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  • Question 1 - A 43-year-old Nigerian woman comes to the clinic with complaints of heavy menstrual...

    Incorrect

    • A 43-year-old Nigerian woman comes to the clinic with complaints of heavy menstrual bleeding and pelvic discomfort for the past 3 months. During the physical examination, a solid, non-painful abdominal mass is detected, which originates from the pelvis. The pelvic ultrasound confirms the presence of a sizable uterine fibroid. The medical team decides to perform a hysterectomy. What medication should be administered to prepare her for the surgery?

      Your Answer: Combined oral contraceptive pill

      Correct Answer: GnRH agonist e.g. Leuprolide

      Explanation:

      GnRH agonists can be effective in reducing the size of uterine fibroids, but their use is typically limited to short-term treatment. It is important to note that these agonists are primarily used to decrease the size of the uterus prior to surgery, as the risk of post-operative blood loss is directly related to the size of the uterus. Progesterone receptor inhibitors, on the other hand, do not have an impact on overall uterine size and are therefore not useful in preparing for surgery. However, they can be helpful in reducing the severity of fibroid-related bleeding. It is also important to avoid taking COCP 4-6 weeks prior to major surgery due to an increased risk of venous thromboembolism, and to avoid antiplatelet drugs such as Ibuprofen before surgery. While antifibrinolytics like tranexamic acid can be useful in reducing the severity of uterine bleeding, they are not helpful in preparing for surgery.

      Understanding Uterine Fibroids

      Uterine fibroids are non-cancerous growths that develop in the uterus. They are more common in black women and are thought to occur in around 20% of white women in their later reproductive years. Fibroids are usually asymptomatic, but they can cause menorrhagia, which can lead to iron-deficiency anaemia. Other symptoms include lower abdominal pain, bloating, and urinary symptoms. Fibroids may also cause subfertility.

      Diagnosis is usually made through transvaginal ultrasound. Asymptomatic fibroids do not require treatment, but periodic monitoring is recommended. Menorrhagia secondary to fibroids can be managed with various treatments, including the levonorgestrel intrauterine system, NSAIDs, tranexamic acid, and hormonal therapies.

      Medical treatment to shrink or remove fibroids may include GnRH agonists or ulipristal acetate, although the latter is not currently recommended due to concerns about liver toxicity. Surgical options include myomectomy, hysteroscopic endometrial ablation, hysterectomy, and uterine artery embolization.

      Fibroids generally regress after menopause, but complications such as subfertility and iron-deficiency anaemia can occur. Red degeneration, which is haemorrhage into the tumour, is a common complication during pregnancy.

    • This question is part of the following fields:

      • Reproductive Medicine
      41.6
      Seconds
  • Question 2 - A 45-year-old man presents to the Emergency Department feeling very sick. He reports...

    Correct

    • A 45-year-old man presents to the Emergency Department feeling very sick. He reports having flu-like symptoms for the past few days and is having difficulty keeping anything down. He feels weak, drowsy, and disoriented. He experiences dizziness when he stands up. Upon observation, he is found to be tachycardic and hypotensive with a fever. He reports taking only hydrocortisone 10 mg PO bidaily for Addison's disease. What is the most crucial management step in this case?

      Your Answer: Give 100 mg hydrocortisone intravenous (IV) STAT

      Explanation:

      Managing Addisonian Crisis: Treatment Options and Considerations

      Addisonian crisis is a life-threatening condition that requires prompt intervention. Patients with Addison’s disease are at risk of developing an Addisonian crisis if they forget to take their steroids or if steroids have not been increased appropriately during an accompanying illness. In such cases, the first-line treatment is to administer 100 mg hydrocortisone intravenously (IV) STAT. This should be followed by fluid resuscitation and IV glucose if hypoglycemia is present.

      It is important to note that treatment should be initiated before biochemical results are obtained. Patients with Addison’s disease should carry an IM autoinjector in case of an emergency. If an Addisonian crisis is suspected, hydrocortisone should be administered immediately, and blood tests for cortisol, ACTH, urea and electrolytes, and glucose should be carried out urgently.

      Oral hydrocortisone is not recommended in cases where the patient is vomiting. In such cases, IM hydrocortisone injection is the preferred treatment option. Additionally, glucose gel sublingually may be given for hypoglycemia, but the primary focus should be on restoring cortisol levels.

      Fludrocortisone may be of use if the cause of the Addisonian crisis is adrenal disease. However, it should be noted that hydrocortisone is the first-line treatment as it acts mainly on glucocorticoid receptors to increase blood sugar levels and counteract insulin. Fludrocortisone, on the other hand, acts mainly at mineralocorticoid receptors.

      In conclusion, managing Addisonian crisis requires prompt intervention and careful consideration of treatment options. Administering hydrocortisone, fluid resuscitation, and IV glucose if necessary should be the primary focus, with fludrocortisone being considered only if the cause is adrenal disease.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      42.3
      Seconds
  • Question 3 - A 32-year-old female sex worker presents to the emergency department complaining of a...

    Incorrect

    • A 32-year-old female sex worker presents to the emergency department complaining of a high fever and severe headache. During the physical examination, you observe neck stiffness and mild photophobia, prompting you to perform a lumbar puncture. The results of the lumbar puncture reveal the presence of a yeast and a capsule in the CSF stained with India ink.
      What is the most probable diagnosis?

      Your Answer: Histoplasmosis

      Correct Answer: Cryptococcal meningitis

      Explanation:

      Cryptococcus neoformans is a yeast that has a protective capsule and requires oxygen to survive. It can thrive in both plants and animals, and when it infects humans, it causes cryptococcosis. While the infection typically affects the lungs, it can also lead to fungal meningitis and encephalitis in individuals with weakened immune systems. HIV-positive patients are particularly susceptible to this infection, and given the patient’s history as a sex worker, it’s possible that they have an undiagnosed HIV infection that has progressed to AIDS. Additionally, cryptococcus neoformans can be detected through india ink staining during a lumbar puncture.

      The investigation and management of suspected bacterial meningitis are intertwined due to the potential negative impact of delayed antibiotic treatment. Patients should be urgently transferred to the hospital, and an ABC approach should be taken initially. A lumbar puncture should be delayed in certain circumstances, and IV antibiotics should be given as a priority if there is any doubt. The bloods and CSF should be tested for various parameters, and prophylaxis should be offered to households and close contacts of patients affected with meningococcal meningitis.

    • This question is part of the following fields:

      • Infectious Diseases
      42.3
      Seconds
  • Question 4 - A 35-year-old man comes to the clinic complaining of pain and swelling in...

    Correct

    • A 35-year-old man comes to the clinic complaining of pain and swelling in his right testicle that has been gradually developing over the past two days. He rates the pain as 5/10 on the pain scale. Although he recently returned from a trip to Spain four weeks ago, he denies experiencing any dysuria or urethral discharge. Upon examination, the right testicle is tender and swollen. The patient's heart rate is 84/min and his temperature is 36.8ºC. Based on these symptoms, what is the most probable underlying diagnosis?

      Your Answer: Epididymo-orchitis

      Explanation:

      The symptoms and pain caused by testicular torsion are usually more severe and acute, while a patient with mumps would experience prodromal symptoms and parotitis.

      Epididymo-orchitis is a condition where the epididymis and/or testes become infected, leading to pain and swelling. It is commonly caused by infections spreading from the genital tract or bladder, with Chlamydia trachomatis and Neisseria gonorrhoeae being the usual culprits in sexually active younger adults, while E. coli is more commonly seen in older adults with a low-risk sexual history. Symptoms include unilateral testicular pain and swelling, with urethral discharge sometimes present. Testicular torsion, which can cause ischaemia of the testicle, is an important differential diagnosis and needs to be excluded urgently, especially in younger patients with severe pain and an acute onset.

      Investigations are guided by the patient’s age, with sexually transmitted infections being assessed in younger adults and a mid-stream urine (MSU) being sent for microscopy and culture in older adults with a low-risk sexual history. Management guidelines from the British Association for Sexual Health and HIV (BASHH) recommend ceftriaxone 500mg intramuscularly as a single dose, plus doxycycline 100mg orally twice daily for 10-14 days if the organism causing the infection is unknown. Further investigations are recommended after treatment to rule out any underlying structural abnormalities.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      51.9
      Seconds
  • Question 5 - A 29-year-old female of Afro-Caribbean descent visits the oncology clinic after being referred...

    Incorrect

    • A 29-year-old female of Afro-Caribbean descent visits the oncology clinic after being referred by her primary care physician. She has observed some painless, asymmetrical lymphadenopathy lumps on her neck. She reports experiencing more night sweats lately and has noticed some discomfort when consuming alcohol.
      What characteristic is linked to a negative prognosis for the most probable diagnosis?

      Your Answer: Asymmetrical lymphadenopathy

      Correct Answer: Night sweats

      Explanation:

      Experiencing fever above 38ºC and night sweats in the past 6 months is linked to a poor prognosis if at least one of these ‘B’ symptoms is present. While acute lymphoblastic leukemia has a worse prognosis in individuals of Afro-Caribbean descent, Hodgkin’s lymphoma does not typically present with bone marrow failure and is more common in children. Alcohol-induced pain may be present in some cases of Hodgkin’s lymphoma, but it does not indicate a poor prognosis. While female sex is not linked to a poor prognosis, some studies suggest that males may have a worse outcome. Asymmetrical lymphadenopathy is a characteristic of Hodgkin’s lymphoma but has not been associated with a worse prognosis.

      Understanding Hodgkin’s Lymphoma: Histological Classification and Prognosis

      Hodgkin’s lymphoma is a type of cancer that affects the lymphocytes and is characterized by the presence of Reed-Sternberg cells. It is most commonly seen in individuals in their third and seventh decades of life. The histological classification of Hodgkin’s lymphoma is based on the type of cells present and their frequency. The most common type is nodular sclerosing, which is more common in women and has a good prognosis. Mixed cellularity is the second most common type and is associated with a large number of Reed-Sternberg cells. Lymphocyte predominant is a rare type with the best prognosis, while lymphocyte depleted is the rarest and has the worst prognosis.

      In addition to the histological classification, there are other factors that can affect the prognosis of Hodgkin’s lymphoma. The presence of B symptoms, such as weight loss, fever, and night sweats, is associated with a poor prognosis. Other factors identified in a 1998 NEJM paper include age over 45 years, stage IV disease, low hemoglobin levels, low lymphocyte count, male gender, low albumin levels, and high white blood cell count. Understanding the histological classification and prognosis of Hodgkin’s lymphoma can help guide treatment decisions and improve outcomes for patients.

    • This question is part of the following fields:

      • Haematology/Oncology
      21.9
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  • Question 6 - A 15-year-old student presents with low back pain that radiates to the back...

    Incorrect

    • A 15-year-old student presents with low back pain that radiates to the back of their legs. They have an elevated ESR and negative serum rheumatoid factor. A spine radiograph reveals anterior squaring of the vertebrae.
      What is the most probable diagnosis?

