00
Correct
00
Incorrect
00 : 00 : 00
Session Time
00 : 00
Average Question Time ( Secs)
  • Question 1 - You are seeing a 60-year-old woman in your afternoon clinic for her annual...

    Correct

    • You are seeing a 60-year-old woman in your afternoon clinic for her annual review. She feels well, although over the last 6 months she has been more tired than usual. She puts this down to starting a new job with increased hours.

      Her past medical history includes hypertension, for which she takes amlodipine 5mg once a day. She was diagnosed with mild chronic kidney disease (CKD) last year. She is a non-smoker and drinks 5-10 units of alcohol a week.

      Her blood pressure today is 130/82 mmHg. A respiratory and cardiovascular examination are both normal. A urine dip is also normal.

      Her blood results today show an estimated glomerular filtration rate (eGFR) of 57 mL/min/1.73 m2. An early morning albumin: creatinine ratio is 25 mg/mmol. The rest of her blood test results are as follows:


      Na+ 140 mmol/l
      K+ 4.9mmol/l
      Urea 6.5 mmol/l
      Creatinine 100 µmol/l

      Looking back through her notes, her eGFR was 77 mL/min/1.73 m2 12 months ago and >90 mL/min/1.73 m2 2 years ago.

      What would be a correct next step for this woman?

      Your Answer: Nephrology referral

      Explanation:

      Referral to a nephrologist is necessary if there is a sustained decrease in eGFR of 15 mL/min/1.73 m2 or more within 12 months. However, in the case of this patient with a normal urine dip, a urology referral would not be necessary. According to NICE guidelines, treatment for hypertension should be followed if the patient has an ACR of <30 mg/mmol, and ACE-i can be started in non-diabetic patients. Aspirin is not recommended for primary prevention of cardiovascular disease. Chronic kidney disease is often without symptoms and is typically identified through abnormal urea and electrolyte levels. However, some individuals with advanced, undetected disease may experience symptoms. These symptoms may include swelling in the ankles, weight gain, increased urination, fatigue, itching due to uraemia, loss of appetite leading to weight loss, difficulty sleeping, nausea and vomiting, and high blood pressure.

    • This question is part of the following fields:

      • Kidney And Urology
      306
      Seconds
  • Question 2 - At what age will a death certified as due to old age or...

    Correct

    • At what age will a death certified as due to old age or senility alone not be referred to the coroner?

      Your Answer: 80

      Explanation:

      Changes in Acceptable Age for Old Age as Sole Cause of Death

      The acceptable age for old age as the sole cause of death has changed from 70 years to 80 years. Doctors are now advised to avoid using old age alone as a cause of death whenever possible. However, there are limited circumstances where it is acceptable, such as when the doctor has personally cared for the deceased over a long period, observed a gradual decline in their health and functioning, and is not aware of any identifiable disease or injury that contributed to the death. In such cases, the doctor must be certain that there is no reason to report the death to the coroner. For more information, doctors can refer to the Guidance for doctors completing Medical Certificates of Cause of Death in England and Wales from the Office for National Statistics’ Death Certification Advisory Group.

    • This question is part of the following fields:

      • Older Adults
      44.1
      Seconds
  • Question 3 - A 31-year-old patient presents to you seeking help with quitting smoking. He currently...

    Incorrect

    • A 31-year-old patient presents to you seeking help with quitting smoking. He currently smokes 20-30 cigarettes per day. After counseling him on his options, you decide to prescribe bupropion. As per NICE guidelines, what is the recommended duration for the initial prescription of bupropion?

      Your Answer: 14 days

      Correct Answer: 84 days

      Explanation:

      Duration of Nicotine Replacement Therapy and Other Medications for Smoking Cessation

      The recommended duration for prescribing nicotine replacement therapy (NRT), varenicline, or bupropion is until two weeks after the target stop date. For NRT, this typically means two weeks of therapy, while varenicline and bupropion may require three to four weeks. It is important to adhere to this timeline to ensure the effectiveness of the medication and to avoid potential side effects from prolonged use. By following this guideline, individuals can increase their chances of successfully quitting smoking and improving their overall health.

    • This question is part of the following fields:

      • Population Health
      427.5
      Seconds
  • Question 4 - A 68 year old woman with chronic asthma has been using a lot...

    Correct

    • A 68 year old woman with chronic asthma has been using a lot of salbutamol including via a nebuliser. She has a tremor, headache and tachycardia.
      Select from the list the single most likely biochemical finding.

      Your Answer: Hypokalaemia

      Explanation:

      Cautionary Measures for β2-Adrenergic Agonist Treatment

      β2-adrenergic agonist treatment may lead to potentially serious hypokalaemia, especially in severe asthma cases. This effect can be intensified by theophylline, corticosteroids, diuretics, and hypoxia. Therefore, it is crucial to monitor plasma-potassium concentration in severe asthma patients. People with diabetes should also exercise caution when using β2 agonists, particularly when given intravenously, as it may increase the risk of ketoacidosis. These cautionary measures are necessary to ensure the safe and effective use of β2-adrenergic agonist treatment.

    • This question is part of the following fields:

      • Respiratory Health
      20.7
      Seconds
  • Question 5 - You see a 13-year-old boy who has burns on his hands. Three months...

    Correct

    • You see a 13-year-old boy who has burns on his hands. Three months ago he had a fractured radius.

      You talk to him and he reveals that his father has been causing the injuries. You inform him that you will be referring him to child protection services, but he pleads with you not to. He comprehends the situation and the role of the child protection team, but he expresses his love for his family and doesn't want to be separated from them. You are familiar with his father and his grandfather, as they are all patients of yours.

      What course of action should you take?

      Your Answer: Refer her to the child protection team

      Explanation:

      Referring Child Abuse Cases: A Doctor’s Responsibility

      As a doctor, it is your responsibility to protect children and young people from abuse. In cases where there is ongoing risk of serious abuse, it is important to refer the child in a timely manner, even if it goes against their wishes. This is because the safety of the child should always be the top priority.

