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Question 1
Correct
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A 67-year-old man comes in for a routine health check-up. He has a medical history of hypercholesterolaemia and peripheral vascular disease, and is currently taking aspirin and atorvastatin.
During the examination, his clinic blood pressure averages at 195/108mmHg. All other observations are normal, and there are no signs of neurological issues.
The doctor decides to prescribe nifedipine.
What is a potential side effect of this medication?Your Answer: Tachycardia
Explanation:Reflex tachycardia may occur as a result of the peripheral vasodilation caused by nifedipine.
Calcium channel blockers are a class of drugs commonly used to treat cardiovascular disease. These drugs target voltage-gated calcium channels found in myocardial cells, cells of the conduction system, and vascular smooth muscle. The different types of calcium channel blockers have varying effects on these areas, making it important to differentiate their uses and actions.
Verapamil is used to treat angina, hypertension, and arrhythmias. It is highly negatively inotropic and should not be given with beta-blockers as it may cause heart block. Side effects include heart failure, constipation, hypotension, bradycardia, and flushing.
Diltiazem is used to treat 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. Side effects include hypotension, bradycardia, heart failure, and ankle swelling.
Nifedipine, amlodipine, and felodipine are dihydropyridines used to treat hypertension, angina, and Raynaud’s. They affect peripheral vascular smooth muscle more than the myocardium, which means they do not worsen heart failure but may cause ankle swelling. Shorter acting dihydropyridines like nifedipine may cause peripheral vasodilation, resulting in reflex tachycardia. Side effects include flushing, headache, and ankle swelling.
According to current NICE guidelines, the management of hypertension involves a flow chart that takes into account various factors such as age, ethnicity, and comorbidities. Calcium channel blockers may be used as part of the treatment plan depending on the individual patient’s needs.
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This question is part of the following fields:
- General Principles
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Question 2
Correct
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A 33-year-old woman is 28 weeks pregnant and has been diagnosed with gestational diabetes following an oral glucose tolerance test. What are the possible complications associated with this condition?
Your Answer: Macrosomia, shoulder dystocia, polyhydramnios
Explanation:During pregnancy, the development of carbohydrate intolerance is referred to as gestational diabetes mellitus. To diagnose this condition, an OGTT is typically performed at 28 weeks, although it may be done earlier for those at higher risk (such as those of Asian or Afro-Caribbean ethnicity, with a BMI over 30, a history of stillbirth, or family members with diabetes). Diabetes during pregnancy can increase the likelihood of various complications, including macrosomia, polyhydramnios, shoulder dystocia, congenital heart defects, neural tube defects, and neonatal hypoglycemia. Ebstein’s anomaly of the heart can occur as a result of lithium use during pregnancy, while prolonged rupture of membranes during pregnancy can lead to neonatal infection.
Gestational diabetes is a common medical disorder that affects around 4% of pregnancies. It can develop during pregnancy or be a pre-existing condition. According to NICE, 87.5% of cases are gestational diabetes, 7.5% are type 1 diabetes, and 5% are type 2 diabetes. Risk factors for gestational diabetes include a BMI of > 30 kg/m², previous gestational diabetes, a family history of diabetes, and family origin with a high prevalence of diabetes. Screening for gestational diabetes involves an oral glucose tolerance test (OGTT), which should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal.
To diagnose gestational diabetes, NICE recommends using the following thresholds: fasting glucose is >= 5.6 mmol/L or 2-hour glucose is >= 7.8 mmol/L. Newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week and taught about self-monitoring of blood glucose. Advice about diet and exercise should be given, and if glucose targets are not met within 1-2 weeks of altering diet/exercise, metformin should be started. If glucose targets are still not met, insulin should be added to the treatment plan.
For women with pre-existing diabetes, weight loss is recommended for those with a BMI of > 27 kg/m^2. Oral hypoglycaemic agents, apart from metformin, should be stopped, and insulin should be commenced. Folic acid 5 mg/day should be taken from pre-conception to 12 weeks gestation, and a detailed anomaly scan at 20 weeks, including four-chamber view of the heart and outflow tracts, should be performed. Tight glycaemic control reduces complication rates, and retinopathy should be treated as it can worsen during pregnancy.
Targets for self-monitoring of pregnant women with diabetes include a fasting glucose level of 5.3 mmol/l and a 1-hour or 2-hour glucose level after meals of 7.8 mmol/l or 6.4 mmol/l, respectively. It is important to manage gestational diabetes and pre-existing diabetes during pregnancy to reduce the risk of complications for both the mother and baby.
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This question is part of the following fields:
- Reproductive System
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Question 3
Incorrect
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A 63-year-old male on the wards has come to you with recent onset indigestion. He denies any red flag symptoms and has a medical history of hypertension, congestive heart failure, depression, and gout. Later in the day, while reviewing his routine blood results, you notice an abnormality.
