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  • Question 1 - A 65-year-old woman with a history of depression and non-paroxysmal atrial fibrillation is...

    Correct

    • A 65-year-old woman with a history of depression and non-paroxysmal atrial fibrillation is brought to the emergency department by her daughter after being found unconscious with an empty bottle of medication. She is disoriented and complains of feeling nauseous. Shortly after arriving at the hospital, she experiences visual hallucinations and yellowing of her vision.

      The patient denies smoking or substance abuse and leads a sedentary lifestyle. On examination, her pulse is irregular with a rate of 70 beats per minute, blood pressure is 110/70 mmHg, and respiratory rate is 18 breaths per minute. An ECG shows frequent premature ventricular contractions and ventricular bigeminy.

      What is the most likely diagnosis, and what management should be implemented for this patient?

      Your Answer: Administer digoxin-specific antibody fab fragments (Digibind) intravenously

      Explanation:

      In cases of non-paroxysmal atrial fibrillation with a sedentary lifestyle, digoxin monotherapy is recommended as the first line treatment according to NICE guidelines from 2014. However, if a patient experiences severe digoxin toxicity due to an overdose with suicidal intention, Digibind, which contains digoxin-specific antibody fab fragments, is the recognized antidote. Symptoms of digoxin toxicity include gastrointestinal issues, visual disturbances, cardiovascular problems, and central nervous system complications. N-acetylcysteine is used as an antidote for paracetamol overdose, while naloxone and diazepam are used for opioid overdose and alcohol withdrawal, respectively. Cardioversion should be avoided if possible due to the risk of asystole, and if necessary, the lowest energy possible should be used.

      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
      60.3
      Seconds
  • Question 2 - A 50-year-old woman visited her doctor with complaints of intense pain in the...

    Correct

    • A 50-year-old woman visited her doctor with complaints of intense pain in the anal area. She recalled that the pain began after straining during a bowel movement. She had been constipated for the past week and had been using over-the-counter laxatives. During the examination, the doctor noticed a painful, firm, blue-black lump at the edge of the anus. What is the probable cause of her symptoms?

      Your Answer: Thrombosed haemorrhoid

      Explanation:

      Thrombosed haemorrhoids are characterized by severe pain and the presence of a tender lump. Upon examination, a purplish, swollen, and tender subcutaneous perianal mass can be observed. If the patient seeks medical attention within 72 hours of onset, referral for excision may be necessary. However, if the condition has progressed beyond this timeframe, patients can typically manage their symptoms with stool softeners, ice packs, and pain relief medication. Symptoms usually subside within 10 days.

    • This question is part of the following fields:

      • Surgery
      21.5
      Seconds
  • Question 3 - A mental state examination is conducted on a 32-year-old individual. When asked about...

    Incorrect

    • A mental state examination is conducted on a 32-year-old individual. When asked about their breakfast, they start by describing their morning routine, then talk about their favourite recipes, followed by a story about a cooking competition they participated in, and finally mention having cereal for breakfast. Their speech is at a regular pace and flow.

      What type of thought process is demonstrated in this scenario?

      Your Answer: Flight of ideas

      Correct Answer: Circumstantiality

      Explanation:

      Circumstantiality refers to the tendency to provide excessive and unnecessary detail when answering a question, ultimately reaching the intended goal but taking a circuitous route. This is different from tangentiality, where the patient wanders away from the topic without returning, derailment of thoughts, where there are illogical jumps between topics, and flight of ideas, where the patient quickly moves from one related topic to another.

      Thought disorders can manifest in various ways, including circumstantiality, tangentiality, neologisms, clang associations, word salad, Knight’s move thinking, flight of ideas, perseveration, and echolalia. Circumstantiality involves providing excessive and unnecessary detail when answering a question, but eventually returning to the original point. Tangentiality, on the other hand, refers to wandering from a topic without returning to it. Neologisms are newly formed words, often created by combining two existing words. Clang associations occur when ideas are related only by their similar sounds or rhymes. Word salad is a type of speech that is completely incoherent, with real words strung together into nonsensical sentences. Knight’s move thinking is a severe form of loosening of associations, characterized by unexpected and illogical leaps from one idea to another. Flight of ideas is a thought disorder that involves jumping from one topic to another, but with discernible links between them. Perseveration is the repetition of ideas or words despite attempts to change the topic. Finally, echolalia is the repetition of someone else’s speech, including the question that was asked.

    • This question is part of the following fields:

      • Psychiatry
      25.1
      Seconds
  • Question 4 - An 85-year-old man with renal failure attends hospital for dialysis three times per...

    Correct

    • An 85-year-old man with renal failure attends hospital for dialysis three times per week. He presents to the Emergency Department with acute shortness of breath and is found to have suffered from a large anterior myocardial infarct. The medical team decides to discuss a DNACPR decision with him. When is it appropriate to consider a DNACPR order?

      Your Answer: Where successful CPR is likely to be followed by a length and quality of life that are not in the best interests of the patient to sustain

      Explanation:

      When to Consider DNACPR Orders: Factors to Consider

      Deciding whether or not to perform cardiopulmonary resuscitation (CPR) on a patient can be a difficult decision. While CPR can be life-saving, it is not always the best course of action. Here are some factors to consider when deciding whether to issue a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order:

      1. Length and quality of life: If successful CPR is likely to result in a poor quality of life for the patient, it may not be in their best interests to sustain it.

      2. Patient wishes: If a mentally competent patient has expressed a desire not to receive CPR, their wishes should be respected.

