-
Question 1
Correct
-
A 55-year-old woman with a body mass index of 32 kg/m² and type 2 diabetes mellitus presents to you. She has had a Mirena coil (levonorgestrel-releasing intrauterine system) for the past 3 years and has been without periods since 4 months after insertion. Recently, she has experienced 2 episodes of post-coital bleeding and a 4-day episode of vaginal bleeding. What is the best course of action for management?
Your Answer: Refer to postmenopausal bleeding clinic for endometrial biopsy
Explanation:To address the patient’s condition, it is recommended to refer her to the postmenopausal bleeding clinic for an endometrial biopsy. According to the Faculty of Sexual and Reproductive Health, women aged 45 years who use hormonal contraception and experience persistent problematic bleeding or a change in bleeding pattern should undergo endometrial biopsy. Given that the patient is obese and has type two diabetes, both of which are risk factors for endometrial malignancy, watchful waiting and reassurance are not appropriate responses. While the Mirena may be nearing the end of its lifespan after 4 years of insertion, bleeding cannot be attributed to this without ruling out underlying pathology. Hormone replacement therapy is not recommended for this patient at this time.
Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Postmenopausal bleeding is the most common symptom of endometrial cancer, which is usually slight and intermittent initially before becoming more heavy. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.
When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness (< 4 mm). Hysteroscopy with endometrial biopsy is also commonly used for investigation. The management of localized disease involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may have postoperative radiotherapy. progesterone therapy is sometimes used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.
-
This question is part of the following fields:
- Gynaecology
-
-
Question 2
Correct
-
A 6-month-old boy is brought to the Emergency Department by his concerned parents. They have observed that he has been experiencing painful swelling in his fingers and toes over the past few days. They have also noticed that he has been excessively fatigued and that his skin and eyes appear to have a yellowish tint. The family recently relocated from Ghana but were unable to access prenatal or postnatal screening tests. The parents had plans to travel by plane for a pre-booked vacation in three days.
What is the safe duration for the family to travel, given the probable diagnosis for this infant?Your Answer: Ten days
Explanation:Guidelines for Air Travel with Sickle-Cell Disease
Air travel can pose risks for individuals with sickle-cell disease, particularly following a sickle-cell crisis. The following guidelines are recommended:
– Wait ten days before travelling to reduce the risk of complications such as deep vein thrombosis.
– Patients with sickle-cell anaemia can travel with supplemental oxygen if needed, provided there are no recent crises or other medical concerns. Patients with sickle-cell trait can travel as normal.
– Avoid flying within three days of a crisis to reduce the risk of sickling.
– Patients without other medical concerns should not need to wait longer than four weeks following a crisis.
– Short flights of 4-6 hours should not pose issues for those with sickle-cell disease, as long as they stay hydrated during travel. There is no need to wait six months following a crisis.By following these guidelines, individuals with sickle-cell disease can safely travel by air.
-
This question is part of the following fields:
- Ethics And Legal
-
-
Question 3
Correct
-
A 40-year-old baker presents to his General Practitioner with rhinitis, breathlessness and wheeze. He reports his symptoms have acutely worsened since he returned from a 2-week holiday in Spain. He has been experiencing these symptoms on and off for the past year. He has a fifteen-pack-year smoking history.
What is the most likely diagnosis?Your Answer: Occupational asthma
Explanation:Differential Diagnosis for a Patient with Breathlessness and Rhinitis
Possible diagnoses for a patient presenting with breathlessness and rhinitis include occupational asthma, Legionnaires’ disease, hay fever, COPD, and pulmonary embolus. In the case of a baker experiencing worsening symptoms after returning from holiday, baker’s asthma caused by alpha-amylase allergy is the most likely diagnosis. Legionnaires’ disease, which can be contracted through contaminated water sources, may also be a possibility. Hay fever, COPD, and pulmonary embolus are less likely given the patient’s symptoms and medical history.
-
This question is part of the following fields:
- Respiratory
-
-
Question 4
Correct
-
A 63-year-old man was diagnosed with granulomatosis with polyangiitis (GPA) two years ago and achieved remission after receiving pulsed cyclophosphamide. He has been maintained on oral azathioprine and a low dose of prednisolone since then. Recently, he returned to the clinic before his scheduled appointment with worsening ENT symptoms, haemoptysis, and declining renal function. Two months prior, he had a superficial bladder cancer (stage Ta, no invasion, single lesion) that was resected, followed by a single dose of postoperative chemotherapy. Given his new diagnosis, what is the most appropriate treatment for his vasculitis flare?
Your Answer: Rituximab therapy
Explanation:Treatment Dilemma for a Patient with Vasculitis
This patient is facing a difficult situation as he requires immunosuppressive therapy to manage his vasculitis, which is organ-threatening, but most immunosuppressants increase the risk of cancer. Increasing oral steroids would provide short-term relief but come with significant side effects. Azathioprine and mycophenolate mofetil are unlikely to control his disease in time and are associated with an increased risk of malignancy. Cyclophosphamide should be avoided as it is known to cause bladder cancer.
