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Question 1
Incorrect
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A 48-year-old man presents with complaints of blurred vision, redness and itching of the eyes. He reports having this chronic 'eye infection' on and off for the past four years. He has been using chloramphenicol drops without much relief. Upon examination, there is evidence of blepharitis, lid margin telangiectasia and mild conjunctival hyperaemia.
What is the most probable diagnosis?Your Answer: Ulcerative colitis
Correct Answer: Rosacea
Explanation:Common Eye Conditions Associated with Systemic Diseases
Rosacea is a skin condition that can also affect the eyes, causing chronic blepharitis, meibomian cysts, conjunctivitis, and keratitis. Ocular rosacea symptoms may occur before, during, or after skin symptoms, and may not always match the severity of skin symptoms.
Ulcerative colitis, an inflammatory bowel disease, can cause scleritis or uveitis, which can lead to eye pain, redness, and vision loss.
Recurrent herpes simplex can cause a linear branching corneal ulcer, known as a dendritic ulcer, as well as epithelial and disciform keratitis, resulting in foreign-body sensation, light sensitivity, redness, and blurred vision.
Rheumatoid arthritis may be associated with episcleritis, scleritis, and dry eyes, which can cause eye pain, redness, and irritation.
Systemic sclerosis, a connective tissue disorder, can cause eyelid tightening and telangiectasia, which are visible blood vessels on the surface of the skin, including the eyelids.
Overall, it is important for individuals with these systemic diseases to be aware of potential eye complications and to seek prompt medical attention if they experience any changes in their vision or eye health.
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This question is part of the following fields:
- Eyes And Vision
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Question 2
Correct
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A 68-year-old woman with a recent diagnosis of chronic obstructive pulmonary disease (COPD) is seen.
Her spirometry shows an FEV1 of 42% predicted with an FEV1:FVC ratio of 64%. Her current treatment consists of a short-acting beta agonist (SABA) used as required which was started when a clinical diagnosis was made two to three months ago prior to her having had the spirometry performed. A chest x Ray was normal and she gave up cigarettes a few weeks ago. Her home peak flow measurments show a 30% diurnal variation.
On reviewing her symptoms she needs to use the SABA at least four times a day and despite this still feels persistently breathless. In addition, she tells you that over the last few years she gets attacks of 'bronchitis' two to three times a year. You can see from her notes that she has received at least two courses of antibiotics each year for the last three years for acute episodes of productive cough and shortness of breath.
Which of the following is the next most appropriate step in her pharmacological management?Your Answer: Add in a LABA and ICS in a combination inhaler
Explanation:Management of COPD with Persistent Breathlessness
Patients with COPD who experience persistent breathlessness despite regular SABA use require additional inhaled treatment to improve symptom control and prevent exacerbations. Spirometry results confirming an obstructive picture, frequent exacerbations, and an FEV1 of less than 50% are useful in determining the next step in management.
The two options for add-on inhaled treatment are a LABA+ICS combination inhaler or a LAMA. The choice depends on the presence of asthmatic features, such as a previous diagnosis of asthma or atopy, a higher eosinophil count, substantial variation on FEV1 over time, or a substantial diurnal variation in peak flow. If asthmatic features are present, a LABA & ICS combination inhaler is preferred.
Adding a regular ICS on its own has no role in the COPD treatment ladder, while a regular SAMA can be used instead of a SABA but is not an option for add-in treatment. Adding a LABA may improve symptoms, but the combination of ICS/LABA is more beneficial for patients with a history of frequent exacerbations.
In addition to inhaled treatment, it may be necessary to issue an emergency supply of antibiotics and oral steroids for patients with persistent breathlessness and frequent exacerbations. For more information on managing stable COPD, refer to the NICE Visual Summary guide and NICE NG115 guidelines.
Overall, the management of COPD with persistent breathlessness requires a tailored approach based on individual patient characteristics and the presence of asthmatic features.
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This question is part of the following fields:
- Respiratory Health
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Question 3
Incorrect
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John is a 55-year-old man who is currently experiencing severe hot flashes which are causing him significant distress sleeping and going to work. He is adamant he doesn't want hormonal replacement therapy. What are some possible non-hormonal treatments for hot flashes?
Your Answer: Amitriptyline
Correct Answer: Clonidine
Explanation:Clonidine is the only option listed above that is recognized as a non-hormonal treatment for hot flashes during menopause. Amitriptyline is an antidepressant, Tibolone is a synthetic compound with estrogenic, progestogenic, and androgenic activity, Danazol is a synthetic steroid that suppresses gonadotropin production, and Clomiphene is a selective estrogen receptor modulator used in fertility treatments. According to the NICE Clinical Knowledge Summaries article on treating menopause symptoms, non-hormonal therapies for hot flashes include lifestyle changes, a trial of certain medications such as paroxetine, fluoxetine, citalopram, or venlafaxine, a 24-week trial of clonidine, or a progestogen like norethisterone or megestrol (with specialist advice).
Managing Menopause: Lifestyle Modifications, HRT, and Non-HRT Options
Menopause is a natural biological process that marks the end of a woman’s reproductive years. It is diagnosed when a woman has not had a period for 12 months. Menopausal symptoms are common and can last for several years. The management of menopause can be divided into three categories: lifestyle modifications, hormone replacement therapy (HRT), and non-hormone replacement therapy.
Lifestyle modifications can help manage symptoms such as hot flashes, sleep disturbance, mood changes, and cognitive symptoms. Regular exercise, weight loss, stress reduction, and good sleep hygiene are recommended.
HRT is an effective treatment for menopausal symptoms, but it is not suitable for everyone. Women with current or past breast cancer, any oestrogen-sensitive cancer, undiagnosed vaginal bleeding, or untreated endometrial hyperplasia should not take HRT. HRT brings certain risks, including an increased risk of venous thromboembolism, stroke, coronary heart disease, breast cancer, and ovarian cancer.
