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  • Question 1 - A 32-year-old woman presents to her General Practitioner with a 4-day history of...

    Incorrect

    • A 32-year-old woman presents to her General Practitioner with a 4-day history of abdominal cramps and watery diarrhoea. Her symptoms started two days after she ate a salad from a restaurant.
      Which of the following is the most likely causative organism?

      Your Answer: Rotavirus

      Correct Answer: Campylobacter jejuni

      Explanation:

      Campylobacter jejuni is a prevalent cause of bacterial food poisoning in the UK, typically transmitted through contaminated food or drink. Symptoms usually appear 2-5 days after exposure and may include abdominal cramps, diarrhea (which may or may not be bloody), nausea, vomiting, and fever. While symptoms are usually mild and self-limiting, severe cases or immunocompromised patients may require antibiotic treatment. Bacillus cereus and Clostridium perfringens are less likely causes of food poisoning due to their short incubation periods and milder symptoms. Rotavirus is a common cause of viral gastroenteritis in children, but adults are rarely affected due to immunity. Staphylococcus aureus can also cause food poisoning, with symptoms appearing 2-6 hours after ingestion and including nausea, vomiting, and abdominal pain.

    • This question is part of the following fields:

      • Infectious Diseases
      14.7
      Seconds
  • Question 2 - A 47-year-old male presents to the emergency department with a productive cough and...

    Correct

    • A 47-year-old male presents to the emergency department with a productive cough and fever. He has a medical history of systemic lupus erythematosus, gout, dyspepsia, and had a renal transplant 3 years ago. His current medications include azathioprine, allopurinol, and omeprazole. He drinks 25 units of alcohol a week and has done so for the past decade.

      His vital signs are as follows:
      Respiratory rate of 34 /min
      Pulse of 123 bpm
      Temperature of 39.4ºC
      Blood pressure of 84/56 mmHg
      Oxygen saturation of 94% on room air

      Blood results show:
      Hb 90 g/L Male: (135-180)
      Platelets 85 * 109/L (150 - 400)
      WBC 1.3 * 109/L (4.0 - 11.0)
      Neuts 0.7 * 109/L (2.0 - 7.0)

      What drug interaction is likely responsible for this patient's presentation?

      Your Answer: Azathioprine and allopurinol use

      Explanation:

      The use of allopurinol in combination with azathioprine can increase the risk of myelosuppression and neutropenic sepsis. This is because azathioprine is metabolized to its active form, 6-mercaptopurine, which is then metabolized by xanthine oxidase. Allopurinol inhibits xanthine oxidase, leading to an accumulation of 6-mercaptopurine and an increased risk of myelosuppression. Chronic alcohol use and omeprazole use do not significantly increase the risk of myelosuppression when used with azathioprine or allopurinol.

      Allopurinol is a medication used to prevent gout by inhibiting xanthine oxidase. Traditionally, it was believed that urate-lowering therapy (ULT) should not be started until two weeks after an acute attack to avoid further attacks. However, the evidence supporting this is weak, and the British Society of Rheumatology (BSR) now recommends delaying ULT until inflammation has settled to make long-term drug decisions while the patient is not in pain. The initial dose of allopurinol is 100 mg once daily, with the dose titrated every few weeks to aim for a serum uric acid level of less than 300 µmol/l. Colchicine cover should be considered when starting allopurinol, and NSAIDs can be used if colchicine cannot be tolerated. ULT is recommended for patients with two or more attacks in 12 months, tophi, renal disease, uric acid renal stones, prophylaxis if on cytotoxics or diuretics, and Lesch-Nyhan syndrome.

      The most significant adverse effects of allopurinol are dermatological, and patients should stop taking the medication immediately if they develop a rash. Severe cutaneous adverse reaction (SCAR), drug reaction with eosinophilia and systemic symptoms (DRESS), and Stevens-Johnson syndrome are potential risks. Certain ethnic groups, such as the Chinese, Korean, and Thai people, are at an increased risk of these dermatological reactions. Patients at high risk of severe cutaneous adverse reaction should be screened for the HLA-B *5801 allele. Allopurinol can interact with other medications, such as azathioprine, cyclophosphamide, and theophylline. Azathioprine is metabolized to the active compound 6-mercaptopurine, which is oxidized to 6-thiouric acid by xanthine oxidase. Allopurinol can lead to high levels of 6-mercaptopurine, so a much-reduced dose must be used if the combination cannot be avoided. Allopurinol also reduces renal clearance of cyclophosphamide, which may cause marrow toxicity. Additionally, allopurinol causes an increase in plasma concentration of theophylline by inhibiting its breakdown.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      43.6
      Seconds
  • Question 3 - A 65-year-old man with a history of type 2 diabetes, angina, and erectile...

    Correct

    • A 65-year-old man with a history of type 2 diabetes, angina, and erectile dysfunction presents with complaints of rectal pain. During a per rectum examination, the patient experiences discomfort and an anal ulceration is discovered. What is the most probable cause of this man's symptoms?

      Your Answer: Nicorandil

      Explanation:

      Nicorandil, a medication used for angina, can lead to anal ulceration as a potential adverse effect. GTN spray may cause headaches, dizziness, and low blood pressure. Gastric discomfort is a possible side effect of both metformin and ibuprofen. Excessive use of paracetamol can result in liver damage.

      Nicorandil is a medication that is commonly used to treat angina. It works by activating potassium channels, which leads to vasodilation. This process is achieved by stimulating guanylyl cyclase, which increases the levels of cGMP in the body. However, there are some adverse effects associated with the use of nicorandil, including headaches, flushing, and the development of ulcers in the skin, mucous membranes, and eyes. Additionally, nicorandil can cause gastrointestinal ulcers, including anal ulceration. It is important to note that nicorandil should not be used in patients with left ventricular failure.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      37.5
      Seconds
  • Question 4 - A 55-year-old woman presents to the Emergency Department with a sudden-onset blurring of...

    Incorrect

    • A 55-year-old woman presents to the Emergency Department with a sudden-onset blurring of vision in both eyes as well as light sensitivity. She is a known type II diabetic with blood sugars well maintained with medication.
      On examination, her temperature is 36.8 oC, while her blood pressure (BP) is 180/110 mmHg. Her pulse is 70 beats per minute. Her respiratory rate is 18 breaths per minute, and her oxygen saturations are 98% on room air.
      On dilated fundoscopy, both optic discs are swollen with widespread flame-shaped haemorrhages and cotton-wool spots.
      What is the most appropriate first-line management of this condition?

      Your Answer: Oral amlodipine

      Correct Answer: Intravenous (IV) labetalol

      Explanation:

      Misconceptions about Treatment for Hypertensive Retinopathy

      Hypertensive retinopathy is a condition that occurs when high blood pressure damages the blood vessels in the retina. However, there are several misconceptions about the treatment for this condition.

      Firstly, in a hypertensive emergency with retinopathy, it is important to lower blood pressure slowly to avoid brain damage. Intravenous labetalol is a suitable medication for this purpose, with the aim of reducing diastolic blood pressure to 100 mmHg or reducing it by 20-25 mmHg per day, whichever is less.

      Secondly, oral calcium channel blockers like amlodipine are not useful in an acute setting of hypertensive emergency. They are not effective in treating hypertensive retinopathy.

      Thirdly, intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection is not a treatment for hypertensive retinopathy. It is used to treat wet age-related macular degeneration.

      Fourthly, pan-retinal photocoagulation or any laser treatment for the eye is not a treatment for hypertensive retinopathy. It is a treatment for proliferative diabetic retinopathy.

      Lastly, sublingual glyceryl trinitrate (GTN) spray is not a suitable treatment for hypertensive retinopathy. It is typically used in patients with angina and acute coronary syndrome.

      In conclusion, it is important to understand the appropriate treatments for hypertensive retinopathy to avoid misconceptions and ensure proper care for patients.

    • This question is part of the following fields:

      • Ophthalmology
      33.9
      Seconds
  • Question 5 - You assess a 45-year-old male with Marfan's syndrome. What is the probable reason...

    Correct

    • You assess a 45-year-old male with Marfan's syndrome. What is the probable reason for mortality in individuals with this condition?

      Your Answer: Aortic dissection

      Explanation:

      Aortic dissection may be more likely to occur in individuals with Marfan’s syndrome due to the dilation of the aortic sinuses.

      Understanding Marfan’s Syndrome

      Marfan’s syndrome is a genetic disorder that affects the connective tissue in the body. It is caused by a defect in the FBN1 gene on chromosome 15, which codes for the protein fibrillin-1. This disorder is inherited in an autosomal dominant pattern, meaning that a person only needs to inherit one copy of the defective gene from one parent to develop the condition. Marfan’s syndrome affects approximately 1 in 3,000 people.

      The features of Marfan’s syndrome include a tall stature with an arm span to height ratio greater than 1.05, a high-arched palate, arachnodactyly (long, slender fingers), pectus excavatum (sunken chest), pes planus (flat feet), and scoliosis (curvature of the spine). In addition, individuals with Marfan’s syndrome may experience cardiovascular problems such as dilation of the aortic sinuses, mitral valve prolapse, and aortic aneurysm. They may also have lung issues such as repeated pneumothoraces. Eye problems are also common, including upwards lens dislocation, blue sclera, and myopia. Finally, dural ectasia, or ballooning of the dural sac at the lumbosacral level, may also occur.

      In the past, the life expectancy of individuals with Marfan’s syndrome was around 40-50 years. However, with regular echocardiography monitoring and the use of beta-blockers and ACE inhibitors, this has improved significantly in recent years. Despite these improvements, aortic dissection and other cardiovascular problems remain the leading cause of death in individuals with Marfan’s syndrome.

    • This question is part of the following fields:

      • Musculoskeletal
      12.8
      Seconds
  • Question 6 - A 45-year-old woman, who came to the Emergency Department two days ago for...

    Correct

    • A 45-year-old woman, who came to the Emergency Department two days ago for uncontrolled epistaxis, has been admitted following Ear, Nose and Throat (ENT) referral. Bleeding was located and managed by anterior nasal packing. She had no complications following the procedure. However, on the third day, she developed fever, myalgia, hypotension, rashes in the genital mucocutaneous junctions, generalized oedema and several episodes of bloody diarrhoea, with nausea and vomiting.
      Which of the following investigations/findings would help you make a diagnosis?

      Your Answer: Culture and sensitivity of posterior nasal swab

      Explanation:

      Interpreting Laboratory Findings in a Patient with Posterior Nasal Swab Procedure

      Toxic shock syndrome (TSS) is a potential complication of an infected posterior nasal swab in the management of epistaxis. A culture and sensitivity test of the posterior nasal swab can confirm the presence of Staphylococcus aureus, which is recovered in 80-90% of cases. However, a positive result is not necessary for a clinical diagnosis of TSS if the patient presents with fever, rashes, hypotension, nausea, vomiting, and watery diarrhea, along with derangements reflecting shock and organ failure.

      Blood cultures are not required for the diagnosis of TSS caused by S. aureus, as only 5% of cases turn out to be positive. Eosinophilia is not characteristic of TSS, but rather a hallmark of drug reactions with eosinophilia and systemic symptoms (DRESS). TSS is characterized by leukocytosis, while Kawasaki’s disease is characterized by an increase in acute phase reactants (erythrocyte sedimentation rate and C-reactive protein) and localized edema.

      A non-blanching purpuric rash is typically seen in meningococcal infection and does not match with the other clinical features and history of posterior nasal swab procedure in this patient.

    • This question is part of the following fields:

      • ENT
      52.8
      Seconds
  • Question 7 - A 35-year-old woman presents with postcoital bleeding and intermenstrual bleeding. She reports a...