      According to the General Medical Council (UK), doctors have a duty to protect children and young people from harm. Referring cases of abuse is a crucial step in ensuring their safety. It is important to act quickly and make the necessary referrals to safeguard the child’s well-being. Even if the child expresses reluctance or resistance to the referral, it is important to prioritize their safety and take appropriate action. By doing so, doctors can fulfill their responsibility to protect vulnerable children and young people from harm.

    • This question is part of the following fields:

      • Children And Young People
      586.3
      Seconds
  • Question 6 - A 30-year-old man with a history of chronic constipation presents with acute perianal...

    Incorrect

    • A 30-year-old man with a history of chronic constipation presents with acute perianal pain. The pain has been present for a week and is exacerbated during defecation. He also notes a small amount of bright red blood on the paper when he wipes himself.

      Abdominal examination is unremarkable but rectal examination is not possible due to pain.

      What is the likely diagnosis?

      Your Answer: Fistula

      Correct Answer: Fissure

      Explanation:

      Understanding Fissures: Symptoms and Treatment

      Perianal pain that worsens during defecation and is accompanied by fresh bleeding is a common symptom of fissures. However, due to the pain associated with rectal examination, visualizing the fissure is often not possible. Most fissures are located in the midline posteriorly and can be treated with GTN cream during the acute phase, providing relief in two-thirds of cases. Understanding the symptoms and treatment options for fissures can help individuals seek appropriate medical attention and manage their condition effectively.

    • This question is part of the following fields:

      • Gastroenterology
      26.9
      Seconds
  • Question 7 - A 60-year-old patient of yours has a persistently high diastolic blood pressure above...

    Incorrect

    • A 60-year-old patient of yours has a persistently high diastolic blood pressure above 90 mmHg.

      Ambulatory blood pressure monitoring is not currently available so you decide to check his home blood pressures.

      According to NICE what is the minimum number of blood pressure readings a patient should record at home?

      Your Answer:

      Correct Answer: Twice a day for 4 days

      Explanation:

      NICE Guidelines for Hypertension Monitoring

      The management of hypertension is a crucial aspect of general practice, and knowledge of the NICE guidelines is essential for GPs. According to the 2019 NICE guidance on Hypertension (NG136), updated in March 2022, blood pressure should be recorded twice daily for at least four days, ideally for seven days. Two consecutive measurements should be taken for each recording, at least one minute apart, with the person seated. The first day’s measurements should be discarded, and the average value of the remaining measurements used to confirm the diagnosis. Although home readings are acceptable if ambulatory equipment is unavailable, they should not be considered equal to ambulatory monitoring. This question tests your knowledge of the NICE guidelines for hypertension monitoring, which have remained consistent since the earlier guidance (CG127) issued in 2011.

    • This question is part of the following fields:

      • Cardiovascular Health
      0
      Seconds
  • Question 8 - Which of the following is not a recognized feature of temporal arteritis in...

    Incorrect

    • Which of the following is not a recognized feature of temporal arteritis in elderly patients?

      Your Answer:

      Correct Answer: Elevated creatine kinase

      Explanation:

      Temporal arteritis doesn’t cause an increase in creatine kinase levels.

      Temporal arteritis is a type of large vessel vasculitis that often occurs in patients over the age of 60 and is commonly associated with polymyalgia rheumatica. This condition is characterized by changes in the affected artery that skip certain sections while damaging others. Symptoms of temporal arteritis include headache, jaw claudication, and visual disturbances, with anterior ischemic optic neuropathy being the most common ocular complication. A tender, palpable temporal artery is also often present, and around 50% of patients may experience symptoms of PMR, such as muscle aches and morning stiffness.

      To diagnose temporal arteritis, doctors will typically look for elevated inflammatory markers, such as an ESR greater than 50 mm/hr or elevated CRP levels. A temporal artery biopsy may also be performed to confirm the diagnosis, with skip lesions often being present. Treatment for temporal arteritis involves urgent high-dose glucocorticoids, which should be given as soon as the diagnosis is suspected and before the temporal artery biopsy. If there is no visual loss, high-dose prednisolone is typically used, while IV methylprednisolone is usually given if there is evolving visual loss. Patients with visual symptoms should be seen by an ophthalmologist on the same day, as visual damage is often irreversible. Other treatments may include bone protection with bisphosphonates and low-dose aspirin, although the evidence supporting the latter is weak.

    • This question is part of the following fields:

      • Neurodevelopmental Disorders, Intellectual And Social Disability
      0
      Seconds
  • Question 9 - A 42-year-old woman with rheumatoid arthritis has been switched from methotrexate to leflunomide....

    Incorrect

    • A 42-year-old woman with rheumatoid arthritis has been switched from methotrexate to leflunomide. Her full blood count and liver function tests are being monitored. What other aspects of her treatment should be monitored?

      Your Answer:

      Correct Answer: Blood pressure

      Explanation:

      Hypertension can be a possible side effect of taking leflunomide.

      Leflunomide: A DMARD for Rheumatoid Arthritis

      Leflunomide is a type of disease modifying anti-rheumatic drug (DMARD) that is commonly used to manage rheumatoid arthritis. It is important to note that this medication has a very long half-life, which means that its teratogenic potential should be taken into consideration. As such, it is contraindicated in pregnant women, and effective contraception is essential during treatment and for at least two years after treatment in women, and at least three months after treatment in men. Caution should also be exercised in patients with pre-existing lung and liver disease.

      Like any medication, leflunomide can cause adverse effects. Some of the most common side effects include gastrointestinal issues such as diarrhea, hypertension, weight loss or anorexia, peripheral neuropathy, myelosuppression, and pneumonitis. To monitor for any potential complications, patients taking leflunomide should have their full blood count (FBC), liver function tests (LFT), and blood pressure checked regularly.

