbated by coughing or sneezing.
On examination, the patient is in shock, with a palpable 7 cm mass deep in the epigastrium above the umbilicus. Her past medical history includes a 5 cm abdominal aortic aneurysm diagnosed three years ago at the time of appendectomy. The patient is a non-smoker and drinks one glass of wine a week.
What is the most likely diagnosis?Your Answer: Rupturing abdominal aortic aneurysm
Explanation:Possible Causes of Sudden-Onset Severe Back Pain: A Differential Diagnosis
Sudden-onset severe back pain can be a sign of various medical conditions. In the case of a male patient with increasing age and a known history of abdominal aortic aneurysm, a rupturing aortic aneurysm should be suspected until proven otherwise. This suspicion is supported by the presence of shock, a large palpable mass deep in the epigastrium, and severe back pain that may radiate to the abdomen. The risk of rupture increases with the size of the aneurysm, and blood initially leaks into the retroperitoneal space before spilling into the peritoneal cavity.
Other possible causes of sudden-onset severe back pain include acute cholecystitis, which is unlikely in a patient who had a previous cholecystectomy. Acute pancreatitis may also cause epigastric pain that radiates to the back, but this condition is usually accompanied by vomiting and diarrhea, and the patient does not have significant risk factors for it. Renal colic, which is characterized by acute severe pain that radiates from the loin to the groin, may cause tachycardia but is less likely in a patient who is haemodynamically unstable and has a known large AAA. Herniated lumbar disc, which may cause back pain that worsens with coughing or sneezing and radiates down the leg, is also less likely in this case.
Therefore, a rupturing abdominal aortic aneurysm is the most probable cause of the patient’s sudden-onset severe back pain, and urgent management is necessary to prevent further complications.
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This question is part of the following fields:
- Cardiovascular
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Question 19
Incorrect
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Which infection is most strongly linked to the development of Guillain-Barre syndrome?
Your Answer: Shigella
Correct Answer: Campylobacter jejuni
Explanation:Understanding Guillain-Barre Syndrome and Miller Fisher Syndrome
Guillain-Barre syndrome is a condition that affects the peripheral nervous system and is often triggered by an infection, particularly Campylobacter jejuni. The immune-mediated demyelination of the peripheral nervous system occurs due to the cross-reaction of antibodies with gangliosides. Studies have shown a correlation between the clinical features of the syndrome and the presence of anti-ganglioside antibodies, particularly anti-GM1 antibodies, which are present in 25% of patients.
Miller Fisher syndrome is a variant of Guillain-Barre syndrome that is characterized by ophthalmoplegia, areflexia, and ataxia. Unlike other forms of Guillain-Barre syndrome, Miller Fisher syndrome usually presents as a descending paralysis, with the eye muscles typically affected first. In 90% of cases, anti-GQ1b antibodies are present.
Understanding the pathogenesis and clinical features of Guillain-Barre syndrome and Miller Fisher syndrome is crucial for accurate diagnosis and effective treatment. Further research is needed to fully understand the mechanisms behind these conditions and to develop more targeted therapies.
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This question is part of the following fields:
- Infectious Diseases
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Question 20
Incorrect
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A teenage boy presents with bizarre delusions, a blunted affect and tangential thought processes.
Which one of the following characteristics would indicate an unfavourable prognosis?
Your Answer: Rapid onset of illness
Correct Answer: A prolonged premorbid history of social withdrawal
Explanation:Understanding Prognostic Factors in Schizophrenia
Schizophrenia is a complex mental illness that can have a significant impact on a person’s life. While there is no cure for schizophrenia, early diagnosis and treatment can help manage symptoms and improve outcomes. Understanding prognostic factors can also be helpful in predicting the course of the illness and developing appropriate treatment plans.
One important factor to consider is the premorbid history of the patient. A prolonged history of social withdrawal is predictive of more severe and long-lasting psychopathology. Additionally, a family history of schizophrenia in first-degree relatives can have a negative impact on prognosis, while a history in second-degree relatives has little significance.
The onset of illness is also an important factor to consider. In schizophrenia, a sudden onset of illness has a more favourable prognosis than an insidious one. However, if the patient presents with catatonic symptoms, this is actually an indicator of a relatively good prognosis.
Finally, MRI changes are associated with more severe symptoms and clinical course in people with schizophrenia. While it is not fully clear whether these changes are fixed or progress over time, they can be an important factor to consider in developing a treatment plan.
Overall, understanding these prognostic factors can help clinicians develop appropriate treatment plans and provide better support for patients with schizophrenia.
