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Question 1
Incorrect
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Which of these patients have an absolute contraindication for the COCP?
Your Answer: 38-year-old smoker, smoking 10 cigarettes/day
Correct Answer: 25-year-old breastfeeding at 4 weeks postpartum
Explanation:1: If you are over 35 years old and smoke at least 15 cigarettes a day, smoking is not recommended.
2: A BMI over 35 kg/m² should be evaluated by a medical professional, but it is not considered an absolute contraindication.
3: A history of ectopic pregnancies does not affect the use of COCP.
4: It is not recommended to use COCP within 6 weeks after giving birth.
5: There is no evidence linking the use of COCP to carpal tunnel syndrome.The decision to prescribe the combined oral contraceptive pill is now based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential contraindications and cautions on a four-point scale. UKMEC 1 indicates no restrictions for use, while UKMEC 2 suggests that the benefits outweigh the risks. UKMEC 3 indicates that the disadvantages may outweigh the advantages, and UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, a family history of thromboembolic disease in first-degree relatives under 45 years old, and current gallbladder disease. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. In 2016, Breastfeeding between 6 weeks and 6 months postpartum was changed from UKMEC 3 to UKMEC 2.
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This question is part of the following fields:
- Gynaecology
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Question 2
Incorrect
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In a study investigating the usefulness of serum procalcitonin level in detecting bacteraemia in febrile patients, 100 consecutive individuals were tested for both serum procalcitonin and bacterial culture. The study found that a serum procalcitonin level below 0.5 microgram/L had a negative predictive value of 95% in identifying bacteraemia.
What does this negative predictive value signify?Your Answer:
Correct Answer: 5% of the patients who have serum procalcitonin level below 0.5 microgram/L would be expected to have bacteraemia
Explanation:Negative Predictive Value in Bacteraemia Testing
Negative predictive value is the proportion of patients who test negative for a disease and do not actually have it. In the case of bacteraemia testing, if a patient has a serum procalcitonin level below 0.5 microgram/L, they are considered negative for the disease. It is estimated that 95% of these patients do not have bacteraemia, while 5% do have the disease.
It is important to note that the number of patients being tested does not affect the negative predictive value. This value is solely based on the proportion of patients who test negative and do not have the disease. negative predictive value is crucial in accurately interpreting test results and making informed medical decisions.
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This question is part of the following fields:
- Clinical Sciences
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Question 3
Incorrect
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You are asked to assess a 50-year-old woman who has a medical history of bipolar disorder and is currently undergoing lithium therapy. The patient seems disoriented and restless. The nurse informs you that she has ingested a significant amount of lithium, and her blood tests reveal a rapid deterioration in kidney function. As part of your initial treatment, you order fluids.
What is the most suitable course of action for further management?Your Answer:
Correct Answer: Haemodialysis
Explanation:Haemodialysis is necessary in cases of severe lithium toxicity.
When a patient presents with acute lithium toxicity, particularly if it has led to renal impairment and neurological symptoms, haemodialysis is the recommended course of action. While supportive measures like fluid resuscitation may be used initially, dialysis is the most effective way to clear the body of excess lithium in cases of severe toxicity.
Understanding Lithium Toxicity
Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in refractory depression. However, it has a narrow therapeutic range of 0.4-1.0 mmol/L and a long plasma half-life, making it crucial to monitor its levels in the blood. Lithium toxicity occurs when the concentration exceeds 1.5 mmol/L, which can be caused by dehydration, renal failure, and certain medications such as diuretics, ACE inhibitors, NSAIDs, and metronidazole.
Symptoms of lithium toxicity include a coarse tremor, hyperreflexia, acute confusion, polyuria, seizures, and even coma. It is important to manage toxicity promptly, as mild to moderate cases may respond to volume resuscitation with normal saline. However, severe cases may require hemodialysis to remove excess lithium from the body. Some healthcare providers may also use sodium bicarbonate to increase the alkalinity of the urine and promote lithium excretion, although evidence supporting its effectiveness is limited.
In summary, understanding lithium toxicity is crucial for healthcare providers and individuals taking lithium. Monitoring lithium levels in the blood and promptly managing toxicity can prevent serious complications and ensure the safe use of this medication.
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This question is part of the following fields:
- Pharmacology
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Question 4
Incorrect
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Sarah is a 23-year-old female who has been brought to the emergency department via ambulance after a car accident. On arrival, her Glasgow Coma Score (GCS) is E2V2M4. Due to concerns about her airway, the attending anaesthetist decides to perform rapid sequence induction and intubation. The anaesthetist administers sedation followed by a muscle relaxant to facilitate intubation. Shortly after, you observe a series of brief muscle twitches throughout Sarah's body, followed by complete paralysis. Which medication is most likely responsible for these symptoms?
Your Answer:
Correct Answer: Suxamethonium
Explanation:Suxamethonium, also known as succinylcholine, is a type of muscle relaxant that works by inducing prolonged depolarization of the skeletal muscle membrane. This non-competitive agonist can cause fasciculations, which are uncoordinated muscle contractions or twitches that last for a few seconds before profound paralysis occurs. However, it is important to note that succinylcholine is typically only used in select cases, such as for rapid sequence intubation in emergency settings, due to its fast onset and short duration of action. Atracurium and vecuronium, on the other hand, are competitive muscle relaxants that do not typically cause fasciculations. Glycopyrrolate is not a muscle relaxant, but rather a competitive antagonist of acetylcholine at peripheral muscarinic receptors. Propofol is an induction agent and not a muscle relaxant.
Understanding Neuromuscular Blocking Drugs
Neuromuscular blocking drugs are commonly used in surgical procedures as an adjunct to anaesthetic agents. These drugs are responsible for inducing muscle paralysis, which is a necessary prerequisite for mechanical ventilation. There are two types of neuromuscular blocking drugs: depolarizing and non-depolarizing.
Depolarizing neuromuscular blocking drugs bind to nicotinic acetylcholine receptors, resulting in persistent depolarization of the motor end plate. On the other hand, non-depolarizing neuromuscular blocking drugs act as competitive antagonists of nicotinic acetylcholine receptors. Examples of depolarizing neuromuscular blocking drugs include succinylcholine (also known as suxamethonium), while examples of non-depolarizing neuromuscular blocking drugs include tubcurarine, atracurium, vecuronium, and pancuronium.
While these drugs are effective in inducing muscle paralysis, they also come with potential adverse effects. Depolarizing neuromuscular blocking drugs may cause malignant hyperthermia and transient hyperkalaemia, while non-depolarizing neuromuscular blocking drugs may cause hypotension. However, these adverse effects can be reversed using acetylcholinesterase inhibitors such as neostigmine.
It is important to note that suxamethonium is contraindicated for patients with penetrating eye injuries or acute narrow angle glaucoma, as it increases intra-ocular pressure. Additionally, suxamethonium is the muscle relaxant of choice for rapid sequence induction for intubation and may cause fasciculations. Understanding the mechanism of action and potential adverse effects of neuromuscular blocking drugs is crucial in ensuring their safe and effective use in surgical procedures.
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This question is part of the following fields:
- Surgery
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Question 5
Incorrect
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A 32-year-old mother of two presents to her general practitioner with depression. She explains that for the last 4 months, she has been unable to leave her house or socialize with friends due to an embarrassing and uncomfortable incontinence problem.
What is the most common type of urinary incontinence in women?Your Answer:
Correct Answer: Genuine stress incontinence
Explanation:Understanding the Different Types of Urinary Incontinence in Women
Urinary incontinence is a common condition that affects many women. There are different types of urinary incontinence, each with its own causes and treatment options. The most common type of incontinence in women is genuine stress incontinence, which is caused by sphincter incompetence and leads to leakage of small amounts of urine on stress, such as sneezing, standing, laughing, and coughing.
To diagnose incontinence, common investigations include a midstream urine specimen, frequency volume chart, filling urodynamic assessment, and voiding urodynamic assessment. Treatment options vary depending on the patient’s wishes, desire for future children, and severity of symptoms. Conservative treatment involves pelvic floor exercises, vaginal cones, and drugs such as estrogen. Surgery is the most effective way of restoring continence, with a cure rate of 80-90%. Procedures include burch colposuspension, anterior repair and bladder buttress, tension-free vaginal tape, and suburethral sling.
Other types of urinary incontinence in women include fistula, which is a rare cause of incontinence caused by pelvic surgery, overactive bladder, which is the second most common type of incontinence, retention with overflow, which is a rare cause of incontinence more common in men, and congenital abnormalities, which is a rare cause of incontinence that is often apparent since early life.
It is important for women to understand the different types of urinary incontinence and seek medical advice if they experience any symptoms. With proper diagnosis and treatment, urinary incontinence can be effectively managed, improving quality of life and overall health.
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This question is part of the following fields:
- Gynaecology
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Question 6
Incorrect
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Select the phrase that accurately characterizes the method by which gene transcription is triggered.
Your Answer:
Correct Answer: Promoters
Explanation:Understanding Gene Transcription: Promoters, Silencers, Exons, Introns, and Enhancers
Gene transcription is the process by which genetic information is copied from DNA to RNA. This process involves several key elements, including promoters, silencers, exons, introns, and enhancers.
Promoters are specialized sequences found upstream of a gene that serve as binding sites for RNA polymerase, the enzyme responsible for RNA synthesis from DNA. Silencers, on the other hand, are sequences found upstream or downstream of a gene that can prevent RNA polymerase from binding, thereby inhibiting gene transcription.
Following transcription, an RNA transcript is produced that contains both introns and exons. Exons are the sections of the RNA transcript that will be translated to protein, while introns are non-coding sections that are spliced out prior to translation.
Enhancers are sequences found upstream or downstream of a gene that promote transcription when bound by specific transcription factors. They can be located thousands of base pairs from the promoter region of the gene in question.
Understanding these key elements of gene transcription is essential for understanding how genetic information is expressed and regulated in cells.
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This question is part of the following fields:
- Genetics
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Question 7
Incorrect
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What are the expected urinalysis results for a 23-year-old patient with abdominal pain, dehydration, anorexia, and marked hyperglycemia who may have a new diagnosis of type 1 diabetes?
A) Haemoglobin: Negative
Urobilinogen: Negative
Bilirubin: Negative
Protein: Positive
Glucose: Positive (+++)
Nitrites: Negative
Leucocytes: Positive
B) Haemoglobin: Negative
Urobilinogen: Negative
Bilirubin: Negative
Protein: Negative
Glucose: Positive
Nitrites: ++
Leucocytes: ++
C) Haemoglobin: Negative
Urobilinogen: Negative
Bilirubin: Negative
Protein: Negative
Glucose: +
Nitrites: +++
Leucocytes: +++
D) Haemoglobin: Negative
Urobilinogen: Negative
Bilirubin: Negative
Protein: Negative
Glucose: Negative
Nitrites: Negative
Leucocytes: Negative
E) Haemoglobin: +++
Urobilinogen: +
Bilirubin: +
Protein: Negative
Glucose: Negative
Nitrites: Negative
Leucocytes: NegativeYour Answer:
Correct Answer: B
Explanation:Diabetic Ketoacidosis and Urinary Tract Infection
This patient is exhibiting symptoms that are commonly associated with diabetic ketoacidosis (DKA), a serious complication of diabetes. The presence of high levels of glucose and ketones in the urine, as indicated by the urinalysis, further supports this diagnosis. DKA can occur in both new and established type 1 diabetic patients and is often triggered by an infection. In this case, it is likely that a urinary tract infection (UTI) was the precipitating factor.
