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Question 1
Incorrect
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A 32-year-old man presents to the Ophthalmology Clinic with a painful red right eye and reduced visual acuity. He complains of watery eyes and photophobia. Upon examination, inflammatory cells are found in the anterior chamber. The patient is typically healthy, but has been receiving treatment from the Physiotherapy Team for back pain. What investigation would be most useful in identifying the underlying cause of his symptoms?
Your Answer: Intraocular pressure
Correct Answer: MRI pelvis
Explanation:Diagnosis and Workup of Anterior Uveitis with Back Pain
Anterior uveitis is a condition characterized by an acutely red painful eye with blurred vision, eye watering, and photophobia. In young men, it is strongly associated with ankylosing spondylitis, which presents with lower back pain. Definitive diagnosis requires evidence of sacroiliitis, which can take years to show up on plain X-rays. However, changes can be seen earlier on MRI of the sacroiliac joints. Patients may also have raised ESR, normochromic anemia, and mildly raised alkaline phosphatase. HLA-B27 may also be raised.
An ESR test may be useful as part of the workup, but it would not help determine the specific underlying cause of the symptoms. Increased intraocular pressure is seen in patients with glaucoma, which may present with an acutely painful red eye, but it would not explain the presence of inflammatory cells or back pain. An MRI brain may be used in the workup of optic neuritis, which is commonly associated with multiple sclerosis. However, multiple sclerosis does not explain the back pain. Positive rheumatoid factor would indicate an underlying diagnosis of rheumatoid arthritis, which can be associated with scleritis but not uveitis. Back pain is also less likely in rheumatoid arthritis, as it typically affects the smaller joints first and would be less common in someone of this age.
Therefore, an MRI of the pelvis is the most appropriate diagnostic test for this patient with anterior uveitis and back pain.
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This question is part of the following fields:
- Ophthalmology
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Question 2
Correct
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A 65-year-old African-American has marked left-sided weakness and an expressive aphasia. He is diagnosed with a stroke. Blood results show the following:
Investigation Result Normal value
Haemoglobin (Hb) 90 g/l 135–175 g/l
Platelets 80 × 109/l 150–400 × 109/l
calcium 3.80 mmol/l 2.20–2.60 mmol/l
creatinine 128 µmol/l 50–120 µmol/l
Which investigation is likely to reveal the cause of this man’s stroke?Your Answer: Urinary Bence Jones proteins
Explanation:Investigations for a Patient with Stroke and Suspected Multiple Myeloma
When a patient presents with symptoms of stroke and possible multiple myeloma, several investigations may be necessary to confirm the diagnosis and determine the cause of the stroke. The mnemonic CRAB (high Calcium, Renal insufficiency, Anaemia and Bone lesions) can help identify the key symptoms of multiple myeloma.
One potential test is a urinary Bence Jones protein test, which can confirm the presence of multiple myeloma. However, this test alone cannot determine the cause of the stroke.
An MRI of the head may show areas of damage, but it will not reveal the cause of the stroke. A CT scan of the head, on the other hand, can identify changes caused by an ischaemic stroke, but it cannot differentiate the cause of the clot.
Liver function tests and X-rays of the spine are not first-line investigations for this condition, but they may be useful in identifying bone lesions associated with multiple myeloma.
Overall, a combination of tests and imaging may be necessary to diagnose and treat a patient with stroke and suspected multiple myeloma.
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This question is part of the following fields:
- Haematology
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Question 3
Correct
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A 20-year-old man presented to the psychiatry outpatients department with a sense of unsettling alteration in his personality. He expressed feeling peculiar, as if he is not his usual self. Despite being anxious and tense, he was unable to identify the exact nature of this change. What term best characterizes this sensation?
Your Answer: Depersonalisation
Explanation:Depersonalisation
Depersonalisation is a distressing experience where an individual feels disconnected from their own body and reality. It is often described as feeling like living in a dream or being in immediate danger of disappearing. Despite cognitive functioning remaining intact, the sufferer may interpret the experience as a sign of losing their mind. This can lead to the development of an autochthonous delusion, which arises spontaneously.
The delusional mood is a sense of unease that can be resolved when a delusional belief forms. Over valued ideas are also present in depersonalisation, but they are not held with the same level of fixity as delusional beliefs. Overall, depersonalisation can be a frightening and disturbing experience that can leave individuals feeling disconnected from themselves and their surroundings.
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This question is part of the following fields:
- Psychiatry
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Question 4
Incorrect
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A 65-year-old patient, with advanced liver cirrhosis and a diagnosis of hepatocellular carcinoma, is experiencing intense back pain. Considering his liver dysfunction, which medication would be the most appropriate for pain relief?
Your Answer: Tramadol
Correct Answer: Fentanyl
Explanation:Safe and Unsafe Pain Medications for Patients with Chronic Liver Disease
Patients with chronic liver disease or cirrhosis require special consideration when it comes to pain management. Some pain medications can cause histamine release, haemodynamic disturbance, altered bioavailability, and accumulation of toxic metabolites and intermediates. Here are some examples:
Safe Choices:
– Fentanyl: causes less histamine release and haemodynamic disturbance than other opiates.
– Acetaminophen: does not cause liver damage when used in recommended doses.Unsafe Choices:
– Codeine: should be avoided due to the risk of altered bioavailability and elevated risk of accumulation of toxic metabolites and intermediates.
– Pethidine: there is an increased risk of accumulation when opioids are used in patients with liver impairment.
– Tramadol: has the same risks associated with pethidine and codeine in liver impairment.It is also important to note that non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin should be avoided in patients with chronic liver disease and cirrhosis. Always consult with a healthcare provider before taking any pain medication.
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This question is part of the following fields:
- Pharmacology
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Question 5
Correct
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A 20-year-old woman was diagnosed with an early miscarriage 3 weeks ago through transvaginal ultrasound. She has no significant medical history and was G1P0. Expectant management was chosen as the course of action. However, she now presents with light vaginal bleeding that has persisted for 10 days. A recent urinary pregnancy test still shows positive results. She denies experiencing cramps, purulent vaginal discharges, fever, or muscle aches. What is the next appropriate step in managing her condition?