Non-HRT options include fluoxetine, citalopram, or venlafaxine for vasomotor symptoms, vaginal lubricants or moisturisers for vaginal dryness, self-help groups, cognitive behaviour therapy, or antidepressants for psychological symptoms, and vaginal oestrogen for urogenital symptoms.
When stopping HRT, it is important to gradually reduce the dosage to limit recurrence in the short term. Women should be referred to secondary care if treatment has been ineffective, if there are ongoing side effects, or if there is unexplained bleeding.
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This question is part of the following fields:
- Gynaecology And Breast
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Question 4
Correct
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A 28-year-old woman presents to her General Practitioner with a 6-month history of progressive tiredness. She has been working alternative night and day shifts for many months. In the last two months she has experienced intermittent constipation. She reports that her diet is not great because of these awkward shift patterns but that she doesn't restrict it. She thinks she may have lost a small amount of weight over this period. Her legs ache after a long shift and that the tan she obtained in the summer seems to have lingered.
She has no significant previous illness and doesn't take any regular medications.
Investigations:
Investigation Result Normal values
Haemoglobin (Hb) 130 g/l 115–155 g/l
White cell count (WCC) 4.5 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 222 × 109/l 150–400 × 109/l
Sodium (Na+) 128 mmol/l 135–145 mmol/l
Potassium (K+) 5.3 mmol/l 3.5–5.0 mmol/l
Urea 4.8 mmol/l 2.5–7.8 mmol/l
Creatinine (Cr) 56 µmol/l 45–84 µmol/l
Free thyroxine (T4) 12 pmol/l 9–24 pmol/l
Thyroid-stimulating hormone (TSH) 2.2 mU/l 0.4–4.0 mU/l
Haemoglobin A1c (HbA1c) 39 mmol/mol < 41 mmol/mol
Ferritin 50 ng/ml 10–300 ng/ml
Glucose 5.2 mmol/l 3.9–7.1 mmol/l
What is the most likely diagnosis?Your Answer: Addison's disease
Explanation:Differential diagnosis for a patient with fatigue, weight loss, and electrolyte abnormalities
Addison’s disease: The most likely diagnosis for this patient is Addison’s disease, an autoimmune disorder that affects the adrenal glands and leads to a deficiency of cortisol and aldosterone. The gradual onset of symptoms, including fatigue, weight loss, muscle aches, constipation, and hyperpigmentation, along with mild hyponatremia and hyperkalemia, are consistent with this diagnosis.
Subclinical hypothyroidism: Although the patient has some symptoms that could be attributed to low thyroid hormone levels, her thyroid function tests are normal, making this diagnosis less likely.
Dietary related hyponatremia: Mild hyponatremia in a young person is unlikely to be caused by dietary differences or deficiency, suggesting a pathological process.
Renal disease: While electrolyte abnormalities could be a sign of renal insufficiency, the patient’s normal urea and creatinine levels make this diagnosis less likely.
Cushing’s disease: Although some symptoms, such as fatigue and muscle weakness, could be attributed to excess cortisol, other expected symptoms, such as weight gain and high blood sugar, are not present in this patient.
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This question is part of the following fields:
- Allergy And Immunology
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Question 5
Correct
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A 70-year-old man is undergoing a routine health check with his family doctor. He reports feeling less active than he used to but has no other specific complaints and is not taking any regular medication. Biochemical tests reveal the following results: serum alkaline phosphatase of 550 U/l (normal range: 44-147 U/l), serum creatinine concentration of 132 µmol/l (normal range: 60-120 µmol/l), calcium of 2.42 mmol/l (normal range: 2.25-2.5 mmol/l), phosphate of 1.21 mmol/l (normal range: 0.8-1.4 mmol/l), and albumin of 41 g/l (normal range: 35-50 g/l). What is the most likely cause of the high alkaline phosphatase?
Your Answer: Paget’s disease of bone
Explanation:Understanding Elevated Serum Alkaline Phosphatase Activity in Bone Diseases
Elevated serum alkaline phosphatase activity is a common finding in bone diseases that involve increased osteoblastic activity. One such condition is Paget’s disease of bone, which is often seen in elderly patients and may not always present with symptoms. In contrast, osteomalacia typically presents with symptoms such as pain, proximal muscle weakness, or a general feeling of being unwell, and is characterized by low-normal or low serum calcium levels. Osteoporosis, on the other hand, doesn’t typically result in elevated alkaline phosphatase levels or abnormal serum biochemistry results. Primary hyperparathyroidism, which is characterized by elevated levels of both alkaline phosphatase and calcium, is unlikely in patients with normal calcium levels. Finally, while renal osteodystrophy may be associated with elevated alkaline phosphatase levels, the severity of renal impairment in this patient is not likely to be the cause of such a high level. In addition, serum phosphate levels are usually elevated and calcium levels are low in this condition. Overall, understanding the relationship between serum alkaline phosphatase activity and various bone diseases can help clinicians make accurate diagnoses and develop appropriate treatment plans.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 6
Correct
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A 25-year-old single man comes to the GP with a severe psoriatic type rash on the palmar surface of his hands and the soles of his feet. He has recently returned from a trip to Thailand.
He also reports experiencing conjunctivitis, joint pains, and a rash on his penis.
What is the most probable diagnosis?Your Answer: Reactive arthritis
Explanation:Rash on Soles and Palms: Possible Causes
A rash on the soles and palms can be a symptom of various conditions, including reactive arthritis (Reiter’s), syphilis, psoriasis (excluding guttate form), eczema (pompholyx), and erythema multiforme. Palmoplantar psoriasis may also present as a pustular form, while athlete’s foot can be caused by Trichophyton rubrum.
In this particular case, the symptoms are most consistent with reactive arthritis, which can be associated with sexually transmitted infections or bacterial gastroenteritis. The fact that the patient recently traveled to Ibiza raises the possibility of a sexually transmitted infection.
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This question is part of the following fields:
- Dermatology
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Question 7
Correct
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A 12-year-old girl is brought in for an urgent appointment with her mother. She has been experiencing a sore throat, fever, malaise, and headache for the past two days. Yesterday, she complained of pain in her right ear, which has now spread to both ears. She has difficulty eating and drinking due to discomfort.