It is important to recognize the signs and symptoms of DKA, as prompt treatment is necessary to prevent serious complications. Patients with DKA may experience symptoms such as excessive thirst, frequent urination, nausea, vomiting, abdominal pain, and confusion. If left untreated, DKA can lead to coma or even death. In addition to treating the underlying infection, treatment for DKA typically involves insulin therapy, fluid replacement, and electrolyte management.
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This question is part of the following fields:
- Nephrology
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Question 8
Incorrect
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A 47-year-old woman is recuperating after a live donor related kidney transplant. She is experiencing considerable abdominal discomfort. What pain-relieving medication should she steer clear of?
Your Answer:
Correct Answer: Diclofenac
Explanation:Patients who have received renal transplants are typically advised to avoid non-steroidal anti-inflammatory drugs due to their potential nephrotoxicity. The liver is primarily responsible for metabolizing paracetamol and morphine, although there is some renal involvement in the metabolism and excretion of morphine. If the transplanted kidney ceases to function, morphine should be administered in lower doses or avoided altogether.
Organ Transplant: Matching and Rejection
Organ and tissue transplants have become increasingly available, with allografts being the most common type of transplant where an organ is transplanted from one individual to another. However, allografts can elicit an immune response, leading to organ rejection. This is mainly due to allelic differences at genes that code immunohistocompatability complex genes, such as ABO blood group, human leucocyte antigens (HLA), and minor histocompatibility antigens. ABO incompatibility can result in early organ rejection, while HLA mismatching can lead to acute or chronic rejection. An ideal organ match would be one in which all eight alleles are matched.
There are three types of organ rejection: hyperacute, acute, and chronic. Hyperacute rejection occurs immediately due to pre-formed antigens, such as ABO incompatibility. Acute rejection occurs during the first six months and is usually T cell mediated, while chronic rejection occurs after the first six months and is characterized by vascular changes. All types of transplanted organs are susceptible to acute and chronic rejection, with renal transplants being at the greatest risk for hyperacute rejection and liver transplants being at the least risk.
In renal transplantation, patients with end-stage renal failure who are dialysis dependent or likely to become so in the immediate future are considered for transplant. Donor kidneys may be taken from live related donors or brain dead or dying patients. Laparoscopic donor nephrectomy minimizes operative morbidity for the donor, while minimizing warm ischaemic time in the donor phase is crucial. The kidney is prepared on the bench in theatre by the transplant surgeon immediately prior to implantation. The operation is performed under general anaesthesia, with the external iliac artery and vein being anastomosed to the iliacs and the ureter being implanted into the bladder. Acute tubular necrosis is a common problem encountered in cadaveric kidneys, but it tends to resolve. Graft survival times from cadaveric donors are typically of the order of 9 years, while monozygotic twin transplants may survive as long as 25 years.
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This question is part of the following fields:
- Surgery
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Question 9
Incorrect
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A 55-year-old man presented with non-specific abdominal discomfort lasting for 8 months. Physical examination revealed no lymphadenopathy, abdominal masses or organomegaly, and bowel sounds were present. A stool sample tested negative for occult blood. Imaging with abdominal CT revealed a 22-cm retroperitoneal soft tissue mass that was obstructing the left psoas muscle. What is the most probable neoplasm in this case?
Your Answer:
Correct Answer: Liposarcoma
Explanation:Liposarcoma is a type of sarcoma that commonly affects adults in their 40s to 60s. It typically develops in the deep soft tissues of the proximal extremities and retroperitoneum and can grow into large tumors. There are different histological variants of liposarcoma, with varying degrees of malignancy. All types of liposarcoma have a high likelihood of recurring locally unless completely removed.
Adenocarcinoma is a type of cancer that originates from glandular tissue in organs such as the oesophagus, pancreas, prostate, cervix, stomach, colorectal, and lungs. It does not arise in soft tissues.
Melanoma is a type of skin cancer that can occur in younger patients and often arises from pre-existing moles. Suspicious signs include changes in size, shape, color, itching, crusting, bleeding, inflammation, or sensory changes. Melanomas can metastasize.
Hamartoma is a benign neoplasm that consists of normal tissues in a disorganized mass. The most common type is pulmonary hamartoma, which grows at the same rate as surrounding tissue.
Lymphoma is a type of cancer that results from the malignant proliferation of lymphocytes. It typically presents with lymphadenopathy and constitutional symptoms, and may also involve organs such as the liver and spleen. Matted nodes of this size are unlikely to be caused by lymphoma.
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This question is part of the following fields:
- Oncology
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Question 10
Incorrect
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A 60-year-old man is admitted from the angiography suite after the cardiologist discovered severe triple vessel disease. He awaits transfer to a tertiary hospital for a coronary artery bypass graft. After 48 hours of admission, you receive a call to see him as he has become confused, sweaty, tremulous, and agitated.
Upon reviewing his record, you note a history of asthma, variceal bleed, and cirrhosis secondary to alcohol excess. His observations show a pyrexia at 37.9ºC, heart rate of 105 bpm, and blood pressure 175/98 mmHg. What would be the most appropriate immediate intervention given the likely diagnosis?Your Answer:
Correct Answer: Chlordiazepoxide
Explanation:Chlordiazepoxide or diazepam are effective treatments for delirium tremens and alcohol withdrawal. Symptoms of alcohol withdrawal can include confusion, agitation, tremors, hallucinations, and autonomic dysfunction such as high blood pressure, sweating, and fever.
Chlordiazepoxide is the most appropriate answer for this scenario. While confusion, sweating, and agitation can be signs of infection, the patient’s alcohol history suggests that delirium tremens is the more likely diagnosis. IV antibiotics would not address the primary issue of alcohol withdrawal. The patient’s high blood pressure also suggests that infection is not the cause of their symptoms.
Intravenous hydration may be necessary if the patient is experiencing excessive fluid loss due to sweating, but it would not be the best treatment for alcohol withdrawal in this case.
Alcohol withdrawal occurs when an individual who has been consuming alcohol chronically suddenly stops or reduces their intake. Chronic alcohol consumption enhances the inhibitory effects of GABA in the central nervous system, similar to benzodiazepines, and inhibits NMDA-type glutamate receptors. However, alcohol withdrawal leads to the opposite effect, resulting in decreased inhibitory GABA and increased NMDA glutamate transmission. Symptoms of alcohol withdrawal typically start at 6-12 hours and include tremors, sweating, tachycardia, and anxiety. Seizures are most likely to occur at 36 hours, while delirium tremens, which includes coarse tremors, confusion, delusions, auditory and visual hallucinations, fever, and tachycardia, peak at 48-72 hours.
Patients with a history of complex withdrawals from alcohol, such as delirium tremens, seizures, or blackouts, should be admitted to the hospital for monitoring until their withdrawals stabilize. The first-line treatment for alcohol withdrawal is long-acting benzodiazepines, such as chlordiazepoxide or diazepam, which are typically given as part of a reducing dose protocol. Lorazepam may be preferable in patients with hepatic failure. Carbamazepine is also effective in treating alcohol withdrawal, while phenytoin is said to be less effective in treating alcohol withdrawal seizures.
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This question is part of the following fields:
- Psychiatry
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Question 11
Incorrect
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A 75-year-old male presents to his GP after receiving the results of his recent blood tests. He had initially complained of aches and pains a week ago, specifically in his shoulders and hips, which had been progressively worsening over the past 3 months. Upon examination, bilateral pain is noted in both the shoulders and hips, which is exacerbated by movement. No signs of muscular atrophy or weakness are observed. What would be the primary investigation recommended for the suspected diagnosis?
Your Answer:
Correct Answer: ESR and CRP
Explanation:Polymyalgia rheumatica is the most likely diagnosis based on the patient’s symptoms. The pain affecting both the pelvic and shoulder girdle in a bilateral manner, without any signs of weakness or wasting, is typical of this condition. Additionally, the patient’s age and gender are also consistent with a diagnosis of polymyalgia rheumatica.
The recommended first-line investigation for this condition is to check the blood inflammatory markers, specifically the ESR and CRP. These markers are often elevated in polymyalgia rheumatica and typically return to normal levels following steroid treatment. An antibody screen is not necessary as this condition is not associated with auto-antibodies.
A full-body MRI is not appropriate as it is not a specific test for polymyalgia rheumatica and is typically reserved for more invasive investigations. Ultrasound of the affected joints is also not necessary as there are no structural abnormalities associated with this condition that would be detected by this test. Similarly, X-rays of the shoulders and hips would not aid in the diagnosis of polymyalgia rheumatica as they do not provide visualization of the muscle.
Polymyalgia Rheumatica: A Condition of Muscle Stiffness in Older People
Polymyalgia rheumatica (PMR) is a common condition that affects older people. It is characterized by muscle stiffness and elevated inflammatory markers. Although it is closely related to temporal arthritis, the underlying cause is not fully understood, and it does not appear to be a vasculitic process. PMR typically affects patients over the age of 60 and has a rapid onset, usually within a month. Patients experience aching and morning stiffness in proximal limb muscles, along with mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, and night sweats.
To diagnose PMR, doctors look for raised inflammatory markers, such as an ESR of over 40 mm/hr. Creatine kinase and EMG are normal. Treatment for PMR involves prednisolone, usually at a dose of 15 mg/od. Patients typically respond dramatically to steroids, and failure to do so should prompt consideration of an alternative diagnosis.
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This question is part of the following fields:
- Musculoskeletal
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Question 12
Incorrect
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A 31-year-old man is urgently referred to the Medical Admission Unit by his general practitioner due to a 2-week history of worsening diarrhoea that has become bloody over the past few days. He has no recent history of foreign travel and no significant medical history. Over the last 48 hours, he has been experiencing bowel movements approximately 10 times a day. Upon examination, he appears dehydrated, and his abdomen is diffusely tender to palpation with active bowel sounds. There is no rebound tenderness or guarding. Initial investigations have been requested, including FBC, U&Es, liver function tests, and C-reactive protein. Stool has been sent for microscopy, and Clostridium difficile toxin testing has been requested. What is the most appropriate next step in the investigation?
Your Answer:
Correct Answer: Plain abdominal film
Explanation:Investigations for Suspected Inflammatory Bowel Disease
Suspected cases of inflammatory bowel disease (IBD) require a thorough assessment to determine the underlying cause. A plain abdominal film is essential in the initial evaluation to exclude colon dilation and assess the extent of disease. Sigmoidoscopy is recommended for all patients presenting with diarrhea, as it allows for the visualization of the sigmoid colon and rectal biopsies for histology. Colonoscopy may be preferred in mild to moderate disease, while CT scans are helpful in evaluating disease activity and complications. An erect chest X-ray is important if a pneumoperitoneum is suspected. However, in the absence of peritonism or upper gastrointestinal pathology, the abdominal film is the most appropriate next investigation to exclude a toxic megacolon.
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This question is part of the following fields:
- Gastroenterology
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Question 13
Incorrect
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A 35-year-old man comes to the Emergency Department (ED) with a fever of 40 °C, vomiting and diarrhea, and is extremely restless. He has hyperthyroidism but is known to not take his medication regularly. The ED registrar suspects that he is experiencing a thyroid storm.