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This question is part of the following fields:
- Psychiatry
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Question 21
Correct
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A 28-year-old woman is referred by her General Practitioner due to irregular and unpredictable menstrual cycle and headaches. Magnetic resonance imaging of the brain shows a midline lesion. Further investigations reveal that her prolactin level is 2314 ng/ml (normal range: 2–29 ng/ml). To reduce the prolactin level, which mediator is manipulated for medical treatment?
Your Answer: Dopamine
Explanation:Targeting Hormones in Prolactinoma Treatment
Prolactinoma is a pituitary lesion that results in excessive prolactin secretion. To reduce prolactin levels, dopamine agonists like bromocriptine are used to target dopamine receptors in the anterior pituitary. While increased prolactin can indirectly decrease gonadotropin-releasing hormone (GnRH) secretion, GnRH receptors are not a therapeutic target in prolactin disorders. Corticotropin-releasing hormone (CRH) increases adrenocorticotropic hormone secretion and is not a target in prolactin disorders. Somatostatin decreases thyroid-stimulating hormone (TSH) and growth hormone secretion but does not affect prolactin levels. Thyrotropin-releasing hormone (TRH) increases prolactin and TSH release, but its use is limited due to side-effects on thyroid regulation and the superiority of dopamine agonists.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 22
Incorrect
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A 63-year-old male with a recent myocardial infarction experiences ventricular fibrillation while in the coronary care unit. The heart monitor records this event. An emergency call is made and a defibrillator is quickly brought to the scene. What is the best course of action to take?
Your Answer: Administer one shock, then commence CPR
Correct Answer: Administer three successive shocks, then commence CPR
Explanation:In a witnessed cardiac arrest with VF/VT rhythm, up to three quick successive shocks should be given before starting chest compressions. This is regarded as the first shock in the ALS algorithm. Adrenaline should be given every 3-5 minutes and a praecordial thump should only be used if a defibrillator is not available. Commencing CPR after just one shock would miss the opportunity to deliver three rapid shocks.
The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.
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This question is part of the following fields:
- Cardiovascular
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Question 23
Incorrect
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An 80-year-old man has been experiencing recurrent falls due to orthostatic hypotension. Despite trying conservative measures such as increasing fluid and salt intake, reviewing medications, and wearing compression stockings, he still experiences dizziness upon standing. What medication options are available to alleviate his symptoms?
Your Answer: Isoprenaline
Correct Answer: Fludrocortisone
Explanation:Fludrocortisone and midodrine are two medications that can be used to treat orthostatic hypotension. However, doxazosin, a medication used for hypertension, can actually worsen orthostatic hypotension. Prochlorperazine is used for vertigo and isoprenaline and dobutamine are not used for orthostatic hypotension as they are ionotropic agents used for patients in shock.
Fludrocortisone works by increasing renal sodium reabsorption and plasma volume, which helps counteract the physiological orthostatic vasovagal reflex. Its effectiveness has been supported by two small observational studies and one small double-blind trial, leading the European Society of Cardiology to give it a Class IIa recommendation.
To manage orthostatic hypotension, patients should be educated on lifestyle measures such as staying hydrated and increasing salt intake. Vasoactive drugs like nitrates, antihypertensives, neuroleptic agents, or dopaminergic drugs should be discontinued if possible. If symptoms persist, compression garments, fludrocortisone, midodrine, counter-pressure manoeuvres, and head-up tilt sleeping can be considered.
Understanding Syncope: Causes and Evaluation
Syncope is a temporary loss of consciousness caused by a sudden decrease in blood flow to the brain. This condition is characterized by a rapid onset, short duration, and complete recovery without any medical intervention. It is important to note that syncope is different from other causes of collapse, such as epilepsy. To better understand syncope, the European Society of Cardiology has classified it into three categories: reflex syncope, orthostatic syncope, and cardiac syncope.
Reflex syncope, also known as neurally mediated syncope, is the most common cause of syncope in all age groups. It can be triggered by emotional stress, pain, or other situational factors such as coughing or gastrointestinal issues. Orthostatic syncope occurs when there is a sudden drop in blood pressure upon standing up, and it is more common in older patients. Cardiac syncope is caused by heart-related issues such as arrhythmias, structural abnormalities, or pulmonary embolism.
To evaluate syncope, doctors may perform a series of tests, including a cardiovascular examination, postural blood pressure readings, ECG, carotid sinus massage, tilt table test, and 24-hour ECG monitoring. These tests help to identify the underlying cause of syncope and determine the appropriate treatment plan. By understanding the causes and evaluation of syncope, patients and healthcare providers can work together to manage this condition effectively.