During the examination, bilateral swelling is observed, which is obstructing the angle of the jaw on both sides. When attempting to open her mouth to examine her throat, she experiences discomfort.
The patient has no significant medical history, and her mother is unsure if she has received all of her scheduled vaccinations.
What is the incubation period for this infection?Your Answer: 14-21 days
Explanation:Mumps: Symptoms, Complications, and Incubation Period
Mumps is a viral infection that has an incubation period of 14-21 days. The patient typically experiences a nonspecific prodrome of sore throat, fever, malaise, and headache, which eventually leads to inflammation of the parotid gland. Fortunately, symptomatic treatment is usually sufficient, and the illness resolves within one to two weeks.
However, mumps can lead to serious complications, with meningoencephalitis occurring in 10% of patients with parotitis, and orchitis occurring in 25% of postpubertal males affected by mumps. In about 15% of those affected by orchitis, it is bilateral.
It’s worth noting that the incubation period for mumps may vary slightly depending on the reference source. However, the correct answer should always fall within a reasonable range, so don’t be too concerned if the limits of the reference range differ slightly from what you may have read elsewhere.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 8
Incorrect
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What parameter is the GP measuring by asking 100 randomly selected patients from his patient list if they are currently experiencing symptoms of eczema?
Your Answer: Incidence rate
Correct Answer: Point prevalence
Explanation:Understanding Epidemiological Measures: Point Prevalence, Incidence Rate, Cumulative Incidence, Incidence Proportion, and Period Prevalence
Epidemiological measures are essential in determining the prevalence and incidence of diseases in a population. Among the commonly used measures are point prevalence, incidence rate, cumulative incidence, incidence proportion, and period prevalence.
Point prevalence refers to the proportion of people with a particular disease at a specific time point. For instance, a doctor may send a questionnaire to determine the number of people suffering from a disease at a particular time, and the data collected can be used to determine the point prevalence.
Incidence rate, on the other hand, refers to the rate at which a new event occurs over a specified period. For example, the number of new cases of a disease in a population over a year.
Cumulative incidence is another term for incidence proportion, which refers to the number of new cases in a population during a specified time period.
Incidence proportion is similar to cumulative incidence, but it only considers new cases in a population during a specified time period.
Period prevalence, on the other hand, refers to the proportion of people with a particular disease during a given time period.
Understanding these epidemiological measures is crucial in determining the prevalence and incidence of diseases in a population, which can help in developing effective prevention and treatment strategies.
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This question is part of the following fields:
- Population Health
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Question 9
Incorrect
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A 36-year-old large goods vehicle (LGV) driver visits your clinic. He has type II diabetes, managed with metformin and tolbutamide.
He reports experiencing a hypoglycaemic episode while at work. He was conversing with a colleague before embarking on a delivery when he suddenly felt hot, dizzy, and disoriented. His colleague escorted him to the first-aid station, where his blood glucose was checked. It was 3.2. The first-aider administered oral glucose, and he quickly recovered.
What guidance will you provide to your patient regarding his Group 2 (LGV) driving license?Your Answer: If a further episode occurs, he will have to stop driving
Correct Answer: No driving for 12 months and he must notify the DVLA
Explanation:Diabetes and Driving: DVLA Guidelines
People with diabetes who are managed by tablets that carry a risk of inducing hypoglycaemia must meet certain criteria to maintain their driving licence. The Driver and Vehicle Licensing Agency (DVLA) guidelines state that patients must have no episode of hypoglycaemia requiring assistance in the past 12 months, have full awareness of hypoglycaemia, regularly monitor their blood glucose levels, and demonstrate an understanding of the risks of hypoglycaemia. Additionally, there should be no other complications of diabetes that could affect driving, such as a visual field defect.
If a patient experiences an episode of hypoglycaemia requiring assistance, they must give up their Group 2 licence until they have been clear of any similar episodes for 12 months. It is also important to note that a lack of hypoglycaemic awareness can be a worrying feature, and referral to a specialist diabetic team may be necessary to optimize diabetic control and re-establish hypoglycaemic awareness. By following these guidelines and working with healthcare professionals, people with diabetes can maintain their driving privileges while ensuring their safety and the safety of others on the road.
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This question is part of the following fields:
- Consulting In General Practice
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Question 10
Correct
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You have been asked to advise whether the household contacts of a case of pertussis need further management apart from antibiotics.
The household consists of the case who is a 2-year-old child, his siblings, who are 4 and 6 (and have had their immunisations to date), parents aged 31 and 33 and grandmother aged 63. There is also a lodger, a student aged 19, who is out of the house for much of the time.
You are aware that the case and his siblings should all complete their primary immunisation course and preschool boosters as planned. The mother did not receive the vaccine during pregnancy.
Which of the adults should be offered post-exposure immunisation?Your Answer: All of them: the lodger, parents and grandmother
Explanation:Post-Exposure Immunisation for Pertussis: Guidelines and Recommendations
According to The Green Book, post-exposure immunisation with pertussis-containing vaccine should be offered to all household contacts over 10 years of age who have not received a dose of pertussis-containing vaccine in the last five years and no Td-IPV vaccine in the preceding month. This is a new recommendation in guidelines published in February 2011. The rationale for this is that the duration of immunity conferred by immunisation is increased by the addition of the preschool booster, which was only introduced in October 2001.
Children born before November 1996 would have been eligible for only three primary doses of (whole cell) pertussis-containing vaccine during infancy, and immunity is likely to have waned in these individuals. Therefore, contacts over 10 may benefit from a dose of pertussis-containing vaccine. Studies have shown the safety and immunogenicity of a tetanus/low dose diphtheria/low dose acellular pertussis (Tdap) vaccine in adolescents and adults up to 65.