Here are his blood results from two days ago and today:
Parameter 2 days ago Today
Hb 135 g/l 134 g/l
Platelets 310 * 109/l 312 * 109/l
WBC 6.5 * 109/l 6.4 * 109/l
Na+ 142 mmol/l 128 mmol/l
K+ 4.2 mmol/l 3.8 mmol/l
Urea 4.8 mmol/l 4.8 mmol/l
Creatinine 60 µmol/l 61 µmol/l
What could be the reason for the discrepancy in his blood results?Your Answer: Hospital acquired gastroenteritis
Correct Answer: Combined use of indapamide and omeprazole
Explanation:Severe hyponatraemia can occur when PPIs and thiazide diuretics are used together. The patient in question has recently experienced hyponatraemia, which is most likely caused by the combination of indapamide and omeprazole. It is probable that omeprazole was prescribed for his indigestion, while he is likely taking indapamide due to his history of congestive heart failure. It is important to note that the other options listed can cause hypernatraemia, not hyponatraemia.
Thiazide diuretics are medications that work by blocking the thiazide-sensitive Na+-Cl− symporter, which inhibits sodium reabsorption at the beginning of the distal convoluted tubule (DCT). This results in the loss of potassium as more sodium reaches the collecting ducts. While thiazide diuretics are useful in treating mild heart failure, loop diuretics are more effective in reducing overload. Bendroflumethiazide was previously used to manage hypertension, but recent NICE guidelines recommend other thiazide-like diuretics such as indapamide and chlorthalidone.
Common side effects of thiazide diuretics include dehydration, postural hypotension, and electrolyte imbalances such as hyponatremia, hypokalemia, and hypercalcemia. Other potential adverse effects include gout, impaired glucose tolerance, and impotence. Rare side effects may include thrombocytopenia, agranulocytosis, photosensitivity rash, and pancreatitis.
It is worth noting that while thiazide diuretics may cause hypercalcemia, they can also reduce the incidence of renal stones by decreasing urinary calcium excretion. According to current NICE guidelines, the management of hypertension involves the use of thiazide-like diuretics, along with other medications and lifestyle changes, to achieve optimal blood pressure control and reduce the risk of cardiovascular disease.
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This question is part of the following fields:
- Cardiovascular System
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Question 4
Correct
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A 32-year-old male is admitted for elective surgery for a lymph node biopsy in the supraclavicular region. Following the surgery, the patient experiences difficulty in shrugging his left shoulder. What could be the probable cause?
Your Answer: Accessory nerve lesion
Explanation:The posterior triangle is where the accessory nerve is located, and it is susceptible to injury in this area. In addition to experiencing issues with shoulder shrugging, the individual may also encounter challenges when attempting to raise their arm above their head.
The posterior triangle of the neck is an area that is bound by the sternocleidomastoid and trapezius muscles, the occipital bone, and the middle third of the clavicle. Within this triangle, there are various nerves, vessels, muscles, and lymph nodes. The nerves present include the accessory nerve, phrenic nerve, and three trunks of the brachial plexus, as well as branches of the cervical plexus such as the supraclavicular nerve, transverse cervical nerve, great auricular nerve, and lesser occipital nerve. The vessels found in this area are the external jugular vein and subclavian artery. Additionally, there are muscles such as the inferior belly of omohyoid and scalene, as well as lymph nodes including the supraclavicular and occipital nodes.
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This question is part of the following fields:
- Cardiovascular System
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Question 5
Incorrect
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A 65-year-old man with type 2 diabetes mellitus is undergoing his annual diabetic examination. He reports feeling more fatigued than usual and has missed his previous three annual check-ups. His blood glucose control has been inadequate, and he has not been adhering to his medications. His blood pressure measures 170/90 mmHg, and a urinalysis reveals microalbuminuria. A blood test shows that his glomerular filtration rate (GFR) is 27mL/min per 1.73m².
Assuming a renal biopsy is conducted on this patient, what are the anticipated findings?Your Answer: Enlarged and hypercellular glomeruli
Correct Answer: Nodular glomerulosclerosis and hyaline arteriosclerosis
Explanation:The patient in question is suffering from T2DM that is poorly controlled, resulting in diabetic nephropathy. The histological examination reveals the presence of Kimmelstiel-Wilson lesions (nodular glomerulosclerosis) and hyaline arteriosclerosis, which are caused by nonenzymatic glycosylation.
Amyloidosis is characterized by apple-green birefringence under polarised light.
Acute post-streptococcal glomerulonephritis is identified by enlarged and hypercellular glomeruli.
Rapidly progressive (crescentic) glomerulonephritis is characterized by crescent moon-shaped glomeruli.
Diffuse proliferative glomerulonephritis (often due to SLE) is identified by wire looping of capillaries in the glomeruli.