      If a patient needs to stop taking leflunomide, it is important to note that the medication has a very long wash-out period of up to a year. To help speed up the process, co-administration of cholestyramine may be necessary. Overall, leflunomide can be an effective treatment option for rheumatoid arthritis, but it is important to carefully consider its potential risks and benefits before starting treatment.

    • This question is part of the following fields:

      • Musculoskeletal Health
      0
      Seconds
  • Question 10 - A 67-year-old woman has a T-score of -2.5 from her dual-energy X-ray absorptiometry...

    Incorrect

    • A 67-year-old woman has a T-score of -2.5 from her dual-energy X-ray absorptiometry (DEXA) scan at the hip. It was performed because she was worried about osteoporosis, as her mother had died following a fractured neck of femur.
      What is the most appropriate management option?

      Your Answer:

      Correct Answer: Alendronate

      Explanation:

      Treatment Options for Osteoporosis

      Osteoporosis can be diagnosed through a DEXA scan, and if the bone mineral density is 2.5 standard deviations or more below the young adult reference mean, a bisphosphonate such as alendronate or risedronate is recommended by the National Institute for Health and Care Excellence. Calcium and vitamin D supplements may also be given alongside bisphosphonates. Repeat DEXA scans are not necessary unless the T-score is greater than -2.5. Raloxifene is not typically recommended for primary prevention of osteoporotic fragility fractures due to the risk of venous thromboembolism. If bisphosphonates are not tolerated or contraindicated, specialist referral may be necessary for alternative treatments such as zoledronic acid, strontium ranelate, denosumab, teriparatide, and sometimes raloxifene.

      Understanding Treatment Options for Osteoporosis

    • This question is part of the following fields:

      • Musculoskeletal Health
      0
      Seconds
  • Question 11 - A 42-year-old woman presents to her General Practitioner with complaints of fatigue and...

    Incorrect

    • A 42-year-old woman presents to her General Practitioner with complaints of fatigue and joint pain in her lower limbs. Upon examination, both of her knees are warm and swollen, with tenderness upon palpation of the joint. The joints exhibit crepitus and painful active and passive movement, but there is no ligamental instability. Which of the following findings would indicate an inflammatory cause of joint pain, rather than osteoarthritis, in this patient?

      Your Answer:

      Correct Answer: Swelling and warmth

      Explanation:

      Distinguishing Between Inflammatory Arthritis and Osteoarthritis: Symptoms and Signs

      When it comes to joint pain, it can be difficult to determine whether it is caused by inflammatory arthritis or osteoarthritis. However, there are certain symptoms and signs that can help distinguish between the two.

      Swelling and warmth are more likely to be associated with inflammatory arthritis, as it is characterized by the presence of synovial fluid and inflammation. On the other hand, osteoarthritis is more commonly associated with bony joint enlargement and tenderness, rather than swelling and warmth.

      Crepitus, or joint cracking and popping, can occur in both types of arthritis, but is more common in osteoarthritis due to joint-space narrowing. Joint instability can also occur in all types of arthritis, but is most commonly caused by injury or trauma that has damaged ligaments.

      Painful range of motion is another symptom that can occur in both inflammatory arthritis and osteoarthritis. However, it can be managed with analgesia and physiotherapy.

      In summary, understanding the symptoms and signs of inflammatory arthritis and osteoarthritis can help with proper diagnosis and treatment.

    • This question is part of the following fields:

      • Musculoskeletal Health
      0
      Seconds
  • Question 12 - A 16-year-old female presents with a four day history of fever, sore throat...

    Incorrect

    • A 16-year-old female presents with a four day history of fever, sore throat and rash on the front of her left leg. On examination she has tonsillar enlargement with cervical lymphadenopathy and has erythema nodosum on her left shin.

      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Beta-haemolytic streptococcus

      Explanation:

      Strep. pyogenes and its Characteristics

      This girl exhibits features that are consistent with Strep. pyogenes, a beta-haemolytic streptococcus. The bacterium is known to cause pharyngitis, and erythema nodosum is also commonly associated with the infection. Additionally, it is responsible for acute rheumatic fever, which is described by the Jones criteria. The treatment of choice for this infection is Penicillin V.

      While Epstein-Barr may be a consideration, it is not typically associated with erythema nodosum. It is important to identify the causative agent in order to provide appropriate treatment and prevent further complications.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      0
      Seconds
  • Question 13 - A 76-year-old woman presents for review. Her daughter is very concerned because her...

    Incorrect

    • A 76-year-old woman presents for review. Her daughter is very concerned because her mother is becoming increasingly apathetic, some days not getting out of bed and wearing the same clothes for a number of days in a row. She appears to be having difficulty with word finding. You understand that her husband died three months earlier. Apart from hypertension, she is otherwise physically well.
      Physical examination is unremarkable. Her body mass index is 23 kg/m2. Her heart rate is 72 bpm and regular.
      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Depression

      Explanation:

      Differentiating between types of dementia and depression

      When assessing a patient with cognitive decline, it is important to consider the various possible diagnoses. In the case of a patient who recently lost their spouse and is experiencing symptoms such as apathy and sleep disturbance, depression is the most likely diagnosis. Cognitive behavioural therapy is the recommended intervention in this situation.

      Multi-infarct dementia, on the other hand, is typically seen in patients with vascular risk factors such as diabetes and atrial fibrillation. This type of dementia is characterized by a stepwise decline in functioning, with personality traits remaining relatively intact until late in the disease.

      Alcohol abuse can also lead to cognitive decline, with weight loss and signs of chronic liver disease being common physical manifestations.

      Alzheimer’s dementia is associated with progressive short-term memory loss, difficulties with language and decision-making, and problems with planning. While patients may present with dementia after the death of a partner, the symptoms described here are more consistent with depression.

      Finally, frontal lobe dementia is characterized by early symptoms of inappropriate social behaviour, disinhibition, and loss of empathy and sympathy. Memory loss is a late feature of this disease. By carefully considering the patient’s symptoms and medical history, healthcare professionals can make an accurate diagnosis and provide appropriate treatment.