What is the most probable statement about a thyrotoxic crisis (thyroid storm)?Your Answer:
Correct Answer: Fluid resuscitation, propranolol and carbimazole are used in the management of a thyroid storm
Explanation:When managing a patient with a thyroid storm, it is important to first stabilize them by addressing their presenting symptoms. This may involve fluid resuscitation, a nasogastric tube if vomiting, and sedation if necessary. Beta-blockers are often used to reduce the effects of excessive thyroid hormones on end-organs, and high-dose digoxin may be used with close cardiac monitoring. Antithyroid drugs, such as carbimazole, are then used. Tepid sponging is used to manage excessive hyperthermia, and active warming may be used in cases of myxoedema coma. Men are actually more commonly affected by thyroid storms than women. Precipitants of a thyroid storm include recent thyroid surgery, radioiodine, infection, myocardial infarction, and trauma. Levothyroxine is given to replace low thyroxine levels in cases of hypothyroidism, while hydrocortisone or dexamethasone may be given to prevent peripheral conversion of T4 to T3 in managing a patient with a thyroid storm.
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This question is part of the following fields:
- Acute Medicine And Intensive Care
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Question 14
Incorrect
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What is the causative agent of roseola in toddlers?
Your Answer:
Correct Answer: Human herpes virus 6
Explanation:Understanding Roseola Infantum
Roseola infantum, also known as exanthem subitum or sixth disease, is a common illness that affects infants and is caused by the human herpes virus 6 (HHV6). This disease has an incubation period of 5-15 days and is typically seen in children aged 6 months to 2 years. The most common symptoms of roseola infantum include a high fever that lasts for a few days, followed by a maculopapular rash. Other symptoms may include Nagayama spots, which are papular enanthems on the uvula and soft palate, as well as cough and diarrhea.
In some cases, febrile convulsions may occur in around 10-15% of children with roseola infantum. While this can be concerning for parents, it is important to note that this is a common occurrence and typically resolves on its own. Additionally, HHV6 infection can lead to other possible consequences such as aseptic meningitis and hepatitis.
It is important to note that school exclusion is not necessary for children with roseola infantum. While this illness can be uncomfortable for infants, it is typically not serious and resolves on its own within a few days.
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This question is part of the following fields:
- Paediatrics
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Question 15
Incorrect
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A 35-year-old male comes to your clinic at the suggestion of his partner. He has been experiencing hyperarousal to loud noises and difficulty concentrating at work since his stay in the ICU 4 weeks ago. His partner believes he may have acute stress disorder, but you diagnose him with PTSD and discuss treatment options. He asks you to explain the difference between the two to his partner. You explain that while the presentation is similar, the main difference is temporal.
At what point after the event can you confirm a diagnosis of PTSD?Your Answer:
Correct Answer: 4 weeks
Explanation:Acute stress disorder is characterized by an acute stress reaction that occurs within four weeks of a traumatic event, while PTSD is diagnosed after four weeks have passed. Symptoms presented within two weeks would suggest acute stress disorder. Both acute stress disorder and PTSD share similar features, including re-experiencing, avoidance, hyperarousal, and emotional numbing. Re-experiencing symptoms may include flashbacks, nightmares, and repetitive and distressing intrusive images. Avoidance symptoms may involve avoiding people, situations, or circumstances associated with the traumatic event. Hyperarousal symptoms may include hypervigilance for threat, exaggerated startle response, sleep problems, irritability, and difficulty concentrating. Emotional numbing may result in a lack of ability to experience feelings and feeling detached.
Acute stress disorder is a condition that occurs within the first four weeks after a person has experienced a traumatic event, such as a life-threatening situation or sexual assault. It is characterized by symptoms such as intrusive thoughts, dissociation, negative mood, avoidance, and arousal. These symptoms can include flashbacks, nightmares, feeling disconnected from reality, and being hypervigilant.
To manage acute stress disorder, trauma-focused cognitive-behavioral therapy (CBT) is typically the first-line treatment. This type of therapy helps individuals process their traumatic experiences and develop coping strategies. In some cases, benzodiazepines may be used to alleviate acute symptoms such as agitation and sleep disturbance. However, caution must be taken when using these medications due to their addictive potential and potential negative impact on adaptation. Overall, early intervention and appropriate treatment can help individuals recover from acute stress disorder and prevent the development of more chronic conditions such as PTSD.
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This question is part of the following fields:
- Psychiatry
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Question 16
Incorrect
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A 57-year-old man arrives at the Emergency Department with sudden onset central crushing chest pain. The patient reports feeling pain in his neck and jaw as well. He has no significant medical history, but he does smoke occasionally and consumes up to 60 units of alcohol per week. An ECG is performed, revealing widespread ST elevation indicative of an acute coronary syndrome. At what point do the microscopic changes of acute MI become visible?
Your Answer:
Correct Answer: 12-24 hours after the infarct
Explanation:The Pathological Progression of Myocardial Infarction: A Timeline of Changes
Myocardial infarction, commonly known as a heart attack, is a serious medical condition that occurs when blood flow to the heart is blocked, leading to tissue damage and potentially life-threatening complications. The pathological progression of myocardial infarction follows a predictable sequence of events, with macroscopic and microscopic changes occurring over time.
Immediately after the infarct occurs, there are usually no visible changes to the myocardium. However, within 3-6 hours, maximal inflammatory changes occur, with the most prominent changes occurring between 24-72 hours. During this time, coagulative necrosis and acute inflammatory responses are visible, with marked infiltration by neutrophils.
Between 3-10 days, the infarcted area begins to develop a hyperaemic border, and the process of organisation and repair begins. Granulation tissue replaces dead muscle, and dying neutrophils are replaced by macrophages. Disintegration and phagocytosis of dead myofibres occur during this time.
If a patient survives an acute infarction, the infarct heals through the formation of scar tissue. However, scar tissue does not possess the usual contractile properties of normal cardiac muscle, leading to contractile dysfunction or congestive cardiac failure. The entire process from coagulative necrosis to the formation of well-formed scar tissue takes 6-8 weeks.
In summary, understanding the timeline of changes that occur during myocardial infarction is crucial for early diagnosis and effective treatment. By recognising the macroscopic and microscopic changes that occur over time, healthcare professionals can provide appropriate interventions to improve patient outcomes.
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This question is part of the following fields:
- Cardiology
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Question 17
Incorrect
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A 65-year-old retired librarian presents to her General Practitioner complaining of a feeling of fullness in her vagina. She states that this feeling is present at all times. On further questioning she also has a 1-year history of urinary frequency and has been treated for urinary tract infections in two instances in the past year. She has never smoked and is teetotal.
What is the most likely diagnosis?Your Answer:
Correct Answer: Cystocele
Explanation:Common Vaginal Conditions: Symptoms and Management
Cystocele: A weakening of pelvic muscles can cause the bladder to prolapse into the vagina, resulting in stress incontinence, frequent urinary tract infections, and a dragging sensation or lump in the vagina. Management ranges from conservative with pelvic floor exercises to surgery.
Rectocele: Women with a rectocele experience pressure and a lump in the vagina, as well as difficulty with bowel movements. Treatment may involve pelvic floor exercises or surgery.
Bartholin cyst: A blocked Bartholin gland can lead to a cyst that presents as a tender mass in the vaginal wall. Treatment involves incision and drainage, as well as antibiotics.
Vaginal cancer: Symptoms include vaginal or postcoital bleeding, vaginal discharge, and persistent pelvic pain.
Bladder cancer: Painless hematuria is a common symptom, with risk factors including smoking, working in the aniline dye industry, or previous infection with Schistosoma haematobium.
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This question is part of the following fields:
- Gynaecology
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Question 18
Incorrect
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A 16-year-old boy comes to the emergency department with a painful knee that started 3 days ago. Upon examination, the patient is stable but has a fever of 38.5ºC. The left knee is red and has limited range of motion. The patient also reports having a severe sore throat 3 weeks ago, which was treated with antibiotics. There are no other symptoms reported. What is the next best course of action for managing this patient?
Your Answer:
Correct Answer: Synovial fluid sampling
Explanation:When a patient presents with an acutely painful, red joint and is systemically unwell, septic arthritis must be considered until proven otherwise. The most important investigation in such cases is synovial fluid sampling, according to NICE guidelines. This is the only reliable method of evaluating a potentially infected joint and should be done before starting antibiotics. Referral to the GUM clinic is not appropriate in the urgent management of this patient, and imaging the joint is useful but not mandatory. While blood cultures are important, synovial fluid sampling is the most appropriate investigation due to its specificity. Ultrasound can also be helpful in identifying abnormalities not visible on plain X-ray.
Septic Arthritis in Adults: Causes, Symptoms, and Treatment
Septic arthritis is a condition that occurs when bacteria infect a joint, leading to inflammation and pain. The most common organism that causes septic arthritis in adults is Staphylococcus aureus, but in young adults who are sexually active, Neisseria gonorrhoeae is the most common organism. The infection usually spreads through the bloodstream from a distant bacterial infection, such as an abscess. The knee is the most common location for septic arthritis in adults. Symptoms include an acute, swollen joint, restricted movement, warmth to the touch, and fever.
To diagnose septic arthritis, synovial fluid sampling is necessary and should be done before administering antibiotics if necessary. Blood cultures may also be taken to identify the cause of the infection. Joint imaging may also be used to confirm the diagnosis.
Treatment for septic arthritis involves intravenous antibiotics that cover Gram-positive cocci. Flucloxacillin or clindamycin is recommended if the patient is allergic to penicillin. Antibiotic treatment is typically given for several weeks, and patients are usually switched to oral antibiotics after two weeks. Needle aspiration may be used to decompress the joint, and arthroscopic lavage may be required in some cases.
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This question is part of the following fields:
- Musculoskeletal
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Question 19
Incorrect
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A 28-year-old primigravida woman is rushed for an emergency caesarean section due to fetal distress and hypoxia detected on cardiotocography. She is currently at 31 weeks gestation.
After delivery, the baby is admitted to the neonatal intensive care unit (NICU) and given oxygen to aid breathing difficulties.
Several weeks later, during an ophthalmological examination, the baby is found to have bilateral absent red reflex and retinal neovascularisation.
What is the probable diagnosis?Your Answer:
Correct Answer: Retinopathy of prematurity
Explanation:Risks Associated with Prematurity
Prematurity is a condition that poses several risks to the health of newborns. The risk of mortality increases with decreasing gestational age. Premature babies are at risk of developing respiratory distress syndrome, intraventricular haemorrhage, necrotizing enterocolitis, chronic lung disease, hypothermia, feeding problems, infection, jaundice, and retinopathy of prematurity. Retinopathy of prematurity is a significant cause of visual impairment in babies born before 32 weeks of gestation. The cause of this condition is not fully understood, but it is believed that over oxygenation during ventilation can lead to the proliferation of retinal blood vessels, resulting in neovascularization. Screening for retinopathy of prematurity is done in at-risk groups. Premature babies are also at risk of hearing problems.
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This question is part of the following fields:
- Obstetrics
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Question 20
Incorrect
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You are the Foundation Year 2 doctor on a general practice (GP) attachment when a 65-year-old man presents, complaining of malaise, cough and breathlessness. He says these symptoms have been present for 2 days, and he has brought up some yellow-coloured sputum on a few occasions. He reports no pain and no palpitations and is coping at home, although he has taken 2 days off work. He has no long-standing conditions but smokes five cigarettes a day and has done so for the last 15 years. He has no known allergies. On examination, he is alert and orientated, and has a respiratory rate of 22 breaths per minute, a blood pressure of 126/84 mmHg and a temperature of 38.1 °C. There is bronchial breathing and crepitations on auscultation, particularly on the right-hand side of the chest, and heart sounds are normal.