It is important to note that all household contacts aged 10-64 should be offered post-exposure immunisation, not just those in closest contact with the case. This includes the lodger, parents, and grandmother in the given scenario. The 6-month-old case should complete their course of primary immunisation and have the preschool booster dose as planned, while the 3- and 5-year-old contacts should complete their normal course of primary vaccination and preschool booster as planned to prolong the duration of immunity.
In summary, understanding and implementing key national guidelines for respiratory problems, such as post-exposure immunisation for pertussis, is important for healthcare providers.
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This question is part of the following fields:
- Respiratory Health
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Question 11
Incorrect
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A 48-year-old woman comes to see you to discuss her contraception. She has been using the progestogen-only pill for the past 4 years. She is currently amenorrhoeic. She is not sure how long she should continue to use contraception for and asks your advice.
She was seen two months ago by a colleague who advised her to have her FSH levels checked. This has shown an FSH level of 42 (normal range: less than 30).
What do you advise?Your Answer: Repeat FSH now and if >30, then contraception can be stopped in 6 months
Correct Answer: Repeat FSH now and if >30, then she can stop contraception in 1 year
Explanation:FSH Testing for Women on Contraception
Current guidance from the Faculty for Sexual and Reproductive Healthcare suggests that women using progestogen-only contraception can have their FSH levels measured, but only if they are over 50 years old. However, a single elevated FSH reading is not enough to determine ovarian failure. If FSH levels are consistently above 30, contraception can be stopped after a year. It’s important to note that amenorrhea alone is not a reliable indicator of ovarian failure in women taking exogenous hormones. Additionally, for women using combined hormones, FSH testing during a hormone-free period is not a reliable indicator of ovarian failure. Proper testing and monitoring are crucial for women on contraception to ensure their reproductive health.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 12
Correct
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A 16-year-old girl with a learning disability has started exhibiting aggressive behavior, causing concern for the safety of her caregivers. They are considering medication as a possible solution. What is the best course of action in this situation?
Your Answer: Assess for environmental, psychological or physical causes of the change in behaviour
Explanation:Assessing and Managing Behavioural Changes in Individuals with Learning Disabilities
When an individual with a learning disability experiences a change in behaviour, it is important to assess for any potential causes. This can include environmental, psychological, or physical factors, and input from family or carers can be helpful. If no cause is identified, seeking specialist input may be necessary.
Prescribing amitriptyline would not be appropriate for longer-term use in this situation. Antipsychotics are the first choice for longer-term use, while lorazepam, haloperidol, or promethazine are recommended for short-term rapid tranquillisation by NICE.
Prescribing a short supply of diazepam may worsen agitation or confusion, so it is not recommended.
Referring to the learning disabilities team is a reasonable option, but assessing for potential causes should be the first step.
Olanzapine may be used in this situation, but it should only be initiated by a specialist according to NICE guidance. Overall, a thorough assessment and appropriate management can help address behavioural changes in individuals with learning disabilities.
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This question is part of the following fields:
- Neurodevelopmental Disorders, Intellectual And Social Disability
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Question 13
Incorrect
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A 32-year-old woman presents to the General Practice Surgery with multiple skin lesions that she has noticed over the past few weeks. She is a single mother and works as a waitress, and has a long history of smoking and poor engagement with health and social services.
On examination, she is overweight with a body mass index (BMI) of 30 kg/m2 (normal range: 20-25 kg/m2), with obvious cigarette burns on her arms. She has multiple small (ranging from 2-12 mm in diameter), flat, purple bruise-like lesions across her chest, back and arms.
What causative agent is associated with the most likely underlying diagnosis?Your Answer: Cytomegalovirus (CMV)
Correct Answer: Human herpesvirus-8 (HHV-8)
Explanation:The patient in this case has Kaposi’s sarcoma, a common tumor found in individuals with HIV infection. The tumor presents as dark purple/brown intradermal lesions that resemble bruises and can appear anywhere on the skin or oropharynx. Since HIV often goes undiagnosed, it is important to consider this diagnosis in patients with risk factors. This patient has a history of IV drug use and poor engagement with services, making it possible that they have never been tested for HIV. The patient is underweight with a low BMI, which could be a sign of HIV infection. Kaposi’s sarcoma is caused by the human herpesvirus-8 (HHV-8), also known as Kaposi’s Sarcoma-associated herpesvirus (KSHV).
Shingles, caused by the varicella-zoster virus, is not related to Kaposi’s sarcoma. Cytomegalovirus (CMV) is a herpesvirus that can cause serious infections in immunocompromised individuals, but it is not associated with Kaposi’s sarcoma. Human papillomavirus (HPV) is linked to cervical cancer and is not a herpesvirus. Herpes simplex virus (HSV) causes oral and genital herpes, but it is not responsible for Kaposi’s sarcoma.
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This question is part of the following fields:
- Allergy And Immunology
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Question 14
Incorrect
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A 70-year-old man has a very poor memory. He makes up stories to account for gaps in his memory. He doesn't realise what he is doing.
On examination he seems apathetic and has an unsteady gait. What is the most likely diagnosis?Your Answer: Korsakoff's syndrome
Correct Answer: Complex partial seizures
Explanation:Korsakoff’s Syndrome: A Case of Poor Memory and Confabulation
Looking at this case history, it is evident that the patient is experiencing poor memory, confabulation, lack of insight, apathy, and an ataxic gait. These symptoms are typical of Korsakoff’s Syndrome, which is commonly caused by alcohol abuse. The syndrome presents with a triad of symptoms, including mental confusion, ataxia, and ophthalmoplegia. Confabulation is a characteristic of Korsakoff’s, making it the most likely diagnosis of those given above. However, it can be prevented by administering thiamine.
In summary, Korsakoff’s Syndrome is a serious condition that can result in poor memory, confabulation, and other debilitating symptoms. Early diagnosis and treatment are crucial in preventing further damage and improving the patient’s quality of life.