    • This question is part of the following fields:

      • Mental Health
      0
      Seconds
  • Question 14 - A 57-year-old insulin-treated diabetic complains of severe burning pain in his feet, particularly...

    Incorrect

    • A 57-year-old insulin-treated diabetic complains of severe burning pain in his feet, particularly at night, pins and needles, and hyperaesthesia for several months. On examination his feet have normal pulses, sensation and reflexes.
      Select the single correct statement regarding his management.

      Your Answer:

      Correct Answer: Duloxetine should be prescribed

      Explanation:

      Treatment Options for Painful Diabetic Neuropathy

      Painful diabetic neuropathy is a common complication of diabetes that can significantly impact a person’s quality of life. While there is no cure for neuropathy, there are several treatment options available to manage the symptoms.

      Improved diabetic control is the first line of defense in preventing the progression of neuropathy. However, it is important to note that good control doesn’t reverse neuropathy. In cases where diabetic control alone is not enough, medications such as duloxetine, amitriptyline, gabapentin, or pregabalin may be prescribed. These drugs are suggested by NICE as options for managing neuropathic pain.

      For localized neuropathy, capsaicin 0.0075% cream can be used. Tramadol may also be prescribed on a short-term basis while a patient awaits an appointment with a specialized pain service.

      In cases of Raynaud’s phenomenon, calcium antagonists are used. Epidural injections of local anesthetic and steroid may be used for acute sciatica. However, fluoxetine is not recommended as a treatment option.

      Overall, there are several treatment options available for managing painful diabetic neuropathy. It is important to work closely with a healthcare provider to determine the best course of action for each individual case.

      Managing Painful Diabetic Neuropathy: Treatment Options

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
      0
      Seconds
  • Question 15 - At what point in the NHS vaccination schedule would you provide routine immunisation...

    Incorrect

    • At what point in the NHS vaccination schedule would you provide routine immunisation for Hepatitis B?

      Your Answer:

      Correct Answer: At 15 months of age

      Explanation:

      The Importance of Understanding Immunisation Schedules

      Immunisation schedules are crucial to understand, especially with recent changes to UK guidance in January 2020. One significant change relates to the timing of pneumococcal immunisation. Additionally, hepatitis B vaccination is routinely available as part of the NHS vaccination schedule. It is offered to all babies at 8, 12, and 16 weeks of age, as well as those at increased risk of hepatitis B or its complications.

      It is essential to memorise the latest schedule, as it may feature in your exam. We have included a reference to a summary guide below for your convenience. Understanding immunisation schedules is crucial for healthcare professionals to ensure that patients receive the appropriate vaccinations at the correct time.

    • This question is part of the following fields:

      • Infectious Disease And Travel Health
      0
      Seconds
  • Question 16 - A 45 year-old man complains of constant fatigue. Despite his tanned appearance, he...

    Incorrect

    • A 45 year-old man complains of constant fatigue. Despite his tanned appearance, he denies having been on vacation. During examination, pigmentation is noted on the palmar creases and buccal mucosa.

      What underlying condition could be responsible for these findings?

      Your Answer:

      Correct Answer: Addison's disease

      Explanation:

      Addison’s disease is a condition where the adrenal glands do not produce enough hormones. The symptoms may start slowly and include fatigue. One common sign is hyperpigmentation, which affects areas such as skin creases, the inside of the cheeks, and scars. This happens because the hormone ACTH, which is made by the pituitary gland to stimulate the adrenals, has a similar precursor molecule to MSH, a hormone that affects skin color. As a result, increased ACTH levels can cause higher MSH levels and skin darkening. In cases of kidney failure, the skin may appear yellowish or pale due to anemia.

      Addison’s disease is the most common cause of primary hypoadrenalism in the UK, with autoimmune destruction of the adrenal glands being the main culprit, accounting for 80% of cases. This results in reduced production of cortisol and aldosterone. Symptoms of Addison’s disease include lethargy, weakness, anorexia, nausea and vomiting, weight loss, and salt-craving. Hyperpigmentation, especially in palmar creases, vitiligo, loss of pubic hair in women, hypotension, hypoglycemia, and hyponatremia and hyperkalemia may also be observed. In severe cases, a crisis may occur, leading to collapse, shock, and pyrexia.

      Other primary causes of hypoadrenalism include tuberculosis, metastases (such as bronchial carcinoma), meningococcal septicaemia (Waterhouse-Friderichsen syndrome), HIV, and antiphospholipid syndrome. Secondary causes include pituitary disorders, such as tumours, irradiation, and infiltration. Exogenous glucocorticoid therapy can also lead to hypoadrenalism.

      It is important to note that primary Addison’s disease is associated with hyperpigmentation, while secondary adrenal insufficiency is not.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
      0
      Seconds
  • Question 17 - A 25-year-old man has a 3-week history of persistent conjunctivitis in his right...

    Incorrect

    • A 25-year-old man has a 3-week history of persistent conjunctivitis in his right eye. He has tried using over-the-counter medication but this has not helped. Of note, he returned from a visit to Amsterdam four weeks ago, following which he was treated for urinary symptoms at the local walk-in centre. On examination, he has some mucopurulent discharge and hyperaemia. The inferior tarsal conjunctival follicles are obvious.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Chlamydial conjunctivitis

      Explanation:

      Differentiating Conjunctivitis: Causes and Symptoms

      Conjunctivitis, commonly known as pink eye, is an inflammation of the conjunctiva, the thin membrane that covers the white part of the eye and the inner surface of the eyelids. It can be caused by various factors, including bacteria, viruses, allergens, and sexually transmitted infections. Here are some of the different types of conjunctivitis and their distinguishing features:

      Chlamydial Conjunctivitis: This type of conjunctivitis is transmitted through autoinoculation or eye-to-eye spread and is associated with urethritis or cervicitis. It is caused by Chlamydia trachomatis and can last for up to 12 months if left untreated. It is usually unilateral and presents with chronic follicular conjunctivitis.