However, there is a potential solution in rituximab, a monoclonal antibody that targets CD20, a surface marker on most B cells. Rituximab has been shown to be as effective as cyclophosphamide in treating ANCA vasculitis, but with a much better side effect profile. A two-year course of rituximab therapy can even allow for the withdrawal of other immunosuppressants, which would be particularly helpful in this patient’s case. Overall, while the patient’s situation is challenging, rituximab may provide a viable treatment option.
-
This question is part of the following fields:
- Nephrology
-
-
Question 5
Incorrect
-
A 6-year-old boy is admitted to the paediatric ward with a cough and lethargy. His dad is concerned as his breathing is fast and he has had a high temperature which hasn't improved with paracetamol. He is normally healthy and up to date with all his vaccinations.
Upon examination, he is tachypnoeic with a temperature of 39.5ºC. He has crackles in the left lower zone on auscultation. Blood tests reveal the following results:
- Hb 132 g/L (Male: 135-180, Female: 115-160)
- Platelets 290* 109/L (150-400)
- WBC 18.5* 109/L (4.0-11.0)
- Na+ 140 mmol/L (135-145)
- K+ 4.2 mmol/L (3.5-5.0)
- Urea 5.5 mmol/L (2.0-7.0)
- Creatinine 90 µmol/L (55-120)
- CRP 85 mg/L (<5)
A chest radiograph shows a left lower lobe consolidation. What is the most likely causative agent of his pneumonia?Your Answer: Respiratory syncytial virus (RSV)
Correct Answer: Streptococcus pneumoniae
Explanation:In children, S. pneumoniae is the most probable cause of bacterial pneumonia, as indicated by the presentation of raised inflammatory markers and lobar consolidation on chest x-ray. The child is experiencing persistent fever and tachypnea. Other potential causes include Mycoplasma pneumonia or Chlamydia pneumoniae, while RSV is more commonly associated with bronchiolitis in children under 2 years old. Haemophilus influenzae and Bordetella pertussis are less likely to be responsible for pneumonia in immunized and non-immunocompromised children. Legionella pneumophila is an unlikely cause of pneumonia in a child of this age, despite its potential to cause severe pneumonia.
Pneumonia is a common illness in children, with S. pneumoniae being the most likely cause of bacterial pneumonia. The British Thoracic Society has published guidelines for the management of community acquired pneumonia in children. According to these guidelines, amoxicillin is the first-line treatment for all children with pneumonia. Macrolides may be added if there is no response to first-line therapy, or if mycoplasma or chlamydia is suspected. In cases of pneumonia associated with influenzae, co-amoxiclav is recommended. It is important to follow these guidelines to ensure effective treatment and management of pneumonia in children.
-
This question is part of the following fields:
- Paediatrics
-
-
Question 6
Incorrect
-
A 38-year-old woman comes to the emergency department with a complaint of unequal pupil size. Upon examination, there is an anisocoria of >1mm. The anisocoria appears to be more pronounced when a light is shone on the patient's face compared to when the room is darkened. The patient's eye movements are normal, and a slit-lamp examination reveals no evidence of synechiae. What possible condition could be responsible for these findings?
Your Answer: Horner syndrome
Correct Answer: Adie's tonic pupil
Explanation:When a patient presents with anisocoria, it is important to determine whether the issue lies with dilation or constriction. In this case, the anisocoria is exacerbated by bright light, indicating a problem with the parasympathetic innervation and the affected pupil’s inability to constrict. Adie’s tonic pupil is a likely cause, as it involves dysfunction of the ciliary ganglion. Horner syndrome and oculomotor nerve palsy are unlikely causes, as they would result in different symptoms. Physiological anisocoria and pilocarpine are also incorrect answers.
Mydriasis, which is the enlargement of the pupil, can be caused by various factors. These include third nerve palsy, Holmes-Adie pupil, traumatic iridoplegia, pheochromocytoma, and congenital conditions. Additionally, certain drugs can also cause mydriasis, such as topical mydriatics like tropicamide and atropine, sympathomimetic drugs like amphetamines and cocaine, and anticholinergic drugs like tricyclic antidepressants. It’s important to note that anisocoria, which is when one pupil is larger than the other, can also result in the appearance of mydriasis.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 7
Correct
-
The mother of a 3-year-old boy contacts you for advice on febrile convulsions. Her son had his first seizure a few days ago while suffering from a viral respiratory infection. She describes it as a typical, simple febrile convulsion lasting 2-3 minutes with full recovery in about 30 minutes. The mother recalls being informed that there is a risk of recurrence, but she was not given any treatment and was discharged home. She wants to know when she should call an ambulance if it happens again.