Understanding Diabetic Nephropathy: The Common Cause of End-Stage Renal Disease
Diabetic nephropathy is the leading cause of end-stage renal disease in the western world. It affects approximately 33% of patients with type 1 diabetes mellitus by the age of 40 years, and around 5-10% of patients with type 1 diabetes mellitus develop end-stage renal disease. The pathophysiology of diabetic nephropathy is not fully understood, but changes to the haemodynamics of the glomerulus, such as increased glomerular capillary pressure, and non-enzymatic glycosylation of the basement membrane are thought to play a key role. Histological changes include basement membrane thickening, capillary obliteration, mesangial widening, and the development of nodular hyaline areas in the glomeruli, known as Kimmelstiel-Wilson nodules.
There are both modifiable and non-modifiable risk factors for developing diabetic nephropathy. Modifiable risk factors include hypertension, hyperlipidaemia, smoking, poor glycaemic control, and raised dietary protein. On the other hand, non-modifiable risk factors include male sex, duration of diabetes, and genetic predisposition, such as ACE gene polymorphisms. Understanding these risk factors and the pathophysiology of diabetic nephropathy is crucial in the prevention and management of this condition.
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This question is part of the following fields:
- Renal System
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Question 6
Correct
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What type of hallucination is Lillian experiencing while being unwell in bed with pneumonia and seeing a tiny marching band on her bedclothes?
Your Answer: Visual hallucination - Lilliputian hallucinations
Explanation:Types of Hallucinations
Hallucinations are false perceptions that occur simultaneously with real perceptions. There are different types of hallucinations, including visual hallucinations associated with micropsia, which are known as Lilliputian hallucinations. These hallucinations often occur in patients suffering from delirium. Another type of visual hallucination is elementary hallucinations, which appear as flashes of light.
Extracampine hallucinations occur when an individual experiences a hallucination outside their sensory field, such as seeing someone standing behind them while looking straight ahead. Reflex hallucinations happen when a true sensory stimulus causes a hallucination in another sensory modality. Lastly, autoscopy is the experience of seeing oneself and knowing it is oneself, also known as the phantom mirror-image. the different types of hallucinations can help in identifying and treating them appropriately.
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This question is part of the following fields:
- Psychiatry
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Question 7
Incorrect
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A 32-year-old man with a history of cystic fibrosis presents to the respiratory ward after feeling unwell for 4 days. He reports experiencing pleuritic chest pain, shortness of breath, and producing more purulent sputum than usual. Upon examination, his heart rate is 110 beats per minute, his temperature is 38.2ºC, and his blood pressure is 126/86mmHg.
A sputum sample is collected and reveals the presence of gram-negative encapsulated bacilli, which are negative on Ziehl-Neelsen stain.
What is the most likely pathogen responsible for this patient's symptoms?Your Answer: Staphylococcus aureus
Correct Answer: Pseudomonas aeruginosa
Explanation:The organism responsible for causing lower respiratory tract infections in cystic fibrosis patients is Pseudomonas aeruginosa.
Pseudomonas aeruginosa: A Gram-negative Rod Causing Various Infections
Pseudomonas aeruginosa is a type of bacteria that is commonly found in the environment. It is a Gram-negative rod that can cause a range of infections in humans. Some of the infections it causes include chest infections, skin infections such as burns and wound infections, otitis externa, and urinary tract infections.
In the laboratory, Pseudomonas aeruginosa is identified as a Gram-negative rod that does not ferment lactose and is oxidase positive. The bacteria produce both an endotoxin and exotoxin A. The endotoxin causes fever and shock, while exotoxin A inhibits protein synthesis by catalyzing ADP-ribosylation of elongation factor EF-2.
Overall, Pseudomonas aeruginosa is a pathogenic bacteria that can cause a variety of infections in humans. Its ability to produce toxins makes it particularly dangerous and difficult to treat. Proper hygiene and infection control measures can help prevent the spread of this bacteria.
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This question is part of the following fields:
- General Principles
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Question 8
Correct
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A 68-year-old woman visits her doctor with complaints of excessive thirst and constipation. Upon conducting a blood test, the doctor observes elevated PTH levels. What electrolyte would you anticipate to be increased, considering the most probable diagnosis?
Your Answer: Calcium
Explanation:The regulation of calcium metabolism is mainly controlled by PTH and calcitriol. This patient is displaying symptoms of hyperparathyroidism, such as excessive thirst, constipation, and elevated PTH levels. Primary hyperparathyroidism is often caused by a single adenoma, resulting in the continuous release of PTH from a source outside of the parathyroid glands. The recommended treatment for primary hyperparathyroidism is a complete parathyroidectomy. PTH plays a crucial role in increasing calcium levels by releasing calcium from bones and enhancing calcium absorption in the small intestine. If calcium levels in the blood become too high, the parathyroid glands will produce less PTH. On the other hand, chloride and potassium levels are not typically elevated in primary hyperparathyroidism and are not responsible for this patient’s symptoms. Additionally, phosphate levels are usually low in primary hyperparathyroidism, as PTH increases phosphate excretion in the kidneys.