      Trachoma: This type of conjunctivitis is caused by poor sanitation and is the third most common cause of blindness in the world. It is caused by serotypes A to C of C. trachomatis and presents with severe conjunctival scarring and secondary corneal ulceration and scarring.

      Allergic Conjunctivitis: This type of conjunctivitis occurs in atopic individuals and presents with itchy, watering eyes.

      Gonococcal Conjunctivitis: This type of conjunctivitis is caused by gonorrhea and presents with a rapid onset of unilateral/bilateral red eyes with a severe purulent discharge and tender preauricular lymph nodes.

      Simple Bacterial Conjunctivitis: This type of conjunctivitis is usually bilateral and should have resolved by three weeks. The discharge is mucopurulent but less copious than in gonococcal conjunctivitis.

      Viral Conjunctivitis: This type of conjunctivitis is usually bilateral and should have resolved by three weeks. The discharge is usually watery, and follicles may be seen on eyelid eversion.

      In summary, the type of conjunctivitis can be determined by the symptoms and the underlying cause. It is important to seek medical attention if symptoms persist or worsen.

    • This question is part of the following fields:

      • Eyes And Vision
      0
      Seconds
  • Question 18 - An 80-year-old man comes to the clinic complaining of occasional palpitations without any...

    Incorrect

    • An 80-year-old man comes to the clinic complaining of occasional palpitations without any accompanying chest pain, shortness of breath, or lightheadedness. He has no notable medical history and is not taking any medications at present. Physical examination and vital signs are normal except for an irregular heartbeat, which is later diagnosed as atrial fibrillation. What is the suggested preventive therapy for a stroke?

      Your Answer:

      Correct Answer: Consider an anticoagulant

      Explanation:

      Anticoagulation must be taken into account for individuals with a CHA2DS2-VASC score of 1 or higher if they are male, and a score of 2 or higher if they are female. In this case, the gentleman’s CHA2DS2-VASC score is 1, indicating that he should be considered for anticoagulation after assessing his HAS-BLED score. It is important to note that if his HAS-BLED score is 3 or higher, alternative options to anticoagulation should be considered. Beta-blockers, aspirin, and clopidogrel are not recommended for primary prevention against cerebrovascular accidents. It is incorrect to assume that no treatment is necessary, as the CHA2DS2-VASC score indicates a need for consideration of anticoagulation.

      Atrial fibrillation (AF) is a condition that requires careful management, including the use of anticoagulation therapy. The latest guidelines from NICE recommend assessing the need for anticoagulation in all patients with a history of AF, regardless of whether they are currently experiencing symptoms. The CHA2DS2-VASc scoring system is used to determine the most appropriate anticoagulation strategy, with a score of 2 or more indicating the need for anticoagulation. However, it is important to ensure a transthoracic echocardiogram has been done to exclude valvular heart disease, which is an absolute indication for anticoagulation.

      When considering anticoagulation therapy, doctors must also assess the patient’s bleeding risk. NICE recommends using the ORBIT scoring system to formalize this risk assessment, taking into account factors such as haemoglobin levels, age, bleeding history, renal impairment, and treatment with antiplatelet agents. While there are no formal rules on how to act on the ORBIT score, individual patient factors should be considered. The risk of bleeding increases with a higher ORBIT score, with a score of 4-7 indicating a high risk of bleeding.

      For many years, warfarin was the anticoagulant of choice for AF. However, the development of direct oral anticoagulants (DOACs) has changed this. DOACs have the advantage of not requiring regular blood tests to check the INR and are now recommended as the first-line anticoagulant for patients with AF. The recommended DOACs for reducing stroke risk in AF are apixaban, dabigatran, edoxaban, and rivaroxaban. Warfarin is now used second-line, in patients where a DOAC is contraindicated or not tolerated. Aspirin is not recommended for reducing stroke risk in patients with AF.

    • This question is part of the following fields:

      • Cardiovascular Health
      0
      Seconds
  • Question 19 - What is the most valuable tool for assessing a patient with suspected occupational...

    Incorrect

    • What is the most valuable tool for assessing a patient with suspected occupational asthma?

      Your Answer:

      Correct Answer: Documentation of a known sensitising agent at the patient's workplace

      Explanation:

      Understanding Occupational Asthma

      Occupational asthma is a type of asthma that is caused by conditions and factors present in a particular work environment. It is characterized by variable air flow limitation and/or airway hyper-responsiveness. This type of asthma accounts for about 10% of adult asthma cases.

      To diagnose occupational asthma, there are several investigations that are proven to be effective. These include serial peak flow measurements at and away from work, specific IgE assay or skin prick testing, and specific inhalation testing. If there is a consistent fall in peak flow values and increased intraday variability on working days, and improvement on days away from work, then occupational asthma is confirmed.

      It is important to understand occupational asthma and its causes to prevent and manage this condition effectively. Proper diagnosis and management can help individuals continue to work safely and maintain their quality of life.

    • This question is part of the following fields:

      • Respiratory Health
      0
      Seconds
  • Question 20 - A 65-year-old woman comes to the GP complaining of urge incontinence. She frequently...

    Incorrect

    • A 65-year-old woman comes to the GP complaining of urge incontinence. She frequently feels the need to use the restroom but often doesn't make it in time and has started wearing incontinence pads during the day. She has a medical history of hypertension and takes ramipril 5 mg daily. She doesn't drink much water but consumes around 10 cups of tea and coffee per day. What is the best treatment option for her?

      Your Answer:

      Correct Answer: Electrical bladder stimulation

      Explanation:

      Treatment options for urge incontinence

      Caffeine reduction is the first recommended therapy for patients with significant urge incontinence and a history of excessive caffeine use. If symptoms persist, bladder training is the next step. For those who do not respond to bladder training, oxybutynin may be effective. In postmenopausal women with significant vaginal atrophy, oestrogen cream may also be tried. However, electrical stimulation is not routinely recommended. It is important to consult with a healthcare professional to determine the best treatment plan for individual cases of urge incontinence.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
      0
      Seconds
  • Question 21 - A 75-year-old man presents to you after being seen at the TIA clinic...