What would be the most appropriate management for this patient?Your Answer:
Correct Answer: 5-day course of amoxicillin
Explanation:Treatment and Management of Community-Acquired Pneumonia
Community-acquired pneumonia is a common respiratory infection that can be effectively managed in the community with appropriate treatment and management. The severity of the infection can be assessed using the CRB-65 score, which takes into account confusion, respiratory rate, blood pressure, and age. A score of zero indicates low severity and suggests that oral antibiotics and community treatment should suffice. However, admission to hospital may be necessary in certain cases.
The first-choice antibiotic for community-acquired pneumonia is amoxicillin, although a macrolide may be considered in patients with penicillin allergy. Flucloxacillin may be added if there is suspicion of a staphylococcal infection or associated influenzae.
It is important to provide safety-netting advice to patients, advising them to return if symptoms worsen or do not improve on antibiotics. Additionally, the absence of wheeze on auscultation and no history of respiratory disease suggests that a salbutamol inhaler is not necessary.
While the CURB-65 score is commonly used, the CRB-65 score is more practical in community settings as it does not require laboratory analysis. Overall, prompt and appropriate treatment and management can effectively manage community-acquired pneumonia in the community.
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This question is part of the following fields:
- Respiratory
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Question 21
Incorrect
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A woman with known angina currently managed on glyceryl trinitrate (GTN) spray presents to Accident and Emergency with crushing central chest pain. A 12-lead electrocardiogram (ECG) reveals ST depression and flat T waves. She is managed as acute coronary syndrome without ST elevation.
Which one of the following options is most likely to be used in her immediate management?Your Answer:
Correct Answer: Fondaparinux
Explanation:Medications for Acute Coronary Syndrome: Indications and Uses
Acute coronary syndrome (ACS) is a medical emergency that requires prompt and appropriate treatment to prevent further damage to the heart muscle. The management of ACS involves a combination of medications and interventions, depending on the type and severity of the condition. Here are some commonly used medications for ACS and their indications:
1. Fondaparinux: This medication is a factor Xa inhibitor that is used for anticoagulation in ACS without ST-segment elevation. It is usually given along with other drugs such as aspirin, clopidogrel, and nitrates to prevent blood clots and reduce the risk of future cardiovascular events.
2. Warfarin: This medication is used for the treatment and prevention of venous thrombosis and thromboembolism. It is not indicated for the immediate management of ACS.
3. Furosemide: This medication is a diuretic that is used to treat pulmonary edema in patients with heart failure. It is not indicated for ACS as it may cause dehydration.
4. Paracetamol: This medication is not effective as an analgesic option for ACS. Morphine is commonly used for pain relief in ACS.
5. Simvastatin: This medication is a statin that is used for the long-term management of high cholesterol levels. It is not indicated for the initial management of ACS.
In summary, the management of ACS involves a combination of medications and interventions that are tailored to the individual patient’s needs. Prompt and appropriate treatment can help improve outcomes and reduce the risk of future cardiovascular events.
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This question is part of the following fields:
- Cardiology
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Question 22
Incorrect
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A 23-year-old man who is currently living in student accommodation is brought in by ambulance. His flatmates returned from lectures and found him slumped over a chair with features of dizziness, headache and a reduced conscious level. He lives in student accommodation and his flatmates reveal there have had problems with the boiler but the landlord has not sorted these out. He denies any illicit drug use or relevant past medical or surgical history. The paramedics arrived and found him lying on the floor with cyanosis of his skin.
Examination findings:
Oxygen saturations on room air are 97%
Blood pressure is 120/80 mmHg
Heart rate 80 bpm
Respiratory rate 16 breaths per minute
Temperature 37.1 C
Heart sounds normal without added sounds
Chest clear without added sounds and vesicular in nature
pH 7.35
pO2 8.3 kPa
pCO2 5.8 kPa
Bicarbonate 24 mmol/l
What is the most appropriate target oxygen saturations to aim for, given the likely diagnosis?Your Answer:
Correct Answer: 100%
Explanation:Understanding Carbon Monoxide Poisoning
Carbon monoxide poisoning occurs when carbon monoxide, a toxic gas, is inhaled and binds to haemoglobin and myoglobin in the body, resulting in tissue hypoxia. This leads to a left-shift of the oxygen dissociation curve, causing a decrease in oxygen saturation of haemoglobin. In the UK, there are approximately 50 deaths per year from accidental carbon monoxide poisoning.
Symptoms of carbon monoxide toxicity include headache, nausea and vomiting, vertigo, confusion, and subjective weakness. Severe toxicity can result in pink skin and mucosae, hyperpyrexia, arrhythmias, extrapyramidal features, coma, and even death.
To diagnose carbon monoxide poisoning, pulse oximetry may not be reliable due to similarities between oxyhaemoglobin and carboxyhaemoglobin. Therefore, a venous or arterial blood gas should be taken to measure carboxyhaemoglobin levels. Non-smokers typically have levels below 3%, while smokers have levels below 10%. Symptomatic patients have levels between 10-30%, and severe toxicity is indicated by levels above 30%. An ECG may also be useful to check for cardiac ischaemia.
In the emergency department, patients with suspected carbon monoxide poisoning should receive 100% high-flow oxygen via a non-rebreather mask. This decreases the half-life of carboxyhemoglobin and should be administered as soon as possible, with treatment continuing for a minimum of six hours. Target oxygen saturations are 100%, and treatment is generally continued until all symptoms have resolved. For more severe cases, hyperbaric oxygen therapy may be considered, as it has been shown to have better long-term outcomes than standard oxygen therapy. Indications for hyperbaric oxygen therapy include loss of consciousness, neurological signs other than headache, myocardial ischaemia or arrhythmia, and pregnancy.
Overall, understanding the pathophysiology, symptoms, and management of carbon monoxide poisoning is crucial in preventing and treating this potentially deadly condition.
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This question is part of the following fields:
- Pharmacology
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Question 23
Incorrect
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A 27-year-old woman, who is 30 weeks pregnant, reports feeling breathless during a routine prenatal appointment. Upon examination, you observe that everything appears normal except for mild hyperventilation. What is the probable discovery during pregnancy?
Your Answer:
Correct Answer: Decrease in total lung capacity
Explanation:Changes in Physiological Parameters during Pregnancy
During pregnancy, various physiological changes occur in a woman’s body to support the growing fetus. One of these changes is a decrease in total lung capacity by approximately 200 ml. This reduction is due to a decrease in residual volume caused by the fetus. However, the basal metabolic rate increases during pregnancy. Additionally, cardiac output can increase by up to 40%, while the glomerular filtration rate (GFR) normally increases. Maternal oxygen consumption also rises during pregnancy to meet the oxygen demands of the fetus, leading to an increase in minute volume. These changes in physiological parameters are essential for the healthy development of the fetus and the mother’s well-being during pregnancy.
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This question is part of the following fields:
- Obstetrics
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Question 24
Incorrect
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A 35-year-old woman presents to her GP complaining of numbness and tingling in both hands, particularly at night. Upon examination, there is no weakness in finger flexion, extension, or abduction, but there is weakened pincer grip. Bilateral mild wasting of the thenar eminence is observed, and both Tinel's and Phalen's signs are positive in both hands. Based on her medical history, which of the following conditions is most likely to have predisposed her to this condition?
Your Answer:
Correct Answer: Rheumatoid Arthritis
Explanation:Bilateral carpal tunnel syndrome is frequently caused by rheumatoid arthritis, which is a common condition. This woman displays symptoms of bilateral carpal tunnel syndrome, which is an uncommon occurrence and typically results from conditions that enlarge the interstitial space with soft tissue growth or fluid. Although all of these conditions are linked to bilateral carpal tunnel syndrome, rheumatoid arthritis is the most probable cause in a 33-year-old. Acromegaly is more likely to cause carpal tunnel syndrome after the age of 50, and this association is well-known and frequently tested in exams.
Understanding Carpal Tunnel Syndrome
Carpal tunnel syndrome is a condition that occurs when the median nerve in the carpal tunnel is compressed. Patients with this condition typically experience pain or pins and needles in their thumb, index, and middle fingers. In some cases, the symptoms may even ascend proximally. Patients often shake their hand to obtain relief, especially at night.
During an examination, doctors may observe weakness of thumb abduction and wasting of the thenar eminence (not the hypothenar). Tapping on the affected area may cause paraesthesia, which is known as Tinel’s sign. Flexion of the wrist may also cause symptoms, which is known as Phalen’s sign.
Carpal tunnel syndrome can be caused by a variety of factors, including idiopathic reasons, pregnancy, oedema (such as heart failure), lunate fracture, and rheumatoid arthritis. Electrophysiology tests may show prolongation of the action potential in both motor and sensory nerves.
Treatment for carpal tunnel syndrome may include a 6-week trial of conservative treatments, such as corticosteroid injections and wrist splints at night. If symptoms persist or are severe, surgical decompression (flexor retinaculum division) may be necessary.
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This question is part of the following fields:
- Musculoskeletal
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Question 25
Incorrect
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A 26-year-old female patient arrives at the emergency department with worsening periorbital oedema, erythema, and drainage in her left eye. During examination, mild proptosis is observed. To further investigate her symptoms, a point of care ultrasound is conducted, revealing retro-orbital soft tissue prominence and oedema with echogenic fat. What is the appropriate treatment plan for this patient based on the underlying diagnosis?
Your Answer:
Correct Answer: Intravenous antimicrobial
Explanation:Hospital admission for IV antibiotics is necessary for patients with orbital cellulitis due to the potential for cavernous sinus thrombosis and intracranial spread. It is imperative that all patients with a clinical diagnosis of orbital cellulitis be admitted to the hospital and receive an ophthalmic evaluation as soon as possible. Oral antimicrobial treatment is inadequate in this situation, as intravenous antibiotic therapy is required to manage this medical emergency. Failure to treat orbital cellulitis promptly may result in blindness or even death. Therefore, no antimicrobial other than intravenous antibiotics is appropriate for this condition. Topical antimicrobial treatment is also insufficient for managing orbital cellulitis.
Understanding Orbital Cellulitis: Causes, Symptoms, and Management
Orbital cellulitis is a serious infection that affects the fat and muscles behind the orbital septum within the orbit, but not the globe. It is commonly caused by upper respiratory tract infections that spread from the sinuses and can lead to a high mortality rate. On the other hand, periorbital cellulitis is a less severe infection that occurs in the superficial tissues anterior to the orbital septum. However, it can progress to orbital cellulitis if left untreated.
Risk factors for orbital cellulitis include childhood, previous sinus infections, lack of Haemophilus influenzae type b (Hib) vaccination, recent eyelid infections or insect bites, and ear or facial infections. Symptoms of orbital cellulitis include redness and swelling around the eye, severe ocular pain, visual disturbance, proptosis, ophthalmoplegia, eyelid edema, and ptosis. In rare cases, meningeal involvement can cause drowsiness, nausea, and vomiting.