Hormones Controlling Calcium Metabolism
Calcium metabolism is primarily controlled by two hormones, parathyroid hormone (PTH) and 1,25-dihydroxycholecalciferol (calcitriol). Other hormones such as calcitonin, thyroxine, and growth hormone also play a role. PTH increases plasma calcium levels and decreases plasma phosphate levels. It also increases renal tubular reabsorption of calcium, osteoclastic activity, and renal conversion of 25-hydroxycholecalciferol to 1,25-dihydroxycholecalciferol. On the other hand, 1,25-dihydroxycholecalciferol increases plasma calcium and plasma phosphate levels, renal tubular reabsorption and gut absorption of calcium, osteoclastic activity, and renal phosphate reabsorption. It is important to note that osteoclastic activity is increased indirectly by PTH as osteoclasts do not have PTH receptors. Understanding the actions of these hormones is crucial in maintaining proper calcium metabolism in the body.
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This question is part of the following fields:
- General Principles
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Question 9
Incorrect
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A pharmaceutical representative visits your clinic and informs you about a new medication that is currently undergoing a trial to determine its appropriate dosage and potential side effects. What categories of patients would you recommend for the trial, and at which stage of the trial is the drug currently in?
Your Answer: Diseased participants, Phase 1
Correct Answer: Healthy participants, Phase 1
Explanation:Experimental drugs must pass through several phases of testing before they can be approved for use. Phase 0 trials involve microdosing and are used to speed up drug development by testing how the drug behaves in humans. However, no therapeutic effect or safety and efficacy data can be measured from these trials. Phase 2 trials, on the other hand, aim to determine the best dosage and evaluate the drug’s effectiveness by testing it on patients with the targeted disease.
Phases of Clinical Trials
Clinical trials are conducted to determine the safety and efficacy of new treatments or drugs. These trials are commonly classified into four phases. The first phase involves determining the pharmacokinetics and pharmacodynamics of the drug, as well as any potential side effects. This phase is conducted on healthy volunteers.
The second phase assesses the efficacy and dosage of the drug. It involves a small number of patients affected by a particular disease. This phase may be further subdivided into IIa, which assesses optimal dosing, and IIb, which assesses efficacy.
The third phase involves assessing the effectiveness of the drug. This phase typically involves a larger number of people, often as part of a randomized controlled trial, comparing the new treatment with established treatments.
The fourth and final phase is postmarketing surveillance. This phase monitors the long-term effectiveness and side effects of the drug after it has been approved and is on the market.
Overall, the phases of clinical trials are crucial in determining the safety and efficacy of new treatments and drugs. They provide valuable information that can help improve patient outcomes and advance medical research.
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This question is part of the following fields:
- General Principles
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Question 10
Incorrect
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A 9-month-old baby is presented to the emergency department by their mother with recurrent seizures and an increasing head circumference. The infant has been experiencing excessive sleeping, vomiting, and irritability. An MRI scan of the brain reveals an enlarged posterior fossa and an absent cerebellar vermis. Which structure is anticipated to be in a raised position in this infant?
Your Answer: Superior cerebellar peduncle
Correct Answer: Tentorium cerebelli
Explanation:The Dandy-Walker malformation causes an enlargement of the posterior fossa, resulting in an accumulation of cerebrospinal fluid that pushes the tentorium cerebelli upwards. This can lead to symptoms due to the mass effect. The falx cerebri, pituitary gland, sphenoid sinus, and superior cerebellar peduncle are unlikely to be significantly affected by this condition.
The Three Layers of Meninges
The meninges are a group of membranes that cover the brain and spinal cord, providing support to the central nervous system and the blood vessels that supply it. These membranes can be divided into three distinct layers: the dura mater, arachnoid mater, and pia mater.
The outermost layer, the dura mater, is a thick fibrous double layer that is fused with the inner layer of the periosteum of the skull. It has four areas of infolding and is pierced by small areas of the underlying arachnoid to form structures called arachnoid granulations. The arachnoid mater forms a meshwork layer over the surface of the brain and spinal cord, containing both cerebrospinal fluid and vessels supplying the nervous system. The final layer, the pia mater, is a thin layer attached directly to the surface of the brain and spinal cord.
The meninges play a crucial role in protecting the brain and spinal cord from injury and disease. However, they can also be the site of serious medical conditions such as subdural and subarachnoid haemorrhages. Understanding the structure and function of the meninges is essential for diagnosing and treating these conditions.
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This question is part of the following fields:
- Neurological System
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Question 11
Correct
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A teenage boy is brought in with clinical indications of Herpes Simplex Virus (HSV) encephalitis. In an MRI, where would the lesions be typically observed?