      Your Answer: Paget’s disease of bone

      Correct Answer: Ankylosing spondylitis (AS)

      Explanation:

      Ankylosing spondylitis (AS) is a type of arthritis that is characterized by morning stiffness lasting more than 30 minutes, improvement of back pain with exercise but not rest, awakening due to back pain during the second half of the night, and alternating buttock pain. It is a seronegative spondyloarthropathy, meaning that the rheumatoid factor will be negative. Radiographically, sacroiliitis is often the first abnormality seen. ESR and CRP are usually raised, and HLA-B27 testing may provide supporting evidence. Lumbar disc prolapse with sciatica, rheumatoid arthritis, spinal stenosis, and Paget’s disease of bone are other conditions that may cause similar symptoms but have different characteristics and diagnostic criteria.

    • This question is part of the following fields:

      • Musculoskeletal
      18.4
      Seconds
  • Question 7 - A 25-year-old man presents to his General Practitioner with a 1-week history of...

    Correct

    • A 25-year-old man presents to his General Practitioner with a 1-week history of an itchy rash on the inner aspect of his elbows on either side. He states that this came on suddenly and that he has had similar episodes in the past, the first of which occurred when he was around seven years old. He claims to only suffer from generally dry skin and asthma, which he controls with emollient creams and inhalers, respectively.
      Given the likely diagnosis, which of the following is the best next step?

      Your Answer: No further testing required; start treatment

      Explanation:

      Diagnosis and Testing for Atopic Eczema

      Atopic eczema is a common skin condition that can cause significant physical and psychological distress to patients. Diagnosis is usually made based on clinical presentation and history, with no further testing required. The UK Working Party Diagnostic Criteria can be used to aid in diagnosis. Treatment options include emollients, topical steroids, and other medications in severe cases.

      Radioallergosorbent testing (RAST) and skin patch testing are not useful in diagnosing atopic eczema, as they are mainly used for other types of hypersensitivity reactions. Skin prick testing may be used to diagnose allergies that could be exacerbating the eczema. However, it is important to note that atopic eczema is a clinical diagnosis and testing is not always necessary.

    • This question is part of the following fields:

      • Dermatology
      28.2
      Seconds
  • Question 8 - A 32-week pregnant woman presents to the early pregnancy unit with a concern...

    Correct

    • A 32-week pregnant woman presents to the early pregnancy unit with a concern that her uterus is small for this stage of pregnancy. Upon ultrasound, she is diagnosed with oligohydramnios. What could be a potential cause of oligohydramnios?

      Your Answer: Renal agenesis

      Explanation:

      Oligohydramnios is a condition that occurs during pregnancy when there is a shortage of amniotic fluid. This can result in a smaller symphysiofundal height.

      Oligohydramnios is a condition characterized by a decrease in the amount of amniotic fluid present in the womb. The definition of oligohydramnios varies, but it is generally considered to be present when there is less than 500ml of amniotic fluid at 32-36 weeks of gestation or an amniotic fluid index (AFI) that falls below the 5th percentile.

      There are several potential causes of oligohydramnios, including premature rupture of membranes, Potter sequence, bilateral renal agenesis with pulmonary hypoplasia, intrauterine growth restriction, post-term gestation, and pre-eclampsia. These conditions can all contribute to a reduction in the amount of amniotic fluid present in the womb, which can have significant implications for fetal development and health. It is important for healthcare providers to monitor amniotic fluid levels and identify any potential causes of oligohydramnios in order to provide appropriate care and support for both the mother and the developing fetus.

    • This question is part of the following fields:

      • Reproductive Medicine
      16.1
      Seconds
  • Question 9 - Which of the following is not a recognized feature of Horner's syndrome? ...

    Incorrect

    • Which of the following is not a recognized feature of Horner's syndrome?

      Your Answer: Ptosis

      Correct Answer: Mydriasis

      Explanation:

      Horner’s syndrome is a medical condition that is characterized by a set of symptoms including a small pupil (miosis), drooping of the upper eyelid (ptosis), sunken eye (enophthalmos), and loss of sweating on one side of the face (anhidrosis). The presence of heterochromia, or a difference in iris color, is often seen in cases of congenital Horner’s syndrome. Anhidrosis is also a distinguishing feature that can help differentiate between central, pre-ganglionic, and post-ganglionic lesions. Pharmacologic tests, such as the use of apraclonidine drops, can be helpful in confirming the diagnosis of Horner’s syndrome and localizing the lesion.

      Central lesions, pre-ganglionic lesions, and post-ganglionic lesions can all cause Horner’s syndrome, with each type of lesion presenting with different symptoms. Central lesions can result in anhidrosis of the face, arm, and trunk, while pre-ganglionic lesions can cause anhidrosis of the face only. Post-ganglionic lesions, on the other hand, do not typically result in anhidrosis.

      There are many potential causes of Horner’s syndrome, including stroke, syringomyelia, multiple sclerosis, tumors, encephalitis, thyroidectomy, trauma, cervical rib, carotid artery dissection, carotid aneurysm, cavernous sinus thrombosis, and cluster headache. It is important to identify the underlying cause of Horner’s syndrome in order to determine the appropriate treatment plan.

    • This question is part of the following fields:

      • Ophthalmology
      13.8
      Seconds
  • Question 10 - A middle-aged man presents with a round, slowly enlarging erythema on his thigh....

    Correct

    • A middle-aged man presents with a round, slowly enlarging erythema on his thigh. He also complains of joint discomfort and fatigue. Lyme disease is suspected.
      Which of the following is the most appropriate laboratory test to confirm this diagnosis?
      Select the SINGLE most appropriate laboratory test from the list below.

      Your Answer: Anti-Borrelia burgdorferi titre

      Explanation:

      Diagnostic Tests for Lyme Disease: Understanding the Results

      Lyme disease is a common illness caused by the spirochaete B. burgdorferi, transmitted to humans via tick bites. Serologic testing is the most frequently used diagnostic tool, but false positives and negatives are common. The enzyme immunoassay (EIA) or enzyme-linked immunosorbent assay (ELISA) is the first step, followed by a western blot if necessary. However, serologic results cannot distinguish active from inactive disease. Antinuclear antibodies and rheumatoid factor test results are negative in B. burgdorferi infection. The erythrocyte sedimentation rate is usually elevated but is not specific to detect infection. Culture of joint fluids can rule out gout and pseudogout, but detection of B. burgdorferi DNA in synovial fluid is not reliable. Blood cultures are impractical. Understanding the limitations of these tests is crucial for accurate diagnosis and treatment of Lyme disease.

    • This question is part of the following fields:

      • Infectious Diseases
      34
      Seconds
  • Question 11 - A 29-year-old man presents to the emergency department with a 3-day history of...

    Correct

    • A 29-year-old man presents to the emergency department with a 3-day history of fever, fatigue, and a tingling sensation in the lateral aspect of his left thigh. The tingling was initially tolerable but has become increasingly painful over the past 24 hours. Upon examination, the area described is erythematous with a macular rash appearing. The patient has a history of HIV and is currently taking antiretroviral therapy with an undetectable viral load. He denies any cough, coryzal symptoms, focal neurological signs, or trauma to the site.

      What is the appropriate management for this patient, given the likely diagnosis? Choose from the options provided.

      Your Answer: Aciclovir

      Explanation:

      Patients suspected of having shingles should receive antiviral treatment within 72 hours of symptom onset, as this can help reduce the risk of post-herpetic complications. In the case of this patient, who is experiencing symptoms of shingles within the 72-hour window and has an immunosuppressive condition, antivirals such as aciclovir should be prescribed. Amitriptyline, which is used to manage post-herpetic neuralgia, would not be appropriate at this stage. Chlorphenamine is typically used to manage itching associated with chickenpox, but as this patient is only experiencing symptoms in one dermatome, it is more likely to be shingles. Flucloxacillin, an antibiotic used to treat bacterial skin infections, would not be appropriate in this case as the patient’s symptoms are consistent with herpes zoster infection.

      Shingles is a painful blistering rash caused by reactivation of the varicella-zoster virus. It is more common in older individuals and those with immunosuppressive conditions. The rash is well demarcated by the affected dermatome and may be accompanied by fever and lethargy. Treatment includes analgesia, antivirals, and potentially oral corticosteroids. Complications include post-herpetic neuralgia, ocular and ear complications. Antivirals should be used within 72 hours to reduce the risk of post-herpetic neuralgia.

    • This question is part of the following fields:

      • Dermatology
      44.9
      Seconds
  • Question 12 - A 56-year-old man visits his doctor. He was prescribed fluoxetine for depression eight...

    Incorrect

    • A 56-year-old man visits his doctor. He was prescribed fluoxetine for depression eight weeks ago and now wants to discontinue the medication as he feels much better. What advice should be given regarding his treatment?

      Your Answer: It should be continued for at least 6 weeks

      Correct Answer: It should be continued for at least 6 months

      Explanation:

      The risk of relapse is significantly decreased, and patients should be comforted by the fact that antidepressants are non-addictive.

      Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.

      The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.

      When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.

      When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.

    • This question is part of the following fields:

      • Psychiatry
      22.3
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  • Question 13 - A 29-year-old male arrives at the Emergency Department complaining of feeling extremely sick....

    Correct

    • A 29-year-old male arrives at the Emergency Department complaining of feeling extremely sick. He reports that his GP had prescribed him antibiotics for a chest infection. Upon examination, an ECG reveals polymorphic ventricular tachycardia (torsades de pointes). What medication is he likely taking?

      Your Answer: Clarithromycin

      Explanation:

      Torsades de pointes can be caused by macrolides, particularly clarithromycin, due to its potential to prolong the QT interval and trigger polymorphic ventricular tachycardia. This risk is higher in patients with an underlying channelopathy. Long QT syndrome can be caused by genetic factors such as potassium or sodium channel mutations, as well as electrolyte imbalances like hypocalcaemia, hypomagnesaemia, and hypokalaemia. Certain drugs, including antiarrhythmics, antibiotics, and psychotropic medications, can also cause long QT syndrome.

      Torsades de Pointes: A Life-Threatening Condition

      Torsades de pointes is a type of ventricular tachycardia that is associated with a prolonged QT interval. This condition can lead to ventricular fibrillation, which can cause sudden death. There are several causes of a prolonged QT interval, including congenital conditions such as Jervell-Lange-Nielsen syndrome and Romano-Ward syndrome, as well as certain medications like antiarrhythmics, tricyclic antidepressants, and antipsychotics. Other causes include electrolyte imbalances, myocarditis, hypothermia, and subarachnoid hemorrhage.

      The management of torsades de pointes involves the administration of intravenous magnesium sulfate. This can help to stabilize the heart rhythm and prevent further complications.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      23.9
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  • Question 14 - A 26-year-old man with a family history of adult polycystic kidney disease approaches...