    Incorrect

    • A 35-year-old woman presents with postcoital bleeding and intermenstrual bleeding. She reports a history of chlamydia infection in her early 20s but has been in a monogamous relationship for the past five years. Pelvic examination six months ago was normal, with an unremarkable and easily located cervix. However, the sample was positive for human papillomavirus (HPV) and demonstrates high-grade dyskaryosis.
      Which of the following is the most appropriate diagnostic test?

      Your Answer: Endocervical swab for Chlamydia spp.

      Correct Answer: Colposcopy and biopsy within two weeks

      Explanation:

      Understanding Cervical Cancer and Abnormal Smear Test Results

      Cervical cancer is a common malignancy in women worldwide and can be detected through routine cervical screening. An abnormal Papanicolaou (‘smear’) test result is the most common finding in patients with cervical cancer. Physical symptoms may include abnormal vaginal bleeding, vaginal discomfort, malodorous discharge, and dysuria. Referral for colposcopy and biopsy should be made within two weeks for patients with symptoms of cervical cancer. Women with a cervical cytology result of moderate, high-grade dyskaryosis, suspected invasive cancer or glandular neoplasia should also be referred for colposcopy within two weeks. Cervical cauterisation with silver nitrate is not associated with the development of cervical cancer and is used to treat cervical ectropion. Endocervical swab for Chlamydia spp. may be necessary for women presenting with mucopurulent cervicitis. Understanding these guidelines and symptoms can help with early detection and treatment of cervical cancer.

    • This question is part of the following fields:

      • Reproductive Medicine
      30.6
      Seconds
  • Question 8 - A 48-year-old man presents to the emergency department with his spouse. He is...

    Incorrect

    • A 48-year-old man presents to the emergency department with his spouse. He is experiencing significant swelling of his tongue and lips, rendering him unable to speak. His wife reports that his symptoms have worsened during their wait, and she is unsure of the cause as he has no known allergies. However, she does mention that he was recently prescribed a new medication by his primary care physician.
      Which of the following medications is the most probable culprit?

      Your Answer: Omeprazole

      Correct Answer: Ramipril

      Explanation:

      Although it is possible for the man to have been prescribed any of the medications listed, it is evident that he is experiencing angioedema, as indicated by the swelling of his tongue and lips. Ramipril, an ACE inhibitor, is the medication most commonly associated with this side effect. Even if the patient has no history of allergies or negative reactions to ACE inhibitors, angioedema can still occur. While the likelihood of this happening is low, it is important to keep in mind due to the large number of patients taking this type of medication and the potential complications associated with angioedema.

      Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. These inhibitors are also used to treat diabetic nephropathy and for secondary prevention of ischaemic heart disease. The mechanism of action of ACE inhibitors is to inhibit the conversion of angiotensin I to angiotensin II. They are metabolized in the liver through phase 1 metabolism.

      ACE inhibitors may cause side effects such as cough, which occurs in around 15% of patients and may occur up to a year after starting treatment. This is thought to be due to increased bradykinin levels. Angioedema may also occur up to a year after starting treatment. Hyperkalaemia and first-dose hypotension are other potential side effects, especially in patients taking diuretics. ACE inhibitors should be avoided during pregnancy and breastfeeding, and caution should be exercised in patients with renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema.

      Patients receiving high-dose diuretic therapy (more than 80 mg of furosemide a day) are at an increased risk of hypotension when taking ACE inhibitors. Before initiating treatment, urea and electrolytes should be checked, and after increasing the dose, a rise in creatinine and potassium may be expected. Acceptable changes include an increase in serum creatinine up to 30% from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment. The current NICE guidelines provide a flow chart for the management of hypertension.

    • This question is part of the following fields:

      • Immunology/Allergy
      30.4
      Seconds
  • Question 9 - A 19-year-old man is being examined for excessive bleeding after a tooth extraction....

    Incorrect

    • A 19-year-old man is being examined for excessive bleeding after a tooth extraction. The test results show:
      Platelet count: 173 * 109/l
      Prothrombin time (PT): 12.9 seconds
      Activated partial thromboplastin time (APTT): 84 seconds
      Which clotting factor is he most likely deficient in?

      Your Answer: Factor IX

      Correct Answer: Factor VIII

      Explanation:

      Understanding Haemophilia

      Haemophilia is a genetic disorder that affects blood coagulation. It is caused by a deficiency in either factor VIII (Haemophilia A) or factor IX (Haemophilia B), which are essential for blood clotting. Although it is an X-linked recessive disorder, up to 30% of patients have no family history of the condition.

      The symptoms of haemophilia include haemoarthroses, haematomas, and prolonged bleeding after surgery or trauma. Blood tests can confirm the diagnosis, with a prolonged APTT being a common finding. However, the bleeding time, thrombin time, and prothrombin time are usually normal.

      Treatment for haemophilia involves replacing the missing clotting factor through regular infusions. However, up to 10-15% of patients with haemophilia A may develop antibodies to factor VIII treatment, which can make it less effective.

      In summary, haemophilia is a genetic disorder that affects blood coagulation and can cause symptoms such as haemoarthroses and prolonged bleeding. Diagnosis is confirmed through blood tests, and treatment involves replacing the missing clotting factor.

    • This question is part of the following fields:

      • Haematology/Oncology
      15.6
      Seconds
  • Question 10 - An 80-year-old woman comes in for a routine eye exam and is found...

    Correct

    • An 80-year-old woman comes in for a routine eye exam and is found to have a reproducible peripheral vision defect in her left eye. She reports no noticeable changes in her vision. Tonometry shows intraocular pressure of 17 mmHg in the left eye and 19 mmHg in the right eye (normal range is 10-21 mmHg). Direct ophthalmoscopy reveals a cup-to-disc ratio of 0.8 (increased) in the left eye. Gonioscopy is normal and she has no significant medical history. What is the most likely diagnosis?

      Your Answer: Chronic open-angle glaucoma

      Explanation:

      The correct diagnosis for this patient is chronic open-angle glaucoma, which can sometimes occur even with normal intraocular pressure. The patient’s symptoms, such as gradual peripheral vision loss, and the increased cup-to-disc ratio seen on investigations point towards this diagnosis. Gonioscopy also revealed a normal drainage angle, confirming that this is open-angle glaucoma.

      Dry age-related macular degeneration is an incorrect diagnosis in this case, as it typically presents with central vision loss and drusen on ophthalmoscopy, not changes in the cup-to-disc ratio.

      Hypertensive retinopathy is also an unlikely diagnosis, as it is often asymptomatic and associated with a medical history of hypertension. Additionally, it has a characteristic appearance on ophthalmoscopy that does not include changes in the cup-to-disc ratio.

      Optic neuritis is another incorrect diagnosis, as it typically presents with painful vision loss and other symptoms such as loss of color vision or acuity. It is also often associated with multiple sclerosis, which would present with additional symptoms such as sensory or motor deficits or other cranial nerve palsies.

      Glaucoma is a condition where the optic nerve is damaged due to increased pressure in the eye. Primary open-angle glaucoma (POAG) is a type of glaucoma where the peripheral iris is clear of the trabecular meshwork, which is important in draining aqueous humour from the eye. POAG is more common in older individuals and those with a family history of the condition. It may present insidiously with symptoms such as peripheral visual field loss, decreased visual acuity, and optic disc cupping. Diagnosis is made through a series of investigations including automated perimetry, slit lamp examination, applanation tonometry, central corneal thickness measurement, and gonioscopy. It is important to assess the risk of future visual impairment based on factors such as IOP, CCT, family history, and life expectancy. Referral to an ophthalmologist is typically done through a GP.

    • This question is part of the following fields:

      • Ophthalmology
      49.2
      Seconds
  • Question 11 - A 50-year-old woman presents to you with a 3-week history of shoulder pain...

    Incorrect

    • A 50-year-old woman presents to you with a 3-week history of shoulder pain in both shoulders. A shoulder X-ray taken 2 weeks ago did not reveal any signs of osteoarthritis. Her blood tests show an elevated ESR of 50mm/hour. What is the most appropriate course of action for this probable diagnosis?

      Your Answer: Prescribe a trial of oral prednisolone 15mg daily and arrange follow up after 1 month to assess clinical response

      Correct Answer: Prescribe a trial of oral prednisolone 15mg daily and arrange follow up after 1 week to assess clinical response

      Explanation:

      The symptoms exhibited by this patient strongly indicate the presence of polymyalgia rheumatica, and thus, a one-week course of steroids should be administered to produce a significant improvement. Prescribing paracetamol for a month is unlikely to yield any noticeable relief. An MRI scan is not likely to aid in the diagnosis. Administering a prolonged course of steroids without periodic review is not recommended.

      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 arteritis, 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 15mg/od. Patients typically respond dramatically to steroids, and failure to do so should prompt consideration of an alternative diagnosis.

    • This question is part of the following fields:

      • Musculoskeletal
      41.3
      Seconds
  • Question 12 - A 42-year-old man from Burkina Faso visits his GP with a complaint of...

    Incorrect

    • A 42-year-old man from Burkina Faso visits his GP with a complaint of a persistent cough and unintentional weight loss of 2kg over the last 8 weeks. He denies experiencing night sweats and has never smoked or consumed alcohol. He works as a baker. During the examination, the doctor observes sensitive, erythematous pretibial nodules. The Mantoux test results are negative. What is the probable diagnosis?

      Your Answer: Mycoplasma pneumoniae infection

      Correct Answer: Sarcoidosis

      Explanation:

      Understanding Sarcoidosis: A Multisystem Disorder

      Sarcoidosis is a condition that affects multiple systems in the body and is characterized by the presence of non-caseating granulomas. Although the exact cause of sarcoidosis is unknown, it is more commonly seen in young adults and people of African descent.

      The symptoms of sarcoidosis can vary depending on the severity of the condition. Acute symptoms may include erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, and polyarthralgia. On the other hand, insidious symptoms may include dyspnea, non-productive cough, malaise, and weight loss. In some cases, sarcoidosis can also cause skin lesions such as lupus pernio and hypercalcemia due to increased conversion of vitamin D to its active form.

      Sarcoidosis can also present as different syndromes. Lofgren’s syndrome is an acute form of the disease characterized by bilateral hilar lymphadenopathy, erythema nodosum, fever, and polyarthralgia. It usually has a good prognosis. Mikulicz syndrome, which is now considered outdated and unhelpful by many, is characterized by enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis, or lymphoma. Heerfordt’s syndrome, also known as uveoparotid fever, is characterized by parotid enlargement, fever, and uveitis secondary to sarcoidosis.

      In conclusion, sarcoidosis is a complex condition that affects multiple systems in the body. Understanding the different symptoms and syndromes associated with sarcoidosis can help in the diagnosis and management of this condition.

    • This question is part of the following fields:

      • Respiratory Medicine
      23.4
      Seconds
  • Question 13 - A 43-year-old male patient presents with a chief complaint of hearing difficulty. During...

    Incorrect

    • A 43-year-old male patient presents with a chief complaint of hearing difficulty. During the examination, you perform Weber's test and find that he hears the sound most loudly in his right ear. On conducting Rinne test, the sound is loudest when the tuning fork is placed in front of the ear canal on the left and loudest when placed on the mastoid process on the right. What type of hearing loss is evident in this case?

      Your Answer: Mixed conductive and sensorineural hearing loss on left

      Correct Answer: Conductive hearing loss on the right

      Explanation:

      The presence of conductive hearing loss can be identified by conducting Rinne and Weber tests. During the Rinne test, bone conduction will be more audible than air conduction, while the Weber test will indicate the affected ear.

      If the hearing loss is conductive and affects the right ear, bone conduction will be louder than air conduction. This is because the ear canal, middle ear, or tympanic membrane is unable to conduct sound waves effectively. The Weber test will also indicate that the affected ear is where the sound is loudest.

      The other options provided are incorrect as they do not align with the results of the examination. In sensorineural hearing loss, air conduction is louder than bone conduction.