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This question is part of the following fields:
- Older Adults
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Question 15
Incorrect
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When two medical conditions are related through the presence of a confounding factor, the association is said to be:
Your Answer: Factitious
Correct Answer: Indirect
Explanation:Association and Causation: Understanding the Difference
Association refers to the relationship between two variables where one is more commonly found in the presence of the other. However, not all associations are causal. There are three types of association: spurious, indirect, and direct. Spurious associations are those that arise by chance and are not real, while indirect associations are due to the presence of another factor, also known as a confounding variable. Direct associations, on the other hand, are true associations not linked by a third variable.
To establish causation, the Bradford Hill Causal Criteria are used. These criteria include strength, temporality, specificity, coherence, and consistency. The strength of the association is an important factor in determining causation, as a stronger association is more likely to be truly causal. Temporality refers to whether the exposure precedes the outcome, while specificity asks whether the suspected cause is associated with a specific outcome or disease. Coherence considers whether the association fits with other biological knowledge, and consistency looks at whether the same association is found in many studies.
Understanding the difference between association and causation is important in research and decision-making. While an association may suggest a relationship between two variables, it doesn’t necessarily mean that one causes the other. By using the Bradford Hill Causal Criteria, researchers can determine whether an association is truly causal and make informed decisions based on their findings.
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This question is part of the following fields:
- Evidence Based Practice, Research And Sharing Knowledge
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Question 16
Incorrect
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A 55-year-old man who gave up smoking ten years ago presents at surgery with hoarseness.
It has been present for four weeks and is not improving. He has no systemic illness to explain it and the only thing of note is that he is a heavy whisky drinker.
You suspect he may have laryngeal cancer.
Which of the following symptoms would augment that suspicion?Your Answer: Hoarseness worse in the morning
Correct Answer: Odynophagia
Explanation:Symptoms of Laryngeal and Lung Cancer
Laryngeal cancer can present with two main symptoms: dysphagia and odynophagia, which are difficulty and painful swallowing, respectively. On the other hand, lung cancer may cause bovine cough, a distinct coughing sound, and recurrent laryngeal palsy. Hoarseness is a common symptom of both types of cancer, but submandibular swelling may indicate other head and neck cancers. It is important to note that vomiting is not typically a symptom of these cancers, except in advanced stages. Early detection and treatment are crucial for improving outcomes in cancer patients.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 17
Incorrect
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A 55-year-old woman presents with urgency and frequency. Three weeks ago she consulted with a colleague as she felt 'dry' during intercourse. She has been treated for urinary tract infections on multiple occasions in the past but urine culture is always negative. Her only medication is continuous hormone replacement therapy which she has taken since her periods stopped three years ago. A vaginal examination is performed which shows no evidence of vaginal atrophy and no masses are felt. An ultrasound is requested:
Both kidneys, spleen and liver are normal size. Outline of the bladder normal. 3 cm simple ovarian cyst noted on left ovary. Right ovary and uterus normal
What is the most appropriate next step?Your Answer: Refer for bladder retraining
Correct Answer: Urgent referral to gynaecology
Explanation:Investigation is necessary for any ovarian mass found in a woman who has undergone menopause.
When a patient presents with suspected ovarian cysts or tumors, the first imaging modality used is typically ultrasound. The ultrasound report will indicate whether the cyst is simple or complex. Simple cysts are unilocular and more likely to be benign, while complex cysts are multilocular and more likely to be malignant. Management of ovarian enlargement depends on the patient’s age and whether they are experiencing symptoms. It is important to note that ovarian cancer diagnosis is often delayed due to a vague presentation.
For premenopausal women, a conservative approach may be taken, especially if they are younger than 35 years old, as malignancy is less common. If the cyst is small (less than 5 cm) and reported as simple, it is highly likely to be benign. A repeat ultrasound should be scheduled for 8-12 weeks, and referral should be considered if the cyst persists.
Postmenopausal women, on the other hand, are unlikely to have physiological cysts. Any postmenopausal woman with an ovarian cyst, regardless of its nature or size, should be referred to gynecology for assessment.
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This question is part of the following fields:
- Gynaecology And Breast
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Question 18
Incorrect
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A 30-year-old woman complains of heavy menstrual bleeding and a constant sore throat. Upon examination, she is found to have pancytopenia. Which medication is the most probable cause of this condition?
Your Answer: Clomifene
Correct Answer: Trimethoprim
Explanation:Causes of Pancytopenia Due to Drug Intake
Pancytopenia is a medical condition characterized by a decrease in the number of red blood cells, white blood cells, and platelets in the blood. It can be caused by various factors, including drug intake. Some drugs can lead to pancytopenia by suppressing the bone marrow’s ability to produce blood cells.
Cytotoxic drugs, antibiotics such as trimethoprim and chloramphenicol, and anti-rheumatoid drugs like gold and penicillamine are some of the drugs that can cause pancytopenia. Carbimazole, an anti-thyroid drug, can also lead to this condition. Additionally, anti-epileptic drugs like carbamazepine and sulphonylureas such as tolbutamide have been known to cause pancytopenia.
It is important to monitor blood counts regularly when taking these drugs to detect any potential side effects. If pancytopenia is suspected, the drug should be discontinued immediately, and appropriate treatment should be initiated.
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This question is part of the following fields:
- Haematology
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Question 19
Incorrect
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You are requested to evaluate an elderly patient with advanced esophageal cancer. The patient has metastatic cancer and is receiving palliative care with home visits. The patient reports increasing trouble in swallowing over the past few weeks, which is now hindering their ability to consume food properly. The patient describes the feeling of food getting stuck while swallowing. There is no pain while swallowing. What is the most suitable treatment to alleviate these symptoms?
Your Answer: Dexamethasone
Correct Answer: Nifedipine
Explanation:Managing Dysphagia in Palliative Care
When managing dysphagia in a palliative care setting, it is crucial to identify the underlying cause of the condition. Depending on the cause, different treatments may be necessary. For instance, a physical obstruction caused by a tumour may require a corticosteroid such as dexamethasone, while oesophageal spasm may respond to a muscle relaxant like nifedipine or baclofen.