    Incorrect

    • A 26-year-old man with a family history of adult polycystic kidney disease approaches his GP for screening. What would be the most suitable screening test?

      Your Answer: PKD1 gene testing

      Correct Answer: Ultrasound abdomen

      Explanation:

      The recommended screening test for adult polycystic kidney disease is ultrasound, while genetic testing is not yet routinely advised for screening relatives.

      Autosomal dominant polycystic kidney disease (ADPKD) is a prevalent genetic condition that affects approximately 1 in 1,000 Caucasians. The disease is caused by mutations in two genes, PKD1 and PKD2, which produce polycystin-1 and polycystin-2, respectively. ADPKD type 1 accounts for 85% of cases, while ADPKD type 2 accounts for the remaining 15%. Individuals with ADPKD develop multiple fluid-filled cysts in their kidneys, which can lead to renal failure.

      To diagnose ADPKD in individuals with a positive family history, an abdominal ultrasound is typically performed. The diagnostic criteria for ultrasound include the presence of two cysts, either unilateral or bilateral, in individuals under 30 years of age, two cysts in both kidneys for those aged 30-59 years, and four cysts in both kidneys for those over 60 years of age.

      Management of ADPKD may involve the use of tolvaptan, a vasopressin receptor 2 antagonist, for select patients. Tolvaptan has been recommended by NICE as an option for treating ADPKD in adults with chronic kidney disease stage 2 or 3 at the start of treatment, evidence of rapidly progressing disease, and if the company provides it with the agreed discount in the patient access scheme. The goal of treatment is to slow the progression of cyst development and renal insufficiency. An enlarged kidney with extensive cysts is a common finding in individuals with ADPKD.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      18.2
      Seconds
  • Question 15 - A 28-year-old Afro-Caribbean woman presents with a 3-month history of a non-productive cough,...

    Correct

    • A 28-year-old Afro-Caribbean woman presents with a 3-month history of a non-productive cough, dyspnoea and pleuritic chest pain, especially when climbing stairs. She reports intermittent fevers of up to 39°C and a 3.5-kg weight loss. She complains of wrist and ankle pain that has interfered with her work. She smokes two packets of cigarettes per day. Her full blood count is normal and serum ANA is negative. On examination there are red nodules over her lower legs.
      Which of the following is the most likely diagnosis?

      Your Answer: Sarcoidosis

      Explanation:

      Sarcoidosis is a condition where non-caseating granulomata develop in at least two organs, causing systemic inflammation. It is most common in African-Caribbean women and often affects the lungs, causing symptoms such as dry cough, dyspnea, and weight loss. Erythema nodosum is also frequently seen in patients with sarcoidosis. Histoplasmosis, Goodpasture’s syndrome, adenocarcinoma of the lung, and systemic lupus erythematosus are all possible differential diagnoses, but the absence of specific features makes sarcoidosis more likely in this case.

    • This question is part of the following fields:

      • Respiratory Medicine
      28.2
      Seconds
  • Question 16 - A 72-year-old man with metastatic breast cancer presents to surgery with his wife....

    Incorrect

    • A 72-year-old man with metastatic breast cancer presents to surgery with his wife. He has known bone metastases in his pelvis and ribs, but his pain is not adequately managed with paracetamol, diclofenac, and MST 30 mg bd. His wife reports that he is using 10mg of oral morphine solution approximately 6-7 times a day for breakthrough pain. The hospice palliative care team attempted to use a bisphosphonate, but it resulted in persistent myalgia and arthralgia. What is the next appropriate step?

      Your Answer: Switch to oxycodone

      Correct Answer: Increase MST + refer for radiotherapy

      Explanation:

      Palliative care prescribing for pain is guided by NICE and SIGN guidelines. NICE recommends starting treatment with regular oral modified-release or immediate-release morphine, with immediate-release morphine for breakthrough pain. Laxatives should be prescribed for all patients initiating strong opioids, and antiemetics should be offered if nausea persists. Drowsiness is usually transient, but if it persists, the dose should be adjusted. SIGN advises that the breakthrough dose of morphine is one-sixth the daily dose, and all patients receiving opioids should be prescribed a laxative. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred to morphine in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and all patients should be considered for referral to a clinical oncologist for further treatment. When increasing the dose of opioids, the next dose should be increased by 30-50%. Conversion factors between opioids are also provided. Opioid side-effects are usually transient, such as nausea and drowsiness, but constipation can persist. In addition to strong opioids, bisphosphonates, and radiotherapy, denosumab may be used to treat metastatic bone pain.

      Overall, the guidelines recommend starting with regular oral morphine and adjusting the dose as needed. Laxatives should be prescribed to prevent constipation, and antiemetics may be needed for nausea. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and referral to a clinical oncologist should be considered. Conversion factors between opioids are provided, and the next dose should be increased by 30-50% when adjusting the dose. Opioid side-effects are usually transient, but constipation can persist. Denosumab may also be used to treat metastatic bone pain.

    • This question is part of the following fields:

      • Haematology/Oncology
      42.8
      Seconds
  • Question 17 - A 35-year-old woman presents to the Emergency Department with a 2-month history of...

    Incorrect

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

      Your Answer: Unilateral laparoscopic adrenalectomy

      Correct Answer: Spironolactone

      Explanation:

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      84
      Seconds
  • Question 18 - You are consulted by the parents of a 5-year-old girl. She has a...

    Correct

    • You are consulted by the parents of a 5-year-old girl. She has a lifelong history of bedwetting at night, and they are becoming increasingly concerned that the problem is not getting any better. She never has accidents in the day and opens her bowels at least once a day. She has been potty-trained since the age of two. Apart from hay fever, there is no relevant family history. Physical examination is normal. Urinalysis reveals no abnormality. Things have come to a head as she is starting school in two weeks’ time, and they do not want her to wet the bed.
      What is the most appropriate management plan?

      Your Answer: Give general advice on enuresis, reassure the parents that he is almost certain to grow out of the problem and prescribe desmopressin to be taken during the camping trip to prevent bedwetting

      Explanation:

      Managing Primary Enuresis in Children: Advice and Treatment Options

      Primary enuresis, or bedwetting, is a common condition affecting 15-20% of children. It is characterized by nocturnal wetting without daytime symptoms and is thought to be caused by bladder dysfunction. Parents of children with primary enuresis may be reassured that their child is likely to grow out of the problem by age 15, with only 1% of patients continuing to have symptoms into adulthood.

      Treatment options for primary enuresis include the use of an enuresis alarm combined with a reward system to teach and reward good habits. Fluid should not be restricted. In children over the age of 5, short-term control can be achieved with a prescription of desmopressin to prevent enuresis during sleepovers or school trips.

      It is important to involve the child in the management plan and explore family habits. Referral to a paediatric urologist may be necessary for children with primary enuresis and daytime symptoms or for those who have failed two complete courses of treatment with an enuresis alarm or desmopressin.

      Managing Primary Enuresis in Children: Advice and Treatment Options

    • This question is part of the following fields:

      • Paediatrics
      38.2
      Seconds
  • Question 19 - You have requested a B-type natriuretic peptide (BNP) test for a patient with...

    Correct

    • You have requested a B-type natriuretic peptide (BNP) test for a patient with suspected heart failure who is in their 60s. The results have shown a slightly elevated BNP level. What could be a possible factor that may cause a falsely elevated BNP result?

      Your Answer: COPD

      Explanation:

      Chronic heart failure is a condition that requires proper diagnosis and management. In 2018, NICE updated their guidelines on the diagnosis and management of this condition. Previously, the first-line investigation was determined by whether the patient had previously had a myocardial infarction or not. However, this is no longer the case. All patients should now have an N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test as the first-line investigation.

      Interpreting the NT-proBNP blood test is crucial in determining the severity of the condition. If the levels are high, specialist assessment, including transthoracic echocardiography, should be arranged within two weeks. If the levels are raised, specialist assessment, including echocardiogram, should be arranged within six weeks. B-type natriuretic peptide (BNP) is a hormone produced mainly by the left ventricular myocardium in response to strain. Very high levels of BNP are associated with a poor prognosis.

      There are different levels of BNP, and each level indicates a different severity of the condition. High levels of BNP are greater than 400 pg/ml (116 pmol/litre) for BNP and greater than 2000 pg/ml (236 pmol/litre) for NTproBNP. Raised levels of BNP are between 100-400 pg/ml (29-116 pmol/litre) for BNP and between 400-2000 pg/ml (47-236 pmol/litre) for NTproBNP. Normal levels of BNP are less than 100 pg/ml (29 pmol/litre) for BNP and less than 400 pg/ml (47 pmol/litre) for NTproBNP.

      It is important to note that several factors can alter the BNP level. Factors that increase BNP levels include left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia (including pulmonary embolism), GFR < 60 ml/min, sepsis, COPD, diabetes, and age > 70. On the other hand, factors that decrease BNP levels include diuretics, ACE inhibitors, beta-blockers, angiotensin 2 receptor blockers, and aldosterone antagonists.

    • This question is part of the following fields:

      • Cardiovascular
      20.5
      Seconds
  • Question 20 - A 35-year-old woman who is 36 weeks pregnant complains of dysuria and frequent...

    Correct

    • A 35-year-old woman who is 36 weeks pregnant complains of dysuria and frequent urination. Upon urine dipstick examination, nitrites and leukocytes are detected. What is the most appropriate course of action?

      Your Answer: Cefalexin

      Explanation:

      In this scenario, it is also advisable to use Amoxicillin.

      Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is teratogenic in the first trimester. Asymptomatic bacteriuria in pregnant women should also be treated to prevent progression to acute pyelonephritis. Men with UTIs should be offered a seven-day course of trimethoprim or nitrofurantoin unless prostatitis is suspected. A urine culture should be sent before antibiotics are started. Catheterised patients should not be treated for asymptomatic bacteria, but if symptomatic, a seven-day course of antibiotics should be given. Acute pyelonephritis requires hospital admission and treatment with a broad-spectrum cephalosporin or quinolone for 10-14 days. Referral to urology is not routinely required for men who have had one uncomplicated lower UTI.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      20.9
      Seconds
  • Question 21 - A 28-year-old pregnant woman presents at 34 weeks gestation with a blood pressure...

    Correct

    • A 28-year-old pregnant woman presents at 34 weeks gestation with a blood pressure reading of 175/105 mmHg and 3+ proteinuria. She is started on magnesium sulphate and labetalol. The patient reports decreased foetal movements. Upon examination, a cardiotocogram reveals late decelerations and a foetal heart rate of 90 beats/minute. What is the next course of action in managing this situation?

      Your Answer: Emergency caesarian section

      Explanation:

      Pre-eclampsia can be diagnosed based on the presence of high levels of protein in the urine and hypertension. To prevent the development of eclampsia, magnesium sulphate is administered, while labetalol is used to manage high blood pressure. If a cardiotocography (CTG) shows late decelerations and foetal bradycardia, this is a concerning sign and may necessitate an emergency caesarean section. Induction would not be recommended if the CTG is abnormal.