Your Answer: A further simple febrile convulsion lasting > 5 minutes
Explanation:Parents should be informed that if their child experiences a febrile convulsion lasting more than 5 minutes, they should call for an ambulance. While some children may have recurrent febrile convulsions, simple ones typically last up to 15 minutes and result in complete recovery within an hour. In these cases, parents can manage their child at home with clear guidance on when to seek medical help, including the use of buccal midazolam or rectal diazepam. However, if a febrile convulsion lasts longer than 5 minutes, an ambulance should be called. If there is a subsequent convulsion lasting less than 5 minutes with a recovery time of 30-60 minutes, the child may be able to stay at home. However, if a febrile convulsion lasts longer than 10 or 15 minutes, an ambulance should have already been called after the initial 5 minutes.
Febrile convulsions are seizures caused by fever in children aged 6 months to 5 years. They typically last less than 5 minutes and are most commonly tonic-clonic. There are three types: simple, complex, and febrile status epilepticus. Children who have had a first seizure or any features of a complex seizure should be admitted to pediatrics. Regular antipyretics do not reduce the chance of a febrile seizure occurring. The overall risk of further febrile convulsion is 1 in 3, with risk factors including age of onset, fever duration, family history, and link to epilepsy. Children without risk factors have a 2.5% risk of developing epilepsy, while those with all three features have a much higher risk.
-
This question is part of the following fields:
- Paediatrics
-
-
Question 8
Incorrect
-
A 70-year-old man is referred to the medical team on call. He has been feeling fatigued for two months and is now experiencing shortness of breath with minimal exertion. He has also had several episodes of syncope with postural hypotension. The GP conducted a blood count and the results showed:
- Haemoglobin 64 g/L (120-160)
- MCV 62 fL (80-96)
- WCC 11.6 ×109L (4-11)
- Platelets 170 ×109L (150-400)
- MCH 22 pg (28-32)
What is the most appropriate next step?Your Answer:
Correct Answer: Transfuse packed red cells
Explanation:Microcytic Hypochromic Anaemia and the Importance of Blood Transfusion
This patient is presenting with a microcytic hypochromic anaemia, which is commonly caused by iron deficiency due to occult gastrointestinal (GI) blood loss in a Caucasian population. To determine the cause of the anaemia, a full history and examination should be conducted to look for clues of GI blood loss. Given the microcytic hypochromic picture, it is likely that blood loss has been ongoing for some time.
Although there is no evidence of haemodynamic compromise or congestive cardiac failure (CCF), the patient is experiencing breathlessness on minimal exertion. This justifies an upfront transfusion to prevent the patient from going into obvious cardiorespiratory failure. At a Hb of 64 g/L in a 72-year-old, the benefits of transfusion outweigh the risks.
While haematinics such as ferritin, vitamin B12, and folate are important investigations, the most crucial management step is organising a blood transfusion. This will help to address the immediate issue of anaemia and prevent further complications.
-
This question is part of the following fields:
- Haematology
-
-
Question 9
Incorrect
-
A 35-year-old female patient complains of erythematous papulo-pustular lesions on the convexities of her face for the past two years. She also has a history of erythema and telangiectasia. What is the most probable diagnosis for this patient?
Your Answer:
Correct Answer: Rosacea
Explanation:Differentiating Skin Conditions
Skin conditions can be easily differentiated based on their characteristic symptoms. Acne is identified by the presence of papules, pustules, and comedones. On the other hand, systemic lupus erythematosus (SLE) is characterized by a photosensitive erythematosus rash on the cheeks, along with other systemic symptoms. Meanwhile, polymorphous light eruption (PLE) does not cause telangiectasia.
One telltale sign of acne is the presence of papules, pustules, and comedones. These are often accompanied by background erythema and telangiectasia. In contrast, SLE is identified by a photosensitive erythematosus rash on the cheeks, which may be accompanied by other systemic symptoms. PLE, on the other hand, does not cause telangiectasia. By the unique symptoms of each skin condition, healthcare professionals can accurately diagnose and treat their patients.
-
This question is part of the following fields:
- Dermatology
-
-
Question 10
Incorrect
-
Drug X activates an enzyme Y to produce a biochemical response. Drug Z, when administered, will bind to the same site on Y and halt the biochemical response. What term could be used to refer to drug Z?
Your Answer:
Correct Answer: Competitive antagonist
Explanation:An agonist is a drug that binds to a receptor and causes an increase in receptor activity. The effects of an agonist are determined by efficacy of agonism and degree of receptor occupancy. An antagonist is a ligand that binds to a receptor and reduces or inhibits receptor activity, causing no biological response. The effects of an antagonist are determined by degree of receptor occupancy, affinity to the receptor, and efficacy. A competitive antagonist has a similar structure to an agonist and will bind to the same site on the same receptor. A non-competitive antagonist has a different structure to the agonist and may cause an alteration in the receptor structure or the interaction of the receptor with downstream effects in the cell.
-
This question is part of the following fields:
- Pharmacology
-
00
Correct
00
Incorrect
00
:
00
:
0
00
Session Time
00
:
00
Average Question Time (
Mins)