Your Answer: Temporal lobes
Explanation:HSV encephalitis is commonly linked with damage to the bitemporal lobes, but it can also affect the inferior frontal lobe. However, the parietal lobes, occipital lobes, and cerebellum are not typically affected by this condition.
Herpes Simplex Encephalitis: Symptoms, Diagnosis, and Treatment
Herpes simplex encephalitis is a common topic in medical exams. This viral infection affects the temporal lobes of the brain, causing symptoms such as fever, headache, seizures, and vomiting. Focal features like aphasia may also be present. It is important to note that peripheral lesions, such as cold sores, are not related to the presence of HSV encephalitis.
HSV-1 is responsible for 95% of cases in adults and typically affects the temporal and inferior frontal lobes. Diagnosis is made through CSF analysis, PCR for HSV, and imaging studies like CT or MRI. EEG patterns may also show lateralized periodic discharges at 2 Hz.
Early treatment with intravenous acyclovir is crucial for a good prognosis. Mortality rates can range from 10-20% with prompt treatment, but can approach 80% if left untreated. MRI is a better imaging modality for detecting changes in the medial temporal and inferior frontal lobes.
In summary, herpes simplex encephalitis is a serious viral infection that affects the brain. It is important to recognize the symptoms and seek prompt medical attention for early diagnosis and treatment.
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This question is part of the following fields:
- Neurological System
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Question 12
Correct
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A 67-year-old man has visited the doctor with concerns about his blood glucose levels. He has type 1 diabetes and also suffers from chronic obstructive pulmonary disease (COPD). Following a recent bout of pneumonia, he has been experiencing difficulty in managing his blood sugars. You suspect that one of his newly prescribed medications may be contributing to this issue. Which medication could be causing acute problems with diabetic control?
Your Answer: Prednisolone
Explanation:The use of corticosteroids, such as prednisolone, can have a negative impact on diabetic control due to their anti-insulin effects. This can cause an increase in glucagon levels, leading to elevated blood sugar levels. While this effect is usually temporary and should resolve on its own, higher doses of insulin may be necessary during treatment. Prednisolone is often prescribed to manage exacerbations of COPD.
Amoxicillin, a penicillin antibiotic, can be prescribed alongside prednisolone to treat infective asthma exacerbations. Its bactericidal effects are unlikely to affect diabetes control.
Carbocisteine is a mucolytic medication commonly used for long-term management of COPD and bronchiectasis. It helps to thin sputum in the lungs, making it easier to cough up and preventing colonization. It is not known to worsen diabetes control.
Doxycycline, a tetracycline antibiotic, is commonly used to treat COPD exacerbations. However, it does not typically affect blood sugar control and is unlikely to be a contributing factor in this case.
Corticosteroids are commonly prescribed medications that can be taken orally or intravenously, or applied topically. They mimic the effects of natural steroids in the body and can be used to replace or supplement them. However, the use of corticosteroids is limited by their numerous side effects, which are more common with prolonged and systemic use. These side effects can affect various systems in the body, including the endocrine, musculoskeletal, gastrointestinal, ophthalmic, and psychiatric systems. Some of the most common side effects include impaired glucose regulation, weight gain, osteoporosis, and increased susceptibility to infections. Patients on long-term corticosteroids should have their doses adjusted during intercurrent illness, and the medication should not be abruptly withdrawn to avoid an Addisonian crisis. Gradual withdrawal is recommended for patients who have received high doses or prolonged treatment.
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This question is part of the following fields:
- Endocrine System
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Question 13
Correct
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A 45-year-old man complains of dyspepsia and is scheduled for an upper GI endoscopy. The procedure reveals diffuse gastric and duodenal ulcers. Upon conducting a Clo test, Helicobacter pylori infection is confirmed. What is the probable cause of the ulcers?
Your Answer: Increased acid production
Explanation:H-Pylori is capable of causing both gastric and duodenal ulcers, but the mechanism behind this is not fully understood. One theory suggests that the organism induces gastric metaplasia in the duodenum by increasing acid levels. This metaplastic transformation is necessary for H-Pylori to colonize the duodenal mucosa and cause ulcers. Therefore, only individuals who have undergone this transformation are at risk for duodenal ulcers caused by H-Pylori.
Helicobacter pylori: A Bacteria Associated with Gastrointestinal Problems
Helicobacter pylori is a type of Gram-negative bacteria that is commonly associated with various gastrointestinal problems, particularly peptic ulcer disease. This bacterium has two primary mechanisms that allow it to survive in the acidic environment of the stomach. Firstly, it uses its flagella to move away from low pH areas and burrow into the mucous lining to reach the epithelial cells underneath. Secondly, it secretes urease, which converts urea to NH3, leading to an alkalinization of the acidic environment and increased bacterial survival.