      Cardiotocography (CTG) is a medical procedure that measures pressure changes in the uterus using either internal or external pressure transducers. It is used to monitor the fetal heart rate, which normally ranges between 100-160 beats per minute. There are several features that can be observed during a CTG, including baseline bradycardia (heart rate below 100 beats per minute), which can be caused by increased fetal vagal tone or maternal beta-blocker use. Baseline tachycardia (heart rate above 160 beats per minute) can be caused by maternal pyrexia, chorioamnionitis, hypoxia, or prematurity. Loss of baseline variability (less than 5 beats per minute) can be caused by prematurity or hypoxia. Early deceleration, which is a decrease in heart rate that starts with the onset of a contraction and returns to normal after the contraction, is usually harmless and indicates head compression. Late deceleration, on the other hand, is a decrease in heart rate that lags behind the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction. This can indicate fetal distress, such as asphyxia or placental insufficiency. Variable decelerations, which are independent of contractions, may indicate cord compression.

    • This question is part of the following fields:

      • Reproductive Medicine
      50.8
      Seconds
  • Question 22 - A 26-year-old woman presents to gastroenterology clinic with severe ulcerative colitis. Before starting...

    Correct

    • A 26-year-old woman presents to gastroenterology clinic with severe ulcerative colitis. Before starting azathioprine to improve her symptoms, what potential contraindications should be ruled out?

      Your Answer: Thiopurine methyltransferase deficiency (TPMT)

      Explanation:

      Azathioprine is a medication that is broken down into mercaptopurine, which is an active compound that inhibits the production of purine. To determine if someone is at risk for azathioprine toxicity, a test for thiopurine methyltransferase (TPMT) may be necessary. Adverse effects of this medication include bone marrow depression, which can be detected through a full blood count if there are signs of infection or bleeding, as well as nausea, vomiting, pancreatitis, and an increased risk of non-melanoma skin cancer. It is important to note that there is a significant interaction between azathioprine and allopurinol, so lower doses of azathioprine should be used in conjunction with allopurinol. Despite these potential side effects, azathioprine is generally considered safe to use during pregnancy.

    • This question is part of the following fields:

      • Musculoskeletal
      24.4
      Seconds
  • Question 23 - A 35-year-old woman presents to the Emergency Department complaining of right-eye pain. She...

    Correct

    • A 35-year-old woman presents to the Emergency Department complaining of right-eye pain. She suspects that something may be stuck in her eye as she has been unable to wear her contact lenses for the past day due to the pain.
      On examination, there is diffuse hyperaemia of the right eye. The right cornea appears hazy, and the pupillary reaction is normal. Visual acuity is reduced on the right side and a degree of photophobia is noted. A hypopyon is also seen.
      Given the likely diagnosis, which of the following management procedures should be done immediately?
      Select the SINGLE most appropriate management from the list below.

      Your Answer: Urgent referral to an eye specialist

      Explanation:

      Urgent Referral and Management of Keratitis: Importance of Eye Specialist Review

      Keratitis is the inflammation of the cornea, which can be potentially sight-threatening if left untreated. Microbial keratitis requires urgent evaluation and treatment, as an accurate diagnosis can only be made with a slit-lamp. Therefore, an immediate referral to an eye specialist is crucial to rule out this condition.

      Topical antibiotics, such as quinolones eye drops, are used as first-line treatment for keratitis and corneal ulcers. However, this is not as crucial as an immediate review by the eye specialist. Cyclopentolate eye drops are used for pain relief, but again, an eye specialist review is more important.

      It is crucial to stop using contact lenses until the symptoms have fully resolved, but this is not as crucial as an immediate review by the eye specialist. Timolol drops, which are used to reduce raised intraocular pressure in glaucoma, have no role in keratitis treatment.

      In summary, an urgent referral to an eye specialist is crucial in the management of keratitis, as an accurate diagnosis and immediate treatment can prevent potential sight-threatening complications.

    • This question is part of the following fields:

      • Ophthalmology
      22.3
      Seconds
  • Question 24 - A 32-year-old man with a known diagnosis of ulcerative colitis visits his General...

    Incorrect

    • A 32-year-old man with a known diagnosis of ulcerative colitis visits his General Practitioner (GP) complaining of a 4-day history of a feeling of rectal fullness, tenesmus, diarrhoea with small, frequent stools and mucus, and rectal bleeding. He denies systemic symptoms. He is not sexually active. Physical examination is unremarkable. The GP thinks a diagnosis of inflammatory exacerbation of proctitis is likely and contacts the local Inflammatory Bowel Disease (IBM) specialist nurse for advice.
      Which of the following is the most appropriate treatment?
      Select the SINGLE most appropriate treatment from the list below.
      Select ONE option only.

      Your Answer: Loperamide

      Correct Answer: Per-rectal administration of aminosalicylate

      Explanation:

      Treatment Options for Proctitis: Aminosalicylates, Topical Corticosteroids, and More

      Proctitis, an inflammation of the rectal mucosa, can be caused by various factors such as radiation, infections, autoimmune diseases, and trauma. Symptoms include rectal bleeding, pain, and diarrhea. To manage proctitis, aminosalicylates in the form of enemas or suppositories are often used as first-line therapy to reduce inflammation and relieve symptoms. Topical corticosteroids are less effective but can be used in patients who cannot tolerate aminosalicylates. Oral prednisolone is a second-line therapy for ulcerative colitis. Ibuprofen is not recommended, and codeine phosphate and loperamide may aggravate symptoms. Treatment depends on the underlying cause and severity of proctitis.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      39
      Seconds
  • Question 25 - A 67-year-old man presents for a review of his chronic obstructive pulmonary disease....

    Correct

    • A 67-year-old man presents for a review of his chronic obstructive pulmonary disease. He reports experiencing constant shortness of breath during physical activity, which has remained stable over the past year. He has a history of asbestos exposure and is currently under the care of a respiratory physician. During the examination, no abnormalities are detected, but a chest X-ray reveals the presence of pleural plaques. The patient expresses concern that these plaques may develop into cancer. What advice do you offer this patient regarding his test results?

      Your Answer: Benign and do not require follow-up

      Explanation:

      Pleural plaques are benign and do not develop into cancerous growths, so there is no need for any follow-up. These plaques are the most common form of lung disease caused by asbestos exposure, but they do not increase the risk of lung cancer or mesothelioma. While ongoing monitoring of the patient’s lung disease is recommended, there is no need to specifically monitor the pleural plaques. It is important to note that pleural plaques are a sign of past asbestos exposure, which could increase the risk of mesothelioma, but the plaques themselves are not a cause for concern. Therefore, the patient does not require a specialist referral for the pleural plaques alone. However, if the patient experiences worsening shortness of breath or frequent exacerbations, a specialist referral may be necessary to assess for disease progression or malignancy.

      Asbestos-Related Lung Diseases

      Asbestos exposure can lead to various lung diseases, ranging from benign pleural plaques to malignant mesothelioma. Pleural plaques are non-cancerous and do not require any follow-up, but they are the most common form of asbestos-related lung disease and typically appear after a latent period of 20-40 years. Asbestos exposure may also cause diffuse pleural thickening, which is similar to the pattern seen after an empyema or haemothorax, but the underlying pathophysiology is not fully understood.

      Asbestosis is a lung disease that is related to the length of exposure to asbestos. It causes lower lobe fibrosis and is typically characterized by dyspnea, reduced exercise tolerance, clubbing, bilateral end-inspiratory crackles, and a restrictive pattern with reduced gas transfer on lung function tests. Asbestosis is treated conservatively, as no interventions offer significant benefits. The latent period for asbestosis is typically 15-30 years.

      Mesothelioma is a malignant disease of the pleura that is caused by asbestos exposure, with crocidolite (blue) asbestos being the most dangerous form. Possible features of mesothelioma include progressive shortness-of-breath, chest pain, and pleural effusion. Patients are usually offered palliative chemotherapy, and there is a limited role for surgery and radiotherapy. Unfortunately, the prognosis for mesothelioma is very poor, with a median survival from diagnosis of 8-14 months.

      Although mesothelioma is often associated with asbestos exposure, lung cancer is actually the most common form of cancer related to asbestos exposure. It has a synergistic effect with cigarette smoke, which increases the risk of developing lung cancer.

    • This question is part of the following fields:

      • Respiratory Medicine
      17.1
      Seconds
  • Question 26 - A pregnant woman presents at 24 weeks pregnant. What would be the expected...

    Correct

    • A pregnant woman presents at 24 weeks pregnant. What would be the expected symphysis-fundal height?

      Your Answer: 22 - 26 cm

      Explanation:

      The symphysis-fundal height in centimeters after 20 weeks of gestation is equal to the number of weeks of gestation.

      The symphysis-fundal height (SFH) is a measurement taken from the pubic bone to the top of the uterus in centimetres. It is used to determine the gestational age of a fetus and should match within 2 cm after 20 weeks. For example, if a woman is 24 weeks pregnant, a normal SFH would be between 22 and 26 cm. Proper measurement of SFH is important for monitoring fetal growth and development during pregnancy.

    • This question is part of the following fields:

      • Reproductive Medicine
      8.2
      Seconds
  • Question 27 - A 27-year-old female patient visits the genitourinary medicine clinic seeking treatment for recurring...

    Correct

    • A 27-year-old female patient visits the genitourinary medicine clinic seeking treatment for recurring genital warts. Which virus is the most probable cause of this condition?

      Your Answer: Human papilloma virus 6 & 11

      Explanation:

      Understanding Genital Warts

      Genital warts, also known as condylomata accuminata, are a common reason for visits to genitourinary clinics. These warts are caused by various types of the human papillomavirus (HPV), with types 6 and 11 being the most common culprits. It is important to note that HPV, particularly types 16, 18, and 33, can increase the risk of cervical cancer.

      The warts themselves are small, fleshy protrusions that are typically 2-5mm in size and may be slightly pigmented. They can cause discomfort, itching, and even bleeding. Treatment options for genital warts include topical podophyllum or cryotherapy, depending on the location and type of lesion. Topical agents are generally used for multiple, non-keratinised warts, while solitary, keratinised warts respond better to cryotherapy. Imiquimod, a topical cream, is often used as a second-line treatment. It is important to note that genital warts can be resistant to treatment, and recurrence is common. However, most anogenital HPV infections clear up on their own within 1-2 years without intervention.

    • This question is part of the following fields:

      • Reproductive Medicine
      12.4
      Seconds
  • Question 28 - A 67-year-old man presents to the memory clinic with a history of cognitive...