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This question is part of the following fields:
- Cardiovascular
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Question 24
Incorrect
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A 25-year-old female presents to her GP complaining of pain in her right knee. She is an avid runner and reports that the pain is most noticeable after exercise. She denies any swelling or redness in the joint and has not experienced any locking of the knee. Upon examination, the knee has a full range of motion, but there is sharp pain when palpating the lateral epicondyle of the femur, especially when the knee is flexed at 30 degrees. What is the most probable diagnosis?
Your Answer: Patellofemoral pain syndrome
Correct Answer: Iliotibial band syndrome
Explanation:Iliotibial band syndrome is a prevalent reason for knee pain, especially among runners. A typical history and examination for this condition involves assessing lateral knee pain in avid runners. In contrast, Osgood-Schlatter disease, also known as tibial apophysitis, would result in pain and swelling around the tibial tubercle. Osteochondritis dissecans would cause joint locking, swelling, and tenderness. Patellar tendonitis would also cause post-exercise pain, but it would typically be located at the lower part of the patella.
Understanding Iliotibial Band Syndrome
Iliotibial band syndrome is a prevalent condition that causes lateral knee pain in runners. It affects approximately 10% of people who engage in regular running. The condition is characterized by tenderness 2-3 cm above the lateral joint line.
To manage iliotibial band syndrome, activity modification and iliotibial band stretches are recommended. These measures can help alleviate the pain and discomfort associated with the condition. However, if the symptoms persist, it is advisable to seek physiotherapy referral for further assessment and treatment.
In summary, iliotibial band syndrome is a common condition that affects runners. It is important to recognize the symptoms and seek appropriate management to prevent further complications. With the right treatment, individuals can continue to engage in running and other physical activities without experiencing pain and discomfort.
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This question is part of the following fields:
- Musculoskeletal
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Question 25
Correct
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A 29-year-old pregnant woman presents to the GP clinic for a review. She is currently 8 weeks pregnant and has undergone urine microscopy, culture, and sensitivity tests. Despite having no fever or dysuria, the following results were obtained:
- Red blood cells < 106/L
- White blood cells 100 x 106/L
- Culture Escherichia coli > 106/L colonies
- Sensitivity trimethoprim sensitive, cefalexin sensitive, nitrofurantoin resistant
What would be the most appropriate course of action for management?Your Answer: Cefalexin for 7 days
Explanation:Pregnant women with asymptomatic bacteriuria should receive immediate antibiotic treatment. In this case, cefalexin for 7 days is the appropriate choice based on the sensitivity results of the culture. Amoxicillin is another option, but without sensitivity data, it cannot be recommended. Nitrofurantoin should be avoided as the bacteria are resistant, and a 5-day course is insufficient. No treatment is not an option for pregnant women as it increases the risk of pyelonephritis. Trimethoprim should also be avoided due to its potential impact on fetal development as a folate antagonist.
Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is teratogenic in the first trimester. Asymptomatic bacteriuria in pregnant women should also be treated to prevent progression to acute pyelonephritis. Men with UTIs should be offered a seven-day course of trimethoprim or nitrofurantoin unless prostatitis is suspected. A urine culture should be sent before antibiotics are started. Catheterised patients should not be treated for asymptomatic bacteria, but if symptomatic, a seven-day course of antibiotics should be given. Acute pyelonephritis requires hospital admission and treatment with a broad-spectrum cephalosporin or quinolone for 10-14 days. Referral to urology is not routinely required for men who have had one uncomplicated lower UTI.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 26
Incorrect
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As a foundation doctor in general practice, you have a patient who is a sexually active sixteen-year-old seeking advice about her contraceptive patch. She typically changes the patch on Saturday mornings but forgot to do so this week. What guidance should you provide?
Your Answer: Change the patch now and use barrier contraceptives for two days and consider emergency contraception
Correct Answer: Change the patch now, use barrier contraceptives for seven days and consider emergency contraception
Explanation:To ensure the effectiveness of the contraceptive patch, it should be applied to clean, dry skin on a weekly basis for three weeks, followed by a patch-free week to stimulate a withdrawal bleed. However, if the patch change is delayed for more than 48 hours, it is important to change it immediately and use a barrier method of contraception for the next 7 days. In case of unprotected intercourse, emergency contraceptives should be considered.
The Evra patch is the only contraceptive patch that is approved for use in the UK. The patch cycle lasts for four weeks, during which the patch is worn every day for the first three weeks and changed weekly. During the fourth week, the patch is not worn, and a withdrawal bleed occurs.