      Conductive hearing loss can be caused by various factors, including impacted earwax, inner ear effusion, debris or foreign objects in the ear canal, a perforated eardrum, or otosclerosis.

      Rinne’s and Weber’s Test for Differentiating Conductive and Sensorineural Deafness

      Rinne’s and Weber’s tests are two diagnostic tools used to differentiate between conductive and sensorineural deafness. Rinne’s test involves placing a tuning fork over the mastoid process until the sound is no longer heard, then repositioning it just over the external acoustic meatus. A positive test indicates that air conduction (AC) is better than bone conduction (BC), while a negative test suggests conductive deafness if BC is greater than AC.

      On the other hand, Weber’s test involves placing a tuning fork in the middle of the forehead equidistant from the patient’s ears and asking which side is loudest. In unilateral sensorineural deafness, sound is localized to the unaffected side, while in unilateral conductive deafness, sound is localized to the affected side.

      To interpret the results of Rinne’s and Weber’s tests, a normal result indicates that AC is greater than BC bilaterally, and the sound is midline in Weber’s test. Conductive hearing loss is indicated by BC being greater than AC in the affected ear, while AC is greater than BC in the unaffected ear, and the sound lateralizes to the affected ear in Weber’s test. Sensorineural hearing loss is indicated by AC being greater than BC bilaterally, and the sound lateralizes to the unaffected ear in Weber’s test.

    • This question is part of the following fields:

      • ENT
      65.1
      Seconds
  • Question 14 - A 16-year-old high school student visits his doctor because he is struggling with...

    Incorrect

    • A 16-year-old high school student visits his doctor because he is struggling with his self-esteem due to skin problems. During the examination, you observe multiple open and closed comedones mainly on his chin and cheeks. He also reports experiencing painful papules on his back. About six weeks ago, your colleague prescribed him topical benzoyl peroxide and topical fusidic acid, but he feels that they have not been effective. He has no medical history and is not taking any other medications. What is the most suitable treatment to initiate?

      Your Answer: Oral + topical antibiotics

      Correct Answer: Oral oxytetracycline

      Explanation:

      Acne vulgaris is a common skin condition that typically affects adolescents, with the face, neck, and upper trunk being the most commonly affected areas. It is characterized by the obstruction of hair follicles with keratin plugs, leading to the formation of comedones, inflammation, and pustules. The severity of acne can be classified as mild, moderate, or severe, depending on the presence and extent of inflammatory lesions, papules, and pustules.

      The management of acne vulgaris typically involves a step-up approach, starting with single topical therapy such as topical retinoids or benzoyl peroxide. If this is not effective, topical combination therapy may be used, which includes a topical antibiotic, benzoyl peroxide, and topical retinoid. Oral antibiotics such as tetracyclines may also be prescribed, but they should be avoided in pregnant or breastfeeding women and children under 12 years of age. Erythromycin may be used in pregnancy, while minocycline is now considered less appropriate due to the possibility of irreversible pigmentation. Oral antibiotics should be used for a maximum of three months and always co-prescribed with a topical retinoid or benzoyl peroxide to reduce the risk of antibiotic resistance.

      Combined oral contraceptives (COCP) are an alternative to oral antibiotics in women, and Dianette (co-cyrindiol) may be used as it has anti-androgen properties. However, it has an increased risk of venous thromboembolism compared to other COCPs, so it should generally be used second-line and for only three months. Oral isotretinoin is a potent medication that should only be used under specialist supervision, and it is contraindicated in pregnancy. Finally, there is no evidence to support dietary modification in the management of acne vulgaris.

    • This question is part of the following fields:

      • Dermatology
      29.3
      Seconds
  • Question 15 - A 32-year-old man comes to your clinic complaining of feeling down. He reports...

    Incorrect

    • A 32-year-old man comes to your clinic complaining of feeling down. He reports experiencing anhedonia, fatigue, weight loss, insomnia, and agitation. His PHQ-9 score is 20. What is the most appropriate course of action?

      Your Answer: Start fluoxetine

      Correct Answer: Start citalopram and refer for CBT

      Explanation:

      Based on the man’s PHQ-9 score and varied symptoms, it appears that he is suffering from severe depression. According to NICE guidelines, a combination of an antidepressant and psychological intervention is recommended for this level of depression, with an SSRI being the first choice antidepressant. Therefore, citalopram with CBT would be the appropriate treatment in this case. Referral to psychiatry is not necessary at this time. Venlafaxine would be considered as a later option if other antidepressants were ineffective. While fluoxetine is a good first-line antidepressant, it should be combined with a psychological intervention for severe depression. CBT alone is suitable for mild to moderate depression, but for severe depression, an antidepressant in combination with psychological intervention is recommended.

      In 2022, NICE updated its guidelines on managing depression and now classifies it as either less severe or more severe based on a patient’s PHQ-9 score. For less severe depression, NICE recommends discussing treatment options with patients and considering the least intrusive and resource-intensive treatment first. Antidepressant medication should not be routinely offered as first-line treatment unless it is the patient’s preference. Treatment options for less severe depression include guided self-help, group cognitive behavioral therapy, group behavioral activation, individual CBT or BA, group exercise, group mindfulness and meditation, interpersonal psychotherapy, SSRIs, counseling, and short-term psychodynamic psychotherapy. For more severe depression, NICE recommends a shared decision-making approach and suggests a combination of individual CBT and an antidepressant as the preferred treatment option. Other treatment options for more severe depression include individual CBT or BA, antidepressant medication, individual problem-solving, counseling, short-term psychodynamic psychotherapy, interpersonal psychotherapy, guided self-help, and group exercise.

    • This question is part of the following fields:

      • Psychiatry
      34.5
      Seconds
  • Question 16 - A 65-year-old man is being discharged after undergoing percutaneous coronary intervention for an...

    Incorrect

    • A 65-year-old man is being discharged after undergoing percutaneous coronary intervention for an acute coronary syndrome. He has no significant medical history prior to this event. What type of lipid modification therapy should have been initiated during his hospitalization?

      Your Answer: Atorvastatin 40mg on

      Correct Answer: Atorvastatin 80mg on

      Explanation:

      Atorvastatin 80 mg should be taken by patients who have already been diagnosed with CVD.

      The 2014 NICE guidelines recommend using the QRISK2 tool to identify patients over 40 years old who are at high risk of CVD, with a 10-year risk of 10% or greater. A full lipid profile should be checked before starting a statin, and atorvastatin 20mg should be offered first-line. Lifestyle modifications include a cardioprotective diet, physical activity, weight management, limiting alcohol intake, and smoking cessation. Follow-up should occur at 3 months, with consideration of increasing the dose of atorvastatin up to 80 mg if necessary.

    • This question is part of the following fields:

      • Cardiovascular
      21.6
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  • Question 17 - You are assessing a 50-year-old man who has been diagnosed with Barrett's oesophagus...

    Correct

    • You are assessing a 50-year-old man who has been diagnosed with Barrett's oesophagus following difficult to control symptoms. Biopsies did not reveal any dysplasia. What is the most strongly linked risk factor modification for the development of Barrett's oesophagus?

      Your Answer: Gastro-oesophageal reflux disease

      Explanation:

      Barrett’s oesophagus is most strongly associated with the presence of GORD as a risk factor.

      Understanding Barrett’s Oesophagus

      Barrett’s oesophagus is a condition where the lower oesophageal mucosa is replaced by columnar epithelium, increasing the risk of oesophageal adenocarcinoma by 50-100 fold. It is typically identified during an endoscopy for upper gastrointestinal symptoms such as dyspepsia. The length of the affected segment correlates strongly with the chances of identifying metaplasia, with the overall prevalence estimated to be around 1 in 20. Risk factors include gastro-oesophageal reflux disease (GORD), male gender, smoking, and central obesity. Interestingly, alcohol does not seem to be an independent risk factor for Barrett’s. Management includes high-dose proton pump inhibitors and endoscopic surveillance with biopsies every 3-5 years for patients with metaplasia. If dysplasia of any grade is identified, endoscopic intervention such as radiofrequency ablation or endoscopic mucosal resection is offered.

      Barrett’s oesophagus is a condition where the lower oesophageal mucosa is replaced by columnar epithelium, increasing the risk of oesophageal adenocarcinoma. It is typically identified during an endoscopy for upper gastrointestinal symptoms such as dyspepsia. The length of the affected segment correlates strongly with the chances of identifying metaplasia, with the overall prevalence estimated to be around 1 in 20. Risk factors include GORD, male gender, smoking, and central obesity. Interestingly, alcohol does not seem to be an independent risk factor for Barrett’s. Management includes high-dose proton pump inhibitors and endoscopic surveillance with biopsies every 3-5 years for patients with metaplasia. If dysplasia of any grade is identified, endoscopic intervention such as radiofrequency ablation or endoscopic mucosal resection is offered.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      20.7
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  • Question 18 - An 80-year-old man comes to the liver clinic for his regular check-up. He...

    Incorrect

    • An 80-year-old man comes to the liver clinic for his regular check-up. He has been a patient of the clinic for a while due to his liver cirrhosis caused by alcohol abuse. During the examination, he appears cachexic and jaundiced. Upon closer inspection of his abdomen, it is distended, and the shifting dullness test indicates the presence of free fluid in the abdomen. A sample of the fluid is collected, which shows 17g/l of fluid protein. What medication would be the most appropriate to prescribe?

      Your Answer: Terlipressin

      Correct Answer: Spironolactone

      Explanation:

      The recommended treatment for ascites in this patient with liver cirrhosis is spironolactone. This medication is an aldosterone antagonist that helps counteract the fluid overload caused by secondary hyperaldosteronism in patients with hepatic cirrhosis. Azathioprine is not appropriate for this patient as it is used to treat autoimmune hepatitis. Ciprofloxacin may be prescribed for spontaneous ascites, but only if the ascitic protein is 15 g/litre or less, which is not the case for this patient. Prednisolone is used for acute liver failure, which is not the diagnosis for this patient with chronic liver disease.

      Spironolactone is a medication that works as an aldosterone antagonist in the cortical collecting duct. It is used to treat various conditions such as ascites, hypertension, heart failure, nephrotic syndrome, and Conn’s syndrome. In patients with cirrhosis, spironolactone is often prescribed in relatively large doses of 100 or 200mg to counteract secondary hyperaldosteronism. It is also used as a NICE ‘step 4’ treatment for hypertension. However, it is important to note that spironolactone can cause hyperkalaemia and gynaecomastia, although the latter is less common with eplerenone.

      One study, known as RALES, found that low dose spironolactone can reduce all-cause mortality in patients with NYHA III + IV heart failure who are already taking an ACE inhibitor. It is important to consult with a healthcare professional before taking spironolactone to determine if it is the right medication for your specific condition and to monitor for any potential adverse effects.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      46.3
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  • Question 19 - You are having a consultation with a 49-year-old man for his initial diabetes...

    Correct

    • You are having a consultation with a 49-year-old man for his initial diabetes review. Following 3 months of metformin treatment, his HbA1c has shown improvement. Unfortunately, he hasn't been able to make any lifestyle modifications. You are content with the management of his type 2 diabetes mellitus. However, the patient reports experiencing significant gastrointestinal (GI) adverse effects due to metformin.

      What would be your approach to managing this patient?

      Your Answer: Switch to a modified-release formulation of metformin

      Explanation:

      If the patient experiences GI side-effects with metformin, it is recommended to try a modified-release formulation before considering switching to a second-line agent. Modified-release formulations are known to cause fewer GI side-effects compared to other formulations. It is advisable to continue with metformin as it is effective for the patient rather than trying another medication that may not work as well.

      Continuing with the same formulation of metformin is not a suitable solution as the patient is experiencing significant GI side-effects. Modified-release formulations can help manage diabetes while reducing these side-effects.