    Incorrect

    • A 67-year-old man presents to the memory clinic with a history of cognitive decline over the past 10 months. His wife reports that he is struggling with basic tasks and becoming increasingly forgetful and confused. She has also noticed a change in his personality, including more frequent swearing and inappropriate behavior such as answering the door naked. Interestingly, his mother had a similar reputation in her later years. The patient reports smoking 20 cigarettes per day and drinking one glass of wine each evening. What is the most probable diagnosis?

      Your Answer: Vascular dementia

      Correct Answer: Frontotemporal dementia

      Explanation:

      The patient is likely suffering from frontotemporal dementia, which is also known as Pick’s disease. This type of dementia is characterized by a change in personality and social disinhibition, and it often has a positive family history. In contrast, Alzheimer’s disease typically presents with a decline in episodic memory and visuospatial awareness, while Lewy body dementia is characterized by fluctuating confusion and hallucinations. Creutzfeldt-Jakob disease is a rare condition that causes rapid neurodegeneration and may present with cognitive decline and personality changes, as well as additional symptoms such as abnormal movements and loss of coordination.

      Understanding Frontotemporal Lobar Degeneration

      Frontotemporal lobar degeneration (FTLD) is a type of cortical dementia that is the third most common after Alzheimer’s and Lewy body dementia. There are three recognized types of FTLD: Frontotemporal dementia (Pick’s disease), Progressive non-fluent aphasia (chronic progressive aphasia, CPA), and Semantic dementia. Common features of frontotemporal lobar dementias include onset before 65, insidious onset, relatively preserved memory and visuospatial skills, personality change, and social conduct problems.

      Pick’s disease is the most common type of FTLD and is characterized by personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviors. Focal gyral atrophy with a knife-blade appearance is characteristic of Pick’s disease. Macroscopic changes seen in Pick’s disease include atrophy of the frontal and temporal lobes. Microscopic changes include Pick bodies, spherical aggregations of tau protein (silver-staining), gliosis, neurofibrillary tangles, and senile plaques.

      In contrast, CPA is characterized by non-fluent speech, with short utterances that are agrammatic. Comprehension is relatively preserved. Semantic dementia, on the other hand, is characterized by fluent progressive aphasia. The speech is fluent but empty and conveys little meaning. Unlike in Alzheimer’s, memory is better for recent rather than remote events.

      In terms of management, NICE does not recommend the use of AChE inhibitors or memantine in people with frontotemporal dementia. Understanding the different types of FTLD and their characteristics can aid in early diagnosis and appropriate management.

    • This question is part of the following fields:

      • Neurology
      49.7
      Seconds
  • Question 29 - A 35-year-old woman comes to the clinic worried about a lump in her...

    Correct

    • A 35-year-old woman comes to the clinic worried about a lump in her right breast that she discovered a few days ago. Upon examination, the lump is painless, smooth, soft, and easily movable. There is no history of breast cancer in her family. What is the most probable diagnosis?

      Your Answer: Fibroadenoma

      Explanation:

      Breast masses are a common concern among women, and it is important to understand the possible causes to determine the appropriate course of action. Here are some of the most common causes of breast masses and their characteristics:

      Fibroadenoma: This is the most common cause of breast mass in women under 35 years old. It appears as a singular, firm, rubbery, smooth, mobile, painless mass ranging in size from 1 cm to 5 cm. Ultrasonography reveals a well-defined, hypoechoic, homogeneous mass 1–20 cm in diameter.

      Fat Necrosis: This is a benign inflammatory process that occurs when there is saponification of local fat. It can result from direct trauma or nodular panniculitis. The breast mass is usually firm, round, and painless, and there may be a single mass or multiple masses. It may be tender or painful in some people.

      Breast Abscess: This usually presents with localised breast oedema, erythema, warmth, and pain. There may be associated symptoms of fever, nausea, vomiting, spontaneous drainage from the mass or nipple, and a history of previous breast infection.

      Breast Cancer: Early breast cancer may be asymptomatic, and pain and discomfort are typically not present. It is often first detected as an abnormality on a mammogram before it is felt by the patient or healthcare professional. If a lump is discovered, there may be a change in breast size or shape, skin dimpling or skin changes, recent nipple inversion or skin change, or nipple abnormalities.

      Lipoma: Lipomas are common benign tumors composed of mature adipocytes that typically present clinically as well-circumscribed, soft, mobile, nontender masses. The classic mammographic appearance of lipoma is a circumscribed fat-containing mass.

      It is important to note that the physical examination findings may not always be enough to determine the cause of the breast mass, and further testing may be necessary. Consultation with a healthcare professional is recommended for proper diagnosis and treatment.

    • This question is part of the following fields:

      • Reproductive Medicine
      12.1
      Seconds
  • Question 30 - A 25-year-old man has recurrent, persistent, intrusive, distressing thoughts and images of his...

    Incorrect

    • A 25-year-old man has recurrent, persistent, intrusive, distressing thoughts and images of his friends getting hurt. He reports that these thoughts seem to originate from his own mind, but he considers them to be irrational.
      Which symptom is he reporting?

      Your Answer: Thought interference

      Correct Answer: Obsessions

      Explanation:

      Understanding Psychiatric Symptoms: Obsessions, Compulsions, Delusions, Hallucinations, and Thought Interference

      Psychiatric symptoms can be complex and difficult to understand. Here are some explanations of common symptoms:

      Obsessions are intrusive thoughts, images, or impulses that repetitively and stereotypically enter a person’s mind. They are often distressing and patients try unsuccessfully to resist them. Common themes include aggression, dirt and contamination, fear of causing harm, religion, and sex.

      Compulsions are repetitive and stereotyped acts or rituals that are often carried out as an attempt to neutralize distressing obsessional thoughts. Patients typically recognize these behaviors as pointless and ineffective, and try to resist them, often unsuccessfully.

      Delusions are false, fixed, and firmly held beliefs that are not in keeping with a person’s social, cultural, and religious background. Patients typically do not recognize them as false or irrational and do not try to resist them, even if they find them distressing.

      Hallucinations are sensory experiences that occur without an external stimulus that could produce such perception. They can be perceptions in any sensory modality, such as hearing a voice in the absence of anyone actually talking.

      Thought interference consists of a patient’s firm belief that an external entity is interfering with their thoughts, usually by introducing thoughts in their mind, stealing thoughts from them, or being able to access their thoughts. Patients usually lack insight into these pathological experiences.

      Understanding these symptoms can help individuals and their loved ones seek appropriate treatment and support.

    • This question is part of the following fields:

      • Psychiatry
      24.7
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  • Question 31 - A 75-year-old patient presents for a follow-up appointment after undergoing private health screening....

    Incorrect

    • A 75-year-old patient presents for a follow-up appointment after undergoing private health screening. The patient has been advised to seek medical attention regarding her thyroid function tests (TFTs).
      TSH levels are at 9.2 mU/L and free thyroxine levels are at 14 pmol/L. Despite her age, the patient is currently in good health and shows no symptoms. What is the best course of action for managing her condition?

      Your Answer: Start levothyroxine

      Correct Answer: Repeat TFTs in a few months time

      Explanation:

      According to the guidelines recommended by NICE Clinical Knowledge Summaries, this patient with subclinical hypothyroidism should be monitored at present based on both TSH and age criteria.

      Understanding Subclinical Hypothyroidism

      Subclinical hypothyroidism is a condition where the thyroid-stimulating hormone (TSH) is elevated, but the levels of T3 and T4 are normal, and there are no obvious symptoms. However, there is a risk of the condition progressing to overt hypothyroidism, especially in men, with a 2-5% chance per year. This risk is further increased if thyroid autoantibodies are present.

      Not all patients with subclinical hypothyroidism require treatment, and guidelines have been produced by NICE Clinical Knowledge Summaries (CKS) to help determine when treatment is necessary. If the TSH level is above 10mU/L and the free thyroxine level is within the normal range, levothyroxine may be offered. If the TSH level is between 5.5 – 10mU/L and the free thyroxine level is within the normal range, a 6-month trial of levothyroxine may be considered if the patient is under 65 years old and experiencing symptoms of hypothyroidism. For older patients, a ‘watch and wait’ strategy is often used, and asymptomatic patients may simply have their thyroid function monitored every 6 months.

      In summary, subclinical hypothyroidism is a condition that requires careful monitoring and consideration of treatment options based on individual patient factors.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      50.3
      Seconds
  • Question 32 - A 63-year-old man presents with a complaint of neck and arm pain that...

    Incorrect

    • A 63-year-old man presents with a complaint of neck and arm pain that has been ongoing for four months. He describes the pain as similar to 'electric shocks' and notes that it worsens when he turns his head. There is no history of trauma or any other apparent cause. The patient is in good health and not taking any medications. During the examination, it is noted that he has reduced sensation on the back of his thumb and middle finger. What is the probable underlying diagnosis?

      Your Answer: C5 radiculopathy

      Correct Answer: C6 radiculopathy

      Explanation:

      Understanding Dermatomes: Major Landmarks and Mnemonics

      Dermatomes are areas of skin that are innervated by a single spinal nerve. Understanding dermatomes is important in diagnosing and treating various neurological conditions. The major dermatome landmarks are listed with helpful mnemonics to remember them.

      Starting from the top of the body, the C2 dermatome covers the posterior half of the skull, resembling a cap. Moving down to C3, it covers the area of a high turtleneck shirt. C4 covers the area of a low-collar shirt. The C5 dermatome runs along the ventral axial line of the upper limb, while C6 covers the thumb and index finger. To remember this, make a 6 with your left hand by touching the tip of the thumb and index finger together.

      Moving down to C7, it covers the middle finger and palm of the hand. C8 covers the ring and little finger. The T4 dermatome covers the area of the nipples, while T5 covers the inframammary fold. T6 covers the xiphoid process, and T10 covers the umbilicus. To remember this, think of BellybuT-TEN.

      The L1 dermatome covers the inguinal ligament, which can be remembered by thinking of L for ligament, 1 for 1nguinal. L4 covers the knee caps, and to remember this, think of being down on all fours. L5 covers the big toe and dorsum of the foot (except the lateral aspect), and can be remembered by thinking of it as the largest of the five toes. Finally, the S1 dermatome covers the lateral foot and small toe, while S2 and S3 cover the genitalia.

      Understanding dermatomes and their landmarks can aid in diagnosing and treating various neurological conditions. The mnemonics provided can help in remembering these important landmarks.

    • This question is part of the following fields:

      • Neurology
      34.7
      Seconds
  • Question 33 - Which of the following is not a characteristic of Tetralogy of Fallot? ...

    Correct

    • Which of the following is not a characteristic of Tetralogy of Fallot?

      Your Answer: Atrial septal defect

      Explanation:

      Understanding Tetralogy of Fallot

      Tetralogy of Fallot (TOF) is a congenital heart disease that results from the anterior malalignment of the aorticopulmonary septum. It is the most common cause of cyanotic congenital heart disease, and it typically presents at around 1-2 months, although it may not be detected until the baby is 6 months old. The condition is characterized by four features, including ventricular septal defect (VSD), right ventricular hypertrophy, right ventricular outflow tract obstruction, and overriding aorta. The severity of the right ventricular outflow tract obstruction determines the degree of cyanosis and clinical severity.