    Incorrect

    • A 75-year-old man presents to you after being seen at the TIA clinic and initiated on clopidogrel and atorvastatin. He is currently taking the following repeat medications:
      - Ramipril
      - Metformin
      - Omeprazole
      - Amlodipine
      - Gliclazide

      Are there any of his current medications that you should consider switching to an alternative due to potential drug interactions?

      Your Answer:

      Correct Answer: Omeprazole

      Explanation:

      Clopidogrel: An Antiplatelet Agent for Cardiovascular Disease

      Clopidogrel is a medication used to manage cardiovascular disease by preventing platelets from sticking together and forming clots. It is commonly used in patients with acute coronary syndrome and is now also recommended as a first-line treatment for patients following an ischaemic stroke or with peripheral arterial disease. Clopidogrel belongs to a class of drugs called thienopyridines, which work in a similar way. Other examples of thienopyridines include prasugrel, ticagrelor, and ticlopidine.

      Clopidogrel works by blocking the P2Y12 adenosine diphosphate (ADP) receptor, which prevents platelets from becoming activated. However, concurrent use of proton pump inhibitors (PPIs) may make clopidogrel less effective. The Medicines and Healthcare products Regulatory Agency (MHRA) issued a warning in July 2009 about this interaction, and although evidence is inconsistent, omeprazole and esomeprazole are still cause for concern. Other PPIs, such as lansoprazole, are generally considered safe to use with clopidogrel. It is important to consult with a healthcare provider before taking any new medications or supplements.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
      0
      Seconds
  • Question 22 - A 45-year-old man seeks assistance from his General Practitioner to quit drinking alcohol....

    Incorrect

    • A 45-year-old man seeks assistance from his General Practitioner to quit drinking alcohol. He confesses to consuming over 50 units of alcohol per week and has struggled to maintain a lower level of consumption. Although he has never encountered severe withdrawal symptoms, he is open to attending cognitive behaviour therapy and wonders if there is any medication that could aid him in his journey.
      What is the most suitable medication to recommend?

      Your Answer:

      Correct Answer: No medication should be prescribed

      Explanation:

      Medications for Alcohol Addiction: NICE Guidelines and Recommendations

      The National Institute of Healthcare Excellence (NICE) has issued guidelines on the management of alcohol withdrawal, stating that medication should only be prescribed by specialist teams. Acamprosate is a second-line treatment that stabilizes the chemical balance in the brain disrupted by alcohol withdrawal. Chlordiazepoxide, a long-acting benzodiazepine, is used to reduce withdrawal symptoms in alcohol detoxification programs but should not be prescribed in primary care. Fluoxetine, a selective serotonin re-uptake inhibitor, has been used to decrease drinking but is not licensed for this purpose. Naltrexone and nalmefene are opioid receptor antagonists used as second-line treatments after assisted withdrawal. Nalmefene has advantages over naltrexone, including a longer half-life and greater oral bioavailability, but none of these options should be prescribed in primary care.

    • This question is part of the following fields:

      • Smoking, Alcohol And Substance Misuse
      0
      Seconds
  • Question 23 - A 55-year-old man with alcohol dependency disorder feels unwell. He stopped drinking six...

    Incorrect

    • A 55-year-old man with alcohol dependency disorder feels unwell. He stopped drinking six days ago.

      Which one of the following symptoms is most suggestive of delirium tremens?

      Your Answer:

      Correct Answer: Visual hallucinations

      Explanation:

      Delirium Tremens: Symptoms and Characteristics

      Delirium tremens is a severe form of alcohol withdrawal that can occur in individuals who have been drinking heavily for a prolonged period of time. It is characterised by a range of symptoms, including confusion, agitation, tremors, tachycardia, fevers, high blood pressure, and visual hallucinations.

      One of the key features of delirium tremens is the presence of visual hallucinations, which can be particularly distressing for individuals experiencing this condition. These hallucinations may involve seeing things that are not there, such as animals or people, or distortions of reality, such as objects appearing to move or change shape.

      Other symptoms of delirium tremens can include sweating, nausea, vomiting, and seizures. In severe cases, delirium tremens can be life-threatening, and medical intervention may be necessary to manage the symptoms and prevent complications.

    • This question is part of the following fields:

      • Smoking, Alcohol And Substance Misuse
      0
      Seconds
  • Question 24 - You see a 3-year-old girl who presents with fever, irritability and offensive smelling...

    Incorrect

    • You see a 3-year-old girl who presents with fever, irritability and offensive smelling urine. A urine dipstick shows leucocytes+, nitrites -.

      What would be the next most appropriate management step?

      Your Answer:

      Correct Answer: Send for MC&S and start antibiotic treatment

      Explanation:

      NICE Guidelines for UTI in Children

      According to the National Institute for Health and Care Excellence (NICE), children between 3 months to 3 years old with suspected urinary tract infection (UTI) can start antibiotic treatment if their urine sample shows either leucocyte or nitrite positive, or both. However, it is still recommended to send off the sample for culture to confirm the diagnosis and ensure appropriate treatment. These guidelines aim to provide a standardized approach in managing UTI in children and prevent complications associated with untreated infections.

    • This question is part of the following fields:

      • Children And Young People
      0
      Seconds
  • Question 25 - As the duty doctor, you encounter a 59-year-old woman who complains of increased...

    Incorrect

    • As the duty doctor, you encounter a 59-year-old woman who complains of increased cough and wheeze for the past 3 days. The patient has a history of COPD and is currently taking salbutamol and umeclidinium/vilanterol (Anoro Ellipta). She has no other medical conditions, has not taken antibiotics for 2 years, and has not been admitted for acute exacerbation of COPD. The patient smokes 10 cigarettes daily and denies any changes in sputum production, colour, and thickness. Upon examination, she has mild wheezing and no focal chest signs. Her cardiovascular examination and vital signs are normal.