      Discontinuing all antidiabetic medications is not recommended as the patient has not made any lifestyle changes and requires medical support to manage their diabetes.

      While second-line agents like sulfonylureas may be effective in managing diabetes and reducing GI side-effects, they may not be as effective as metformin and may cause their own set of side-effects. These medications should be considered only when combination therapy is required.

      GLP-1 receptor antagonists are effective antidiabetic medications, but they are expensive and inconvenient as they require injection. Therefore, other medications should be tried before considering these.

      Metformin is a medication commonly used to treat type 2 diabetes mellitus. It belongs to a class of drugs called biguanides and works by activating the AMP-activated protein kinase (AMPK), which increases insulin sensitivity and reduces hepatic gluconeogenesis. Additionally, it may decrease the absorption of carbohydrates in the gastrointestinal tract. Unlike other diabetes medications, such as sulphonylureas, metformin does not cause hypoglycemia or weight gain, making it a first-line treatment option, especially for overweight patients. It is also used to treat polycystic ovarian syndrome and non-alcoholic fatty liver disease.

      While metformin is generally well-tolerated, gastrointestinal side effects such as nausea, anorexia, and diarrhea are common and can be intolerable for some patients. Reduced absorption of vitamin B12 is also a potential side effect, although it rarely causes clinical problems. In rare cases, metformin can cause lactic acidosis, particularly in patients with severe liver disease or renal failure. However, it is important to note that lactic acidosis is now recognized as a rare side effect of metformin.

      There are several contraindications to using metformin, including chronic kidney disease, recent myocardial infarction, sepsis, acute kidney injury, severe dehydration, and alcohol abuse. Additionally, metformin should be discontinued before and after procedures involving iodine-containing x-ray contrast media to reduce the risk of contrast nephropathy.

      When starting metformin, it is important to titrate the dose slowly to reduce the incidence of gastrointestinal side effects. If patients experience intolerable side effects, modified-release metformin may be considered as an alternative.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      25.2
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  • Question 20 - A 35-year-old Jewish woman has been diagnosed with breast cancer and found to...

    Correct

    • A 35-year-old Jewish woman has been diagnosed with breast cancer and found to be BRCA1-positive. What type of cancer is she most susceptible to developing?

      Your Answer: Ovarian cancer

      Explanation:

      BRCA-1 and BRCA-2 Mutations and Their Association with Cancer

      BRCA-1 and BRCA-2 are tumour suppressor genes that play a crucial role in repairing damaged DNA and preventing uncontrolled cell division. Mutations in these genes have been linked to an increased risk of developing various types of cancer, including breast, ovarian, prostate, pancreatic, and colorectal cancers. Ashkenazi Jews have a higher incidence of BRCA mutations, and women with a family history of breast cancer can be tested for these mutations. The risk of developing breast cancer is high for women with abnormal BRCA-1 or -2, but the risk for ovarian cancer is lower. There is currently no association between BRCA-1 mutations and cervical, endometrial, gastric, or lung cancer.

    • This question is part of the following fields:

      • Genetics
      20.3
      Seconds
  • Question 21 - A mother brings her 8-year-old daughter to her General Practitioner, who is acutely...

    Incorrect

    • A mother brings her 8-year-old daughter to her General Practitioner, who is acutely unwell and has a high temperature, runny nose and inflamed eyes. The mother explains that her daughter has not had her vaccinations as she is worried about the long-term effects of the measles, mumps and rubella (MMR) jab.
      Which of the following best reflects the current understanding of measles infection?

      Your Answer: Lifelong immunity is not established after natural infection

      Correct Answer: It is more dangerous in overcrowded households

      Explanation:

      Measles: Symptoms, Complications, and Prevention

      Measles is a highly contagious viral infection that can lead to serious respiratory complications such as pneumonia, bronchiolitis, and bronchiectasis. While it does not cause recurrent pneumothoraces, severe infection from prolonged exposure to infected siblings in overcrowded households can be fatal.

      Koplik’s spots, small red spots with bluish-white centers, are a characteristic late sign of measles infection that may appear on the mucous membranes of the mouth 1-2 days before the rash appears.

      Contrary to popular belief, lifelong immunity is often established after natural infection with measles. This is also the mechanism by which the MMR vaccine prevents measles infection in later life.

      Measles can also lead to corneal ulceration, especially in cases of vitamin A deficiency. High-dose oral vitamin A supplementation is recommended for all children with measles in developing countries to prevent this complication.

      Overall, prevention through vaccination is the best way to avoid the serious complications of measles.

    • This question is part of the following fields:

      • Infectious Diseases
      29.8
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  • Question 22 - A 42-year-old man with schizophrenia is brought to the clinic by one of...

    Incorrect

    • A 42-year-old man with schizophrenia is brought to the clinic by one of his caregivers. He is currently taking clozapine and procyclidine. The caregiver reports that he seems more fatigued than usual and generally not feeling well. She also suspects that he may have gained weight. What is the most crucial examination to conduct?

      Your Answer: Blood sugar

      Correct Answer: Full blood count

      Explanation:

      Monitoring FBC is crucial to detect agranulocytosis/neutropenia, a potentially fatal adverse reaction of clozapine. Additionally, patients taking this medication often experience weight gain.

      Atypical antipsychotics are now recommended as the first-line treatment for patients with schizophrenia, as per the 2005 NICE guidelines. These medications have the advantage of significantly reducing extrapyramidal side-effects. However, they can also cause adverse effects such as weight gain, hyperprolactinaemia, and in the case of clozapine, agranulocytosis. The Medicines and Healthcare products Regulatory Agency has issued warnings about the increased risk of stroke and venous thromboembolism when antipsychotics are used in elderly patients. Examples of atypical antipsychotics include clozapine, olanzapine, risperidone, quetiapine, amisulpride, and aripiprazole.

      Clozapine, one of the first atypical antipsychotics, carries a significant risk of agranulocytosis and requires full blood count monitoring during treatment. Therefore, it should only be used in patients who are resistant to other antipsychotic medication. The BNF recommends introducing clozapine if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs, one of which should be a second-generation antipsychotic drug, each for at least 6-8 weeks. Adverse effects of clozapine include agranulocytosis, neutropaenia, reduced seizure threshold, constipation, myocarditis, and hypersalivation. Dose adjustment of clozapine may be necessary if smoking is started or stopped during treatment.

    • This question is part of the following fields:

      • Psychiatry
      23.2
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  • Question 23 - A 35-year-old woman presents with excessive sweating and weight loss. Her partner reports...

    Incorrect

    • A 35-year-old woman presents with excessive sweating and weight loss. Her partner reports that she is constantly on edge and you notice a fine tremor during the consultation. A large, nontender goitre is also noted. Upon examination of her eyes, there is no evidence of exophthalmos. Her pulse rate is 96/min. The following results were obtained: Free T4 26 pmol/l, Free T3 12.2 pmol/l (3.0-7.5), and TSH < 0.05 mu/l. What is the most likely diagnosis?

      Your Answer: T3-secreting adenoma

      Correct Answer: Graves' disease

      Explanation:

      Graves’ Disease: Common Features and Unique Signs

      Graves’ disease is the most frequent cause of thyrotoxicosis, which is commonly observed in women aged 30-50 years. The condition presents typical features of thyrotoxicosis, such as weight loss, palpitations, and heat intolerance. However, Graves’ disease also exhibits specific signs that are not present in other causes of thyrotoxicosis. These include eye signs, such as exophthalmos and ophthalmoplegia, as well as pretibial myxoedema and thyroid acropachy. The latter is a triad of digital clubbing, soft tissue swelling of the hands and feet, and periosteal new bone formation.

      Autoantibodies are also present in Graves’ disease, including TSH receptor stimulating antibodies in 90% of patients and anti-thyroid peroxidase antibodies in 75% of patients. Thyroid scintigraphy can also aid in the diagnosis of Graves’ disease, as it shows diffuse, homogenous, and increased uptake of radioactive iodine.

      Overall, Graves’ disease presents with both typical and unique features that distinguish it from other causes of thyrotoxicosis. Early diagnosis and treatment are crucial to prevent complications and improve outcomes for patients.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      66.2
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  • Question 24 - A 3-year-old child with a history of atopic eczema presents to the clinic....

    Incorrect

    • A 3-year-old child with a history of atopic eczema presents to the clinic. The child's eczema is typically managed well with emollients, but the parents are worried as the facial eczema has worsened significantly overnight. The child now has painful blisters clustered on both cheeks, around the mouth, and on the neck. The child's temperature is 37.9ºC. What is the best course of action for management?

      Your Answer: Oral flucloxacillin

      Correct Answer: Admit to hospital

      Explanation:

      IV antivirals are necessary for the treatment of eczema herpeticum, which is a severe condition.

      Understanding Eczema Herpeticum

      Eczema herpeticum is a serious skin infection caused by herpes simplex virus 1 or 2. It is commonly observed in children with atopic eczema and is characterized by a rapidly progressing painful rash. The infection can be life-threatening, which is why it is important to seek medical attention immediately.

      During examination, doctors typically observe monomorphic punched-out erosions, which are circular, depressed, and ulcerated lesions that are usually 1-3 mm in diameter. Due to the severity of the infection, children with eczema herpeticum should be admitted to the hospital for intravenous aciclovir treatment. It is important to understand the symptoms and seek medical attention promptly to prevent any complications.

    • This question is part of the following fields:

      • Dermatology
      27.2
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  • Question 25 - A 35-year-old woman visits the clinic to receive the outcome of her initial...

    Incorrect

    • A 35-year-old woman visits the clinic to receive the outcome of her initial blood tests after discovering she is pregnant for the first time. She moved to the UK from Ukraine two years ago and did not receive the MMR vaccine during her childhood. Her rubella IgM and IgG tests both show negative results. What guidance would you offer her?

      Your Answer: To receive the MMR vaccine as soon as possible

      Correct Answer: To keep away from people who might have rubella and receive the MMR vaccine in the postnatal period

      Explanation:

      If a woman who is pregnant lacks immunity to rubella, she should receive the MMR vaccine after giving birth.

      In the absence of any indication that this pregnant woman has been exposed to rubella, she should avoid contact with individuals who may have the disease and receive the MMR vaccine after giving birth, as it cannot be administered during pregnancy. There is no recommended treatment for preventing rubella after exposure based on the clinical history. To prevent complications in future pregnancies, it is important to offer her the MMR vaccine.

      Rubella and Pregnancy: Risks, Features, Diagnosis, and Management

      Rubella, also known as German measles, is a viral infection caused by the togavirus. Thanks to the introduction of the MMR vaccine, it is now rare. However, if contracted during pregnancy, there is a risk of congenital rubella syndrome, which can cause serious harm to the fetus. It is important to note that the incubation period is 14-21 days, and individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash.

      The risk of damage to the fetus is highest in the first 8-10 weeks of pregnancy, with a risk as high as 90%. However, damage is rare after 16 weeks. Features of congenital rubella syndrome include sensorineural deafness, congenital cataracts, congenital heart disease (e.g. patent ductus arteriosus), growth retardation, hepatosplenomegaly, purpuric skin lesions, ‘salt and pepper’ chorioretinitis, microphthalmia, and cerebral palsy.

      If a suspected case of rubella in pregnancy arises, it should be discussed immediately with the local Health Protection Unit (HPU) as type/timing of investigations may vary. IgM antibodies are raised in women recently exposed to the virus. It should be noted that it is very difficult to distinguish rubella from parvovirus B19 clinically. Therefore, it is important to also check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss.

      If a woman is tested at any point and no immunity is demonstrated, they should be advised to keep away from people who might have rubella. Non-immune mothers should be offered the MMR vaccination in the post-natal period. However, MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant.

    • This question is part of the following fields:

      • Reproductive Medicine
      30.4
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  • Question 26 - A 45-year-old woman has noticed progressive enlargement of her hands and feet over...