To differentiate between orbital and preseptal cellulitis, doctors look for reduced visual acuity, proptosis, and ophthalmoplegia, which are not consistent with preseptal cellulitis. Full blood count and clinical examination involving complete ophthalmological assessment are necessary to determine the severity of the infection. CT with contrast can also help identify inflammation of the orbital tissues deep to the septum and sinusitis. Blood culture and microbiological swab are also necessary to determine the organism causing the infection.
Management of orbital cellulitis requires hospital admission for IV antibiotics. It is a medical emergency that requires urgent senior review. Early diagnosis and treatment are crucial to prevent complications and reduce the risk of mortality.
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This question is part of the following fields:
- Ophthalmology
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Question 26
Incorrect
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A 55-year-old woman arrives at the emergency department with a sudden and severe headache, which she describes as the worst she has ever experienced. The headache came on while she was sitting at her desk. She also reports feeling nauseous and vomiting.
During the examination, the woman displays neck stiffness, photophobia, and appears drowsy. A CT scan reveals hyperdense across the basal cisterns and sulci.
What is the appropriate course of action for managing the complications of this condition?Your Answer:
Correct Answer: Nimodipine
Explanation:A subarachnoid haemorrhage (SAH) is a type of bleeding that occurs within the subarachnoid space of the meninges in the brain. It can be caused by head injury or occur spontaneously. Spontaneous SAH is often caused by an intracranial aneurysm, which accounts for around 85% of cases. Other causes include arteriovenous malformation, pituitary apoplexy, and mycotic aneurysms. The classic symptoms of SAH include a sudden and severe headache, nausea and vomiting, meningism, coma, seizures, and ECG changes.
The first-line investigation for SAH is a non-contrast CT head, which can detect acute blood in the basal cisterns, sulci, and ventricular system. If the CT is normal within 6 hours of symptom onset, a lumbar puncture is not recommended. However, if the CT is normal after 6 hours, a lumbar puncture should be performed at least 12 hours after symptom onset to check for xanthochromia and other CSF findings consistent with SAH. If SAH is confirmed, referral to neurosurgery is necessary to identify the underlying cause and provide urgent treatment.
Management of aneurysmal SAH involves supportive care, such as bed rest, analgesia, and venous thromboembolism prophylaxis. Vasospasm is prevented with oral nimodipine, and intracranial aneurysms require prompt intervention to prevent rebleeding. Most aneurysms are treated with a coil by interventional neuroradiologists, but some require a craniotomy and clipping by a neurosurgeon. Complications of aneurysmal SAH include re-bleeding, hydrocephalus, vasospasm, and hyponatraemia. Predictive factors for SAH include conscious level on admission, age, and amount of blood visible on CT head.
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This question is part of the following fields:
- Surgery
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Question 27
Incorrect
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A 35-year-old woman presents to her Accident and Emergency with visual loss. She has known persistently uncontrolled hypertension, previously managed in the community. Blood tests are performed as follows:
Investigation Patient Normal value
Sodium (Na+) 148 mmol/l 135–145 mmol/l
Potassium (K+) 2.7 mmol/l 3.5–5.0 mmol/l
Creatinine 75 μmol/l 50–120 µmol/
Chloride (Cl–) 100 mEq/l 96–106 mEq/l
What is the next most appropriate investigation?Your Answer:
Correct Answer: Aldosterone-to-renin ratio
Explanation:Investigating Hypertension in a Young Patient: The Importance of Aldosterone-to-Renin Ratio
Hypertension in a young patient with hypernatraemia and hypokalaemia can be caused by renal artery stenosis or an aldosterone-secreting adrenal adenoma. To determine the cause, measuring aldosterone levels alone is not enough. Both renin and aldosterone levels should be measured, and the aldosterone-to-renin ratio should be evaluated. If hyperaldosteronism is confirmed, CT or MRI of the adrenal glands is done to locate the cause. If both are normal, adrenal vein sampling may be performed. MR angiogram of renal arteries is not a first-line investigation. Similarly, CT angiogram of renal arteries should not be the first choice. 24-hour urine metanephrine levels are not useful in this scenario. The electrolyte abnormalities point towards elevated aldosterone levels, not towards a phaeochromocytoma.
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This question is part of the following fields:
- Cardiology
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Question 28
Incorrect
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An 80-year-old woman has been referred to a Gastroenterologist by her General Practitioner due to epigastric discomfort and the development of jaundice over several months. The patient reports no pain but has experienced unintentional weight loss. During examination, no abdominal tenderness or mass is detected. Serology results indicate that the patient has recently been diagnosed with diabetes. What is the most probable diagnosis?
Your Answer:
Correct Answer: Pancreatic carcinoma
Explanation:Differentiating between Gastrointestinal Conditions
When presented with a patient experiencing symptoms such as weight loss, jaundice, and epigastric discomfort, it is important to consider various gastrointestinal conditions that may be causing these symptoms. One possible diagnosis is pancreatic carcinoma, which is often associated with painless jaundice and the development of diabetes. Hepatitis, caused by viral infection or excessive alcohol intake, can also lead to liver cancer. Chronic pancreatitis, typically caused by alcohol misuse, can result in pain and dysfunction of the pancreas. Gastritis, on the other hand, is often caused by prolonged use of nonsteroidal anti-inflammatory drugs or infection with Helicobacter pylori, and can lead to gastric ulcers and bleeding. Finally, hepatocellular carcinoma can be caused by chronic hepatitis B or C, or chronic excessive alcohol intake. Proper diagnosis and treatment of these conditions is crucial for the patient’s health and well-being.
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This question is part of the following fields:
- Gastroenterology
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Question 29
Incorrect
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A 63-year-old man, who has had diabetes for the past eight years, visits the Endocrine Clinic with complaints of abdominal fullness and occasional pain. He reports experiencing anorexia, acid reflux, belching, and bloating. He is currently taking glimepiride, metformin, and exenatide and has generally had good control of his blood sugar. However, his last two tests have shown a trend of increasing fasting glucose levels. What is the next appropriate step in managing his condition?
Your Answer:
Correct Answer: Change diabetic medication
Explanation:Changing Diabetic Medication for Gastroparesis
A diabetic patient is experiencing delayed gastric emptying, a common side-effect of GLP-1 agonists like exenatide. To achieve better glycaemic control and prevent current side-effects, the patient’s diabetic medication needs to be changed. However, converting to insulin is not necessary for gastroparesis. Intensifying the current medication is not appropriate due to significant side-effects. Before considering a prokinetic agent like metoclopramide or domperidone, the GLP-1 analogue should be stopped. Treatment for H. pylori infection is not warranted as the patient’s symptoms are not indicative of peptic ulcer disease.
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This question is part of the following fields:
- Endocrinology
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Question 30
Incorrect
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A 35-year-old male executive presents to you after being referred from the Emergency department. He has been experiencing a painful and swollen left knee for the past 24 hours. He denies any history of joint problems or trauma. Additionally, he has noticed redness and soreness in both eyes over the last two days. He is a non-smoker, married, and consumes about 10 units of alcohol weekly. He recently returned from a business trip to Amsterdam two weeks ago.
During examination, his temperature is 38.5°C, and he has a brown macular rash on the soles of his feet. His left knee is hot, swollen, and tender to palpate, while no other joint appears to be affected.
Investigations reveal Hb 129 g/L (130-180), WBC 14.0 ×109/L (4-11), Platelets 200 ×109/L (150-400), ESR 75 mm/hr (0-15), Plasma sodium 140 mmol/L (137-144), Plasma potassium 4.1 mmol/L (3.5-4.9), Plasma urea 5.6 mmol/L (2.5-7.5), Blood cultures without growth after 48 hours, and Urinalysis without blood, glucose, or protein detected. Knee x-ray shows soft tissue swelling around the left knee.
What is the most likely diagnosis?Your Answer:
Correct Answer: Reactive arthritis
Explanation:Reactive Arthritis
Reactive arthritis is a medical condition that is typically characterized by a combination of three symptoms: urethritis, conjunctivitis, and seronegative arthritis. This type of arthritis usually affects the large weight-bearing joints, such as the knee and ankle, but not all three symptoms are always present in a patient. Reactive arthritis can be triggered by either a sexually transmitted infection or a dysenteric infection. One of the most notable signs of this condition is the appearance of a brown macular rash known as keratoderma blennorrhagica, which is usually seen on the palms and soles.
The main treatment for reactive arthritis involves the use of non-steroidal anti-inflammatory drugs (NSAIDs). These medications can help to alleviate the pain and inflammation associated with the condition. Additionally, antibiotics may be prescribed to individuals who have recently experienced a non-gonococcal venereal infection. This can help to reduce the likelihood of that person developing reactive arthritis. Overall, the symptoms and treatment options for reactive arthritis can help individuals to manage this condition and improve their quality of life.
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This question is part of the following fields:
- Rheumatology
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Question 31
Incorrect
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Which substance, when found in high levels in the bloodstream, hinders the production and release of parathyroid hormone (PTH)?
Your Answer:
Correct Answer: Calcium
Explanation:Regulation of PTH secretion
Parathyroid hormone (PTH) secretion is regulated by various factors. One of these factors is the concentration of calcium in the plasma. When the calcium concentration is high, PTH synthesis and secretion are suppressed. On the other hand, an increase in serum phosphate stimulates PTH secretion. Another factor that affects PTH secretion is the extracellular free calcium level. When the level of extracellular free calcium rises, it stimulates a parathyroid membrane-bound calcium receptor, which inhibits PTH secretion. Therefore, the regulation of PTH secretion is a complex process that involves multiple factors, including calcium and phosphate levels in the blood. Proper regulation of PTH secretion is essential for maintaining calcium and phosphate homeostasis in the body.
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This question is part of the following fields:
- Endocrinology
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Question 32
Incorrect
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A 67-year-old woman with a history of rheumatoid arthritis complains of pain in her left middle finger when she tries to bend it. She also experienced it getting 'stuck' once. During examination, a palpable nodule is found at the base of the finger. What is the probable diagnosis?
Your Answer:
Correct Answer: Trigger finger
Explanation:Understanding Trigger Finger
Trigger finger is a condition that affects the flexion of the digits, and is believed to be caused by a discrepancy in size between the tendon and pulleys through which they pass. This results in the tendon becoming stuck and unable to move smoothly through the pulley. While the majority of cases are idiopathic, trigger finger is more common in women than men and is associated with conditions such as rheumatoid arthritis and diabetes mellitus.
The condition typically affects the thumb, middle, or ring finger, and is characterized by stiffness and snapping when extending a flexed digit. A nodule may also be felt at the base of the affected finger. Management of trigger finger often involves steroid injections, which are successful in the majority of patients. A finger splint may be applied afterwards. Surgery is typically reserved for patients who have not responded to steroid injections. While there is some suggestion of a link between trigger finger and repetitive use, evidence to support this is limited.
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This question is part of the following fields:
- Musculoskeletal
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Question 33
Incorrect
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A 20-year-old male patient comes to you with a fever and rash one week after returning from a trip to Puerto Rico. He reports that his fever began five days ago and was followed by the appearance of a rash. Additionally, he has noticed bleeding gums while brushing his teeth and has experienced two nosebleeds since returning from his vacation. During the examination, you observe multiple mosquito bites on his legs. What is the probable diagnosis?
Your Answer:
Correct Answer: Dengue fever
Explanation:Dengue Fever
Dengue fever is a viral infection that is transmitted through the bite of an infected Aedes mosquito. It is prevalent in tropical countries, with an estimated 100 million people being infected annually. The symptoms of dengue fever include fever, headache, muscle pain, nausea, vomiting, skin rash, and mild bleeding. However, it cannot be spread from person to person.