Your Answer: Prescribe vaginal misoprostol alone
Explanation:The appropriate medical management for a miscarriage involves administering vaginal misoprostol alone. This is a prostaglandin analogue that stimulates uterine contractions, expediting the passing of the products of conception. Oral methotrexate and oral mifepristone alone are not suitable for managing a miscarriage, as they are used for ectopic pregnancies and terminations of pregnancy, respectively. The combination of oral misoprostol and oral mifepristone, as well as vaginal misoprostol and oral mifepristone, are also not recommended due to limited evidence of their efficacy. The current recommended approach is to use vaginal misoprostol alone, as it limits side effects and has a strong evidence base.
Management Options for Miscarriage
Miscarriage can be a difficult and emotional experience for women. In the 2019 NICE guidelines, three types of management for miscarriage were discussed: expectant, medical, and surgical. Expectant management involves waiting for a spontaneous miscarriage and is considered the first-line option. However, if it is unsuccessful, medical or surgical management may be offered.
Medical management involves using tablets to expedite the miscarriage. Vaginal misoprostol, a prostaglandin analogue, is used to cause strong myometrial contractions leading to the expulsion of tissue. It is important to advise patients to contact their doctor if bleeding does not start within 24 hours. Antiemetics and pain relief should also be given.
Surgical management involves undergoing a surgical procedure under local or general anaesthetic. The two main options are vacuum aspiration (suction curettage) or surgical management in theatre. Vacuum aspiration is done under local anaesthetic as an outpatient, while surgical management is done in theatre under general anaesthetic. This was previously referred to as ‘Evacuation of retained products of conception’.
It is important to note that some situations are better managed with medical or surgical management, such as an increased risk of haemorrhage, being in the late first trimester, having coagulopathies or being unable to have a blood transfusion, previous adverse and/or traumatic experience associated with pregnancy, evidence of infection, and more. Ultimately, the management option chosen should be based on the individual patient’s needs and preferences.
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This question is part of the following fields:
- Gynaecology
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Question 6
Correct
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A 43-year-old man arrives at the emergency department after experiencing a convulsive episode while heavily drinking at a friend's party. Despite having no history of seizures, he has a medical background of depression and is currently taking sertraline. Urine toxicology reveals a significant amount of cocaine and small traces of cannabis. What is the probable reason for his seizure?
Your Answer: Cocaine toxicity
Explanation:Seizures are a known symptom of cocaine toxicity, making it the most probable cause in this case. While cannabis was detected in the patient’s system, the low level makes it an unlikely culprit compared to cocaine. Alcohol withdrawal can also lead to seizures, but this is more common in chronic alcoholics and unlikely in this patient who has just stopped drinking. While it is possible that this is the patient’s first epileptic seizure, it is more likely that cocaine is the cause. Additionally, there is no indication of hyponatremia in the patient’s history.
Understanding Cocaine Toxicity
Cocaine is a popular recreational stimulant derived from the coca plant. However, its widespread use has resulted in an increase in cocaine toxicity cases. The drug works by blocking the uptake of dopamine, noradrenaline, and serotonin, leading to a variety of adverse effects.
Cardiovascular effects of cocaine include coronary artery spasm, tachycardia, bradycardia, hypertension, QRS widening, QT prolongation, and aortic dissection. Neurological effects may include seizures, mydriasis, hypertonia, and hyperreflexia. Psychiatric effects such as agitation, psychosis, and hallucinations may also occur. Other complications include ischaemic colitis, hyperthermia, metabolic acidosis, and rhabdomyolysis.
Managing cocaine toxicity involves using benzodiazepines as a first-line treatment for most cocaine-related problems. For chest pain, benzodiazepines and glyceryl trinitrate may be used, and primary percutaneous coronary intervention may be necessary if myocardial infarction develops. Hypertension can be treated with benzodiazepines and sodium nitroprusside. The use of beta-blockers in cocaine-induced cardiovascular problems is controversial, with some experts warning against it due to the risk of unopposed alpha-mediated coronary vasospasm.
In summary, cocaine toxicity can lead to a range of adverse effects, and managing it requires careful consideration of the patient’s symptoms and medical history.
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This question is part of the following fields:
- Pharmacology
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Question 7
Incorrect
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A 32-year-old woman is brought to the edge of a roof by a trained practitioner and then left there for as long as possible until she overcomes her phobia of heights.
What sort of behavioural therapy is this?Your Answer: Exposure response therapy
Correct Answer: Flooding
Explanation:Behavioural Therapies: Techniques for Overcoming Fears and Habits
Behavioural therapies are a set of techniques used to treat various mental health conditions. These therapies aim to modify an individual’s behaviour by exposing them to their fears or habits and gradually desensitising them to the stimuli. Here are some common behavioural therapies:
1. Flooding: This therapy involves exposing an individual directly to their worst fear to trigger desensitisation.
2. Graded Exposure: Also known as systematic desensitisation, this therapy involves exposing the patient to the feared stimulus for progressively longer amounts of time or from a ‘virtual’ to a real exposure in an attempt to overcome the fear.
3. Relaxation Training: This therapy involves activities that allow the individual to calm or relax in the exposed situation.
4. Aversion Therapy: This therapy is used in the management of habits such as alcoholism and smoking. It involves exposing the individual to the behaviour while simultaneously evoking a noxious and/or painful stimulus to develop an aversion to the behaviour.
5. Exposure Response Therapy: This therapy is often used as an effective treatment for OCD. It involves gradually increasing exposure to uncomfortable stimuli to build a tolerance and reduce anxiety that feeds obsessions and compulsions.
Overall, behavioural therapies can be effective in treating various mental health conditions and helping individuals overcome their fears and habits.