    Incorrect

    • A 45-year-old woman has noticed progressive enlargement of her hands and feet over the past two years, resulting in increasing glove and shoe size. Six months ago, a deepening of her voice was noted. Her family has observed that she snores most of the time and she reports occasional episodes of daytime sleepiness. For three months, she has had progressive blurring of vision with associated headache and dizziness. Visual acuity examination shows 20/20-2. Visual field testing shows bitemporal hemianopias.
      Which of the following is the most appropriate first line investigation to confirm a diagnosis in this woman?

      Your Answer: Oral glucose tolerance test (OGTT) with growth hormone assay

      Correct Answer: Insulin-like growth factor 1 (IGF-1) measurement

      Explanation:

      The measurement of insulin-like growth factor 1 (IGF-1) is now the preferred method for screening and monitoring suspected cases of acromegaly, replacing the oral glucose tolerance test (OGTT). IGF-1, also known as somatomedin C, is produced by the liver and plays a crucial role in childhood growth and has anabolic effects in adults. OGTT with growth hormone assay is no longer the first-line investigation for acromegaly diagnosis, but can be used as a second-line test to confirm the diagnosis if IGF-1 levels are elevated. The insulin tolerance test is used to assess pituitary and adrenal function, as well as insulin sensitivity, and is not useful for diagnosing acromegaly. Random growth hormone assay is also not helpful in diagnosing acromegaly due to the pulsatile nature of GH secretion. Elevated serum prolactin levels may also be present in up to 20% of GH-secreting pituitary adenomas, but this is not diagnostic.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      34.3
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  • Question 27 - A 62-year-old woman is referred to the medical team from the orthopaedic ward....

    Correct

    • A 62-year-old woman is referred to the medical team from the orthopaedic ward. She underwent a right total-hip replacement six days ago. She is known to have mild COPD and is on regular inhaled steroids and a short-acting b2 agonist. She now complains of left-sided chest pain and is also dyspnoeic. Your clinical diagnosis is pulmonary embolism (PE).
      Which of the following is usually NOT a feature of PE in this patient?

      Your Answer: Bradycardia

      Explanation:

      Symptoms and Signs of Pulmonary Embolism

      Pulmonary embolism (PE) is a serious condition that can be life-threatening. It is important to recognize the symptoms and signs of PE to ensure prompt diagnosis and treatment. Here are some of the common symptoms and signs of PE:

      Dyspnoea: This is the most common symptom of PE, present in about 75% of patients. Dyspnoea can occur at rest or on exertion.

      Tachypnoea: This is defined as a respiratory rate of more than 20 breaths per minute and is present in about 55% of patients with PE.

      Tachycardia: This is present in about 25% of cases of PE. It is important to note that a transition from tachycardia to bradycardia may suggest the development of right ventricular strain and potentially cardiogenic shock.

      New-onset atrial fibrillation: This is a less common feature of PE, occurring in less than 10% of cases. Atrial flutter, atrial fibrillation, and premature beats should alert the doctor to possible right-heart strain.

      Bradycardia: This is not a classic feature of PE. However, if a patient with PE transitions from tachycardia to bradycardia, it may suggest the development of right ventricular strain and potentially cardiogenic shock.

      In summary, dyspnoea, tachypnoea, tachycardia, and new-onset atrial fibrillation are some of the common symptoms and signs of PE. It is important to have a high level of suspicion for PE, especially in high-risk patients, to ensure prompt diagnosis and treatment.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 28 - A 38-year-old, atopic, healthcare worker presents with red wheals and itchy hands within...

    Incorrect

    • A 38-year-old, atopic, healthcare worker presents with red wheals and itchy hands within 20 minutes of wearing latex gloves.
      Which of the following is the most appropriate investigation to perform to establish a diagnosis?

      Your Answer: Skin-patch testing

      Correct Answer: Radioallergosorbent test (RAST)

      Explanation:

      Diagnosis of Latex Allergy: Tests and Considerations

      Latex allergy is an immediate hypersensitivity reaction that is IgE-mediated. The diagnosis of latex allergy involves various tests and considerations. The first choice test for results on latex-specific IgE is the Radioallergosorbent test (RAST). Skin-prick testing with latex extracts is sensitive, specific, and rapid, but carries the risk of anaphylaxis. Skin-patch testing is useful in identifying specific allergens in patients with type IV hypersensitivity to latex products. A gluten exclusion diet would not be the most appropriate investigation if latex allergy were suspected. Complement-mediated and immune complex reactions typically produce vascular damage, so bullae and petechiae would predominate in the skin. In summary, the diagnosis of latex allergy requires careful consideration of the type of hypersensitivity reaction and appropriate testing.

    • This question is part of the following fields:

      • Immunology/Allergy
      15.5
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  • Question 29 - Which of the following is a side-effect of lithium therapy? ...

    Incorrect

    • Which of the following is a side-effect of lithium therapy?

      Your Answer: Leucopenia

      Correct Answer: Hypothyroidism

      Explanation:

      Understanding the Side-Effects of Lithium Maintenance Therapy

      Lithium maintenance therapy is a common treatment for bipolar disorder, but it can also cause a range of side-effects. One of the most common is hypothyroidism, which affects up to 5% of patients on lithium and requires regular thyroid function tests. Weight gain, acne, tremors, and polydipsia are also common, as well as ankle edema and a metallic taste in the mouth. Lithium can also cause renal toxicity, so regular urea and electrolyte tests are necessary. However, lithium does not cause abnormal liver function or fever, and actually causes leukocytosis rather than leucopenia. Cystitis is also not a typical side-effect of lithium. Overall, understanding the potential side-effects of lithium maintenance therapy is crucial for managing bipolar disorder effectively.

    • This question is part of the following fields:

      • Psychiatry
      23
      Seconds
  • Question 30 - Liam, 35, is admitted to the Emergency Department after a fall down the...

    Correct

    • Liam, 35, is admitted to the Emergency Department after a fall down the stairs at home. Upon examination, it is observed that he has bruising around the eyes and behind the ears. What does this indicate?

      Your Answer: Basilar skull fracture

      Explanation:

      The classic signs associated with basilar skull fractures are periorbital bruising, which is bruising around the eye also known as Raccoon eyes, and post-auricular bruising, which is bruising of the mastoid also known as Battle’s sign. Therefore, the correct answer for this question is basilar skull fracture.

      NICE Guidelines for Investigating Head Injuries in Adults

      Head injuries can be serious and require prompt medical attention. The National Institute for Health and Care Excellence (NICE) has provided clear guidelines for healthcare professionals to determine which adult patients need further investigation with a CT head scan. Patients who require immediate CT head scans include those with a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment, suspected open or depressed skull fractures, signs of basal skull fractures, post-traumatic seizures, focal neurological deficits, and more than one episode of vomiting.

      For patients with any loss of consciousness or amnesia since the injury, a CT head scan within 8 hours is recommended for those who are 65 years or older, have a history of bleeding or clotting disorders, experienced a dangerous mechanism of injury, or have more than 30 minutes of retrograde amnesia of events immediately before the head injury. Additionally, patients on warfarin who have sustained a head injury with no other indications for a CT head scan should also receive a scan within 8 hours of the injury.

      It is important for healthcare professionals to follow these guidelines to ensure that patients receive appropriate and timely care for their head injuries. By identifying those who require further investigation, healthcare professionals can provide the necessary treatment and support to prevent further complications and improve patient outcomes.

    • This question is part of the following fields:

      • Neurology
      17.8
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  • Question 31 - A 26-year-old woman gives birth vaginally at 38 weeks gestation and chooses to...

    Incorrect

    • A 26-year-old woman gives birth vaginally at 38 weeks gestation and chooses to have a physiological third stage of labor. She experiences a blood loss of 800 ml shortly after delivery. The medical team follows an ABCDE approach and starts a warmed crystalloid infusion. There is no history of medical issues or delivery-related trauma.

      What should be the next course of action in managing her condition?

      Your Answer: Give IV oxytocin

      Correct Answer: Compress the uterus and catheterise her

      Explanation:

      To manage a postpartum haemorrhage, an ABCDE approach should be taken, with initial steps including compressing the uterus and catheterising the patient. This is known as ‘mechanical management’ and is appropriate for a primary postpartum haemorrhage (PPH) where uterine atony is the most common cause. IV warmed crystalloid should also be given. Medical management options such as IV oxytocin or IM/IV carboprost should only be considered if mechanical methods fail. It is important to note that IV carboprost should not be administered as it can lead to serious side effects.

      Understanding Postpartum Haemorrhage

      Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.

      In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.

      Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.

    • This question is part of the following fields:

      • Cardiovascular
      28.6
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  • Question 32 - The physician is analyzing the routine blood test results for a 65-year-old woman...

    Correct

    • The physician is analyzing the routine blood test results for a 65-year-old woman who has a medical history of hypertension, type 2 diabetes mellitus, and giant cell arteritis. The following are some of the findings:
      - Hemoglobin (Hb) level of 133 g/L (normal range for females: 115-160 g/L; males: 135-180 g/L)
      - Mean cell volume (MCV) of 88 fl (normal range: 82-100 fl)
      - Platelet count of 390 * 109/L (normal range: 150-400 * 109/L)
      - White blood cell (WBC) count of 10.7 * 109/L (normal range: 4.0-11.0 * 109/L)
      - Neutrophil count of 8.4 * 109/L (normal range: 2.0-7.0 * 109/L)
      - Lymphocyte count of 1.4 * 109/L (normal range: 1.0-3.0 * 109/L)

      What could be the possible cause of these abnormal results?

      Your Answer: Prednisolone

      Explanation:

      The slightly high neutrophil count of 8.4 could be attributed to the use of prednisolone, a corticosteroid commonly used in the treatment of giant cell arteritis. This medication is known to induce neutrophilia. On the other hand, amlodipine, an antihypertensive drug, is not associated with neutrophilia but may cause leucopenia as a rare side effect. Dapagliflozin, a medication used in managing type 2 diabetes mellitus, does not affect white cell count, but it may cause frequent urinary tract infections, dizziness, and rash. Similarly, exenatide, a subcutaneous injection used in managing type 2 diabetes mellitus, is not known to cause changes in white cell count, but it may cause nausea, vomiting, and diarrhea.

      Understanding Corticosteroids and Their Side-Effects

      Corticosteroids are commonly prescribed therapies used to replace or augment the natural activity of endogenous steroids. They can be administered systemically or locally, depending on the condition being treated. However, the usage of corticosteroids is limited due to their numerous side-effects, which are more common with prolonged and systemic therapy.

      Glucocorticoid side-effects include impaired glucose regulation, increased appetite and weight gain, hirsutism, hyperlipidaemia, Cushing’s syndrome, moon face, buffalo hump, striae, osteoporosis, proximal myopathy, avascular necrosis of the femoral head, immunosuppression, increased susceptibility to severe infection, reactivation of tuberculosis, insomnia, mania, depression, psychosis, peptic ulceration, acute pancreatitis, glaucoma, cataracts, suppression of growth in children, intracranial hypertension, and neutrophilia.

      On the other hand, mineralocorticoid side-effects include fluid retention and hypertension. It is important to note that patients on long-term steroids should have their doses doubled during intercurrent illness. Longer-term systemic corticosteroids suppress the natural production of endogenous steroids, so they should not be withdrawn abruptly as this may precipitate an Addisonian crisis. The British National Formulary suggests gradual withdrawal of systemic corticosteroids if patients have received more than 40mg prednisolone daily for more than one week, received more than three weeks of treatment, or recently received repeated courses.

    • This question is part of the following fields:

      • Haematology/Oncology
      39.7
      Seconds
  • Question 33 - A breathless 65-year-old smoker presents with the following lung function tests:
    FEV1 (forced expiratory...