In the case of a patient with oesophageal cancer who experiences progressive difficulty in swallowing and food getting stuck on the way down, the most likely cause is a gradually enlarging tumour mass causing obstruction and progressive dysphagia. In this scenario, dexamethasone is the most appropriate treatment to prescribe.
It is worth noting that oesophageal spasm typically causes odynophagia in addition to dysphagia. Therefore, a careful assessment of the patient’s symptoms and medical history is necessary to determine the most effective treatment plan.
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This question is part of the following fields:
- End Of Life
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Question 20
Incorrect
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A 55-year-old man with a chronic medical condition has had two recent upper respiratory tract infections that have been prolonged and complicated with sinusitis and bronchitis. His general practitioner is concerned that the patient may have a secondary immunodeficiency due to the chronic medical condition (rather than being caused by the medication used to treat his condition).
Which of the following conditions is most likely to cause a secondary immunodeficiency?Your Answer: Asthma
Correct Answer: Chronic kidney disease
Explanation:Understanding Immunodeficiency in Various Medical Conditions
Immunodeficiency is a condition where the immune system is weakened, making individuals more susceptible to infections. While some medical conditions are directly associated with immunodeficiency, others are not. Chronic kidney disease, particularly end-stage disease requiring dialysis, is linked to secondary immunodeficiency, making patients vulnerable to infections such as sepsis, peritonitis, influenza, tuberculosis, and pneumonia. Similarly, some disease-modifying drugs used in the treatment of multiple sclerosis have immunomodulatory and immunosuppressive effects, increasing the risk of infection. Asthma and psoriasis are not typically associated with immunodeficiency, but long-term use of oral corticosteroids and certain medications used to treat severe psoriasis can increase the risk of infection. Rheumatoid arthritis is not a direct cause of immunodeficiency, but disease-modifying drugs used in its treatment can increase the risk. Overall, drug treatment is a common cause of secondary immunodeficiency, with cancer treatment being a significant concern. Other causes include HIV, surgery or trauma, and malnutrition. Understanding the relationship between various medical conditions and immunodeficiency is crucial in managing patient care and preventing infections.
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This question is part of the following fields:
- Allergy And Immunology
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Question 21
Incorrect
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A 40-year-old woman is HIV positive and takes antiretroviral therapy. What should she be offered annually in primary care?
Your Answer: Cervical screening
Correct Answer: All of the options listed
Explanation:Managing HIV in Primary Care: Guidelines and Considerations
Patients with HIV are at an increased risk of cardiovascular disease, and antiretroviral therapy can further increase the risk of diabetes and dyslipidaemia. Women with HIV are also more susceptible to human papillomavirus-related diseases and should undergo annual cervical screening. To ensure good sexual health and maintain protective sexual behavior, patients should have access to staff trained to carry out a sexual history and sexual health assessment, as well as counseling and support. Additionally, patients should be offered a full sexual health screen annually. Despite concerns about contraindications, the influenza vaccine is safe for patients with HIV as it is an inactivated virus. These guidelines aim to support primary care teams in managing the unique considerations and risks associated with HIV.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 22
Incorrect
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A 7-year-old girl comes to your clinic with her mother, complaining of persistent dandruff. Her mother also mentions noticing a small area of hair loss at the back of her head. Upon examination, you observe widespread scaling on the scalp and inflamed skin beneath the patch of hair loss. What steps do you take next?
Your Answer: Advise coal tar shampoo
Correct Answer: Send skin scrapings for analysis
Explanation:To effectively manage this fungal infection on the scalp, it is important to identify the specific organism responsible through skin scrapings. Coal tar shampoo may be a suitable treatment for managing dandruff or scalp psoriasis, but it will not address a fungal infection. Topical steroids are not effective against fungal infections. Depending on the type of fungus causing the infection, oral griseofulvin may be an appropriate treatment. Referral to a specialist is not necessary at this stage, as initial investigations can be conducted by primary care providers. This information is sourced from NICE CKS on fungal skin infections of the scalp.
Understanding Tinea: Types, Causes, Diagnosis, and Management
Tinea is a term used to describe dermatophyte fungal infections that affect different parts of the body. There are three main types of tinea infections, namely tinea capitis, tinea corporis, and tinea pedis. Tinea capitis affects the scalp and is a common cause of scarring alopecia in children. If left untreated, it can lead to the formation of a raised, pustular, spongy/boggy mass called a kerion. The most common cause of tinea capitis in the UK and the USA is Trichophyton tonsurans, while Microsporum canis acquired from cats or dogs can also cause it. Diagnosis of tinea capitis is done through scalp scrapings, although lesions due to Microsporum canis can be detected through green fluorescence under Wood’s lamp. Management of tinea capitis involves oral antifungals such as terbinafine for Trichophyton tonsurans infections and griseofulvin for Microsporum infections. Topical ketoconazole shampoo is also given for the first two weeks to reduce transmission.
Tinea corporis, on the other hand, affects the trunk, legs, or arms and is caused by Trichophyton rubrum and Trichophyton verrucosum, which can be acquired from contact with cattle. It is characterized by well-defined annular, erythematous lesions with pustules and papules. Oral fluconazole can be used to treat tinea corporis.
Lastly, tinea pedis, also known as athlete’s foot, is characterized by itchy, peeling skin between the toes and is common in adolescence. Lesions due to Trichophyton species do not readily fluoresce under Wood’s lamp.
In summary, understanding the types, causes, diagnosis, and management of tinea infections is crucial in preventing their spread and ensuring effective treatment.
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This question is part of the following fields:
- Dermatology
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Question 23
Incorrect
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A 50-year-old woman has two sons, the youngest of whom has Down syndrome. During a consultation for a different issue, she brings up that her eldest son is considering having children and she is concerned about the possibility of passing on Down syndrome. What is the most frequent genotypic abnormality observed in Down syndrome?