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This question is part of the following fields:
- Psychiatry
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Question 8
Correct
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A 65-year-old known alcoholic is brought by ambulance after being found unconscious on the road on a Sunday afternoon. He has a superficial laceration in the right frontal region. He is admitted for observation over the weekend. The admission chest X-ray is normal. Before discharge on Tuesday morning, he is noted to be febrile and dyspnoeic. Blood tests reveal a neutrophilia and elevated C-reactive protein (CRP). A chest X-ray demonstrates consolidation in the lower zone of the right lung.
What is the most likely diagnosis?Your Answer: Aspiration pneumonia
Explanation:Aspiration pneumonia is a type of pneumonia that typically affects the lower lobes of the lungs, particularly the right middle or lower lobes or left lower lobe. It is often seen in individuals who have consumed alcohol and subsequently vomited, leading to the aspiration of the contents into the lower bronchi. If an alcoholic is found unconscious with a lower zone consolidation, aspiration pneumonia should be considered when prescribing antibiotics. Hospital-acquired pneumonia (HAP) is unlikely to occur within the first 48 hours of admission. Tuberculosis (TB) is a rare diagnosis in this case as it typically affects the upper lobes and the patient’s chest X-ray from two days earlier was normal. Staphylococcal pneumonia may be seen in alcoholics but is characterized by cavitating lesions and empyema. Pneumocystis jiroveci pneumonia is common in immunosuppressed individuals and presents with bilateral perihilar consolidations and possible lung cyst formation.
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This question is part of the following fields:
- Respiratory
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Question 9
Correct
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A 32-year-old woman presents to the Emergency Department with severe epigastric pain and vomiting. The pain radiates through to her back and began 2 hours ago while she was out with her friends in a restaurant. She has a past medical history of gallstones and asthma.
Which test should be used to confirm this woman’s diagnosis?Your Answer: Serum lipase
Explanation:Diagnostic Tests for Acute Pancreatitis
Acute pancreatitis is a condition that is commonly caused by gallstones and alcohol consumption. Its symptoms include upper abdominal pain, nausea, and vomiting. While serum amylase is widely used for diagnosis, serum lipase is preferred where available. Serum lactate is a useful marker for organ perfusion and can indicate the severity of the inflammatory response. A raised white cell count, particularly neutrophilia, is associated with a poorer prognosis. Serum calcium levels may also be affected, but this is not a specific test for pancreatitis. Blood glucose levels may be abnormal, with hyperglycemia being common, but this is not diagnostic of acute pancreatitis.
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This question is part of the following fields:
- Gastroenterology
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Question 10
Correct
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A 45-year-old patient visits her primary care physician with a complaint of net-like mottled skin on her hands, lower arms, feet, and calves that has persisted for 6 months. She reports no other symptoms. The physician orders routine blood tests, including FBC and coagulation screen, which reveal a haemoglobin level of 140 g/l, platelet count of 98 * 109/L, and white cell count of 8 * 109/L. The APTT is 45s, and the PT is 12s. An autoantibody screen is also performed, with the following significant results: positive for anti-cardiolipin antibodies and lupus anticoagulant, but negative for anti-dsDNA. What is the most appropriate treatment option for the likely diagnosis?
Your Answer: Daily low-dose aspirin
Explanation:Patients who have been diagnosed with antiphospholipid syndrome and have not had a history of thrombosis are typically prescribed low-dose aspirin. This condition is characterized by CLOTS, which stands for clots, livedo reticularis, obstetric complications, and thrombocytopenia. Diagnosis is confirmed through blood tests that show thrombocytopenia, a prolonged APTT, and positive antiphospholipid antibodies such as anti-cardiolipin, anti-beta-2-glycoprotein-1 antibodies, and lupus anticoagulant. Treatment for Raynaud’s phenomena, which causes painful and pale fingers and toes in cold temperatures, involves daily nifedipine. Lifelong LMWH is not recommended, but lifelong warfarin is recommended for patients with antiphospholipid syndrome who have experienced a previous thrombotic event. LMWH may be an option during pregnancy.
Antiphospholipid syndrome is a condition that can be acquired and is characterized by a higher risk of both venous and arterial thrombosis, recurrent fetal loss, and thrombocytopenia. It can occur as a primary disorder or as a secondary condition to other diseases, with systemic lupus erythematosus being the most common. One important point to remember for exams is that antiphospholipid syndrome can cause a paradoxical increase in the APTT. This is due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with phospholipids involved in the coagulation cascade. Other features of this condition include livedo reticularis, pre-eclampsia, and pulmonary hypertension.
Antiphospholipid syndrome can also be associated with other autoimmune disorders, lymphoproliferative disorders, and, rarely, phenothiazines. Management of this condition is based on EULAR guidelines. Primary thromboprophylaxis involves low-dose aspirin, while secondary thromboprophylaxis depends on the type of thromboembolic event. Initial venous thromboembolic events require lifelong warfarin with a target INR of 2-3, while recurrent venous thromboembolic events require lifelong warfarin and low-dose aspirin. Arterial thrombosis should be treated with lifelong warfarin with a target INR of 2-3.
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This question is part of the following fields:
- Musculoskeletal
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Question 11
Incorrect
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In a double blind, randomised, placebo controlled trial of a new medication looking at reduction in blood pressure, 200 patients were enrolled with 100 patients receiving the new medication and 100 patients receiving placebo.
In the treatment group, blood pressure decreased from a mean of 150/90 mmHg to 130/80 mmHg. In the control group, blood pressure decreased from a mean of 148/88 mmHg to 140/85 mmHg. The authors concluded that the new medication was effective in reducing blood pressure as p=0.02 (2-tailed test).
Which of the following statements is correct?Your Answer: The alternative hypothesis is that drug A is more effective than placebo
Correct Answer: The alternative hypothesis is that drug A is more effective or less effective than placebo
Explanation:The alternative hypothesis in a two-tailed statistical hypothesis testing is that there is a difference between the variables being tested. In the case of comparing a new diuretic to a placebo, the alternative hypothesis would be that there is a difference in their potassium reducing effect, meaning the new diuretic is either more or less effective than the placebo.