The high-risk areas for dengue fever include the Indian subcontinent, Southeast Asia, Southern China, Taiwan, Pacific Islands, Caribbean, Mexico, Africa, and Central and South America. Diagnosis is made through a blood test to identify the virus, and treatment is supportive with symptom control. Unfortunately, there are currently no vaccines available to prevent dengue fever.
The best way to prevent infection is to avoid mosquito bites. This can be done by wearing protective clothing, using mosquito repellent, and staying in air-conditioned or screened areas. the symptoms and risk factors of dengue fever can help individuals take necessary precautions to protect themselves from this potentially serious illness.
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This question is part of the following fields:
- Infectious Diseases
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Question 34
Incorrect
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A 76-year-old woman who has recently seen her GP for a change in bowel habit towards constipation arrives in the Emergency Department with a tender, distended abdomen. She has also been suffering with a chest infection recently and has known chronic kidney disease (CKD) stage 4. Bowel sounds are absent. The rectum is empty on examination. Abdominal X-ray reveals distended loops of large bowel, consistent with large bowel obstruction.
Which one of these investigations should be performed next?Your Answer:
Correct Answer: Computed tomography (CT) scan with Gastrografin®
Explanation:Imaging and Diagnostic Procedures for Bowel Obstruction in CKD Patients
Computed tomography (CT) scan with Gastrografin® is a safe and effective diagnostic tool for patients with chronic kidney disease (CKD) who present with bowel obstruction. This oral contrast medium provides crucial diagnostic information without posing a significant risk of renal injury. It is important to differentiate between large bowel obstruction and pseudo-obstruction, which can be achieved through imaging studies. Diagnostic peritoneal lavage is not indicated in the absence of trauma. Gastroscopy is not necessary as the issue is bowel obstruction, and an ultrasound would not provide the level of detail needed. While magnetic resonance imaging (MRI) can provide quality images, a CT scan is more readily available and can be organized faster.
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This question is part of the following fields:
- Colorectal
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Question 35
Incorrect
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A 67-year-old woman has had bowel surgery two days ago. She is currently on postoperative day one, and you are called to see her as she has developed sudden-onset shortness of breath. She denies any coughing but complains of chest discomfort. The surgical scar appears clean. Upon examination, the patient is afebrile; vital signs are stable other than rapid and irregular heartbeat and upon auscultation, the chest sounds are clear. The patient does not have any other significant past medical history, aside from her breast cancer for which she had a mastectomy five years ago. She has no family history of any heart disease.
What is the patient’s most likely diagnosis?Your Answer:
Correct Answer: Pulmonary embolism
Explanation:Differential Diagnosis for Sudden Onset Shortness of Breath postoperatively
When a patient experiences sudden onset shortness of breath postoperatively, it is important to consider various differential diagnoses. One possible diagnosis is pulmonary embolism, which is supported by the patient’s chest discomfort. Anaphylaxis is another potential diagnosis, but there is no mention of an allergen exposure or other signs of a severe allergic reaction. Pneumonia is unlikely given the absence of fever and clear chest sounds. Lung fibrosis is also an unlikely diagnosis as it typically presents gradually and is associated with restrictive respiratory diseases. Finally, cellulitis is not a probable diagnosis as there are no signs of infection and the surgical wound is clean. Overall, a thorough evaluation is necessary to determine the underlying cause of the patient’s sudden onset shortness of breath.
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This question is part of the following fields:
- Respiratory
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Question 36
Incorrect
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A 24-year-old pregnant woman arrives at 16 weeks gestation with painless vaginal bleeding, excessive morning sickness, and shortness of breath. During a routine examination, her abdomen shows a uterus that extends up to the umbilicus. An ultrasound reveals a solid collection of echoes with several small anechoic spaces. What is the probable diagnosis?
Your Answer:
Correct Answer: Hydatidiform mole
Explanation:A Hydatidiform mole, also known as a molar pregnancy, is a type of gestational trophoblastic disease that is precancerous. It occurs due to an imbalance in chromosomes during pregnancy, resulting in non-viable pregnancies. The main symptoms include painless vaginal bleeding in early pregnancy and a uterus that is larger than expected. The abnormal trophoblastic tissue can produce excessive amounts of human chorionic gonadotropin (hCG), leading to hyperemesis gravidarum and thyrotoxicosis. Ultrasound is a useful tool for diagnosis, with the mole appearing as a solid collection of echoes with numerous small anechoic spaces, resembling a bunch of grapes. It is important to note that a large uterus extending up to the umbilicus is indicative of a pregnancy that is large for dates, ruling out fibroids as a possible cause. Miscarriage and ectopic pregnancy are unlikely due to the absence of pain.
Gestational trophoblastic disorders refer to a range of conditions that originate from the placental trophoblast. These disorders include complete hydatidiform mole, partial hydatidiform mole, and choriocarcinoma. Complete hydatidiform mole is a benign tumor of trophoblastic material that occurs when an empty egg is fertilized by a single sperm that duplicates its own DNA, resulting in all 46 chromosomes being of paternal origin. Symptoms of this disorder include bleeding in the first or early second trimester, exaggerated pregnancy symptoms, a uterus that is large for dates, and very high levels of human chorionic gonadotropin (hCG) in the serum. Hypertension and hyperthyroidism may also be present. Urgent referral to a specialist center is necessary, and evacuation of the uterus is performed. Effective contraception is recommended to avoid pregnancy in the next 12 months, as around 2-3% of cases may develop choriocarcinoma.
Partial hydatidiform mole, on the other hand, occurs when a normal haploid egg is fertilized by two sperms or by one sperm with duplication of the paternal chromosomes. As a result, the DNA is both maternal and paternal in origin, and the fetus may have triploid chromosomes, such as 69 XXX or 69 XXY. Fetal parts may also be visible. It is important to note that hCG can mimic thyroid-stimulating hormone (TSH), which may lead to hyperthyroidism.
In summary, gestational trophoblastic disorders are a group of conditions that arise from the placental trophoblast. Complete hydatidiform mole and partial hydatidiform mole are two types of these disorders. While complete hydatidiform mole is a benign tumor of trophoblastic material that occurs when an empty egg is fertilized by a single sperm that duplicates its own DNA, partial hydatidiform mole occurs when a normal haploid egg is fertilized by two sperms or by one sperm with duplication of the paternal chromosomes. It is important to seek urgent medical attention and effective contraception to avoid pregnancy in the next 12 months.
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This question is part of the following fields:
- Obstetrics
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Question 37
Incorrect
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A 65-year-old male with a 10 year history of hypertension and diabetes has been on a medication regimen for the past two years. He takes metformin 1 g bd, gliclazide 80 mg bd, rosuvastatin 10 mg daily, ramipril 10 mg daily, aspirin 75 mg daily, and amlodipine 10 mg daily. During his annual review, his blood pressure is 138/82 mmHg, and he has background diabetic retinopathy. His foot pulses are normal, but he has peripheral sensory loss to the ankles in both feet. His lab results show HbA1c of 55 mmol/mol (20-46), urea of 12.5 mmol/L (2.5-7.5), creatinine of 176 µmol/L (60-110), and cholesterol of 4.8 mmol/L (<5.2). Which medication should be discontinued?
Your Answer:
Correct Answer: Metformin
Explanation:Metformin Use in Patients with Chronic Renal Impairment
Patients with chronic renal impairment may have elevated levels of creatinine and urea, which can affect the clearance of drugs like metformin. Current guidelines recommend discontinuing metformin if creatinine levels exceed 150 µmol/L to prevent life-threatening lactic acidosis. This complication was traditionally thought to be caused by an accumulation of the drug, but recent studies suggest that tissue hypoxia and other acute or chronic conditions may also play a role.
Metformin is excreted unchanged in the urine, and its half-life is prolonged in patients with decreased creatinine clearance. This can occur chronically in patients with chronic renal impairment or acutely with dehydration, shock, or intravascular administration of iodinated contrast agents. These factors can alter renal function and increase the risk of lactic acidosis.
While some conditions may act as triggers for lactic acidosis, such as sepsis, acute myocardial infarction, pulmonary embolism, cardiac failure, and chronic liver disease, it is unlikely that the patient in this case has renal artery stenosis requiring the withdrawal of the ACEi. Therefore, it is important to monitor patients with chronic renal impairment who are taking metformin and adjust their dosage or discontinue the drug if necessary to prevent serious complications.
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This question is part of the following fields:
- Endocrinology
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Question 38
Incorrect
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A 30-year-old man is brought to the Emergency Department after being involved in an altercation, during which he was stabbed in his lower back. On examination, he has right leg weakness in all muscle groups. Further examination reveals that he has loss of vibration and proprioception on the same side. In his left leg, there is loss of pain and temperature sensation, but preserved motor strength. He has no problems with bladder or bowel retention. His motor strength is preserved in his upper limbs.
With which one of the following spinal cord syndromes is his presentation consistent?Your Answer:
Correct Answer: Hemisection of the cord
Explanation:Overview of Spinal Cord Syndromes
Spinal cord syndromes are a group of neurological disorders that affect the spinal cord and its associated nerves. These syndromes can be caused by various factors, including trauma, infection, and degenerative diseases. Here are some of the most common spinal cord syndromes:
Hemisection of the Cord (Brown-Sequard Syndrome)
This syndrome is characterized by ipsilateral loss of vibration and proprioception, as well as ipsilateral hemiplegia. On the other hand, there is contralateral loss of pain and temperature sensation. Hemisection of the cord is usually caused by a stab injury.Central Cord Syndrome
Central cord syndrome causes bilateral weakness of the limbs, with the upper limbs being more affected than the lower extremities. This is because the upper limbs are represented medially in the corticospinal tracts.Anterior Cord Syndrome
In anterior cord syndrome, proprioception, vibratory sense, and light touch are preserved. However, there is bilateral weakness and loss of pain and temperature sensation due to involvement of the spinothalamic tracts.Posterior Cord Syndrome
Posterior cord syndrome is characterized by loss of vibratory sense and proprioception below the level of the lesion, as well as total sensory loss at the level of the lesion.Cauda Equina Syndrome
Cauda equina syndrome is caused by compressive lesions at L4/L5 or L5/S1. Symptoms include asymmetric weakness, saddle anesthesia, decreased reflexes at the knee, and radicular pain. Bowel and bladder retention may develop as late complications.In conclusion, understanding the different types of spinal cord syndromes is crucial in diagnosing and treating patients with neurological disorders.
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This question is part of the following fields:
- Neurosurgery
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Question 39
Incorrect
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A 57-year-old man visits his General Practitioner with complaints of back and hip pain. He has been experiencing pain for a few months and has been taking paracetamol for relief. However, the pain has worsened and is now affecting his quality of life. The patient has a medical history of type 2 diabetes mellitus and hypercholesterolaemia, which are managed with regular metformin and simvastatin. He has never been hospitalized before. Blood tests reveal normal calcium and phosphate levels, but a significantly elevated alkaline phosphatase (ALP) level while the other hepatic aminotransferases are normal. No other blood abnormalities are detected. What condition is most consistent with these blood test results in this patient?