    Incorrect

    • A breathless 65-year-old smoker presents with the following lung function tests:
      FEV1 (forced expiratory volume in 1 second) 1.5 l (60%)
      FVC (forced vital capacity) 1.8 l (55%)
      FEV1:FVC ratio = 84%
      TLC (total lung capacity) = 66% predicted
      RV (residual volume) = 57% predicted
      TLCO (carbon monoxide transfer factor) = 55% predicted
      KCO (carbon monoxide transfer coefficient) = 60% predicted
      Which of the following is the most likely diagnosis in this case?
      Select the SINGLE most likely diagnosis.

      Your Answer: Emphysema

      Correct Answer: Idiopathic pulmonary fibrosis

      Explanation:

      Understanding Idiopathic Pulmonary Fibrosis: Differential Diagnosis with Other Respiratory Conditions

      Idiopathic pulmonary fibrosis (IPF), also known as fibrosing alveolitis, is a chronic and progressive lung disease that affects people between the ages of 50 and 70 years. The disease is characterized by a significant restrictive defect in lung function tests, reduced KCO, and breathlessness. While there is no definitive treatment for IPF, up to 20% of patients can survive more than 5 years from diagnosis.

      When considering a differential diagnosis, it is important to rule out other respiratory conditions that may present with similar symptoms. Anaemia, for example, may cause breathlessness but would not produce a defect in lung function tests. Emphysema, on the other hand, would produce an obstructive pattern with a FEV1:FVC ratio of less than 70%. Obesity may also fit the picture of a restrictive defect, but it would not affect the KCO. In the case of asthma, an obstructive pattern with a FEV1:FVC ratio of less than 70% would be expected.

      In summary, understanding the differential diagnosis of IPF is crucial in providing appropriate treatment and management for patients with respiratory conditions.

    • This question is part of the following fields:

      • Respiratory Medicine
      68
      Seconds
  • Question 34 - A 67-year-old woman presents to the Memory Clinic with a 9-month history of...

    Correct

    • A 67-year-old woman presents to the Memory Clinic with a 9-month history of cognitive decline. Her daughter mentions that she has difficulty remembering basic tasks and is becoming more confused and forgetful than usual. Her daughter noticed a change in her personality and has caught her leaving the stove on and wandering outside alone on multiple occasions.
      Given the likely diagnosis, which of the following is the most appropriate initial step in this patient’s management?
      Select the SINGLE most appropriate management from the list below.

      Your Answer: Stop drugs that may be exacerbating memory problems or confusion (anticholinergics, central nervous system drugs)

      Explanation:

      Managing Frontotemporal Dementia: Treatment Options and Referrals

      Frontotemporal dementia (FTD) is a progressive neurodegenerative disorder that affects behavior, language, and executive function. While there is no cure for FTD, management strategies can help alleviate symptoms and provide support for patients and their families.

      One important step in managing FTD is to stop any drugs that may be exacerbating memory problems or confusion, such as anticholinergics or central nervous system drugs. Multidisciplinary health and social care is also crucial, involving referrals to geriatric medicine, psychiatry, psychology, social work, occupational therapy, speech and language therapy, physiotherapy, and community nursing.

      However, certain treatment options should be avoided or used with caution in FTD patients. Benzodiazepines, for example, are associated with cognitive worsening and fall-related injuries. Anticholinesterase inhibitors, typically used in mild to moderate Alzheimer’s disease, have shown disappointing results in FTD patients who do not have cholinergic loss. Memantine, used in moderate to severe Alzheimer’s disease, has not been shown to be effective in FTD and may even have a detrimental effect on cognition in some individuals.

      Antipsychotics should only be used cautiously and when other options have failed, as FTD patients are at higher risk of extrapyramidal side effects. Overall, a personalized and coordinated approach to FTD management is essential for optimizing patient outcomes.

    • This question is part of the following fields:

      • Neurology
      39.3
      Seconds
  • Question 35 - A 47-year-old man is seen by his General Practitioner for his annual hypertension...

    Correct

    • A 47-year-old man is seen by his General Practitioner for his annual hypertension review. He agrees to be referred to the local smoking cessation service, as he is currently experiencing chest pain.
      Which of the following medications will need to be monitored closely on cessation of smoking?

      Your Answer: Theophylline

      Explanation:

      The Effect of Smoking Cessation on Asthma Medications

      Smoking cessation can have a significant impact on the management of asthma and the use of certain medications. Here is a breakdown of how smoking cessation affects different asthma medications:

      Theophylline: Smoking induces the hepatic enzyme CYP1A2, which plays a major role in metabolizing theophylline. Therefore, quitting smoking can lead to higher plasma levels of theophylline and potentially fatal arrhythmias. Patients need to have their plasma theophylline concentration levels monitored closely and may require a reduced dose after quitting smoking.

      Budesonide/formoterol: Neither budesonide nor formoterol are metabolized by CYP1A2, so there is no need for close monitoring following smoking cessation. Asthma control should improve after quitting smoking, and the inhaler dose should be reviewed as part of stepwise management.

      Montelukast: Montelukast is metabolized by the cytochrome P450 system but not CYP1A2, so smoking cessation does not affect its level.

      Prednisolone: Prednisolone is metabolized by the cytochrome P450 system, but CYP1A2 is not involved. Therefore, smoking cessation does not affect its metabolism.

      Salbutamol: Smoking cessation can improve asthma control, leading to less frequent use of salbutamol or other reliever inhalers. There is no need to monitor this closely as reducing the as-required use of this medication poses no risk.

    • This question is part of the following fields:

      • Haematology/Oncology
      15.5
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  • Question 36 - An 80-year-old man presents with right-sided facial droop, dysphasia, and right-sided hemianopia. He...

    Correct

    • An 80-year-old man presents with right-sided facial droop, dysphasia, and right-sided hemianopia. He has a medical history of gout, recurrent UTIs, dementia, and diabetes mellitus. A CT head is unremarkable, and an MRI head reveals a left-sided infarct. Which of the patient's pre-existing conditions elevate his chances of experiencing an ischemic stroke?

      Your Answer: Diabetes mellitus

      Explanation:

      The following factors increase the risk of ischaemic stroke: age, hypertension, smoking, hyperlipidaemia, diabetes mellitus, and atrial fibrillation. However, gout, recurrent UTIs, and dementia do not have an impact on stroke risk. Taking aspirin can lower the risk of stroke.

      Understanding Stroke: A Basic Overview

      Stroke is a significant cause of morbidity and mortality, with over 150,000 cases reported annually in the UK alone. It is the fourth leading cause of death in the country, killing twice as many women as breast cancer each year. However, the prevention and treatment of strokes have undergone significant changes in the past decade. What was once considered an untreatable condition is now viewed as a brain attack that requires emergency assessment to determine if patients can benefit from new treatments such as thrombolysis.

      A stroke, also known as a cerebrovascular accident (CVA), occurs when there is a sudden interruption in the vascular supply of the brain. This interruption can lead to irreversible damage as neural tissue is entirely dependent on aerobic metabolism. There are two main types of strokes: ischaemic and haemorrhagic. Ischaemic strokes occur when there is a blockage in the blood vessel that stops blood flow, while haemorrhagic strokes happen when a blood vessel bursts, leading to a reduction in blood flow.

      Symptoms of a stroke include motor weakness, speech problems, swallowing difficulties, visual field defects, and balance problems. The Oxford Stroke Classification is a formal system used to classify strokes based on initial symptoms. Patients with suspected stroke require emergency neuroimaging to determine if they are suitable for thrombolytic therapy to treat early ischaemic strokes. If the stroke is haemorrhagic, neurosurgical consultation should be considered for advice on further management.

      In conclusion, understanding the basics of stroke is crucial in identifying and managing the condition. Early intervention and treatment can significantly improve outcomes for patients.

    • This question is part of the following fields:

      • Neurology
      26.6
      Seconds
  • Question 37 - A mother brings in her 7-year-old girl who complains of 'an itchy bottom'...

    Correct

    • A mother brings in her 7-year-old girl who complains of 'an itchy bottom' at night. She is otherwise systemically well, developing normally and denies any change in her bowel habit. An external examination of the anus is unremarkable.
      What is the most probable cause of her symptoms?

      Your Answer: Threadworms

      Explanation:

      Anal itching in children is frequently caused by threadworms, which can be easily detected by observing moving white threads in the anal area at nighttime. Although examination may not reveal any significant findings, it is important to note that human roundworms are uncommon in the UK and typically do not result in itching.

      Threadworm Infestation in Children

      Threadworm infestation, caused by Enterobius vermicularis or pinworms, is a common occurrence among children in the UK. The infestation happens when eggs present in the environment are ingested. In most cases, threadworm infestation is asymptomatic, but some possible symptoms include perianal itching, especially at night, and vulval symptoms in girls. Diagnosis can be made by applying Sellotape to the perianal area and sending it to the laboratory for microscopy to see the eggs. However, most patients are treated empirically, and this approach is supported in the CKS guidelines.

      The CKS recommends a combination of anthelmintic with hygiene measures for all members of the household. Mebendazole is the first-line treatment for children over six months old, and a single dose is given unless the infestation persists. It is essential to treat all members of the household to prevent re-infection. Proper hygiene measures, such as washing hands regularly, keeping fingernails short, and washing clothes and bedding at high temperatures, can also help prevent the spread of threadworm infestation.

    • This question is part of the following fields:

      • Paediatrics
      14.4
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  • Question 38 - A 35-year-old woman presents to the Emergency Department with a 2-month history of...

    Incorrect

    • A 35-year-old woman presents to the Emergency Department with a 2-month history of lethargy and generalised weakness. On examination, she is found to have a blood pressure of 170/100 mmHg. The rest of the examination is unremarkable.
      Routine blood tests show a hypokalaemic metabolic alkalosis, along with a hypernatraemia of 152 mmol/l (135–145 mmol/l). Primary aldosteronism is suspected and investigations reveal bilateral idiopathic adrenal hyperplasia.
      Which of the following is the best treatment option?
      Select the SINGLE most appropriate treatment from the list below.

      Your Answer: Unilateral laparoscopic adrenalectomy

      Correct Answer: Spironolactone

      Explanation:

      The patient’s hypertension, hypokalaemia, and hypernatremia suggest a diagnosis of hyperaldosteronism, where high levels of aldosterone cause increased water and sodium reabsorption in the kidneys and potassium loss. The recommended treatment for primary hyperaldosteronism due to bilateral adrenal disease is a mineralocorticoid antagonist, with spironolactone as the primary agent and eplerenone as an alternative. Losartan, an angiotensin receptor blocker, is an alternative to angiotensin-converting enzyme inhibitors for managing primary hypertension in patients under 55 years of age who are not Afro-Caribbean or diabetic. Nifedipine, a calcium-channel blocker, is a first-line drug for essential hypertension in patients aged 55 years or older or Afro-Caribbean patients. Perindopril, an ACEi, is a first-line drug for managing primary hypertension in patients under 55 years of age who are not Afro-Caribbean or diabetic. However, it is not appropriate for treating hyperaldosteronism, where spironolactone is the preferred option. Unilateral laparoscopic adrenalectomy is recommended for cases of hyperaldosteronism due to unilateral adrenal diseases, but not for bilateral adrenal disease like in this patient.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      37.5
      Seconds
  • Question 39 - A 4-week-old baby boy is brought to the Emergency Department with a two-week...

    Correct

    • A 4-week-old baby boy is brought to the Emergency Department with a two-week history of vomiting after every feed and then appearing very hungry afterwards. His weight has remained at 4 kg for the past two weeks, and for the past two days, the vomiting has become projectile. His birthweight was 3.6 kg. He is exclusively breastfed. A small mass can be palpated in the right upper quadrant of his abdomen.
      What is the most likely diagnosis?