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This question is part of the following fields:
- Clinical Sciences
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Question 12
Correct
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A 70-year-old woman visited her GP complaining of discomfort and pain in her shoulder. The doctor conducted a thorough examination of her shoulder and observed that she was unable to abduct her shoulder while standing with her arm flat against her body. However, the doctor was able to passively abduct her shoulder during the first 20 degrees, and she was able to fully abduct it. Which muscle is likely to be affected?
Your Answer: Supraspinatus
Explanation:The shoulder joint is stabilized by a group of muscles known as the rotator cuffs. To remember them, you can use the following order: Subscapularis, which is located on the front of your chest and assists with internal rotation of the shoulder; Supraspinatus, which runs parallel to your deltoid on top of your shoulder and is necessary for the first 20° of shoulder abduction before the deltoid takes over; and Infraspinatus, which is located on the upper back and helps with external rotation of the shoulder.
Understanding the Rotator Cuff Muscles
The rotator cuff muscles are a group of four muscles that are responsible for the movement and stability of the shoulder joint. These muscles include the supraspinatus, infraspinatus, teres minor, and subscapularis. Each muscle has a specific function that contributes to the overall movement of the shoulder.
The supraspinatus muscle is responsible for abducting the arm before the deltoid muscle. It is also the most commonly injured muscle in the rotator cuff. The infraspinatus muscle rotates the arm laterally, while the teres minor muscle adducts and rotates the arm laterally. Lastly, the subscapularis muscle adducts and rotates the arm medially.
Understanding the functions of each rotator cuff muscle is important in preventing injuries and maintaining shoulder health. By strengthening these muscles through targeted exercises, individuals can improve their shoulder stability and reduce the risk of injury.
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This question is part of the following fields:
- Musculoskeletal
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Question 13
Incorrect
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As a Foundation Year 2 doctor on a four month rotation at an Emergency department, you encounter a 54-year-old female with a history of rheumatoid arthritis. She presents with a two month history of dry mouth and itchy eyes, as well as a three day history of painful eyes and sensitivity to bright light. Despite her well-controlled rheumatoid arthritis with methotrexate and sulfasalazine, she requires NSAIDs for symptomatic relief. Upon examination, you observe a dry oral cavity and a few corneal abrasions on her right eye, but the sclera is otherwise white. Her pupil is normal and visual acuity tests are unremarkable. A bedside Schirmer's test reveals 3 mm of diffusion on filter paper bilaterally. What is the most likely diagnosis?
Your Answer: Ulcerative keratitis
Correct Answer: Keratoconjunctivitis sicca
Explanation:Sjögren’s Syndrome and its Ocular Manifestations
Sjögren’s syndrome is an autoimmune disease that primarily affects the exocrine glands, leading to decreased production of tears and saliva. This results in dry eyes and dry mouth, which can cause corneal abrasions and even ulceration if left untreated. It is commonly associated with connective tissue diseases, particularly rheumatoid arthritis.
When it comes to ocular manifestations, it is important to differentiate Sjögren’s syndrome from other conditions such as scleritis, episcleritis, uveitis, and ulcerative keratitis. The phenylephrine test can help distinguish between episcleritis and scleritis, while uveitis typically presents with ocular pain, photophobia, and blurred vision. Ulcerative keratitis, on the other hand, has an infectious presentation and requires different treatment approaches depending on the depth of the ulcer.
Overall, the pathophysiology and ocular manifestations of Sjögren’s syndrome is crucial for proper diagnosis and management of this autoimmune disease.
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This question is part of the following fields:
- Medicine
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Question 14
Incorrect
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A 22-year-old man is struck on the left side of his face while playing rugby. He reports experiencing double vision when both eyes are open and finds it painful to open his mouth.
What is the likely explanation for his symptoms?Your Answer: Rupture of the globe
Correct Answer: Depressed fracture of the zygoma
Explanation:Facial trauma can result in fractures of the facial bones, which are often caused by assaults or accidents. The location of the impact can determine the type of injury, with a punch to the cheek bone or eye area commonly resulting in a fractured zygoma. If the globe is ruptured, there will be a significant loss of vision. Monocular visual blurring may indicate a hyphaema, which can be diagnosed through inspection. A ramus fracture can cause difficulty opening the mouth, but will not affect vision. A maxillary antrum rupture may occur as a result of a comminuted maxillary fracture or blowout fracture of the orbit. If a patient has binocular vision and facial trauma, it may suggest a depressed fracture of the zygoma. Inspection and palpation of the orbital margins can reveal a step deformity or depressed contour of the cheek.
Patients with head injuries should be managed according to ATLS principles and extracranial injuries should be managed alongside cranial trauma. There are different types of traumatic brain injuries, including extradural hematoma, subdural hematoma, and subarachnoid hemorrhage. Primary brain injury may be focal or diffuse, and secondary brain injury can occur due to cerebral edema, ischemia, infection, or herniation. Management may include IV mannitol/furosemide, decompressive craniotomy, and ICP monitoring. Pupillary findings can provide information on the location and severity of the injury.
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This question is part of the following fields:
- Surgery
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Question 15
Incorrect
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To evaluate the effectiveness of a home cholesterol testing kit, a group of 500 individuals under the age of 40 were recruited. Each participant provided a blood sample for analysis. The results showed that 480 individuals had normal cholesterol levels and 20 individuals had high cholesterol levels. What is the sensitivity of the test?
Your Answer: 20%
Correct Answer: 98%
Explanation:Specificity in Medical Testing
Specificity is a crucial concept in medical testing that refers to the accuracy of a test in identifying individuals who do not have a particular condition. In simpler terms, it measures the proportion of people who are correctly identified as not having the condition by the test. For instance, if a test has a specificity of 98%, it means that 98 out of 100 people who do not have the condition will be correctly identified as negative by the test.