      Other features of TOF include cyanosis, which may cause episodic hypercyanotic ‘tet’ spells due to near occlusion of the right ventricular outflow tract. These spells are characterized by tachypnea and severe cyanosis that may occasionally result in loss of consciousness. They typically occur when an infant is upset, in pain, or has a fever, and they cause a right-to-left shunt. Additionally, TOF may cause an ejection systolic murmur due to pulmonary stenosis, and a right-sided aortic arch is seen in 25% of patients. Chest x-ray shows a ‘boot-shaped’ heart, while ECG shows right ventricular hypertrophy.

      The management of TOF often involves surgical repair, which is usually undertaken in two parts. Cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm. However, it is important to note that at birth, transposition of the great arteries is the more common lesion as patients with TOF generally present at around 1-2 months. Understanding the features and management of TOF is crucial for healthcare professionals to provide appropriate care and treatment for affected infants.

    • This question is part of the following fields:

      • Paediatrics
      9.1
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  • Question 34 - A 72-year-old male presents to the surgical assessment unit with lower abdominal pain...

    Correct

    • A 72-year-old male presents to the surgical assessment unit with lower abdominal pain and inability to pass urine for the past 12 hours. He has a palpable bladder and tenderness in the suprapubic region. On PR examination, his prostate is smooth and not enlarged. He has a medical history of high blood pressure, depression, neuropathic pain, and diabetes. What could be the probable cause of his presentation?

      Your Answer: Amitriptyline

      Explanation:

      Urinary retention can be caused by Amitriptyline due to its anticholinergic activity. The patient, who has a small prostate on PR examination, is currently experiencing urinary retention. None of the other medications are known to cause this condition.

      Drugs that can cause urinary retention

      Urinary retention is a condition where a person is unable to empty their bladder completely. This can be caused by various factors, including certain medications. Some drugs that may lead to urinary retention include tricyclic antidepressants like amitriptyline, anticholinergics such as antipsychotics and antihistamines, opioids, NSAIDs, and disopyramide. These drugs can affect the muscles that control the bladder, making it difficult to urinate.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      31.4
      Seconds
  • Question 35 - A 53-year-old male smoker presents to the emergency department with a sore throat...

    Correct

    • A 53-year-old male smoker presents to the emergency department with a sore throat that has been bothering him for a day. He reports feeling generally unwell and has a hoarse voice, but no cough. He has been unable to swallow for the past three hours and is spitting out saliva. During examination, he has a temperature of 38ºC and trismus. There are no obvious abnormalities in his oropharynx, and his tonsils appear normal. Additionally, he has bilateral cervical lymphadenopathy.

      What is the most appropriate course of action for managing this patient?

      Your Answer: Immediate ENT evaluation

      Explanation:

      If a patient presents with acute sore throat but no visible signs in the oropharynx, and experiences severe symptoms such as difficulty swallowing, sepsis, or trismus, it is crucial to seek urgent evaluation from an ENT specialist. This is because these symptoms may indicate a deeper airway infection, such as supraglottitis, which can be life-threatening. Therefore, the patient should not be discharged without a thorough examination, including flexible nasendoscopy. If supraglottitis is diagnosed, treatment should involve IV antibiotics, IV dexamethasone, and adrenaline nebulizers. The patient should be closely monitored in an airway monitored bed, such as in an ENT ward or ICU if necessary.

      Sore throat is a term used to describe various conditions such as pharyngitis, tonsillitis, and laryngitis. According to Clinical Knowledge Summaries, throat swabs and rapid antigen tests should not be routinely carried out for patients with a sore throat. Pain relief can be managed with paracetamol or ibuprofen, and antibiotics are not typically necessary. However, in cases where there is marked systemic upset, unilateral peritonsillitis, a history of rheumatic fever, an increased risk from acute infection, or when three or more Centor criteria are present, antibiotics may be indicated. The Centor and FeverPAIN scoring systems can be used to determine the likelihood of isolating Streptococci. If antibiotics are necessary, phenoxymethylpenicillin or clarithromycin (for penicillin-allergic patients) can be given for a 7 or 10 day course. It is worth noting that a single dose of oral corticosteroid may reduce the severity and duration of pain, although this has not yet been incorporated into UK guidelines.

    • This question is part of the following fields:

      • ENT
      34.7
      Seconds
  • Question 36 - A 28-year-old woman presents to her GP with a range of symptoms that...

    Correct

    • A 28-year-old woman presents to her GP with a range of symptoms that have been progressively worsening over the past 6 months. Despite no changes in her diet, she has gained over 3 stone of weight, with a concentration on her face and neck. She has also noticed stretch marks on her abdomen and excessive hair growth on her body and face. Upon referral to an endocrinologist, she is diagnosed with a pituitary adenoma causing an increased secretion of adrenocorticotropic hormone.
      What is the best description of this condition?

      Your Answer: Cushing's disease

      Explanation:

      The patient is experiencing Cushing’s disease, which is caused by excessive secretion of adrenocorticotropic hormone (ACTH) from the anterior pituitary gland, often due to a pituitary adenoma. Addison’s disease and acromegaly can be ruled out based on the patient’s symptoms. It is important to differentiate between Cushing’s triad, which includes irregular breathing, bradycardia, and systolic hypertension caused by increased intracranial pressure, and Cushing’s syndrome, a collection of symptoms resulting from prolonged exposure to cortisol. Cushing’s disease is a specific type of Cushing’s syndrome characterized by increased ACTH production due to a pituitary adenoma or excess production of hypothalamus CRH.

      Understanding the Causes of Cushing’s Syndrome

      Cushing’s syndrome is a condition that occurs when the body is exposed to high levels of cortisol for an extended period. While exogenous causes of Cushing’s syndrome, such as glucocorticoid therapy, are more common, endogenous causes can also occur. The causes of Cushing’s syndrome can be divided into two categories: ACTH dependent and ACTH independent.

      ACTH dependent causes of Cushing’s syndrome include Cushing’s disease, which is caused by a pituitary tumor secreting ACTH and producing adrenal hyperplasia. Ectopic ACTH production, which is caused by small cell lung cancer, is another ACTH dependent cause. On the other hand, ACTH independent causes of Cushing’s syndrome include iatrogenic causes such as steroid use, adrenal adenoma, adrenal carcinoma, Carney complex, and micronodular adrenal dysplasia.

      In addition to these causes, there is also a condition called Pseudo-Cushing’s, which mimics Cushing’s syndrome. This condition is often caused by alcohol excess or severe depression and can cause false positive dexamethasone suppression tests or 24-hour urinary free cortisol tests. To differentiate between Cushing’s syndrome and Pseudo-Cushing’s, an insulin stress test may be used. Understanding the causes of Cushing’s syndrome is crucial in diagnosing and treating this condition.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      25.9
      Seconds
  • Question 37 - A 35-year-old woman with indigestion has been taking her friend's omeprazole for the...

    Correct

    • A 35-year-old woman with indigestion has been taking her friend's omeprazole for the past week, which has improved her symptoms. You want to check for the presence of Helicobacter pylori by using a stool antigen test (SAT) or a carbon-13-labelled urea breath test (UBT). What is the recommended waiting period after stopping a proton pump inhibitor (PPI) before conducting these tests?

      Your Answer: 2-week washout period for either UBT or SAT

      Explanation:

      H. pylori Testing and Treatment Guidelines

      To ensure accurate diagnosis and appropriate treatment for H. pylori infection, it is recommended that adults with dyspepsia or reflux symptoms undergo a 2-week washout period before testing for H. pylori if they are receiving PPI therapy. This applies to both the carbon-13-labelled urea breath test (UBT) and stool antigen test (SAT). Testing should not be performed within two weeks of PPI use, as this can lead to false negatives.

      Patients with dyspepsia should be offered H. pylori ‘test and treat’ using a UBT, SAT, or laboratory-based serology. Office-based serological tests should not be used due to their inadequate performance. Retesting for eradication should be performed using a UBT, as there is insufficient evidence to recommend the SAT for this purpose.

      First-line treatment for H. pylori eradication involves a 7-day, twice-daily course of a PPI, amoxicillin, and either clarithromycin or metronidazole. Multiple regimens are available, and local protocols should be consulted.

      Guidelines for Accurate H. pylori Testing and Treatment

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      23
      Seconds
  • Question 38 - A 23-year-old female patient visits the ophthalmologist complaining of painful red eyes. Upon...

    Incorrect

    • A 23-year-old female patient visits the ophthalmologist complaining of painful red eyes. Upon examination, the ophthalmologist diagnoses her with bilateral anterior uveitis. During the medical history, the patient reveals that she has been experiencing a persistent dry cough and has visited her GP several times. The ophthalmologist orders blood tests and a chest x-ray, which reveal elevated angiotensin-converting enzyme levels and bilateral hilar lymphadenopathy. What is the underlying cause of uveitis in this patient?

      Your Answer: Rheumatoid arthritis

      Correct Answer: Sarcoidosis

      Explanation:

      Sarcoidosis may present as bilateral anterior uveitis in young adults, making it an important early consideration. Recurrent uveitis in both eyes, along with a history of pulmonary issues, should prompt investigation for sarcoidosis. The other options, which do not involve a dry cough, are not relevant. Rheumatoid arthritis affects small joints in the hands, feet, and wrists, while ankylosing spondylitis primarily affects the spine with symptoms of back pain and stiffness, neither of which are mentioned in this scenario.

      Anterior uveitis, also known as iritis, is a type of inflammation that affects the iris and ciliary body in the front part of the uvea. It is a common cause of red eye and is associated with HLA-B27, which may also be linked to other conditions. Symptoms of anterior uveitis include sudden onset of eye discomfort and pain, small or irregular pupils, intense sensitivity to light, blurred vision, redness, tearing, and the presence of pus and inflammatory cells in the front part of the eye. This condition may be associated with ankylosing spondylitis, reactive arthritis, ulcerative colitis, Crohn’s disease, Behcet’s disease, and sarcoidosis. Urgent review by an ophthalmologist is necessary, and treatment may involve the use of cycloplegics and steroid eye drops.

    • This question is part of the following fields:

      • Ophthalmology
      75.5
      Seconds
  • Question 39 - A 7-year-old girl is seen in clinic after falling off her scooter two...

    Correct

    • A 7-year-old girl is seen in clinic after falling off her scooter two hours ago. She fell forward and used her right arm to break her fall. Upon examination, she has minor scrapes on her right forearm but no indication of a fracture. Her nose is red and has some scrapes. Upon examination of her nostrils, there is a bilateral red swelling in the middle that is slightly soft. There are no other indications of a head injury. What is the best course of action?