      Your Answer: Pyloric stenosis

      Explanation:

      Differential diagnosis of vomiting and poor weight gain in infants

      Vomiting and poor weight gain are common symptoms in infants, but they can be caused by different conditions that require specific management. One possible cause is pyloric stenosis, which results from an enlarged muscle at the outlet of the stomach, leading to projectile vomiting, dehydration, and failure to thrive. Another possible cause is gastro-oesophageal reflux disease (GORD), which may also involve vomiting, but not projectile, and may respond to conservative measures such as frequent feeds and upright positioning, or medication such as Gaviscon® or proton pump inhibitors. Cow’s milk protein allergy is another potential cause, which may present with a range of symptoms, including vomiting, but not projectile, and may require an exclusion diet for the mother if breastfeeding. Gastroenteritis is a common cause of vomiting and diarrhoea in infants, but it usually resolves within a few days and does not cause an abdominal mass. Finally, volvulus is a rare but serious condition that involves a twisted bowel, leading to acute obstruction and ischaemia, which requires urgent surgical intervention. Therefore, a careful history, examination, and investigations, such as ultrasound or blood tests, may help to differentiate these conditions and guide appropriate treatment.

    • This question is part of the following fields:

      • Paediatrics
      18.4
      Seconds
  • Question 40 - A 30-year-old woman expecting her second child and who is 28 weeks pregnant...

    Correct

    • A 30-year-old woman expecting her second child and who is 28 weeks pregnant is referred to the Obstetric Unit with symptoms of headache, blurred vision and nausea.
      On examination, her blood pressure (BP) is 160/110 mmHg; her antenatal diary shows consistent systolic readings of 115/125 mmHg and consistent diastolic readings of < 85 mmHg. Her urine dip shows proteinuria.
      What is the most appropriate first-line treatment for this patient?

      Your Answer: Labetalol

      Explanation:

      Treatment Options for Pre-eclampsia in Pregnancy

      Pre-eclampsia is a serious condition that can occur during pregnancy, characterized by high blood pressure, headaches, flashing lights, and vomiting. The following are treatment options for pre-eclampsia:

      Labetalol: This beta-blocker is the first-line treatment for pre-eclampsia. According to NICE guidelines, patients should be admitted for monitoring if their blood pressure is above 140/90 mmHg. Labetalol should be used if their systolic blood pressure goes above 150 mmHg or diastolic blood pressure above 100 mmHg. Nifedipine can be used as an alternative if labetalol is contraindicated or not tolerated.

      Ramipril: Angiotensin-converting enzyme inhibitors are not recommended during pregnancy due to potential harm to the fetus.

      Hydralazine: This vasodilator is reserved for severe pre-eclampsia and requires specialist support.

      Methyldopa: This medication is the third-line option if labetalol is ineffective and nifedipine is not tolerated or ineffective.

      Nifedipine: This calcium channel blocker is the second-line treatment if labetalol is ineffective or not tolerated.

      In conclusion, pre-eclampsia requires prompt treatment to prevent serious complications. Labetalol is the first-line treatment, and other medications can be used if necessary. It is important to consult with a healthcare provider to determine the best course of action for each individual case.

    • This question is part of the following fields:

      • Cardiovascular
      30
      Seconds
  • Question 41 - A 65-year-old woman presents to the emergency department with complaints of difficulty breathing....

    Incorrect

    • A 65-year-old woman presents to the emergency department with complaints of difficulty breathing. She has a medical history of left ventricular systolic dysfunction with an ejection fraction of 20%. A chest x-ray confirms acute pulmonary edema, which is immediately treated with high dose IV furosemide. Her vital signs on repeat assessment are as follows: oxygen saturation of 94% on 15L oxygen, heart rate of 124 beats per minute, respiratory rate of 28 breaths per minute, and blood pressure of 74/50 mmHg. What is the next management option to consider?

      Your Answer: Give IV fluid for her hypotension

      Correct Answer: Inotropic support on the high dependency unit (HDU)

      Explanation:

      For patients with severe left ventricular dysfunction who are experiencing potentially reversible cardiogenic shock with hypotension, inotropic support on the high dependency unit (HDU) should be considered. This is because diuresis, which is the primary aim of management in acute pulmonary oedema, could lower blood pressure further and worsen the shock. Inotropes can help increase cardiac contractility and support blood pressure while diuresis is ongoing.

      Biphasic positive airway pressure (BiPAP) is not an immediate consideration for this patient as it is used primarily for non-invasive ventilation in hypoxic and hypercapnic patients. Pulmonary oedema does not typically lead to hypercapnia.

      Giving IV fluid for hypotension would not be appropriate as the hypotension is secondary to cardiogenic shock, not hypovolaemic shock. Administering further fluid in this scenario would worsen the patient’s condition by contributing to fluid overload.

      Bisoprolol is contraindicated in this scenario as it suppresses the compensatory tachycardia that occurs in acute heart failure to maintain cardiac output, which would worsen the cardiogenic shock. However, outside of an acute scenario, a patient can continue on their routine bisoprolol if they are already prescribed this for heart failure, unless they are bradycardic.

      Heart failure requires acute management, with recommended treatments for all patients including IV loop diuretics such as furosemide or bumetanide. Oxygen may also be necessary, with guidelines suggesting oxygen saturations be kept at 94-98%. Vasodilators such as nitrates should not be routinely given to all patients, but may have a role in cases of concomitant myocardial ischaemia, severe hypertension, or regurgitant aortic or mitral valve disease. However, hypotension is a major side-effect/contraindication. Patients with respiratory failure may require CPAP, while those with hypotension or cardiogenic shock may require inotropic agents like dobutamine or vasopressor agents like norepinephrine. Mechanical circulatory assistance such as intra-aortic balloon counterpulsation or ventricular assist devices may also be necessary. Regular medication for heart failure should be continued, with beta-blockers only stopped in certain circumstances. Opiates should not be routinely offered to patients with acute heart failure due to potential increased morbidity.

      In summary, acute management of heart failure involves a range of treatments depending on the patient’s specific condition. It is important to carefully consider the potential side-effects and contraindications of each treatment, and to continue regular medication for heart failure where appropriate. Opiates should be used with caution, and only in cases where they are likely to reduce dyspnoea/distress without causing harm. With appropriate management, patients with acute heart failure can receive the care they need to improve their outcomes and quality of life.

    • This question is part of the following fields:

      • Respiratory Medicine
      47.5
      Seconds
  • Question 42 - A 65-year-old woman presents to the emergency department with a 4-day history of...

    Incorrect

    • A 65-year-old woman presents to the emergency department with a 4-day history of increased shortness of breath, cough with green sputum, and reduced exercise tolerance. She has a history of COPD and is currently on a salbutamol inhaler, combined glycopyrronium and indacaterol inhaler, and oral prednisolone to manage her symptoms. She is being evaluated for BIPAP home therapy. On examination, her respiratory rate is 22/min, oxygen saturations are 85% in room air, heart rate is 86/min, temperature is 37.7ºC, and blood pressure is 145/78 mmHg. What is the most likely causative organism for her presentation?

      Your Answer: Influenza A virus

      Correct Answer: Haemophilus influenzae

      Explanation:

      The most frequent cause of infective exacerbations of COPD is Haemophilus influenzae, according to research. This bacterium’s strains that cause COPD exacerbations are more virulent and induce greater airway inflammation than those that only colonize patients without causing symptoms. Patients with COPD have reduced mucociliary clearance, making them susceptible to H. influenzae, which can lead to airway inflammation and increased breathing effort. Coxsackievirus is linked to hand, foot, and mouth disease, which primarily affects children but can also affect immunocompromised adults. This option is incorrect because the patient does not have the typical symptoms of sore throat, fever, and maculopapular rash on hands, foot, and mucosa. Influenza A virus is associated with the bird flu pandemic and is not the most common cause of infective exacerbations of COPD. Staphylococcus aureus is not commonly associated with infective exacerbations of COPD. This bacterium is more commonly seen in mild cases of skin infections or can lead to infective endocarditis and is associated with biofilms causing infection.

      Acute exacerbations of COPD are a common reason for hospital visits in developed countries. The most common causes of these exacerbations are bacterial infections, with Haemophilus influenzae being the most common culprit, followed by Streptococcus pneumoniae and Moraxella catarrhalis. Respiratory viruses also account for around 30% of exacerbations, with human rhinovirus being the most important pathogen. Symptoms of an exacerbation include an increase in dyspnea, cough, and wheezing, as well as hypoxia and acute confusion in some cases.

      NICE guidelines recommend increasing the frequency of bronchodilator use and giving prednisolone for five days. Antibiotics should only be given if sputum is purulent or there are clinical signs of pneumonia. Admission to the hospital is recommended for patients with severe breathlessness, acute confusion or impaired consciousness, cyanosis, oxygen saturation less than 90%, social reasons, or significant comorbidity.

      For severe exacerbations requiring secondary care, oxygen therapy should be used with an initial saturation target of 88-92%. Nebulized bronchodilators such as salbutamol and ipratropium should also be administered, along with steroid therapy. IV hydrocortisone may be considered instead of oral prednisolone, and IV theophylline may be used for patients not responding to nebulized bronchodilators. Non-invasive ventilation may be used for patients with type 2 respiratory failure, with bilevel positive airway pressure being the typical method used.

    • This question is part of the following fields:

      • Infectious Diseases
      62.9
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  • Question 43 - A 39-year-old woman experiences lower back pain that travels down her left leg...

    Correct

    • A 39-year-old woman experiences lower back pain that travels down her left leg while doing DIY work. She reports a severe, sharp, stabbing pain that worsens with movement. During clinical examination, a positive straight leg raise test is observed on the left side. The patient is given appropriate pain relief. What is the most appropriate next step in management?

      Your Answer: Arrange physiotherapy

      Explanation:

      A prolapsed disc is suspected based on the patient’s symptoms. However, even if an MRI scan confirms this diagnosis, the initial management would remain the same as most patients respond well to conservative treatment like physiotherapy.

      Understanding Prolapsed Disc and its Features

      A prolapsed lumbar disc is a common cause of lower back pain that can lead to neurological deficits. It is characterized by clear dermatomal leg pain, which is usually worse than the back pain. The pain is often aggravated when sitting. The features of the prolapsed disc depend on the site of compression. For instance, L3 nerve root compression can cause sensory loss over the anterior thigh, weak quadriceps, reduced knee reflex, and a positive femoral stretch test. On the other hand, L4 nerve root compression can lead to sensory loss in the anterior aspect of the knee, weak quadriceps, reduced knee reflex, and a positive femoral stretch test.

      The management of prolapsed disc is similar to that of other musculoskeletal lower back pain. It involves analgesia, physiotherapy, and exercises. According to NICE, the first-line treatment for back pain without sciatica symptoms is NSAIDs +/- proton pump inhibitors, rather than neuropathic analgesia. If the symptoms persist after 4-6 weeks, referral for consideration of MRI is appropriate. Understanding the features of prolapsed disc can help in the diagnosis and management of this condition.

    • This question is part of the following fields:

      • Musculoskeletal
      64.5
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  • Question 44 - A 25-year-old G2P1 woman presents to her midwife at 12 weeks gestation. She...

    Correct

    • A 25-year-old G2P1 woman presents to her midwife at 12 weeks gestation. She has a history of well-controlled type 1 diabetes mellitus and a family history of pre-eclampsia. Her urine dipstick and blood pressure are both normal. Based on this information, what advice should be given regarding her risk of developing pre-eclampsia?

      Your Answer: She should take aspirin from 12 weeks gestation until delivery

      Explanation:

      A woman with a moderate or high risk of pre-eclampsia, such as this patient who has a family history of pre-eclampsia and type 1 diabetes mellitus, should take aspirin 75-150mg daily from 12 weeks gestation until delivery to reduce the risk of developing pre-eclampsia.