To calculate specificity, we use the formula: Specificity = True Negative / (False Positive + True Negative). This means that we divide the number of true negatives (people who do not have the condition and are correctly identified as negative) by the sum of false positives (people who do not have the condition but are incorrectly identified as positive) and true negatives.
It is important to note that highly specific tests are useful for ruling conditions in, which means that if the test is positive, the person is very likely to have the disease. However, it is rare to find tests with 100% sensitivity and/or specificity, including pregnancy tests. Therefore, it is crucial to interpret test results in conjunction with other clinical information and to consult with a healthcare professional for proper diagnosis and treatment.
In summary, specificity is essential in medical testing as it helps to determine the accuracy of a test in identifying individuals who do not have a particular condition. By using the formula and interpreting test results in conjunction with other clinical information, healthcare professionals can make informed decisions about diagnosis and treatment.
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This question is part of the following fields:
- Clinical Sciences
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Question 16
Incorrect
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A 20-year-old female patient visited her doctor complaining of general malaise, lethargy, and fatigue. She couldn't pinpoint when the symptoms started but felt that they had been gradually developing for a few months. During the physical examination, the doctor detected a murmur and referred her to a cardiologist based on the findings. The cardiac catheterization results are as follows:
Anatomical site Oxygen saturation (%) Pressure (mmHg)
End systolic/End diastolic
Superior vena cava 77 -
Right atrium (mean) 79 7
Right ventricle 78 -
Pulmonary artery 87 52/17
Pulmonary capillary wedge pressure - 16
Left ventricle 96 120/11
Aorta 97 120/60
What is the most accurate description of the murmur heard during the chest auscultation of this 20-year-old woman?Your Answer: A low-pitched apical mid-diastolic murmur that is reduced in pitch during the Valsalva manoeuvre
Correct Answer: A continuous 'machinery' murmur at the left upper sternal edge with late systolic accentuation
Explanation:Characteristics of Patent Ductus Arteriosus
Patent ductus arteriosus is a condition that is characterized by an unusual increase in oxygen saturation between the right ventricle and pulmonary artery. This is often accompanied by elevated pulmonary artery pressures and a high wedge pressure. These data are typical of this condition and can be used to diagnose it. It is important to note that patent ductus arteriosus can lead to serious complications if left untreated, including heart failure and pulmonary hypertension. Therefore, early detection and treatment are crucial for improving outcomes and preventing long-term complications.
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This question is part of the following fields:
- Cardiology
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Question 17
Incorrect
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Which gland produces thyroid stimulating hormone (TSH) in the endocrine system?
Your Answer: Posterior pituitary
Correct Answer: Anterior pituitary
Explanation:The Thyroid Hormone Axis
The thyroid hormone axis is a complex system that involves the hypothalamus, pituitary gland, and thyroid gland. The hypothalamus produces a hormone called thyrotropin-releasing hormone (TRH), which stimulates the anterior pituitary gland to release thyroid-stimulating hormone (TSH). TSH then stimulates the thyroid gland to produce and release the thyroid hormones thyroxine (T4) and tri-iodothyronine (T3).
Both T4 and T3 are primarily bound to proteins in the bloodstream, but it is the free, unbound hormones that are biologically active. The secretion of TSH is inhibited by the presence of thyroid hormones in the bloodstream. This negative feedback loop helps to regulate the levels of thyroid hormones in the body.
In summary, the thyroid hormone axis is a tightly regulated system that involves multiple hormones and glands working together to maintain proper levels of thyroid hormones in the body.
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This question is part of the following fields:
- Endocrinology
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Question 18
Correct
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A 5-year-old boy visited his doctor last week due to recurring nosebleeds and bruises on his sides. Upon examination, his clotting was found to be prolonged. The following are his test results, along with the normal ranges for a 5-year-old:
- Hemoglobin: 80g/l (115-135)
- Platelets: 100 * 109/l (150-450)
- White blood cells: 10.0 * 109/l (5.0-17.0)
- Neutrophils: 1.0 * 109/l (1.5-8.5)
What is the most probable diagnosis?Your Answer: Acute lymphoblastic leukaemia
Explanation:Leukaemia is the most probable diagnosis given the presence of epistaxis and bruising, along with anaemia and low platelets. The prolonged prothrombin time and low platelets suggest disseminated intravascular coagulation, which is consistent with acute lymphoblastic leukaemia. Acute myeloid leukaemia is unlikely due to the patient’s age. The normal white blood cell count rules out a chronic infection. Aplastic anaemia and myelodysplasia would not account for the symptoms of epistaxis and bruising.
Acute lymphoblastic leukaemia (ALL) is a type of cancer that commonly affects children and accounts for 80% of childhood leukaemias. It is most prevalent in children between the ages of 2-5 years, with boys being slightly more affected than girls. Symptoms of ALL can be divided into those caused by bone marrow failure, such as anaemia, neutropaenia, and thrombocytopenia, and other features like bone pain, splenomegaly, and hepatomegaly. Fever is also present in up to 50% of new cases, which may indicate an infection or a constitutional symptom. Testicular swelling may also occur.
There are three types of ALL: common ALL, T-cell ALL, and B-cell ALL. Common ALL is the most common type, accounting for 75% of cases, and is characterized by the presence of CD10 and a pre-B phenotype. Poor prognostic factors for ALL include age less than 2 years or greater than 10 years, a white blood cell count greater than 20 * 109/l at diagnosis, T or B cell surface markers, non-Caucasian ethnicity, and male sex.
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This question is part of the following fields:
- Paediatrics
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Question 19
Correct
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As a junior doctor in a surgical firm, you are faced with a 54-year-old female patient who has metastatic breast cancer. She has been admitted due to worsening abdominal swelling and ascites. Despite being recommended chemotherapy, she has refused it for the past 6 weeks and opted for herbal treatment instead. Unfortunately, her condition has deteriorated, and she is experiencing significant pain. What steps do you take in this situation?