      Your Answer: Arrange an urgent ENT review

      Explanation:

      Nasal Septal Haematoma: A Complication of Nasal Trauma

      Nasal septal haematoma is a serious complication that can occur after even minor nasal trauma. It is characterized by the accumulation of blood between the septal cartilage and the surrounding perichondrium. The most common symptom is nasal obstruction, but pain and rhinorrhoea may also be present. On examination, a bilateral, red swelling arising from the nasal septum is typically seen. It is important to differentiate this from a deviated septum, which will be firm to the touch.

      If left untreated, nasal septal haematoma can lead to irreversible septal necrosis within just a few days. This occurs due to pressure-related ischaemia of the cartilage, which can result in necrosis and a saddle-nose deformity. To prevent this, surgical drainage and intravenous antibiotics are necessary. It is important to be vigilant for this complication after any nasal trauma, no matter how minor.

    • This question is part of the following fields:

      • ENT
      32.6
      Seconds
  • Question 40 - A 55-year-old man presents to the General Practice with a 4-week history of...

    Incorrect

    • A 55-year-old man presents to the General Practice with a 4-week history of pain in his left hand and forearm. The pain is concentrated around the thumb and index finger and is worse at night. There is no history of trauma. Shaking his hand seems to provide some relief. The likely diagnosis conclusion is carpal tunnel syndrome (CTS).
      Which of the following would suggest an alternative diagnosis?

      Your Answer: Weakness of thumb abduction

      Correct Answer: Wasting of the hypothenar eminence

      Explanation:

      Understanding Carpal Tunnel Syndrome: Symptoms and Examination Findings

      Carpal tunnel syndrome (CTS) is a condition caused by compression of the median nerve in the carpal tunnel. One of the symptoms of CTS is the wasting of the thenar eminence, which is innervated by the median nerve. It is important to note that the hypothenar eminence, which is innervated by the ulnar nerve, is not affected by CTS.

      During examination, weakness of thumb abduction (abductor pollicis brevis) is a common finding in CTS. Tapping along the problematic nerve causes paraesthesia, which is known as Tinel’s sign. Flexion of the wrist also causes symptoms, which is known as Phalen’s sign.

      Treatment for CTS may include a corticosteroid injection, wrist splints at night, and surgical decompression through flexor retinaculum division.

      Overall, understanding the symptoms and examination findings of CTS can help with early diagnosis and appropriate treatment.

    • This question is part of the following fields:

      • Neurology
      65.2
      Seconds
  • Question 41 - A 63-year-old woman with a history of scleroderma presents with recurrent bouts of...

    Correct

    • A 63-year-old woman with a history of scleroderma presents with recurrent bouts of diarrhoea for the past few months. Her stools are pale, bulky, and offensive during these episodes. She consumes 12 units of alcohol per week. Laboratory tests reveal the following results:
      - Hemoglobin: 10.8 g/dL
      - Platelets: 231 * 10^9/L
      - White blood cells: 5.4 * 10^9/L
      - Ferritin: 14 ng/mL
      - Vitamin B12: 170 ng/L
      - Folate: 2.2 nmol/L
      - Sodium: 142 mmol/L
      - Potassium: 3.4 mmol/L
      - Urea: 4.5 mmol/L
      - Creatinine: 77 µmol/L
      - Bilirubin: 21 µmol/L
      - Alkaline phosphatase: 88 U/L
      - Alanine transaminase: 21 U/L
      - Gamma-glutamyl transferase: 55 U/L
      - Albumin: 36 g/L

      What is the most likely complication that has occurred in this patient?

      Your Answer: Malabsorption syndrome

      Explanation:

      Scleroderma (systemic sclerosis) frequently leads to malabsorption syndrome, which is characterized by reduced absorption of certain vitamins (B12, folate), nutrients (iron), and protein (low albumin) as indicated by blood tests.

      Understanding Malabsorption: Causes and Symptoms

      Malabsorption is a condition that is characterized by diarrhea, steatorrhea, and weight loss. It occurs when the body is unable to absorb nutrients from the food that is consumed. The causes of malabsorption can be broadly divided into three categories: intestinal, pancreatic, and biliary. Intestinal causes include conditions such as coeliac disease, Crohn’s disease, tropical sprue, Whipple’s disease, Giardiasis, and brush border enzyme deficiencies. Pancreatic causes include chronic pancreatitis, cystic fibrosis, and pancreatic cancer. Biliary causes include biliary obstruction and primary biliary cirrhosis. Other causes of malabsorption include bacterial overgrowth, short bowel syndrome, and lymphoma.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      46.3
      Seconds
  • Question 42 - A 45-year-old man presents to the Emergency Department with a rash and feeling...

    Correct

    • A 45-year-old man presents to the Emergency Department with a rash and feeling generally unwell. He has a history of epilepsy and recently started taking phenytoin three weeks ago. He developed mouth ulcers, malaise, and a cough about a week ago. Two days ago, he developed a widespread red rash that has now formed large fluid-filled blisters, covering approximately 30% of his body area. The lesions separate when slight pressure is applied. Upon examination, his temperature is 38.3ºC and pulse is 126/min. Blood results reveal:
      Na+ 144 mmol/l
      K+ 4.2 mmol/l
      Bicarbonate 19 mmol/l
      Urea 13.4 mmol/l
      Creatinine 121 µmol/l
      What is the most likely diagnosis?

      Your Answer: Toxic epidermal necrolysis

      Explanation:

      Understanding Toxic Epidermal Necrolysis

      Toxic epidermal necrolysis (TEN) is a severe skin disorder that can be life-threatening and is often caused by a reaction to certain drugs. It is characterized by extensive scalding of the skin, and is considered by some experts to be the most severe form of a range of skin disorders that includes erythema multiforme and Stevens-Johnson syndrome. Symptoms of TEN include fever, rapid heartbeat, and a positive Nikolsky’s sign, which means that the epidermis separates easily with slight lateral pressure.

      The most effective way to manage TEN is to stop the use of the drug that caused the reaction. Supportive care is also necessary, and patients are often treated in an intensive care unit to monitor for potential complications such as electrolyte imbalances and fluid loss. Intravenous immunoglobulin is a commonly used first-line treatment for TEN, and has been shown to be effective. Other treatment options include immunosuppressive agents like ciclosporin and cyclophosphamide, as well as plasmapheresis.

    • This question is part of the following fields:

      • Dermatology
      38.7
      Seconds
  • Question 43 - A 4-year-old boy is brought to his General Practitioner (GP) by his mother....

    Correct

    • A 4-year-old boy is brought to his General Practitioner (GP) by his mother. She is concerned that he has had consistently delayed motor milestones and that he has severe behavioural difficulties. To stand up from a sitting position, he first kneels on all fours and then uses his hands to ‘walk himself up’. The GP notices that the child has hypertrophy of his calf muscles.
      Which of the following tests is useful in the diagnosis of the underlying condition?
      Select the SINGLE most useful test from the list below.

      Your Answer: Creatine kinase

      Explanation:

      Diagnostic Tests for Duchenne Muscular Dystrophy and Wilson’s Disease

      Duchenne muscular dystrophy (DMD) and Wilson’s disease are two conditions that can present with non-specific symptoms. Here, we discuss the diagnostic tests used to identify these conditions.

      DMD is an X-linked recessive condition that predominantly affects males. Diagnosis is usually made by significantly elevated creatine kinase levels and genetic testing. Muscle biopsy may also be required. Symptoms usually present by age three and include delayed walking, muscle weakness, pseudohypertrophy of calf muscles, and learning difficulties. An MRI spine or head is not helpful in diagnosis as DMD is not caused by a central nervous system or spinal pathology.

      Wilson’s disease often presents with signs of liver failure and non-specific symptoms such as tiredness, weight loss, and abdominal pain. Neurological symptoms such as tremors, loss of motor skills, and behavioural problems are more common in teenagers and adults. Diagnosis is made by measuring serum caeruloplasmin levels and genetic testing.

      In summary, elevated creatine kinase levels and genetic testing are used to diagnose DMD, while serum caeruloplasmin levels and genetic testing are used to diagnose Wilson’s disease. MRI scans are not helpful in the diagnosis of either condition.

    • This question is part of the following fields:

      • Paediatrics
      36.8
      Seconds
  • Question 44 - A 50-year-old man who is on antipsychotic medication for schizophrenia complains of extreme...

    Correct

    • A 50-year-old man who is on antipsychotic medication for schizophrenia complains of extreme restlessness. Which side-effect of the medication could be causing this?

      Your Answer: Akathisia

      Explanation:

      Severe restlessness may be caused by antipsychotics, known as akathisia.

      Antipsychotics are a group of drugs used to treat schizophrenia, psychosis, mania, and agitation. They are divided into two categories: typical and atypical antipsychotics. The latter were developed to address the extrapyramidal side-effects associated with the first generation of typical antipsychotics. Typical antipsychotics work by blocking dopaminergic transmission in the mesolimbic pathways through dopamine D2 receptor antagonism. They are associated with extrapyramidal side-effects and hyperprolactinaemia, which are less common with atypical antipsychotics.

      Extrapyramidal side-effects (EPSEs) are common with typical antipsychotics and include Parkinsonism, acute dystonia, sustained muscle contraction, akathisia, and tardive dyskinesia. The latter is a late onset of choreoathetoid movements that may be irreversible and occur in 40% of patients. The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients, including an increased risk of stroke and venous thromboembolism. Other side-effects include antimuscarinic effects, sedation, weight gain, raised prolactin, impaired glucose tolerance, neuroleptic malignant syndrome, reduced seizure threshold, and prolonged QT interval.

    • This question is part of the following fields:

      • Psychiatry
      13.6
      Seconds
  • Question 45 - Can you analyze the post-bronchodilator spirometry findings of a 54-year-old female who has...

    Correct

    • Can you analyze the post-bronchodilator spirometry findings of a 54-year-old female who has been experiencing gradual breathlessness?

      FEV1/FVC ratio: 0.60

      FEV1 percentage predicted: 60%

      What would be the suitable conclusion based on these outcomes?

      Your Answer: COPD (stage 2 - moderate)

      Explanation:

      Investigating and Diagnosing COPD

      COPD is a condition that should be considered in patients over 35 years of age who are smokers or ex-smokers and have symptoms such as chronic cough, exertional breathlessness, or regular sputum production. To confirm a diagnosis of COPD, several investigations are recommended. These include post-bronchodilator spirometry to demonstrate airflow obstruction, a chest x-ray to exclude lung cancer and identify hyperinflation, bullae, or flat hemidiaphragm, a full blood count to exclude secondary polycythaemia, and a calculation of body mass index (BMI).

      The severity of COPD is categorized based on the post-bronchodilator FEV1/FVC ratio. If the ratio is less than 70%, the patient is diagnosed with COPD. The severity of the condition is then determined based on the FEV1 value. Stage 1 is considered mild, and symptoms should be present to diagnose COPD in these patients. Stage 2 is moderate, Stage 3 is severe, and Stage 4 is very severe.