The pathogenesis mechanism of Helicobacter pylori involves the release of bacterial cytotoxins, such as the CagA toxin, which can disrupt the gastric mucosa. This bacterium is associated with several gastrointestinal problems, including peptic ulcer disease, gastric cancer, B cell lymphoma of MALT tissue, and atrophic gastritis. However, its role in gastro-oesophageal reflux disease (GORD) is unclear, and there is currently no role for the eradication of Helicobacter pylori in GORD.
The management of Helicobacter pylori infection involves a 7-day course of treatment with a proton pump inhibitor, amoxicillin, and either clarithromycin or metronidazole. For patients who are allergic to penicillin, a proton pump inhibitor, metronidazole, and clarithromycin are used instead.
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This question is part of the following fields:
- Gastrointestinal System
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Question 14
Correct
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A 50-year-old man is scheduled for a radical prostatectomy to treat prostate cancer. What is the vessel that directly supplies blood to the prostate gland?
Your Answer: Inferior vesical artery
Explanation:The prostate gland receives its arterial supply from the prostatovesical artery, which is a branch of the inferior vesical artery. The prostatovesical artery typically originates from the internal iliac artery’s internal pudendal and inferior gluteal arterial branches.
Anatomy of the Prostate Gland
The prostate gland is a small, walnut-shaped gland located below the bladder and separated from the rectum by Denonvilliers fascia. It receives its blood supply from the internal iliac vessels, specifically the inferior vesical artery. The gland has an internal sphincter at its apex, which can be damaged during surgery and result in retrograde ejaculation.
The prostate gland has four lobes: the posterior lobe, median lobe, and two lateral lobes. It also has an isthmus and three zones: the peripheral zone, central zone, and transition zone. The peripheral zone, which is the subcapsular portion of the posterior prostate, is where most prostate cancers occur.
The gland is surrounded by various structures, including the pubic symphysis, prostatic venous plexus, Denonvilliers fascia, rectum, ejaculatory ducts, lateral venous plexus, and levator ani. Its lymphatic drainage is to the internal iliac nodes, and its innervation comes from the inferior hypogastric plexus.
In summary, the prostate gland is a small but important gland in the male reproductive system. Its anatomy includes lobes, zones, and various surrounding structures, and it plays a crucial role in ejaculation and prostate health.
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This question is part of the following fields:
- Gastrointestinal System
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Question 15
Incorrect
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As per conventional methods, which of the following is deemed to be the most superior level of evidence?
Your Answer: Cohort studies
Correct Answer: RCTs with non-definitive results
Explanation:Levels and Grades of Evidence in Evidence-Based Medicine
In order to evaluate the quality of evidence in evidence-based medicine, levels or grades are often used to organize the evidence. Traditional hierarchies placed systematic reviews or randomized control trials at the top and case-series/report at the bottom. However, this approach is overly simplistic as certain research questions cannot be answered using RCTs. To address this, the Oxford Centre for Evidence-Based Medicine introduced their 2011 Levels of Evidence system which separates the type of study questions and gives a hierarchy for each. On the other hand, the GRADE system is a grading approach that classifies the quality of evidence as high, moderate, low, or very low. The process begins by formulating a study question and identifying specific outcomes. Outcomes are then graded as critical or important, and the evidence is gathered and criteria are used to grade the evidence. Evidence can be promoted or downgraded based on certain circumstances. The use of levels and grades of evidence helps to evaluate the quality of evidence and make informed decisions in evidence-based medicine.
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This question is part of the following fields:
- General Principles
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Question 16
Incorrect
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A 28-year-old man comes to the clinic with a rash that has spread all over his body. The rash is extremely itchy. The patient has a medical history of coeliac disease and asthma. Upon examination, the rash is symmetrical and present on the scalp, shoulders, elbows, and buttocks. It is made up of clusters of papules and vesicles on a red base, which seem to be somewhat scratched.
The blood tests reveal that the patient has anaemia caused by a lack of iron.
What is the most common association with this rash?Your Answer: HLA-DR4
Correct Answer: HLA-DR3
Explanation:Dermatitis herpetiformis is commonly associated with HLA-DR3, as indicated by its appearance and its connection to coeliac disease. This condition is more prevalent in men than in women. While HLA-A3 is linked to haemochromatosis, it is not associated with dermatitis herpetiformis. Similarly, HLA-B27 is typically associated with ankylosing spondylitis and reactive arthritis, not dermatitis herpetiformis. HLA-B51 is linked to Behcet’s disease, but it is not commonly associated with dermatitis herpetiformis.