Your Answer: Abnormal gene
Correct Answer: Extra chromosome
Explanation:Understanding the Genetic Basis of Down Syndrome
Down syndrome is a genetic disorder that affects approximately 1 in 700 births. The majority of cases (over 90%) are caused by trisomy 21, which occurs when there is an extra copy of chromosome 21. This is due to a mistake in cell division during the formation of the egg or sperm cell that leads to the zygote having three copies of chromosome 21 instead of the usual two.
Contrary to popular belief, Down syndrome is not caused by an abnormal gene. Rather, it is a chromosomal disorder that is not inherited in the traditional sense. However, in rare cases (about 3.5%), Down syndrome can be caused by a translocation of chromosome 21, where a piece of the chromosome breaks off and attaches to another chromosome. This can be inherited from a parent who is a balanced translocation carrier, meaning they have no extra chromosome 21 themselves but have a piece of it attached to another chromosome.
Another rare form of Down syndrome is mosaic trisomy 21, which occurs when nondisjunction (the failure of chromosomes to separate properly) happens after fertilization during early cell division. This results in some cells having the normal number of chromosomes while others have an extra chromosome 21. People with mosaic Down syndrome may have milder disabilities and less obvious physical features.
Understanding the genetic basis of Down syndrome is important for families and healthcare providers to provide appropriate care and support for individuals with this condition.
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This question is part of the following fields:
- Genomic Medicine
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Question 24
Correct
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You are working in a GP practice, and your next patient is a female aged 35, who has recently registered. She is living in a hostel near to the practice. She has a previous medical history of anxiety and depression, and is coded to be an ex-intravenous drug user.
She reports having intensely itchy 'lumps' on her arms and legs for the past two weeks. Upon examination, she has multiple red bumps and raised areas on her limbs and torso, with some of these appearing in a curved line pattern. Her hands, feet, and groin are unaffected.
What is the most probable diagnosis?Your Answer: Bedbug infestation
Explanation:If a patient complains of intensely itchy bumps on their arms, torso, or legs, it may be a sign of a bed bug infestation. This is especially true if the patient has recently stayed in a hotel, hostel, or other temporary accommodation, as bed bugs can easily travel on clothing and luggage.
While scabies is a possible differential diagnosis, it is less likely if the patient doesn’t have involvement of the finger webs or linear burrows beneath the skin. Bed bug bites tend to appear as lumps or welts, rather than small spots.
If the lesions are aligned in a line or curve, this is also suggestive of a bed bug infestation, as the insects tend to move across the skin in a linear fashion.
Dealing with Bed Bugs: Symptoms, Treatment, and Prevention
Bed bugs are a type of insect that can cause a range of clinical problems, including itchy skin rashes, bites, and allergic reactions. Infestation with Cimex hemipterus is the primary cause of these symptoms. In recent years, bed bug infestations have become increasingly common in the UK, and they can be challenging to eradicate. These insects thrive in mattresses and fabrics, making them difficult to detect and eliminate.
Topical hydrocortisone can help control the itch. However, the definitive treatment for bed bugs is through a pest management company that can fumigate your home. This process can be costly, but it is the most effective way to eliminate bed bugs.
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This question is part of the following fields:
- Dermatology
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Question 25
Correct
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What is a condition that is not included in the routine immunisation schedule in the United Kingdom?
Your Answer: Diphtheria
Explanation:BCG Immunisation Programme in the UK
Tuberculosis (TB) is a disease that has been targeted by the bacillus Calmette-Guérin (BCG) immunisation programme in the UK since 1953. However, changes in the trends of the disease have led to modifications in the programme to focus on ‘at-risk’ populations. The Green Book, published by Public Health England, provides clear guidelines on who should receive BCG vaccination. Neonatal immunisation is now used to protect children who are most at risk of contracting TB.
In contrast, the other conditions listed in the options are covered in the routine immunisation schedule and are offered to all.
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This question is part of the following fields:
- Children And Young People
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Question 26
Incorrect
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A 30-year-old man presented after several days of high fever and headache, which began to resolve. He presents now with jaundice on returning from a holiday in Spain. As part of a group of 20 he had visited hillside forests and went fishing in mountain streams. Which of the following organisms is most likely to be responsible for his illness?
Your Answer: Pneumococcus
Correct Answer: Leptospira icterohaemorrhagiae
Explanation:Leptospirosis, also known as Weil’s disease, is a bacterial infection that can be transmitted to humans through contact with infected animals, including rodents, skunks, foxes, cattle, and dogs. Rat urine and faeces are common sources of transmission. Due to its varied symptoms, leptospirosis can be easily missed, making thorough history taking essential for diagnosis.
Symptoms of leptospirosis include fever, headache, myalgia, oliguria, jaundice, and enlargement of the liver and spleen. In some cases, patients may also experience haemorrhagic tendencies with purpura or petechiae. It is important to note that not all infected individuals will exhibit all of these symptoms.
Weil’s disease is a particular concern for those who participate in water sports, as the bacteria can survive in fresh and saltwater. In the UK, there are approximately 40 cases of leptospirosis reported each year, with the majority of cases occurring between June and October. Awareness of the potential for leptospirosis is crucial for early diagnosis and treatment.
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This question is part of the following fields:
- Urgent And Unscheduled Care
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Question 27
Incorrect
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A 12-year-old boy presents with dark discolouration of his urine. There is a history of upper respiratory tract infection with severe pharyngitis two weeks earlier. He was previously fit and well. On examination he has a puffy face with periorbital oedema. His blood pressure is 150/90 mmHg.
Given the likely diagnosis, which complication would be most likely to occur in the acute illness?
Your Answer: Acute cardiac failure
Correct Answer: Diffuse proliferative glomerulonephritis
Explanation:Understanding Diffuse Proliferative Glomerulonephritis: Causes, Symptoms, and Complications
Diffuse proliferative glomerulonephritis (DPGN) is a type of nephritic syndrome that causes widespread hypercellularity in the kidneys. The condition is often caused by post-streptococcal glomerulonephritis, which can lead to dark urine and haemolysis of red blood cells. While DPGN is rare in developed countries, it remains common in the developing world and can also be associated with systemic lupus erythematosus.