      It is important to note that measuring peak expiratory flow is of limited value in COPD, as it may underestimate the degree of airflow obstruction. The grading system for COPD severity has changed following the 2010 NICE guidelines. If the FEV1 is greater than 80% predicted but the post-bronchodilator FEV1/FVC is less than 0.7, the patient is classified as Stage 1 – mild.

    • This question is part of the following fields:

      • Respiratory Medicine
      31.1
      Seconds
  • Question 46 - You assess a 79-year-old woman who is on digoxin for atrial fibrillation. What...

    Incorrect

    • You assess a 79-year-old woman who is on digoxin for atrial fibrillation. What factor is most likely to increase her risk of developing digoxin toxicity?

      Your Answer: Concurrent sodium valproate use

      Correct Answer: Hypokalaemia

      Explanation:

      Patients with hypokalaemia are more likely to experience digoxin toxicity.

      Understanding Digoxin and Its Toxicity

      Digoxin is a medication used for rate control in atrial fibrillation and for improving symptoms in heart failure patients. It works by decreasing conduction through the atrioventricular node and increasing the force of cardiac muscle contraction. However, it has a narrow therapeutic index and requires monitoring for toxicity.

      Toxicity may occur even when the digoxin concentration is within the therapeutic range. Symptoms of toxicity include lethargy, nausea, vomiting, anorexia, confusion, yellow-green vision, arrhythmias, and gynaecomastia. Hypokalaemia is a classic precipitating factor, as it allows digoxin to more easily bind to the ATPase pump and increase its inhibitory effects. Other factors that may contribute to toxicity include increasing age, renal failure, myocardial ischaemia, electrolyte imbalances, hypoalbuminaemia, hypothermia, hypothyroidism, and certain medications such as amiodarone, quinidine, and verapamil.

      Management of digoxin toxicity involves the use of Digibind, correction of arrhythmias, and monitoring of potassium levels. It is important to recognize the potential for toxicity and monitor patients accordingly to prevent adverse outcomes.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      15
      Seconds
  • Question 47 - A 45-year-old woman presents after an episode of confusion. She had just finished...

    Correct

    • A 45-year-old woman presents after an episode of confusion. She had just finished cooking dinner when she started to behave in a manner that worried her husband. When he questioned her about what was the matter, she appeared not to know where she was, what day it was or indeed who her husband was. She did, however, have knowledge of her own identity. Her husband mentioned that she also complained of feeling tired, so went to sleep and woke the next day feeling well and having returned to normal, but she was unable to recall exactly what had happened the previous day. She is a non-smoker. On examination there are no abnormalities.
      Which of the following is the most likely diagnosis?

      Your Answer: Transient global amnesia (TGA)

      Explanation:

      Transient Global Amnesia: A Temporary Disorder of Memory

      Transient global amnesia (TGA) is a temporary and isolated disorder of memory that typically affects patients aged over 50. It is characterized by a sudden onset of anterograde amnesia, which can last for several hours. The patient retains remote memories and immediate recall, but has no memory of the event after recovery. TGA can be triggered by various factors, such as sexual intercourse, heavy exercise, and exposure to hot or cold water.

      To diagnose TGA, all of the following criteria must be met: the attack was witnessed and reported, there was obvious anterograde amnesia during the attack, there was no clouding of consciousness, there were no focal neurological signs or deficits during or after the attack, there were no features of epilepsy, the attack resolved within 24 hours, and the patient did not have any recent head injury or active epilepsy.

      Although there is a correlation between TGA and migraine, it is not associated with cerebrovascular disease. The condition usually resolves spontaneously, and there is a small risk of recurrence.

      Other conditions that can cause memory loss or confusion include subarachnoid hemorrhage, right caudate hemorrhage, cerebral venous thrombosis, and right hemisphere TIA. However, these conditions have different clinical presentations and require different diagnostic criteria.

      In conclusion, TGA is a benign condition that can cause temporary memory loss and confusion. It is important to recognize the characteristic features of TGA and differentiate it from other conditions that can cause similar symptoms.

    • This question is part of the following fields:

      • Neurology
      31.7
      Seconds
  • Question 48 - A 42-year-old woman with a history of rheumatic heart disease is urgently admitted...

    Incorrect

    • A 42-year-old woman with a history of rheumatic heart disease is urgently admitted with a fever, worsening shortness of breath, and a note from her primary care physician confirming the presence of a new heart murmur. During the examination, a harsh pansystolic murmur and early diastolic murmur are detected, and she has a temperature of 38.5 °C with fine basal crepitations in both lungs. Which one of the following should take immediate priority?

      Your Answer: Echocardiogram (ECHO)

      Correct Answer: Administration of intravenous (IV) antibiotics

      Explanation:

      Prioritizing Interventions in Suspected Infective Endocarditis

      When a patient presents with suspected infective endocarditis, prompt intervention is crucial to limit valve destruction and prevent potentially life-threatening complications. The following interventions should be considered, prioritized, and administered as soon as possible:

      Administration of intravenous (IV) antibiotics: Empirical treatment with gentamicin and benzylpenicillin may be initiated until microbiological advice suggests an alternative. Antibiotic delivery should take priority over other interventions.

      Administration of paracetamol: Fever is a common symptom of infective endocarditis, and paracetamol can provide symptomatic relief. However, it should not take priority over antibiotic delivery.

      Echocardiogram (ECHO): An ECHO is an important diagnostic tool for identifying infective endocarditis and detecting complications such as cardiac abscess and pseudoaneurysms. While it should be performed in all suspected cases, it does not take priority over antibiotic administration.

      Electrocardiogram (ECG): An ECG can provide additional diagnostic information, including signs of paravalvular extension of infection and emboli in the coronary circulation. It should be part of the initial workup but does not take priority over antibiotic administration.

      Throat swab: While a throat swab may be useful in identifying the causative organism of infective endocarditis, it should not take precedence over commencing antibiotics. Careful examination of the patient’s dentition is also crucial to evaluate for a possible infectious source.

      In summary, when managing suspected infective endocarditis, prompt administration of IV antibiotics should take priority over other interventions. Other diagnostic and therapeutic interventions should be considered and prioritized based on the individual patient’s clinical presentation and needs.

    • This question is part of the following fields:

      • Cardiovascular
      67.9
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  • Question 49 - A 25-year-old woman arrives at the Emergency Department accompanied by a colleague from...

    Incorrect

    • A 25-year-old woman arrives at the Emergency Department accompanied by a colleague from work. She complains of experiencing a 'fluttering' sensation in her chest for the past 30 minutes. Although she admits to feeling 'a bit faint,' she denies any chest pain or difficulty breathing. Upon conducting an ECG, the results show a regular tachycardia of 166 bpm with a QRS duration of 110 ms. Her blood pressure is 102/68 mmHg, and her oxygen saturation levels are at 99% on room air. What is the most appropriate course of action?

      Your Answer: Direct current cardioversion

      Correct Answer: Carotid sinus massage

      Explanation:

      Vagal manoeuvres, such as carotid sinus massage or the Valsalva manoeuvre, are the initial treatment for supraventricular tachycardia. Adenosine should only be administered if these manoeuvres are ineffective. According to the ALS guidelines, direct current cardioversion is not recommended for this condition.

      Understanding Supraventricular Tachycardia

      Supraventricular tachycardia (SVT) is a type of tachycardia that originates above the ventricles. It is commonly associated with paroxysmal SVT, which is characterized by sudden onset of a narrow complex tachycardia, usually an atrioventricular nodal re-entry tachycardia (AVNRT). Other causes include atrioventricular re-entry tachycardias (AVRT) and junctional tachycardias.

      When it comes to acute management, vagal maneuvers such as the Valsalva maneuver or carotid sinus massage can be used. Intravenous adenosine is also an option, with a rapid IV bolus of 6mg given initially, followed by 12mg and then 18mg if necessary. However, adenosine is contraindicated in asthmatics, and verapamil may be a better option for them. Electrical cardioversion is another option.

      To prevent episodes of SVT, beta-blockers can be used. Radio-frequency ablation is also an option. It is important to work with a healthcare provider to determine the best course of treatment for each individual case.

      Overall, understanding SVT and its management options can help individuals with this condition better manage their symptoms and improve their quality of life.

    • This question is part of the following fields:

      • Cardiovascular
      25.4
      Seconds
  • Question 50 - A 45-year-old patient is found to have a missing ankle reflex. To which...

    Correct

    • A 45-year-old patient is found to have a missing ankle reflex. To which nerve root does this correspond?

      Your Answer: S1-S2

      Explanation:

      Understanding Common Reflexes

      Reflexes are automatic responses of the body to certain stimuli. These responses are controlled by the nervous system and do not require conscious thought. Common reflexes include the ankle reflex, knee reflex, biceps reflex, and triceps reflex. Each reflex is associated with a specific root in the spinal cord.

      The ankle reflex is associated with the S1-S2 root, which is located in the lower part of the spinal cord. This reflex is elicited by tapping the Achilles tendon with a reflex hammer. The resulting contraction of the calf muscle indicates the integrity of the spinal cord and the peripheral nerves.

      The knee reflex is associated with the L3-L4 root, which is located in the middle part of the spinal cord. This reflex is elicited by tapping the patellar tendon with a reflex hammer. The resulting contraction of the quadriceps muscle indicates the integrity of the spinal cord and the peripheral nerves.

      The biceps reflex is associated with the C5-C6 root, which is located in the upper part of the spinal cord. This reflex is elicited by tapping the biceps tendon with a reflex hammer. The resulting contraction of the biceps muscle indicates the integrity of the spinal cord and the peripheral nerves.

      The triceps reflex is associated with the C7-C8 root, which is located in the upper part of the spinal cord. This reflex is elicited by tapping the triceps tendon with a reflex hammer. The resulting contraction of the triceps muscle indicates the integrity of the spinal cord and the peripheral nerves.

      Understanding these common reflexes can help healthcare professionals diagnose and treat various neurological conditions. By testing these reflexes, they can determine if there is any damage or dysfunction in the nervous system.

    • This question is part of the following fields:

      • Neurology
      18.7
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Reproductive Medicine (5/6) 83%
Endocrinology/Metabolic Disease (2/4) 50%
Infectious Diseases (1/2) 50%
Renal Medicine/Urology (2/3) 67%
Haematology/Oncology (0/2) 0%
Musculoskeletal (1/2) 50%
Dermatology (3/3) 100%
Ophthalmology (1/3) 33%
Psychiatry (1/3) 33%
Pharmacology/Therapeutics (2/3) 67%
Respiratory Medicine (3/3) 100%
Paediatrics (3/3) 100%
Cardiovascular (1/3) 33%
Gastroenterology/Nutrition (2/3) 67%
Neurology (2/5) 40%
ENT (2/2) 100%
Passmed