      Which of the following options should be excluded from your management plan for this patient?

      Your Answer:

      Correct Answer: Prescribe oral antibiotics

      Explanation:

      According to NICE guidelines, oral antibiotics should only be prescribed in cases of acute exacerbation of COPD if there is purulent sputum or clinical signs of pneumonia. As this patient doesn’t exhibit these symptoms, prescribing oral antibiotics is not recommended.

      Instead, increasing the frequency of inhaled bronchodilators is a suitable step in managing this patient’s acute exacerbation of COPD. The patient’s mild wheeze should improve with this treatment.

      NICE recommends a review in 6 weeks if there is no rapid or significant worsening of symptoms. However, if symptoms worsen rapidly or significantly, the patient should be reviewed sooner by the appropriate healthcare provider.

      Prescribing oral steroids is appropriate for managing this patient’s acute exacerbation of COPD as it can reduce inflammation and improve symptoms.

      It is also appropriate to discuss smoking cessation with the patient, as they are still smoking. However, it should be documented if the patient is not interested in considering smoking cessation. Any opportunity for smoking cessation advice should be utilized.

      Acute exacerbations of COPD are a common reason for hospitalization in developed countries. The most common causes of these exacerbations are bacterial infections, such as Haemophilus influenza, Streptococcus pneumoniae, and Moraxella catarrhalis, as well as respiratory viruses, 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 beta adrenergic agonists and muscarinic antagonists, should also be used. Steroid therapy and IV theophylline may be considered, and non-invasive ventilation may be used for patients with type 2 respiratory failure. BiPAP is typically used with initial settings of EPAP at 4-5 cm H2O and IPAP at 10-15 cm H2O.

    • This question is part of the following fields:

      • Respiratory Health
      0
      Seconds
  • Question 26 - The likelihood of a 34-year-old mother having a baby with Down's syndrome is...

    Incorrect

    • The likelihood of a 34-year-old mother having a baby with Down's syndrome is roughly:

      Your Answer:

      Correct Answer: 1 in 275

      Explanation:

      The risk of Down’s syndrome is 1 in 1,000 at the age of 30, and this risk decreases by a factor of 3 for every 5 years.

      Down’s Syndrome: Epidemiology and Genetics

      Down’s syndrome is a genetic disorder that is caused by the presence of an extra copy of chromosome 21. The risk of having a child with Down’s syndrome increases with maternal age, with a 1 in 1,500 chance at age 20 and a 1 in 50 or greater chance at age 45. This can be remembered by dividing the denominator by 3 for every extra 5 years of age starting at 1/1,000 at age 30.

      There are three main types of Down’s syndrome: nondisjunction, Robertsonian translocation, and mosaicism. Nondisjunction accounts for 94% of cases and occurs when the chromosomes fail to separate properly during cell division. Robertsonian translocation, which usually involves chromosome 14, accounts for 5% of cases and occurs when a piece of chromosome 21 attaches to another chromosome. Mosaicism, which accounts for 1% of cases, occurs when there are two genetically different populations of cells in the body.

      The risk of recurrence for Down’s syndrome varies depending on the type of genetic abnormality. If the trisomy 21 is a result of nondisjunction, the chance of having another child with Down’s syndrome is approximately 1 in 100 if the mother is less than 35 years old. If the trisomy 21 is a result of Robertsonian translocation, the risk is much higher, with a 10-15% chance if the mother is a carrier and a 2.5% chance if the father is a carrier.

    • This question is part of the following fields:

      • Children And Young People
      0
      Seconds
  • Question 27 - A 15-year-old girl presents with difficulty walking and issues with her feet. Upon...

    Incorrect

    • A 15-year-old girl presents with difficulty walking and issues with her feet. Upon examination, she displays mild pes cavus and possible muscle wasting in her distal legs. She has a slight high-steppage gait and exhibits weakness in both feet and ankles with reduced ankle jerks. There are no abnormalities in her cranial nerves or cerebellar function, and she has no significant medical history or regular medications. However, she reports that several family members have experienced similar problems, and her grandfather, who is still alive in his 70s, used to receive special shoes and a foot brace from the hospital. What is the most probable underlying diagnosis?

      Your Answer:

      Correct Answer: Charcot-Marie-Tooth disease

      Explanation:

      Understanding Pes Cavus and its Association with Genetic Diseases

      Pes cavus, also known as claw foot, is a condition characterized by an excessively arched foot that gives an unnaturally high instep. This condition is often associated with genetic diseases such as Charcot-Marie-Tooth (CMT) disease and Friedreich’s ataxia.

      Friedreich’s ataxia is an autosomal recessive condition that affects the nervous system. It is characterized by progressive limb and gait ataxia, dysarthria, loss of proprioception and vibration sense, absent tendon reflexes in the lower limbs, and extensor plantar responses. The disease can also lead to pes cavus and scoliosis due to muscle weakness, as well as cardiomyopathy. Unfortunately, the disease is often debilitating, with more than 95% of those affected being wheelchair-bound by the age of 45 and an average life expectancy of approximately 50.

      On the other hand, CMT affects both motor and sensory nerves and is often first noticed in adolescence or early adulthood. Symptoms include weakness of the foot and lower leg muscles, which may result in foot drop and a characteristic high-stepped gait. Weakness of the small muscles in the feet can lead to deformities such as pes cavus. In addition, the lower legs may take on an ‘inverted champagne bottle’ appearance due to the loss of muscle bulk. Although the disease can progress to affect the hands, it is not considered fatal, and people with most forms of CMT have a normal life expectancy.

      In summary, understanding the association between pes cavus and genetic diseases such as CMT and Friedreich’s ataxia is crucial in diagnosing and managing these conditions. While Friedreich’s ataxia can be debilitating and life-threatening, CMT is generally not fatal, but can still significantly impact a person’s quality of life.