Symptoms of DPGN include hypertension, oedema, and nephrotic-range proteinuria. While most children will recover without treatment, a small proportion of adults may develop renal impairment that can progress to end-stage renal failure requiring dialysis. Acute cardiac failure is unlikely in patients with normal cardiovascular systems, but can be a cause of death in elderly patients.
It is important to differentiate DPGN from other types of nephritic and nephrotic syndromes, such as IgA nephropathy, lupus nephritis, and minimal change disease. Complications such as acute rheumatic fever are rare but can occur in some patients. Overall, understanding the causes, symptoms, and potential complications of DPGN is crucial for proper diagnosis and treatment.
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This question is part of the following fields:
- Kidney And Urology
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Question 28
Incorrect
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A 42-year-old man visits his doctor's office and reports that his wife passed away recently. He shares that he woke up this morning thinking she was lying next to him and heard her voice calling his name. He acknowledges that this is not feasible, but it has caused him considerable anguish. He is concerned that he might be losing his mind. He has no other significant psychiatric history.
What is the probable diagnosis?Your Answer: Psychosis
Correct Answer: Pseudohallucination
Explanation:Pseudohallucinations, which are characterized by the patient’s awareness that the voice or feeling is coming from their own mind, are not indicative of psychosis or serious psychiatric conditions. This makes schizophrenia and other psychotic options less likely, and there are no signs of schizoid personality disorder in the patient. Pseudohallucinations are often observed in individuals who have experienced bereavement.
Understanding Pseudohallucinations: A Controversial Topic in Mental Health
Pseudohallucinations are a type of false sensory perception that occur in the absence of external stimuli. Unlike hallucinations, the affected person is aware that they are experiencing a false perception. However, there is no clear definition of pseudohallucinations in the ICD 10 or DSM-5, leading to controversy among mental health specialists.
Some experts argue that it is more helpful to view hallucinations on a spectrum, ranging from mild sensory disturbances to full-blown hallucinations. This approach can prevent misdiagnosis or mistreatment of symptoms. For example, hypnagogic hallucinations, which occur during the transition from wakefulness to sleep, are a common type of pseudohallucination that many people experience. These hallucinations are fleeting and can be either auditory or visual.
The relevance of pseudohallucinations in mental health practice is that patients may need reassurance that these experiences are normal and do not necessarily indicate the development of a mental illness. Pseudohallucinations are also commonly experienced by people who are grieving, which can add to the confusion and distress of the grieving process.
In conclusion, while the definition and role of pseudohallucinations in mental health treatment remain controversial, it is important for mental health professionals to be aware of this phenomenon and provide appropriate support and reassurance to those who experience it.
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This question is part of the following fields:
- Mental Health
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Question 29
Correct
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A 52-year-old man has a BMI of 32.6 kg/m2, smokes thirty cigarettes daily, and drinks four pints of beer in his local pub every week. He is on the pub darts team and claims it is the only exercise he wants or needs.
He has recently been diagnosed with diabetes by his GP and has been commenced on a diet. He has been told to see you for information regarding foot care.
What is the most likely diagnosis?Your Answer: Type 2 diabetes
Explanation:Types of Diabetes
There are two major types of diabetes: type 1 and type 2. Type 1 diabetes is characterized by a deficiency of insulin and typically affects children. Patients with type 1 diabetes are thin, lose weight, and are treated with insulin. On the other hand, type 2 diabetes affects an older age group and is associated with weight gain (obesity). It is usually treated with diet and/or drugs. Although not inherited in any mendelian fashion, type 2 diabetes has a familial occurrence due to the body type of the family. Iatrogenic diabetes is caused by medical treatments, while mitochondrial diabetes is a very rare form of diabetes resulting from damage to mitochondrial DNA. Finally, secondary diabetes occurs as a consequence of another disease.
It is important to differentiate between the types of diabetes as this guides treatment. Patients with type 1 diabetes require insulin, while those with type 2 diabetes may initially be treated with diet and/or drugs but may eventually require insulin. Understanding the cause of diabetes is also important in determining the appropriate treatment.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 30
Incorrect
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You come across a 79-year-old woman who has a medical history of diabetes, osteoarthritis, and hypertension. She experienced pain while bearing weight after twisting her leg while getting out of a car. The pain has reduced with simple analgesia. She also mentions a lump under her knee. During the examination, you notice a non-tender 4 cm lump just below the popliteal fossa that becomes tense when the leg is extended. The patient has full power throughout. What could be the most probable diagnosis?
Your Answer:
Correct Answer: Baker's cyst
Explanation:The usual individual with a Baker’s cyst is someone who has arthritis or gout and has experienced a minor knee injury. When the knee is extended, Foucher’s sign indicates an increase in tension in the Baker’s cyst. It is important to consider the possibility of a DVT, which can imitate a Baker’s cyst. Furthermore, a DVT may coexist with a Baker’s cyst, and an ultrasound should be performed with a low threshold.
Knee Problems in Older Adults
As people age, they become more susceptible to knee problems. Osteoarthritis of the knee is a common condition in older adults, especially those who are overweight. It is characterized by severe pain, intermittent swelling, crepitus, and limited movement. Infrapatellar bursitis, also known as Clergyman’s knee, is associated with kneeling, while prepatellar bursitis, or Housemaid’s knee, is associated with more upright kneeling.
Anterior cruciate ligament injuries may occur due to twisting of the knee, often accompanied by a popping noise and rapid onset of knee effusion. A positive draw test is used to diagnose this condition. Posterior cruciate ligament injuries may be caused by anterior force applied to the proximal tibia, such as hitting the knee on the dashboard during a car accident.
Collateral ligament injuries are characterized by tenderness over the affected ligament and knee effusion. Meniscal lesions may be caused by twisting of the knee and are often accompanied by locking and giving-way, as well as tenderness along the joint line. Understanding the key features of these common knee problems can help older adults seek appropriate medical attention and treatment.
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This question is part of the following fields:
- Musculoskeletal Health
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