HLA Associations: Diseases and Antigens
HLA antigens are proteins encoded by genes on chromosome 6. There are two classes of HLA antigens: class I (HLA A, B, and C) and class II (HLA DP, DQ, and DR). Diseases can be strongly associated with certain HLA antigens. For example, HLA-A3 is associated with haemochromatosis, HLA-B51 with Behcet’s disease, and HLA-B27 with ankylosing spondylitis, reactive arthritis, and acute anterior uveitis. Coeliac disease is associated with HLA-DQ2/DQ8, while narcolepsy and Goodpasture’s are associated with HLA-DR2. Dermatitis herpetiformis, Sjogren’s syndrome, and primary biliary cirrhosis are associated with HLA-DR3. Finally, type 1 diabetes mellitus is associated with HLA-DR3 but more strongly associated with HLA-DR4, specifically the DRB1 gene (DRB1*04:01 and DRB1*04:04).
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This question is part of the following fields:
- General Principles
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Question 17
Incorrect
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A 50-year-old woman has recently been diagnosed with breast cancer and is now undergoing treatment with docetaxel. What is the mechanism of action for this particular treatment?
Your Answer: It inhibits topoisomerase I which prevents relaxation of supercoiled DNA
Correct Answer: It prevents microtubule depolymerisation and disassembly, decreasing free tubulin
Explanation:Docetaxel, a member of the taxane family, disrupts microtubule function by preventing depolymerisation and disassembly. This reduces free tubulin and halts cell division. Irinotecan inhibits topoisomerase I, preventing relaxation of supercoiled DNA, leading to DNA damage and cell death. Methotrexate inhibits dihydrofolate reductase and thymidylate synthesis, slowing and stopping DNA and protein synthesis necessary for normal cell cycle. Cisplatin binds to DNA, cross-linking and inhibiting replication. Doxorubicin stabilises the topoisomerase II complex, inhibiting DNA and RNA synthesis necessary for cell division.
Cytotoxic agents are drugs that are used to kill cancer cells. There are several types of cytotoxic agents, each with their own mechanism of action and potential adverse effects. Alkylating agents, such as cyclophosphamide, work by causing cross-linking in DNA. However, they can also cause haemorrhagic cystitis, myelosuppression, and transitional cell carcinoma. Cytotoxic antibiotics, like bleomycin and anthracyclines, degrade preformed DNA and stabilize DNA-topoisomerase II complex, respectively. However, they can also cause lung fibrosis and cardiomyopathy. Antimetabolites, such as methotrexate and fluorouracil, inhibit dihydrofolate reductase and thymidylate synthesis, respectively. However, they can also cause myelosuppression, mucositis, and liver or lung fibrosis. Drugs that act on microtubules, like vincristine and docetaxel, inhibit the formation of microtubules and prevent microtubule depolymerisation & disassembly, respectively. However, they can also cause peripheral neuropathy, myelosuppression, and paralytic ileus. Topoisomerase inhibitors, like irinotecan, inhibit topoisomerase I, which prevents relaxation of supercoiled DNA. However, they can also cause myelosuppression. Other cytotoxic drugs, such as cisplatin and hydroxyurea, cause cross-linking in DNA and inhibit ribonucleotide reductase, respectively. However, they can also cause ototoxicity, peripheral neuropathy, hypomagnesaemia, and myelosuppression.
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This question is part of the following fields:
- Haematology And Oncology
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Question 18
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A 33-year-old man presents to the emergency department with lateral knee pain. He reports that the pain began two hours ago while playing hockey, and he was struck on the anteromedial aspect of his extended knee by a hockey stick. An x-ray of the knee reveals an avulsion fracture of the fibular head. Which muscle is the probable culprit for this patient's avulsion fracture?
Your Answer: Biceps femoris
Explanation:The fibular head serves as the insertion point for both the long and short head of the biceps femoris muscle. However, sudden contractions of the biceps femoris can lead to an avulsion fracture of the fibular head, where the fracture fragment may be attached to the lateral collateral ligament or biceps femoris tendon.
The fibularis brevis muscle originates from the distal two-thirds of the fibular bone. If the ankle joint suddenly inverts, it can pull on the fibularis tendon and cause an avulsion of the tuberosity at the base of the fifth metatarsal.
The flexor hallucis longus muscle originates from the distal two-thirds of the posterior surface of the fibular bone. This muscle not only allows for flexion of the big toe but also contributes to plantarflexion and inversion of the foot.
The soleus muscle originates from the proximal one-third of the posterior surface of the fibular bone. It is a large muscle covered in thick fascia, which aids in its secondary function of pumping venous blood back into the heart through the skeletal muscle pump.
The Biceps Femoris Muscle
The biceps femoris is a muscle located in the posterior upper thigh and is part of the hamstring group of muscles. It consists of two heads: the long head and the short head. The long head originates from the ischial tuberosity and inserts into the fibular head. Its actions include knee flexion, lateral rotation of the tibia, and extension of the hip. It is innervated by the tibial division of the sciatic nerve and supplied by the profunda femoris artery, inferior gluteal artery, and the superior muscular branches of the popliteal artery.