Your Answer: Advise them to discuss this with their oncologist and offer to ask the oncologist to see her on the ward
Explanation:According to the GMC’s good medical practice, it is essential to treat all patients with fairness and respect, regardless of their beliefs or lifestyle choices.
Breast cancer management varies depending on the stage of the cancer, type of tumor, and patient’s medical history. Treatment options may include surgery, radiotherapy, hormone therapy, biological therapy, and chemotherapy. Surgery is typically the first option for most patients, except for elderly patients with metastatic disease who may benefit more from hormonal therapy. Prior to surgery, an axillary ultrasound is recommended for patients without palpable axillary lymphadenopathy, while those with clinically palpable lymphadenopathy require axillary node clearance. The type of surgery offered depends on various factors, such as tumor size, location, and type. Breast reconstruction is also an option for patients who have undergone a mastectomy.
Radiotherapy is recommended after a wide-local excision to reduce the risk of recurrence, while mastectomy patients may receive radiotherapy for T3-T4 tumors or those with four or more positive axillary nodes. Hormonal therapy is offered if tumors are positive for hormone receptors, with tamoxifen being used in pre- and perimenopausal women and aromatase inhibitors like anastrozole in postmenopausal women. Tamoxifen may increase the risk of endometrial cancer, venous thromboembolism, and menopausal symptoms. Biological therapy, such as trastuzumab, is used for HER2-positive tumors but cannot be used in patients with a history of heart disorders. Chemotherapy may be used before or after surgery, depending on the stage of the tumor and the presence of axillary node disease. FEC-D is commonly used in the latter case.
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This question is part of the following fields:
- Surgery
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Question 20
Correct
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A 70-year-old woman has been diagnosed with a malignant lesion in the medial part of her left breast. To which one of the following lymph node groups is this site most likely to drain?
Your Answer: Internal thoracic
Explanation:Lymph Nodes and Their Locations in the Body
Lymph nodes are small, bean-shaped structures that play a crucial role in the immune system. They filter lymphatic fluid and trap harmful substances, such as bacteria and cancer cells. Here are some of the lymph nodes found in the body and their locations:
Internal Thoracic: These nodes are located parallel to the internal thoracic artery and vein, draining the medial part of the breast. Metastasis of breast cancer in these nodes can lead to reduced long-term survival.
Coeliac: Found in the abdomen, these nodes drain the stomach, duodenum, spleen, pancreas, and biliary tract.
Infraclavicular: Also known as the deltopectoral group, these nodes are located below the clavicle and receive lymph from the lateral side of the upper limb.
Supraclavicular: These nodes are found above the clavicles and receive lymph from the chest and abdomen.
Tracheobronchial: These nodes drain the trachea and bronchi and can be affected in lung malignancy and inflammatory conditions of the lung.
Understanding the locations of lymph nodes can help in the diagnosis and treatment of various diseases.
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This question is part of the following fields:
- Breast
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Question 21
Incorrect
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A 35-year-old woman comes to the clinic for follow-up three months after undergoing evacuation of a hydatidiform mole. She reports feeling well and has not experienced any significant issues since the procedure.
What blood test is the most effective in monitoring for the recurrence of trophoblastic disease?Your Answer: CA-125
Correct Answer: Beta-HCG
Explanation:Hydatidiform Mole and Trophoblastic Disease
A hydatidiform mole is a type of abnormal pregnancy that only generates placental tissue. However, approximately 10% of cases of hydatidiform mole can transform into malignant trophoblastic disease. To assess if there is any retained tissue or recurrence/malignant transformation, the best way is to measure the levels of HCG, which is primarily produced by the placenta. On the other hand, alpha-fetoprotein, CEA, and CA-125 are tumour markers associated with hepatocellular carcinoma, colonic carcinoma, and ovarian carcinoma, respectively. It is important to note that progesterone levels are not useful in determining the prognosis of trophoblastic disease. the characteristics and markers of hydatidiform mole and trophoblastic disease is crucial in the diagnosis and management of these conditions.
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This question is part of the following fields:
- Haematology
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Question 22
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A 17-year-old girl presents to the Emergency Department on a Saturday night with complaints of palpitations and feeling unwell. Her friends report that she had a negative reaction to the alcohol they consumed and deny any use of illegal substances. Upon examination, she appears anxious and is holding onto her chest. Her pupils are dilated, and her pulse rate is 110/min, blood pressure 135/92 mmHg. She mentions feeling nauseous. Which of the following substances could be responsible for her symptoms?
Your Answer: Cocaine
Explanation:Understanding Cocaine Toxicity
Cocaine is a popular recreational stimulant derived from the coca plant. However, its widespread use has resulted in an increase in cocaine toxicity cases. The drug works by blocking the uptake of dopamine, noradrenaline, and serotonin, leading to a variety of adverse effects.
Cardiovascular effects of cocaine include coronary artery spasm, tachycardia, bradycardia, hypertension, QRS widening, QT prolongation, and aortic dissection. Neurological effects may include seizures, mydriasis, hypertonia, and hyperreflexia. Psychiatric effects such as agitation, psychosis, and hallucinations may also occur. Other complications include ischaemic colitis, hyperthermia, metabolic acidosis, and rhabdomyolysis.
Managing cocaine toxicity involves using benzodiazepines as a first-line treatment for most cocaine-related problems. For chest pain, benzodiazepines and glyceryl trinitrate may be used, and primary percutaneous coronary intervention may be necessary if myocardial infarction develops. Hypertension can be treated with benzodiazepines and sodium nitroprusside. The use of beta-blockers in cocaine-induced cardiovascular problems is controversial, with some experts warning against it due to the risk of unopposed alpha-mediated coronary vasospasm.
In summary, cocaine toxicity can lead to a range of adverse effects, and managing it requires careful consideration of the patient’s symptoms and medical history.
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This question is part of the following fields:
- Pharmacology
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Question 23
Incorrect
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A 32-year-old woman who is 9 weeks pregnant visits you for her booking appointment. She has a brother with Down syndrome and wants to know more about the screening program. You provide information about the combined test. What other blood markers, in addition to nuchal translucency, are measured?