If a woman delays changing the patch at the end of week one or two, she should change it immediately. If the delay is less than 48 hours, no further precautions are necessary. However, if the delay is more than 48 hours, she should change the patch immediately and use a barrier method of contraception for the next seven days. If she has had unprotected sex during this extended patch-free interval or in the last five days, emergency contraception should be considered.
If the patch removal is delayed at the end of week three, the woman should remove the patch as soon as possible and apply a new patch on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed.
If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for seven days following any delay at the start of a new patch cycle. For more information, please refer to the NICE Clinical Knowledge Summary on combined hormonal methods of contraception.
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This question is part of the following fields:
- Reproductive Medicine
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Question 27
Correct
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A 72-year-old retired teacher visits the doctor with a painless gradual loss of vision. She reports difficulty reading as the words on the page are becoming harder to see. Additionally, she notices that straight lines in her artwork are appearing distorted, which is confirmed by Amsler grid testing. What is the probable diagnosis?
Your Answer: Dry age-related macular degeneration
Explanation:The most likely diagnosis for this patient’s gradual central loss of vision and difficulty reading is dry age-related macular degeneration. This subtype accounts for the majority of cases of macular degeneration and typically presents with a gradual loss of vision. Glaucoma and retinal detachment are unlikely diagnoses as they present with different symptoms such as peripheral vision loss and sudden vision loss with flashes and floaters, respectively.
Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by the degeneration of the central retina (macula) and the formation of drusen. It is more prevalent in females and is strongly associated with advancing age, smoking, family history, and conditions that increase the risk of ischaemic cardiovascular disease. ARMD can be classified into two forms: dry and wet. Dry ARMD is more common and is characterized by drusen, while wet ARMD is characterized by choroidal neovascularisation and carries a worse prognosis. Clinical features of ARMD include subacute onset of visual loss, difficulties in dark adaptation, and visual disturbances such as photopsia and glare.
To diagnose ARMD, slit-lamp microscopy and color fundus photography are used to identify any pigmentary, exudative, or haemorrhagic changes affecting the retina. Fluorescein angiography and indocyanine green angiography may also be used to visualize changes in the choroidal circulation. Treatment for dry ARMD involves a combination of zinc with anti-oxidant vitamins A, C, and E, which has been shown to reduce disease progression by around one third. For wet ARMD, anti-VEGF agents such as ranibizumab, bevacizumab, and pegaptanib are used to limit disease progression and stabilize or reverse visual loss. Laser photocoagulation may also be used to slow progression, but anti-VEGF therapies are usually preferred due to the risk of acute visual loss after treatment.
In summary, ARMD is a common cause of blindness in the UK that is strongly associated with advancing age, smoking, and family history. It can be classified into dry and wet forms, with wet ARMD carrying a worse prognosis. Diagnosis involves the use of various imaging techniques, and treatment options include a combination of zinc and anti-oxidant vitamins for dry ARMD and anti-VEGF agents or laser photocoagulation for wet ARMD.
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This question is part of the following fields:
- Ophthalmology
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Question 28
Correct
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An 80-year-old man with a known history of mixed type dementia (Alzheimer's and vascular) is evaluated in memory clinic due to a recent decline in his memory and cognition. His mini-mental state score is 12 and he is started on memantine. What is the mechanism of action of memantine?
Your Answer: NMDA antagonist
Explanation:Memantine is an NMDA receptor antagonist and is not a cholinesterase inhibitor like donepezil and rivastigmine. While memantine does act at the serotonin and dopamine receptors, it acts as an antagonist and agonist respectively, rather than the options given.
Managing Alzheimer’s Disease: Non-Pharmacological and Pharmacological Approaches
Alzheimer’s disease is a type of dementia that progressively affects the brain and is the most common form of dementia in the UK. To manage this condition, there are both non-pharmacological and pharmacological approaches available.
Non-pharmacological management involves offering a range of activities that promote wellbeing and are tailored to the patient’s preferences. Group cognitive stimulation therapy is recommended for patients with mild to moderate dementia, while group reminiscence therapy and cognitive rehabilitation are also options to consider.
Pharmacological management involves the use of medications. The three acetylcholinesterase inhibitors (donepezil, galantamine, and rivastigmine) are options for managing mild to moderate Alzheimer’s disease. Memantine, an NMDA receptor antagonist, is considered a second-line treatment and is recommended for patients with moderate Alzheimer’s who are intolerant of or have a contraindication to acetylcholinesterase inhibitors. It can also be used as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer’s or as monotherapy in severe Alzheimer’s.