    • This question is part of the following fields:

      • Musculoskeletal Health
      0
      Seconds
  • Question 28 - A 42-year-old pregnant woman is curious about why she has been recommended to...

    Incorrect

    • A 42-year-old pregnant woman is curious about why she has been recommended to undergo an oral glucose tolerance test. She has had four previous pregnancies, and her babies' birth weights have ranged from 3.4-4.6kg. She has no history of diabetes, but both her parents have hypertension, and her grandfather has diabetes. She is of white British ethnicity and has a BMI of 29.6kg/m². What makes her eligible for an oral glucose tolerance test?

      Your Answer:

      Correct Answer: Previous macrosomia

      Explanation:

      It is recommended that pregnant women with a family history of diabetes undergo an oral glucose tolerance test (OGTT) for gestational diabetes between 24 and 28 weeks of pregnancy.

      Gestational diabetes is a common medical disorder that affects around 4% of pregnancies. It can develop during pregnancy or be a pre-existing condition. According to NICE, 87.5% of cases are gestational diabetes, 7.5% are type 1 diabetes, and 5% are type 2 diabetes. Risk factors for gestational diabetes include a BMI of > 30 kg/m², previous gestational diabetes, a family history of diabetes, and family origin with a high prevalence of diabetes. Screening for gestational diabetes involves an oral glucose tolerance test (OGTT), which should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal.

      To diagnose gestational diabetes, NICE recommends using the following thresholds: fasting glucose is >= 5.6 mmol/L or 2-hour glucose is >= 7.8 mmol/L. Newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week and taught about self-monitoring of blood glucose. Advice about diet and exercise should be given, and if glucose targets are not met within 1-2 weeks of altering diet/exercise, metformin should be started. If glucose targets are still not met, insulin should be added to the treatment plan.

      For women with pre-existing diabetes, weight loss is recommended for those with a BMI of > 27 kg/m^2. Oral hypoglycaemic agents, apart from metformin, should be stopped, and insulin should be commenced. Folic acid 5 mg/day should be taken from preconception to 12 weeks gestation, and a detailed anomaly scan at 20 weeks, including four-chamber view of the heart and outflow tracts, should be performed. Tight glycaemic control reduces complication rates, and retinopathy should be treated as it can worsen during pregnancy.

      Targets for self-monitoring of pregnant women with diabetes include a fasting glucose level of 5.3 mmol/l and a 1-hour or 2-hour glucose level after meals of 7.8 mmol/l or 6.4 mmol/l, respectively. It is important to manage gestational diabetes and pre-existing diabetes during pregnancy to reduce the risk of complications for both the mother and baby.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
      0
      Seconds
  • Question 29 - A toddler has had a seizure. He has been unwell for a few...

    Incorrect

    • A toddler has had a seizure. He has been unwell for a few hours and has a temperature of 38.2°C. There are no concerning features in his previous medical history.
      Which of the following is most compatible with a diagnosis of ‘simple febrile seizure’?

      Your Answer:

      Correct Answer: Age of child 18 months

      Explanation:

      Febrile seizures are most common in children between 6 months and 6 years old, with the highest incidence at 18 months. They are associated with fever and affect 2-4% of European children. While tonic-clonic movements are typical during febrile seizures, complex febrile seizures may present with focal or myoclonic features. If a seizure lasts longer than 15 minutes, it is considered complex and may require hospitalization. Signs of meningeal irritation, such as neck stiffness and Kernig’s sign, suggest a possible CNS infection and require further evaluation. Recurrence of seizures within 24 hours or during the same illness may indicate a complex febrile seizure.

    • This question is part of the following fields:

      • Children And Young People
      0
      Seconds
  • Question 30 - Which one of the following features is least consistent with Trichomonas vaginalis? ...

    Incorrect

    • Which one of the following features is least consistent with Trichomonas vaginalis?

      Your Answer:

      Correct Answer:

      Explanation:

      A pH level greater than 4.5 is linked to Trichomonas vaginalis and bacterial vaginosis.

      Comparison of Bacterial Vaginosis and Trichomonas Vaginalis

      Bacterial vaginosis and Trichomonas vaginalis are two common sexually transmitted infections that affect women. Bacterial vaginosis is caused by an overgrowth of bacteria in the vagina, while Trichomonas vaginalis is caused by a protozoan parasite. Both infections can cause vaginal discharge and vulvovaginitis, but Trichomonas vaginalis may also cause urethritis in men.

      The vaginal discharge in bacterial vaginosis is typically thin and grayish-white, with a fishy odor. The pH of the vagina is usually higher than 4.5. In contrast, the discharge in Trichomonas vaginalis is offensive, yellow/green, and frothy. The cervix may also appear like a strawberry. The pH of the vagina is also higher than 4.5.

      To diagnose bacterial vaginosis, a doctor may perform a pelvic exam and take a sample of the vaginal discharge for testing. The presence of clue cells, which are vaginal cells covered in bacteria, is a hallmark of bacterial vaginosis. On the other hand, Trichomonas vaginalis can be diagnosed by examining a wet mount under a microscope. The motile trophozoites of the parasite can be seen in the sample.

      Both bacterial vaginosis and Trichomonas vaginalis can be treated with antibiotics. Metronidazole is the drug of choice for both infections. For bacterial vaginosis, a course of oral metronidazole for 5-7 days is recommended. For Trichomonas vaginalis, a one-off dose of 2g metronidazole may also be used. It is important to complete the full course of antibiotics to ensure that the infection is fully treated.

    • This question is part of the following fields:

      • Gynaecology And Breast
      0
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Kidney And Urology (1/1) 100%
Older Adults (1/1) 100%
Population Health (0/1) 0%
Respiratory Health (1/1) 100%
Children And Young People (1/1) 100%
Gastroenterology (0/1) 0%
Passmed