Your Answer: Beta-human chorionic gonadotrophin (beta-hCG) and alpha-fetoprotein (AFP)
Correct Answer: Beta-human chorionic gonadotrophin (beta-hCG) and pregnancy associated plasma protein A (PAPP-A)
Explanation:NICE updated guidelines on antenatal care in 2021, recommending the combined test for screening for Down’s syndrome between 11-13+6 weeks. The test includes nuchal translucency measurement, serum B-HCG, and pregnancy-associated plasma protein A (PAPP-A). The quadruple test is offered between 15-20 weeks for women who book later in pregnancy. Results are interpreted as either a ‘lower chance’ or ‘higher chance’ of chromosomal abnormalities. If a woman receives a ‘higher chance’ result, she may be offered a non-invasive prenatal screening test (NIPT) or a diagnostic test. NIPT analyzes cell-free fetal DNA in the mother’s blood and has high sensitivity and specificity for detecting chromosomal abnormalities. Private companies offer NIPT screening from 10 weeks gestation.
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This question is part of the following fields:
- Obstetrics
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Question 24
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A 67-year-old male patient visits their GP for a routine medication review. They are currently taking ramipril and amlodipine for hypertension, bisoprolol and digoxin for atrial fibrillation, atorvastatin for hypercholesterolemia, and PRN paracetamol for osteoarthritis. The GP decides to change one of their medications. One week after starting the new medication, the patient presents to the emergency department with symptoms of palpitations, nausea and vomiting, lethargy, and disturbances in their color vision. An ECG reveals an AV nodal block. Which of the following new medications is most likely responsible for this event?
Your Answer: Bendroflumethiazide
Explanation:The use of thiazides can lead to the development of digoxin toxicity, as evidenced by the patient’s symptoms of palpitations, nausea & vomiting, and lethargy, along with the presence of AV nodal block on the ECG. Pravastatin does not have any known interactions with digoxin, while bendroflumethiazide and other diuretics may also contribute to the development of toxicity by causing hypokalemia. Losartan, on the other hand, is not associated with any interactions with digoxin.
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.
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This question is part of the following fields:
- Pharmacology
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Question 25
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A 28-year-old female arrives at the emergency department with her husband who is worried about her unusual behavior. The patient discloses that her sister passed away in a car accident recently and the funeral was held last week. She expresses her deep love and closeness with her sister and admits to feeling very sad. The psychiatrist confirms this sentiment with the husband. However, while recounting the events of her sister's death and funeral, she begins to smile and laugh, describing the events in a cheerful tone. What is the most appropriate term to describe the patient's abnormal behavior?
Your Answer: Incongruity of affect
Explanation:Common Psychiatric Terms Explained
Psychiatric terms can be difficult to understand, but it’s important to know what they mean. Incongruity of affect is when a patient’s emotional expression does not match the situation they are describing. This can be confusing for both the patient and the clinician. Anhedonia is another term that is commonly used in psychiatry. It refers to the inability to feel pleasure from activities that were once enjoyable. This can be a symptom of depression or other mental health conditions. Depersonalisation and derealisation are two terms that are often used interchangeably, but they have different meanings. Depersonalisation is the feeling that one’s self is not real, while derealisation is the feeling that the world is not real. Finally, thought blocking is when a person suddenly stops their train of thought. This can be a symptom of schizophrenia or other mental health conditions.
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This question is part of the following fields:
- Psychiatry
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Question 26
Incorrect
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A 49-year-old farmer presented with progressive dyspnoea. He had a dry cough and exercise intolerance. On examination, few crackles were found in the upper zones of both lungs. Surgical lung biopsy was done which was reported as:
Interstitial inflammation, chronic bronchiolitis, and two foci of non-necrotizing granuloma.
What is the most likely clinical diagnosis?Your Answer: Tuberculosis
Correct Answer: Hypersensitivity pneumonitis
Explanation:Differentiating Lung Disorders: Histological Features
Hypersensitivity Pneumonitis: This lung disorder is caused by a hypersensitivity reaction to mouldy hay or other organic materials. A farmer is likely to develop this condition due to exposure to such materials. The histological triad of hypersensitivity pneumonitis includes lymphocytic alveolitis, non-caseating granulomas, and poorly formed granulomas.
Aspergillosis: This lung disorder is rarely invasive. In cases where it is invasive, lung biopsy shows hyphae with vascular invasion and surrounding tissue necrosis.
Sarcoidosis: This lung disorder of unknown aetiology presents with non-caseating granuloma. Schumann bodies, which are calcified, rounded, laminated concretions inside the non-caseating granuloma, are found in sarcoidosis. The granulomas are formed of foreign body giant cells. Within the giant cells, there are star-shaped inclusions called asteroid bodies.
Histiocytosis X: This lung disorder presents with scattered nodules of Langerhans cells. Associated with it are eosinophils, macrophages, and giant cells. The Langerhans cells contain racket-shaped Birbeck granules.
Tuberculosis: This lung disorder typically has caseating granulomas in the lung parenchyma. There is also fibrosis in later stages. Ziehl–Neelsen staining of the smear reveals acid-fast bacilli (AFB) in many cases. Vasculitic lesions can also be found.
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This question is part of the following fields:
- Respiratory
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Question 27
Correct
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A 72-year-old woman is visited by her general practitioner and found to be suffering from constipation. This began after she was started on a new medication. She suffers from ischaemic heart disease, osteoarthritis, atrial fibrillation and moderate depression.