When managing non-cognitive symptoms, NICE does not recommend antidepressants for mild to moderate depression in patients with dementia. Antipsychotics should only be used for patients at risk of harming themselves or others or when the agitation, hallucinations, or delusions are causing them severe distress.
It is important to note that donepezil is relatively contraindicated in patients with bradycardia, and adverse effects may include insomnia. By utilizing both non-pharmacological and pharmacological approaches, patients with Alzheimer’s disease can receive comprehensive care and management.
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This question is part of the following fields:
- Neurology
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Question 29
Incorrect
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A 32-year-old woman presents to her General Practitioner with a 4-week history of diarrhoea, opening her bowels up to 2–3 times per day. She also complains of intermittent bloating and abdominal pain mostly prior to opening her bowels. There is no history of fever or vomiting and she has no past medical history of note. She returned from Thailand two weeks ago.
Stool microscopy: trophozoites and cysts are seen.
Given the likely diagnosis, what is the recommended management for this patient?
Select the SINGLE most appropriate management from the list below.
Your Answer: Ciprofloxacin
Correct Answer: Metronidazole
Explanation:Antibiotics for Diarrhoeal Illnesses: Understanding the Appropriate Treatment
Giardiasis is a diarrhoeal illness caused by the protozoa Giardia lamblia, which is spread through contaminated food, water or faeces. The disease can last up to six weeks and presents with symptoms such as abdominal bloating, flatulence or malabsorption. Metronidazole is the preferred treatment for giardiasis due to its effectiveness and improved compliance.
Doxycycline is used to treat cholera, a severe disease that causes watery diarrhoea and dehydration. However, the chronic duration of symptoms and presence of parasitic organisms make cholera unlikely.
Ciprofloxacin is used to treat urinary-tract infections and some diarrhoeal illnesses such as cholera and Campylobacter jejuni infections. However, Campylobacter is usually self-limiting and has a much shorter duration of illness, making it an unlikely diagnosis.
Clindamycin is not classically used to treat giardiasis and should be used with caution due to the increased risk of developing antibiotic-associated colitis and opportunistic infections such as Clostridium difficile.
Co-amoxiclav may be used to treat intra-abdominal infections such as biliary sepsis, but it is not indicated for giardiasis.
In summary, understanding the appropriate use of antibiotics for diarrhoeal illnesses is crucial in providing effective treatment and avoiding unnecessary risks.
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This question is part of the following fields:
- Immunology/Allergy
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Question 30
Incorrect
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A 27-year-old woman is receiving a blood transfusion at the haematology day unit. She has a medical history of acute lymphoblastic leukaemia and her recent haemoglobin level was 69 g/dL. The doctor has prescribed two units of blood for her.
During the administration of the first unit of blood, the patient experiences difficulty breathing. Upon examination, her vital signs show a temperature of 37.5ºC, heart rate of 99 beats/min, and blood pressure of 90/55 mmHg. Her oxygen saturation level is 96% on air, and she has a respiratory rate of 22 breaths/min. Bilateral wheezing is heard during auscultation.
What is the most probable cause of this patient's symptoms?Your Answer: Minor allergic reaction
Correct Answer: Anaphylaxis
Explanation:The patient experienced hypotension, dyspnoea, wheezing, and angioedema during a blood transfusion, which indicates anaphylaxis, a severe and life-threatening allergic reaction to the blood product. Treatment involves stopping the transfusion immediately and administering intramuscular adrenaline. Acute haemolytic reaction, bacterial contamination, and minor allergic reaction are not likely explanations for the patient’s symptoms.
Complications of Blood Product Transfusion: Understanding the Risks
Blood product transfusion can lead to various complications that can be classified into different categories. Immunological complications include acute haemolytic reactions, non-haemolytic febrile reactions, and allergic/anaphylaxis reactions. Infective complications may also arise, including the transmission of vCJD. Other complications include transfusion-related acute lung injury (TRALI), transfusion-associated circulatory overload (TACO), hyperkalaemia, iron overload, and clotting.
Non-haemolytic febrile reactions are thought to be caused by antibodies reacting with white cell fragments in the blood product and cytokines that have leaked from the blood cell during storage. On the other hand, allergic reactions to blood transfusions are caused by hypersensitivity reactions to components within the transfusion. TRALI is a rare but potentially fatal complication of blood transfusion, while TACO is a relatively common reaction due to fluid overload resulting in pulmonary oedema.
It is important to understand the risks associated with blood product transfusion and to be aware of the different types of complications that may arise. Proper management and prompt treatment are crucial in preventing further harm to the patient.
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This question is part of the following fields:
- Respiratory Medicine
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