      Pre-eclampsia is a condition that occurs during pregnancy and is characterized by high blood pressure, proteinuria, and edema. It can lead to complications such as eclampsia, neurological issues, fetal growth problems, liver involvement, and cardiac failure. Severe pre-eclampsia is marked by hypertension, proteinuria, headache, visual disturbances, and other symptoms. Risk factors for pre-eclampsia include hypertension in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension, first pregnancy, and age over 40. Aspirin may be recommended for women with high or moderate risk factors. Treatment involves emergency assessment, admission for observation, and medication such as labetalol, nifedipine, or hydralazine. Delivery of the baby is the most important step in management, with timing depending on the individual case.

    • This question is part of the following fields:

      • Reproductive Medicine
      23.8
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  • Question 45 - A 28-year-old newly qualified nurse presents with a bilateral erythematous rash on both...

    Incorrect

    • A 28-year-old newly qualified nurse presents with a bilateral erythematous rash on both hands. She has recently moved from the Philippines and has no significant medical history. The suspected diagnosis is contact dermatitis. What is the most appropriate test to determine the underlying cause?

      Your Answer: Radioallergosorbent test (RAST)

      Correct Answer: Skin patch test

      Explanation:

      The skin patch test can be beneficial in this scenario as it has the potential to detect irritants in addition to allergens.

      Types of Allergy Tests

      Allergy tests are used to determine if a person has an allergic reaction to a particular substance. There are several types of allergy tests available, each with its own advantages and limitations. The most commonly used test is the skin prick test, which is easy to perform and inexpensive. Drops of diluted allergen are placed on the skin, and a needle is used to pierce the skin. A wheal will typically develop if a patient has an allergy. This test is useful for food allergies and pollen.

      Another type of allergy test is the radioallergosorbent test (RAST), which determines the amount of IgE that reacts specifically with suspected or known allergens. Results are given in grades from 0 (negative) to 6 (strongly positive). This test is useful for food allergies, inhaled allergens (e.g. pollen), and wasp/bee venom.

      Skin patch testing is useful for contact dermatitis. Around 30-40 allergens are placed on the back, and irritants may also be tested for. The patches are removed 48 hours later, and the results are read by a dermatologist after a further 48 hours. Blood tests may be used when skin prick tests are not suitable, for example if there is extensive eczema or if the patient is taking antihistamines. Overall, allergy tests are an important tool in diagnosing and managing allergies.

    • This question is part of the following fields:

      • Dermatology
      23.9
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  • Question 46 - A 65-year-old female is referred for management of a chronic ulcer above the...

    Incorrect

    • A 65-year-old female is referred for management of a chronic ulcer above the left medial malleolus. The ankle-brachial pressure index readings are as follows:
      Right 0.95
      Left 0.95
      The ulcer has been treated with standard dressings by the District Nurse. What is the best course of action to increase the chances of healing the ulcer?

      Your Answer: Intermittent pneumatic compression

      Correct Answer:

      Explanation:

      Compression bandaging is recommended for the management of venous ulceration, as the ankle-brachial pressure index readings suggest that the ulcers are caused by venous insufficiency rather than arterial issues.

      Venous Ulceration and its Management

      Venous ulceration is a type of ulcer that is commonly seen above the medial malleolus. To assess for poor arterial flow that could impair healing, an ankle-brachial pressure index (ABPI) is important in non-healing ulcers. A normal ABPI is usually between 0.9 – 1.2, while values below 0.9 indicate arterial disease. Interestingly, values above 1.3 may also indicate arterial disease, particularly in diabetics, due to false-negative results caused by arterial calcification.

      The only treatment that has been shown to be of real benefit for venous ulceration is compression bandaging, usually four-layer. Oral pentoxifylline, a peripheral vasodilator, can also improve the healing rate. There is some small evidence supporting the use of flavonoids, but little evidence to suggest benefit from hydrocolloid dressings, topical growth factors, ultrasound therapy, and intermittent pneumatic compression. Proper management of venous ulceration is crucial to promote healing and prevent complications.

    • This question is part of the following fields:

      • Dermatology
      21.5
      Seconds
  • Question 47 - A 28-year-old primip nurse has presented to you 5 days after being in...

    Incorrect

    • A 28-year-old primip nurse has presented to you 5 days after being in contact with a child who had a vesicular rash on their face and chest. She is currently 14 weeks pregnant and has been experiencing some morning sickness, but otherwise feels fine. Her blood tests show that she is not immune to varicella zoster virus. What should be the next course of action in your management plan?

      Your Answer: IV Aciclovir

      Correct Answer: A single dose of varicella-zoster immunoglobulin (VZI)

      Explanation:

      If a pregnant woman is not immune to the varicella zoster virus and has been in close contact with someone who has the virus, it is recommended that she receive varicella-zoster immunoglobulin (VZIG) as soon as possible. VZIG can be effective up to 10 days after contact, or 10 days after the appearance of the rash in the person with the virus if there are continuous exposures.
      For pregnant women who are not immune and have been exposed to chickenpox, they should be considered potentially infectious from 8-28 days after exposure if they receive VZIG, and from 8-21 days after exposure if they do not receive VZIG.
      Source: RCOG

      Chickenpox exposure in pregnancy can pose risks to both the mother and fetus, including fetal varicella syndrome. Post-exposure prophylaxis (PEP) with varicella-zoster immunoglobulin (VZIG) or antivirals should be given to non-immune pregnant women, with timing dependent on gestational age. If a pregnant woman develops chickenpox, specialist advice should be sought and oral aciclovir may be given if she is ≥ 20 weeks and presents within 24 hours of onset of the rash.

    • This question is part of the following fields:

      • Reproductive Medicine
      0.1
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  • Question 48 - A 62-year-old woman comes to her General Practitioner for her annual medication review....

    Correct

    • A 62-year-old woman comes to her General Practitioner for her annual medication review. Her regular medications are levothyroxine 75 µg, lisinopril 10 mg and she has recently completed a course of ibuprofen tablets. She has been feeling tired and sluggish recently with frequent headaches. Examination reveals she has gained 2 kg since her last review, blood pressure is 142/78 mmHg, pulse is 88 bpm and she has a dry skin. Full blood count, urea and electrolytes and liver function tests are normal. Her thyroid-function test (TFT) results are: Thyroid-stimulating hormone (TSH) 6.0 mU/l (0.25–4.0 mU/l) Free T4 10.0 pmol/l (12.0–22.0 pmol/l) What is the most appropriate next step in her management?

      Your Answer: Reduce levothyroxine dose

      Explanation:

      The patient is experiencing hyperthyroidism due to an excess of levothyroxine replacement. It is important to reduce the dose of levothyroxine and monitor the patient with regular blood tests until they become euthyroid again. Starting carbimazole or increasing the dose of levothyroxine is not recommended as it could lead to further complications. Propylthiouracil is only used in cases of thyrotoxic storm and radio-iodine therapy is not necessary in this case as the hyperthyroidism is due to over-replacement of levothyroxine.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      51.6
      Seconds
  • Question 49 - A 60-year-old man presents to his GP with a three month history of...

    Correct

    • A 60-year-old man presents to his GP with a three month history of intermittent pain and numbness in his fourth and fifth fingers.
      Which of the following is the most likely cause of his symptoms?

      Your Answer: Ulnar nerve entrapment

      Explanation:

      Common Hand and Wrist Conditions: Symptoms and Characteristics

      Ulnar Nerve Entrapment
      Ulnar neuropathy is a common condition where the ulnar nerve is compressed at or near the elbow. Patients experience numbness and tingling in the fifth finger and ulnar half of the fourth finger, along with weakness of grip and potential muscle wasting. In severe cases, a claw hand deformity may occur.

      De Quervain’s Tenosynovitis
      Also known as mother’s wrist, this condition is caused by tendinitis in the tendons of the first dorsal compartment of the wrist. Patients experience pain during thumb and wrist movement, along with tenderness and thickening at the radial styloid. Finkelstein’s test causes sharp pain at the first dorsal compartment, and a prominent radial styloid may be visible. There is no associated sensory loss.

      Carpal Tunnel Syndrome
      This condition occurs when the median nerve is compressed as it passes through the carpal tunnel at the wrist. Symptoms include numbness and tingling in the thumb and radial fingers, aching and pain in the anterior wrist and forearm, and potential weakness and clumsiness in the hand. Risk factors include female sex, pregnancy, hypothyroidism, connective tissue disease, obesity, trauma, dialysis, and repetitive stress.

      Dupuytren’s Contracture
      This progressive fibrous tissue contracture of the palmar fascia mainly affects men over 40 with a family history. Patients experience difficulty with manual dexterity, palmar nodules, and eventually flexion contractures in the fourth and fifth fingers. There is no sensory deficit. Risk factors include smoking, alcohol, heavy manual labor, trauma, and diabetes.

      Radial Nerve Palsy
      Radial nerve palsy results in wrist drop and loss of triceps reflex, along with potential sensory loss in the dorsal thumb and forearm. The radial nerve does not supply sensory innervation to the fourth and fifth fingers.

    • This question is part of the following fields:

      • Neurology
      16.1
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  • Question 50 - A 42-year-old woman arrived at the Emergency Department complaining of a painful and...

    Incorrect

    • A 42-year-old woman arrived at the Emergency Department complaining of a painful and red eye with watering and mild sensitivity to light. The diagnosis was uncertain, but it was suspected to be either episcleritis or scleritis. The on-call ophthalmologist was contacted, and they requested that a specific eye drop be administered to differentiate between the two conditions.

      Which of the following eye drops is capable of distinguishing between episcleritis and scleritis?

      Your Answer: Local anaesthesia eye drops

      Correct Answer: Phenylephrine eye drops

      Explanation:

      Distinguishing between episcleritis and scleritis can be achieved using eye drops. By administering the drops, it is possible to observe whether the redness in the eye blanches or not. If it does, then the condition is episcleritis, but if it doesn’t, then it is scleritis. This skill is particularly valuable for those working in an Emergency Medicine rotation. None of the other options are useful for distinguishing between these two conditions.

      Understanding Episcleritis

      Episcleritis is a condition that involves the sudden onset of inflammation in the episclera of one or both eyes. While the majority of cases are idiopathic, there are some associated conditions such as inflammatory bowel disease and rheumatoid arthritis. Symptoms of episcleritis include a red eye, mild pain or irritation, watering, and mild photophobia. However, unlike scleritis, episcleritis is typically not painful.

      One way to differentiate between the two conditions is by applying gentle pressure on the sclera. If the injected vessels are mobile, it is likely episcleritis. In contrast, scleritis involves deeper vessels that do not move. Phenylephrine drops may also be used to distinguish between the two conditions. If the eye redness improves after phenylephrine, a diagnosis of episcleritis can be made.

      Approximately 50% of cases of episcleritis are bilateral. Treatment for episcleritis is typically conservative, with artificial tears sometimes being used. Understanding the symptoms and differences between episcleritis and scleritis can help individuals seek appropriate treatment and management for their eye condition.

    • This question is part of the following fields:

      • Ophthalmology
      43.7
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SESSION STATS - PERFORMANCE PER SPECIALTY

Infectious Diseases (0/3) 0%
Pharmacology/Therapeutics (2/2) 100%
Gastroenterology/Nutrition (2/3) 67%
Ophthalmology (1/3) 33%
Musculoskeletal (2/3) 67%
ENT (1/2) 50%
Reproductive Medicine (1/4) 25%
Immunology/Allergy (0/2) 0%
Haematology/Oncology (2/3) 67%
Respiratory Medicine (1/4) 25%
Dermatology (0/4) 0%
Psychiatry (0/3) 0%
Cardiovascular (1/3) 33%
Genetics (1/1) 100%
Endocrinology/Metabolic Disease (1/4) 25%
Neurology (4/4) 100%
Paediatrics (2/2) 100%
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