On the other hand, the short head originates from the lateral lip of the linea aspera and the lateral supracondylar ridge of the femur. It also inserts into the fibular head and is responsible for knee flexion and lateral rotation of the tibia. It is innervated by the common peroneal division of the sciatic nerve and supplied by the same arteries as the long head.
Understanding the anatomy and function of the biceps femoris muscle is important in the diagnosis and treatment of injuries and conditions affecting the posterior thigh.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 19
Incorrect
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A 67-year-old woman visits her GP for a check-up after suffering from a significant anterior ST-elevation myocardial infarction (STEMI) 3 months ago. She has been feeling constantly fatigued and unwell and is worried that her heart may be causing these symptoms. Additionally, she has been experiencing sharp chest pain that worsens when she lies down and feels slightly breathless.
During the examination, the GP observes that her blood pressure drops by approximately 10mmHg when she inhales.
What is the probable reason for her symptoms and examination results?Your Answer: Heart failure with reduced ejection fraction (HFrEF)
Correct Answer: Dressler syndrome (DS)
Explanation:The most likely pathology in this case is Dressler syndrome (DS), which is a complication that can occur after a myocardial infarction (MI) from 2 weeks to several months post-MI. The patient’s symptoms of fatigue, malaise, pleuritic chest pain, and mild dyspnoea are consistent with DS. Additionally, the physical examination finding of decreased blood pressure (>10mmHg) on inspiration, known as ‘pulsus paradoxes’, is associated with DS.
Heart failure with reduced ejection fraction (HFrEF) is an incorrect option as it does not typically cause pleuritic chest pain or pulsus paradoxes. Medication-related causes are also unlikely as the combination of symptoms described in this stem would not be caused by post-MI medications alone. Post-MI depression is another incorrect option as it would not account for all the symptoms present.
Myocardial infarction (MI) can lead to various complications, which can occur immediately, early, or late after the event. Cardiac arrest is the most common cause of death following MI, usually due to ventricular fibrillation. Cardiogenic shock may occur if a large part of the ventricular myocardium is damaged, and it is difficult to treat. Chronic heart failure may result from ventricular myocardium dysfunction, which can be managed with loop diuretics, ACE-inhibitors, and beta-blockers. Tachyarrhythmias, such as ventricular fibrillation and ventricular tachycardia, are common complications. Bradyarrhythmias, such as atrioventricular block, are more common following inferior MI. Pericarditis is common in the first 48 hours after a transmural MI, while Dressler’s syndrome may occur 2-6 weeks later. Left ventricular aneurysm and free wall rupture, ventricular septal defect, and acute mitral regurgitation are other complications that may require urgent medical attention.
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This question is part of the following fields:
- Cardiovascular System
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Question 20
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Sophie, a 19-year-old girl with type 1 diabetes mellitus, arrives at the emergency department with confusion, vomiting, and abdominal pain. Upon examination, she displays tachycardia and tachypnea. The medical team orders various tests, including an arterial blood gas.
The results are as follows:
pH 7.29 mmol/l
K+ 6.0 mmol/l
Glucose 15mmol/l
The doctors initiate treatment for diabetic ketoacidosis.
What ECG abnormality can be observed in relation to Sophie's potassium level?Your Answer: Tall tented T waves and flattened P waves
Explanation:When a person has hyperkalaemia, their blood has an excess of potassium which can lead to cardiac arrhythmias. One of the common ECG abnormalities seen in hyperkalaemia is tall tented T waves. Other possible ECG changes include wide QRS complexes and flattened P waves. In contrast, hypokalaemia can cause T wave depression, U waves, and tall P waves on an ECG. Delta waves are typically seen in patients with Wolfe-Parkinson-White syndrome.
ECG Findings in Hyperkalaemia
Hyperkalaemia is a condition characterized by high levels of potassium in the blood. This condition can have serious consequences on the heart, leading to abnormal ECG findings. The ECG findings in hyperkalaemia include peaked or ‘tall-tented’ T waves, loss of P waves, broad QRS complexes, sinusoidal wave pattern, and ventricular fibrillation.
The first ECG finding in hyperkalaemia is the appearance of peaked or ‘tall-tented’ T waves. This is followed by the loss of P waves, which are the small waves that represent atrial depolarization. The QRS complexes, which represent ventricular depolarization, become broad and prolonged. The sinusoidal wave pattern is a characteristic finding in severe hyperkalaemia, where the ECG tracing appears as a series of undulating waves. Finally, ventricular fibrillation, a life-threatening arrhythmia, can occur in severe hyperkalaemia.
In summary, hyperkalaemia can have serious consequences on the heart, leading to abnormal ECG findings. These findings include peaked or ‘tall-tented’ T waves, loss of P waves, broad QRS complexes, sinusoidal wave pattern, and ventricular fibrillation. It is important to recognize these ECG findings in hyperkalaemia as they can guide appropriate management and prevent life-threatening complications.
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This question is part of the following fields:
- Gastrointestinal System
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