Your Answer:
Correct Answer: Paget’s disease
Explanation:Differential Diagnosis for Bone and Joint Pain: Paget’s Disease
Paget’s disease is a musculoskeletal pathology that can cause bone and joint pain. This disease is often asymptomatic for many years before being diagnosed through abnormal blood tests or X-ray images. Symptoms of Paget’s disease include constant, dull bone pain, joint pain, stiffness, and swelling. Shooting pain, numbness, tingling, or loss of movement may also occur.
Other potential causes of bone and joint pain were considered and ruled out. Primary hyperparathyroidism, osteoporosis, and osteoarthritis were all unlikely due to normal calcium, phosphate, and ALP levels. Osteomalacia, a condition caused by vitamin D deficiency, can also cause bone and joint pain, but it is accompanied by low calcium and phosphate levels and a raised ALP.
In conclusion, based on the patient’s symptoms and blood test results, Paget’s disease is the most likely diagnosis for their bone and joint pain.
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This question is part of the following fields:
- Orthopaedics
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Question 40
Incorrect
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A mother brings her 18-day old baby to the emergency department with visible jaundice and distress. The baby has been feeding poorly since yesterday. Upon examination, hepatomegaly and splenomegaly are observed. The newborn jaundice screen shows no infection, normal thyroid function tests, raised conjugated bilirubin, liver transaminases, and bile acids. Reducing substances are absent in the urine. What is the initial management option for the most probable diagnosis?
Your Answer:
Correct Answer: Surgical intervention
Explanation:Biliary atresia is diagnosed when a newborn presents with prolonged jaundice, hepatomegaly, splenomegaly, abnormal growth, and cardiac murmurs. Surgery is the preferred treatment, specifically a hepatoportoenterostomy (HPE), also known as Kasai portoenterostomy. This procedure removes the blocked bile ducts and replaces them with a segment of the small intestine, restoring bile flow from the liver to the proximal small bowel. Ursodeoxycholic acid may be given as an adjuvant after surgery to facilitate bile flow and protect the liver. However, it should not be given if the total bilirubin is >256.6 micromol/L (>15 mg/dL). Frequent monitoring is not sufficient, urgent action is required. Liver transplant is not the first-line treatment, but may be considered if HPE is unsuccessful or if there are signs of end-stage liver disease, progressive cholestasis, hepatocellular decompensation, or severe portal hypertension.
Understanding Biliary Atresia in Neonatal Children
Biliary atresia is a condition that affects the extrahepatic biliary system in neonatal children, resulting in an obstruction in the flow of bile. This condition is more common in females than males and occurs in 1 in every 10,000-15,000 live births. There are three types of biliary atresia, with type 3 being the most common. Patients typically present with jaundice, dark urine, pale stools, and abnormal growth.
To diagnose biliary atresia, doctors may perform various tests, including serum bilirubin, liver function tests, serum alpha 1-antitrypsin, sweat chloride test, and ultrasound of the biliary tree and liver. Surgical intervention is the only definitive treatment for biliary atresia, and medical intervention includes antibiotic coverage and bile acid enhancers following surgery.
Complications of biliary atresia include unsuccessful anastomosis formation, progressive liver disease, cirrhosis, and eventual hepatocellular carcinoma. However, the prognosis is good if surgery is successful. In cases where surgery fails, liver transplantation may be required in the first two years of life. Overall, understanding biliary atresia is crucial for early diagnosis and effective management in neonatal children.
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This question is part of the following fields:
- Paediatrics
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Question 41
Incorrect
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A 17-year-old boy with cystic fibrosis is due for his yearly check-up. He was diagnosed with cystic fibrosis 16 years ago. Despite having good exercise tolerance and minimal gastrointestinal symptoms, he has been hospitalized twice in the past year. His recent blood work shows iron-deficient anemia, and multiple sputum cultures have tested positive for Burkholderia species. His latest FEV1 is 55% of his predicted value. What aspect of his medical history poses the greatest risk for mortality?
Your Answer:
Correct Answer: Burkholderia species on sputum culture
Explanation:Increases the likelihood of death and illness to a greater extent.
Managing Cystic Fibrosis: A Multidisciplinary Approach
Cystic fibrosis (CF) is a chronic condition that requires a multidisciplinary approach to management. Regular chest physiotherapy and postural drainage, as well as deep breathing exercises, are essential to maintain lung function and prevent complications. Parents are usually taught how to perform these techniques. A high-calorie diet, including high-fat intake, is recommended to meet the increased energy needs of patients with CF. Vitamin supplementation and pancreatic enzyme supplements taken with meals are also important.
Patients with CF should try to minimize contact with each other to prevent cross-infection with Burkholderia cepacia complex and Pseudomonas aeruginosa. Chronic infection with Burkholderia cepacia is an important CF-specific contraindication to lung transplantation. In cases where lung transplantation is necessary, careful consideration is required to ensure the best possible outcome.
Lumacaftor/Ivacaftor (Orkambi) is a medication used to treat cystic fibrosis patients who are homozygous for the delta F508 mutation. Lumacaftor increases the number of CFTR proteins that are transported to the cell surface, while ivacaftor is a potentiator of CFTR that is already at the cell surface. This increases the probability that the defective channel will be open and allow chloride ions to pass through the channel pore.
It is important to note that the standard recommendation for CF patients has changed from high-calorie, low-fat diets to high-calorie diets to reduce the amount of steatorrhea. With a multidisciplinary approach to management, patients with CF can lead fulfilling lives and manage their condition effectively.
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This question is part of the following fields:
- Paediatrics
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Question 42
Incorrect
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A 15-year-old boy comes to the emergency department complaining of groin pain that has been present for the past two hours. He reports feeling nauseous and has vomited twice. He admits to having unprotected sexual intercourse recently. Upon examination, there is swelling and tenderness in the left testicle and scrotum. The left side lacks the cremaster reflex, and lifting the affected testicle causes more pain. What is the probable diagnosis?
Your Answer:
Correct Answer: Testicular torsion
Explanation:Testicular torsion is a condition where the testis twists on the remnant of the processus vaginalis, leading to restricted blood flow. The main symptom is severe testicular pain, which may be accompanied by nausea and vomiting. The affected testis may also appear swollen and red. The cremaster reflex may be absent on the affected side, and elevating the testicle can worsen the pain.
While the patient had unprotected sex recently, the symptoms are not typical of epididymitis, which usually involves urinary symptoms and relief of pain with testicular elevation (Prehn’s sign positive).Acute Scrotal Disorders in Children: Differential Diagnoses
When a child presents with an acute scrotal problem, it is crucial to rule out testicular torsion as it requires immediate surgical intervention. The most common age for testicular torsion is around puberty. On the other hand, an irreducible inguinal hernia is more common in children under two years old. Epididymitis, which is inflammation of the epididymis, is rare in prepubescent children. It is important to consider these differential diagnoses when evaluating a child with an acute scrotal disorder. Proper diagnosis and prompt treatment can prevent serious complications and ensure the best possible outcome for the child.
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This question is part of the following fields:
- Paediatrics
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Question 43
Incorrect
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You are asked to assess a male infant born 18 hours ago, at 35 weeks gestation, due to concerns raised by the nursing staff. Upon conducting a comprehensive examination and taking note of the mother's positive group B streptococcus status, you tentatively diagnose the baby with neonatal sepsis and commence treatment. What is the most frequently observed feature associated with this condition?
Your Answer:
Correct Answer: Respiratory distress
Explanation:Neonatal Sepsis: Causes, Risk Factors, and Management
Neonatal sepsis is a serious bacterial or viral infection in the blood that affects babies within the first 28 days of life. It is categorized into early-onset (EOS) and late-onset (LOS) sepsis, with each category having distinct causes and common presentations. The most common causes of neonatal sepsis are group B streptococcus (GBS) and Escherichia coli, accounting for approximately two-thirds of cases. Premature and low birth weight babies are at higher risk, as well as those born to mothers with GBS colonization or infection during pregnancy. Symptoms can vary from subtle signs of illness to clear septic shock, and diagnosis is usually established through blood culture. Treatment involves early identification and use of intravenous antibiotics, with duration depending on ongoing investigations and clinical picture. Other important management factors include maintaining adequate oxygenation and fluid and electrolyte status.
Neonatal Sepsis: Causes, Risk Factors, and Management
Neonatal sepsis is a serious infection that affects newborn babies within the first 28 days of life. It can be caused by a variety of bacteria and viruses, with GBS and E. coli being the most common. Premature and low birth weight babies, as well as those born to mothers with GBS colonization or infection during pregnancy, are at higher risk. Symptoms can range from subtle signs of illness to clear septic shock, and diagnosis is usually established through blood culture. Treatment involves early identification and use of intravenous antibiotics, with duration depending on ongoing investigations and clinical picture. Other important management factors include maintaining adequate oxygenation and fluid and electrolyte status.
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This question is part of the following fields:
- Paediatrics
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Question 44
Incorrect
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A 65-year-old woman diagnosed with primary breast cancer is considering whether or not to give her consent for an axillary node clearance. What specific complication should she be informed of regarding this procedure?
Your Answer:
Correct Answer: Lymphedema causing functional arm impairment
Explanation:Functional arm impairment is a potential consequence of lymphedema, which carries a risk following axillary lymph node dissection. While other complications are theoretically possible, they are not commonly observed. A study published in the Annals of Plastic Surgery in April 2019 quantified the impact of radiation and a lymphatic microsurgical preventive healing approach on lymphedema incidence.
Breast cancer management varies depending on the stage of the cancer, type of tumor, and patient’s medical history. Treatment options may include surgery, radiotherapy, hormone therapy, biological therapy, and chemotherapy. Surgery is typically the first option for most patients, except for elderly patients with metastatic disease who may benefit more from hormonal therapy. Prior to surgery, an axillary ultrasound is recommended for patients without palpable axillary lymphadenopathy, while those with clinically palpable lymphadenopathy require axillary node clearance. The type of surgery offered depends on various factors, such as tumor size, location, and type. Breast reconstruction is also an option for patients who have undergone a mastectomy.
Radiotherapy is recommended after a wide-local excision to reduce the risk of recurrence, while mastectomy patients may receive radiotherapy for T3-T4 tumors or those with four or more positive axillary nodes. Hormonal therapy is offered if tumors are positive for hormone receptors, with tamoxifen being used in pre- and perimenopausal women and aromatase inhibitors like anastrozole in postmenopausal women. Tamoxifen may increase the risk of endometrial cancer, venous thromboembolism, and menopausal symptoms. Biological therapy, such as trastuzumab, is used for HER2-positive tumors but cannot be used in patients with a history of heart disorders. Chemotherapy may be used before or after surgery, depending on the stage of the tumor and the presence of axillary node disease. FEC-D is commonly used in the latter case.
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This question is part of the following fields:
- Surgery
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Question 45
Incorrect
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A newborn is 24 hours old and was born at term. The mother had gestational diabetes during her pregnancy. The mother has chosen to exclusively formula feed the baby. The infant is currently comfortable on the postnatal ward, and the latest capillary blood glucose reading is 2.3mmol/L. The physical examination shows no abnormalities.
What is the recommended course of action for management?Your Answer:
Correct Answer: Encourage formula feeding
Explanation:Dextrose intravenously or glucose gel would be necessary only if the baby remained hypoglycemic despite the standard feeding method or exhibited symptoms. Therefore, these responses are incorrect.