Which drug is most likely to have resulted in this woman’s symptoms?Your Answer: Codeine phosphate
Explanation:Codeine phosphate and dihydrocodeine are drugs that activate the μ opioid receptor and are commonly used to alleviate moderate pain. Codeine can also be used as a cough suppressant, but it should be avoided in cases of acute infective diarrhea and ulcerative colitis. Long-term use in the elderly is not recommended due to its constipating effects and potential contribution to delirium. Co-prescribing with a laxative is advisable for those at risk. Digoxin, on the other hand, does not cause constipation but may lead to arrhythmias, blurred vision, conduction disturbances, diarrhea, dizziness, eosinophilia, nausea, rash, vomiting, and yellow vision. Carvedilol and atenolol are beta blockers that are not commonly associated with constipation. While atenolol may cause gastrointestinal disturbances, its side-effects are not well documented. Paroxetine, a selective serotonin reuptake inhibitor, is used to treat anxiety and major depression. It may cause constipation and abdominal pain, but its side-effects are dose-dependent, and in this case, codeine is more likely to be the cause of constipation than paroxetine.
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This question is part of the following fields:
- Pharmacology
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Question 28
Incorrect
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A woman in her mid-thirties arrives at the haemodialysis clinic for her regular appointment. Before the session, a typical amount of unfractionated heparin is given. What is the drug's mechanism of action?
Your Answer: Deactivates antithrombin III
Correct Answer: Activates antithrombin III
Explanation:Unfractionated heparin works by activating antithrombin III, which then inhibits the formation of fibrin and the activation of thrombin and factors Xa, Ixa, XIa, and XIIa. This process can be reversed with protamine sulphate. Antithrombin III is the most clinically important form of antithrombin, and historically, it has been divided into I, II, III, and IV based on different stages of thrombin activity.
Understanding Heparin and its Adverse Effects
Heparin is a type of anticoagulant that comes in two forms: unfractionated or standard heparin, and low molecular weight heparin (LMWH). Both types work by activating antithrombin III, but unfractionated heparin inhibits thrombin, factors Xa, IXa, XIa, and XIIa, while LMWH only increases the action of antithrombin III on factor Xa. However, heparin can cause adverse effects such as bleeding, thrombocytopenia, osteoporosis, and hyperkalemia.
Heparin-induced thrombocytopenia (HIT) is a condition where antibodies form against complexes of platelet factor 4 (PF4) and heparin, leading to platelet activation and a prothrombotic state. HIT usually develops after 5-10 days of treatment and is characterized by a greater than 50% reduction in platelets, thrombosis, and skin allergy. To address the need for ongoing anticoagulation, direct thrombin inhibitors like argatroban and danaparoid can be used.
Standard heparin is administered intravenously and has a short duration of action, while LMWH is administered subcutaneously and has a longer duration of action. Standard heparin is useful in situations where there is a high risk of bleeding as anticoagulation can be terminated rapidly, while LMWH is now standard in the management of venous thromboembolism treatment and prophylaxis and acute coronary syndromes. Monitoring for standard heparin is done through activated partial thromboplastin time (APTT), while LMWH does not require routine monitoring. Heparin overdose may be reversed by protamine sulfate, although this only partially reverses the effect of LMWH.
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This question is part of the following fields:
- Pharmacology
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Question 29
Incorrect
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A 32-year-old woman has reached out for a phone consultation to discuss her recent cervical smear test results. She underwent the routine screening programme and is currently not experiencing any symptoms. Her last cervical smear was conducted 3 years ago and was reported as normal. The results of her latest test are as follows: Positive for high-risk human papillomavirus (hrHPV) and negative for cytology. What should be the next course of action in her management?
Your Answer: Urgent referral to colposcopy
Correct Answer: Repeat cervical smear in 12 months
Explanation:The correct course of action for an individual who tests positive for high-risk human papillomavirus (hrHPV) but receives a negative cytology report during routine primary HPV screening is to repeat the HPV test after 12 months. If the HPV test is negative at this point, the individual can return to routine recall. However, if the individual remains hrHPV positive and cytology negative, another HPV test should be conducted after a further 12 months. If the individual is still hrHPV positive after 24 months, they should be referred to colposcopy. It is incorrect to repeat the cervical smear in 3 months, wait 3 years for a repeat smear, or refer the individual to colposcopy without abnormal cytology.
The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.
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This question is part of the following fields:
- Gynaecology
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Question 30
Correct
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A 6-year-old boy presents to the Emergency Department with periorbital pain, ascites, and oedema. He has no past medical history and is typically healthy, without recent illnesses. Upon examination, his serum urea is elevated and protein in his urine is ++++. What is the probable cause of his symptoms?
Your Answer: Minimal change glomerulonephritis
Explanation:Overview of Different Types of Glomerulonephritis
Glomerulonephritis is a group of kidney diseases that affect the glomeruli, the tiny blood vessels in the kidneys that filter waste and excess fluids from the blood. Here are some of the different types of glomerulonephritis:
1. Minimal Change Glomerulonephritis: This is the most common cause of nephrotic syndrome in children. It is caused by T-cell-mediated injury to the podocytes of the epithelial cells. The diagnosis is made by electron microscopy, and treatment is with steroids.
2. Membranous Glomerulonephritis: This is the second most common cause of nephrotic syndrome in adults. It can be primary or secondary, and some causes of secondary membranous glomerulonephritis include autoimmune conditions, malignancy, viral infections, and drugs. On light microscopy, the basement membrane has characteristic spikes.
3. Mesangiocapillary Glomerulonephritis: This is associated with immune deposition in the glomerulus, thickening of the basement membrane, and activation of complement pathways leading to glomerular damage. It presents with nephrotic syndrome and is seen in both the pediatric and adult population. It is the most common glomerulonephritis associated with hepatitis C.
4. Post-Streptococcal Glomerulonephritis: This presents with haematuria, oedema, hypertension, fever, or acute kidney failure following an upper respiratory tract infection or pharyngitis from Streptococcus spp.
5. IgA Nephropathy Glomerulonephritis: This is a condition associated with IgA deposition within the glomerulus, presenting with haematuria following an upper respiratory tract infection. It is the most common cause of glomerulonephritis in adults.
Understanding the Different Types of Glomerulonephritis
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This question is part of the following fields:
- Renal
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