Neonatal Hypoglycaemia: Causes, Symptoms, and Management
Neonatal hypoglycaemia is a common condition in newborn babies, especially in the first 24 hours of life. While there is no agreed definition, a blood glucose level of less than 2.6 mmol/L is often used as a guideline. Transient hypoglycaemia is normal and usually resolves on its own, but persistent or severe hypoglycaemia may be caused by various factors such as preterm birth, maternal diabetes mellitus, IUGR, hypothermia, neonatal sepsis, inborn errors of metabolism, nesidioblastosis, or Beckwith-Wiedemann syndrome.
Symptoms of neonatal hypoglycaemia can be autonomic, such as jitteriness, irritability, tachypnoea, and pallor, or neuroglycopenic, such as poor feeding/sucking, weak cry, drowsiness, hypotonia, and seizures. Other features may include apnoea and hypothermia. Management of neonatal hypoglycaemia depends on the severity of the condition and whether the newborn is symptomatic or not. Asymptomatic babies can be encouraged to feed normally and have their blood glucose monitored, while symptomatic or severely hypoglycaemic babies may need to be admitted to the neonatal unit and receive intravenous infusion of 10% dextrose.
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This question is part of the following fields:
- Paediatrics
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Question 46
Incorrect
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A 65-year-old man comes to the emergency department complaining of intermittent abdominal pain for the past 24 hours. He is experiencing vomiting and has not been able to eat. During the examination, scleral icterus is observed, and there is guarding in the right upper quadrant. His vital signs show a heart rate of 110 bpm, respiratory rate of 25/min, temperature of 37.9ºC, and blood pressure of 100/60 mmHg. What is the probable diagnosis?
Your Answer:
Correct Answer: Ascending cholangitis
Explanation:The correct diagnosis for this patient is ascending cholangitis, as evidenced by the presence of Charcot’s triad of fever, jaundice, and right upper quadrant pain. This condition is commonly caused by gallstones and is often seen in individuals with recurrent biliary colic. It is important to note that acute cholangitis is a medical emergency and requires immediate treatment with antibiotics and preparation for endoscopic retrograde cholangiopancreatography (ERCP).
Acute cholecystitis is a possible differential diagnosis, but it is less likely in this case as it typically presents without jaundice. Acute pancreatitis is also a potential differential, but it is characterized by epigastric pain that radiates to the back and is relieved by sitting up. A serum amylase or lipase test can help differentiate between the two conditions. Biliary colic is another possible diagnosis, but the presence of secondary infective signs and jaundice suggest a complication of gallstones, such as cholangitis.
Understanding Ascending Cholangitis
Ascending cholangitis is a bacterial infection that affects the biliary tree, with E. coli being the most common culprit. This condition is often associated with gallstones, which can predispose individuals to the infection. Patients with ascending cholangitis may present with Charcot’s triad, which includes fever, right upper quadrant pain, and jaundice. However, this triad is only present in 20-50% of cases. Other common symptoms include hypotension and confusion. In severe cases, Reynolds’ pentad may be observed, which includes the additional symptoms of hypotension and confusion.
To diagnose ascending cholangitis, ultrasound is typically used as a first-line investigation to look for bile duct dilation and stones. Raised inflammatory markers may also be observed. Treatment involves intravenous antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction.
Overall, ascending cholangitis is a serious condition that requires prompt diagnosis and treatment. Understanding the symptoms and risk factors associated with this condition can help individuals seek medical attention early and improve their chances of a successful recovery.
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This question is part of the following fields:
- Surgery
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Question 47
Incorrect
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A 42-year-old man presents to his GP with complaints of persistent flu-like symptoms. Upon further inquiry, he reports experiencing fever, nausea, vomiting, muscle aches, weakness, and an itchy sensation for the past two weeks. He also mentions having red urine on a few occasions. The patient denies having any respiratory symptoms such as cough or haemoptysis. During the examination, the GP observes slight scleral icterus and small palpable purpura on the patient's lower legs and arms. Based on these findings, what is the most probable diagnosis?
Your Answer:
Correct Answer: Polyarteritis nodosa
Explanation:The presence of systemic vasculitic symptoms, along with signs of hepatitis B and the absence of pulmonary symptoms, indicates that the patient may have polyarteritis nodosa. The patient’s symptoms appear to be viral, except for the presence of itchiness, scleral jaundice, haematuria, and purpura, which suggest vasculitis. The absence of respiratory symptoms helps to eliminate other possible diagnoses, such as polymyalgia rheumatica. The patient’s scleral jaundice and itchiness may indicate obstructive hepatic impairment. Polyarteritis nodosa is strongly associated with hepatitis B infection and does not typically present with respiratory symptoms, unlike other types of vasculitis.
Polyarteritis Nodosa: Symptoms, Features, and Diagnosis
Polyarteritis nodosa (PAN) is a type of vasculitis that affects medium-sized arteries, causing inflammation and aneurysm formation. It is more common in middle-aged men and is often associated with hepatitis B infection. Symptoms of PAN include fever, malaise, weight loss, hypertension, and joint pain. It can also cause nerve damage, testicular pain, and a skin condition called livedo reticularis. In some cases, patients may experience kidney damage and renal failure. Diagnosis of PAN may involve testing for perinuclear-antineutrophil cytoplasmic antibodies (ANCA) and hepatitis B serology. Angiograms may also be used to detect changes in the affected arteries.
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This question is part of the following fields:
- Musculoskeletal
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Question 48
Incorrect
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A 50-year-old woman presents with a 1-month history of fatigue, aches, constipation, and nausea. She reports increased thirst and waking at night to pass urine, and has been experiencing a low mood that has kept her from leaving the house frequently. The following investigations were performed:
- Hb 140 g/L (115 - 160)
- WBC 5.9 * 109/L (4.0 - 11.0)
- Calcium 2.8 mmol/L (2.1-2.6)
- PTH 75 pg/mL (10 - 55)
- ALP 130 µmol/L (30 - 100)
- Phosphate 0.4 mmol/L (0.8-1.4)
- Urea 5.3 mmol/L (2.0 - 7.0)
- Creatinine 68 µmol/L (55 - 120)
- 25-hydroxycholecalciferol 48 nmol/L (>50)
- eGFR 62 ml/min/1.73 m2
What is the most likely underlying cause of her presentation?Your Answer:
Correct Answer: Parathyroid adenoma
Explanation:The diagnosis of chronic kidney disease is incorrect in this case. An eGFR below 90 can still be considered normal if it is above 60 and there are no abnormalities in the U&Es. The patient’s eGFR is 62 and their urea and creatinine levels are within normal range, indicating that they do not have CKD. In cases of CKD, secondary hyperparathyroidism may occur, which would result in different blood test results. Since the kidneys are responsible for activating vitamin D, which is essential for the absorption of calcium in the intestines, low serum calcium levels would be expected in CKD. Additionally, due to kidney dysfunction, there would be inadequate excretion of phosphate, leading to increased serum phosphate levels. This increase in phosphate levels would cause calcium to be deposited in the insoluble calcium phosphate salt, further lowering calcium levels. Therefore, the symptoms of hypercalcemia that the patient is experiencing would not be present in secondary hyperparathyroidism caused by CKD. In summary, hyperparathyroidism secondary to CKD would result in low calcium and high phosphate levels, rather than high calcium and low phosphate levels.
Lab Values for Bone Disorders
When it comes to bone disorders, certain lab values can provide important information for diagnosis and treatment. In cases of osteoporosis, calcium, phosphate, alkaline phosphatase (ALP), and parathyroid hormone (PTH) levels are typically within normal ranges. However, in osteomalacia, there is a decrease in calcium and phosphate levels, an increase in ALP levels, and an increase in PTH levels.
Primary hyperparathyroidism, which can lead to osteitis fibrosa cystica, is characterized by increased calcium and PTH levels, but decreased phosphate levels. Chronic kidney disease can also lead to secondary hyperparathyroidism, with decreased calcium levels and increased phosphate and PTH levels.
Paget’s disease, which causes abnormal bone growth, typically shows normal calcium and phosphate levels, but an increase in ALP levels. Osteopetrosis, a rare genetic disorder that causes bones to become dense and brittle, typically shows normal lab values for calcium, phosphate, ALP, and PTH.
Overall, understanding these lab values can help healthcare professionals diagnose and treat various bone disorders.
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This question is part of the following fields:
- Musculoskeletal
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Question 49
Incorrect
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A 60-year-old man visits the clinic with his 35-year-old son, who has been diagnosed with IgA nephropathy and is in CKD stage 5. The man wishes to be evaluated as a potential live kidney donor for his son. He has a history of mild hypertension that is managed with 2.5 mg of ramipril daily. He has never had any surgeries, does not smoke, and only drinks alcohol in moderation.
As part of the consent process for kidney donation, what advice should be provided to the patient?Your Answer:
Correct Answer: There is no significant increase in hypertension in donors compared to the general population
Explanation:The Health Benefits and Risks of Being a Kidney Donor
Surprisingly, being a kidney donor can have health benefits. Studies have shown that live donors have lower long-term morbidity and mortality rates than the general population. This is likely due to the rigorous screening process that selects only those with excellent overall health.
While reducing renal mass could potentially lead to a decrease in glomerular filtration rate and an increased risk of end-stage renal failure or hypertension, large-scale studies with up to 35 years of follow-up have shown no increased risk compared to the general population. However, potential donors should be warned about the possibility of end-stage renal failure, particularly those with borderline GFR for donation.
As with any surgery, there are risks involved in kidney donation. The risk of death is quoted at 1 in 3000, and there is a 1-2% risk of major complications such as pneumothorax, injury to other organs, renovascular injury, DVT, or PE. There is also a 20% risk of minor complications such as post-operative atelectasis, pneumonia, wound infection, hematoma, incisional hernia, or urinary tract infection.
To ensure the safety of potential donors, they undergo thorough screening, including a comprehensive medical history, family history, and physical examination. They also undergo extensive investigations of cardiovascular, respiratory, and psychological fitness, as well as multiple tests of renal function and anatomy to determine if it is safe to proceed and select the kidney to be removed.
In conclusion, kidney donation can have health benefits for the donor, but it is not without risks. Only the healthiest individuals are selected as donors, and they undergo rigorous screening to ensure their safety.
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This question is part of the following fields:
- Nephrology
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Question 50
Incorrect
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A 47-year-old woman with a history of breast cancer, requiring a lumpectomy two years ago, is currently on tamoxifen therapy and presents to her follow-up clinic with her partner.
She is feeling down, has a low mood and reports difficulty sleeping due to hot flashes. She is seeking assistance in improving her mood.
What is the most appropriate course of action for this patient?Your Answer:
Correct Answer: Referral for cognitive behavioural therapy (CBT)
Explanation:Treatment Options for Menopausal Symptoms in Breast Cancer Patients
Breast cancer patients experiencing mood disturbance, anxiety, and depression related to menopausal symptoms can benefit from cognitive behavioural therapy (CBT) and lifestyle modifications. A 2-week trial of fluoxetine may be an option, but it is contraindicated in patients receiving tamoxifen therapy. Combined cyclic hormonal replacement therapy (HRT) is not routinely offered due to the increased risk of breast cancer recurrence, but can be prescribed in exceptional circumstances. Over-the-counter herbal products like black cohosh are not recommended due to safety concerns and potential interactions with medications. Lifestyle changes such as reducing caffeine and alcohol consumption, using a handheld fan, and regular exercise can also help alleviate symptoms.
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This question is part of the following fields:
- Gynaecology
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