      3. Likelihood of success: If the patient’s condition indicates that CPR is unlikely to be successful, it may not be worth attempting.

      4. Shockable rhythms: If the patient is in ventricular fibrillation or ventricular tachycardia, CPR may be successful and should be attempted.

      5. Cost and resources: The cost and availability of facilities should not be a factor in deciding whether to perform CPR.

      6. Family wishes: If the patient is mentally competent, their family cannot make decisions regarding resuscitation.

      7. Age: Age alone should not be a factor in deciding whether to issue a DNACPR order, as a fit and healthy older person may have a good chance of survival.

      Considering these factors can help healthcare professionals make informed decisions about whether or not to perform CPR on a patient.

    • This question is part of the following fields:

      • Palliative Care
      34.4
      Seconds
  • Question 5 - A 50-year-old man presents to the Emergency Department with a 3-week history of...

    Incorrect

    • A 50-year-old man presents to the Emergency Department with a 3-week history of tiredness, epigastric discomfort and an episode of passing black stools. His past medical history includes a 4-year history of rheumatoid arthritis for which he takes regular methotrexate, folic acid and naproxen. He recently received a course of oral corticosteroids for a flare of his rheumatoid arthritis. He denies alcohol consumption and is a non-smoker. On systemic enquiry he reports a good appetite and denies any weight loss. The examination reveals conjunctival pallor and a soft abdomen with tenderness in the epigastrium. His temperature is 36.7°C, blood pressure is 112/68 mmHg, pulse is 81 beats per minute and oxygen saturations are 96% on room air. A full blood count is taken which reveals the following:
      Investigation Result Normal Value
      Haemoglobin 76 g/l 135–175 g/l
      Mean corpuscular volume (MCV) 68 fl 76–98 fl
      White cell count (WCC) 5.2 × 109/l 4–11 × 109/l
      Platelets 380 × 109/l 150–400 × 109/l
      Which of the following is the most likely diagnosis?

      Your Answer: Atrophic gastritis

      Correct Answer: Peptic ulcer

      Explanation:

      Gastrointestinal Conditions: Peptic Ulcer, Atrophic Gastritis, Barrett’s Oesophagus, Gastric Cancer, and Oesophageal Varices

      Peptic Ulcer:
      Peptic ulceration is commonly caused by NSAID use or Helicobacter pylori infection. Symptoms include dyspepsia, upper gastrointestinal bleeding, and iron deficiency anaemia. Treatment involves admission to a gastrointestinal ward for resuscitation, proton pump inhibitor initiation, and urgent endoscopy. If caused by H. pylori, triple therapy is initiated.

      Atrophic Gastritis:
      Atrophic gastritis is a chronic inflammatory change of the gastric mucosa, resulting in malabsorption and anaemia. However, it is unlikely to account for melaena or epigastric discomfort.

      Barrett’s Oesophagus:
      Barrett’s oesophagus is a histological diagnosis resulting from chronic acid reflux. It is unlikely to cause the patient’s symptoms as there is no history of reflux.

      Gastric Cancer:
      Gastric cancer is less likely due to the lack of risk factors and additional ‘red flag’ symptoms such as weight loss and appetite change. Biopsies of peptic ulcers are taken at endoscopy to check for an underlying malignant process.

      Oesophageal Varices:
      Oesophageal varices are caused by chronic liver disease and can result in severe bleeding and haematemesis. However, this diagnosis is unlikely as there is little history to suggest chronic liver disease.

    • This question is part of the following fields:

      • Gastroenterology
      89.8
      Seconds
  • Question 6 - A 29-year-old woman presents to the Emergency Department with a sudden-onset headache that...

    Correct

    • A 29-year-old woman presents to the Emergency Department with a sudden-onset headache that began 12 hours ago. She describes it as ‘an explosion’ and ‘the worst headache of her life’. She denies any vomiting or recent trauma and has not experienced any weight loss. On examination, there are no cranial nerve abnormalities. A CT scan of the head shows no abnormalities. She has no significant past medical history or family history. The pain has subsided with codeine, and she wants to be discharged.

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

      Your Answer: Lumbar puncture

      Explanation:

      Management of Suspected Subarachnoid Haemorrhage: Importance of Lumbar Puncture

      When a patient presents with signs and symptoms suggestive of subarachnoid haemorrhage (SAH), it is crucial to confirm the diagnosis through appropriate investigations. While a CT scan of the head is often the first-line investigation, it may not always detect an SAH. In such cases, a lumbar puncture can be a valuable tool to confirm the presence of blood in the cerebrospinal fluid.

      Xanthochromia analysis, which detects the presence of oxyhaemoglobin and bilirubin in the cerebrospinal fluid, can help differentiate between traumatic and non-traumatic causes of blood in the fluid. To ensure the accuracy of the test, the lumbar puncture should be performed at least 12 hours after the onset of headache, and the third sample should be sent for xanthochromia analysis.

      In cases where an SAH is suspected, it is crucial not to discharge the patient without further investigation. Overnight observation may be an option, but it is not ideal as it delays diagnosis and treatment. Similarly, prescribing analgesia may provide symptomatic relief but does not address the underlying issue.

      The best course of action in suspected SAH is to perform a lumbar puncture to confirm the diagnosis and initiate appropriate management. Early diagnosis and treatment can prevent further damage and improve outcomes for the patient.

    • This question is part of the following fields:

      • Neurology
      22.6
      Seconds
  • Question 7 - An 80-year-old man with aortic stenosis came for his annual check-up. During the...

    Incorrect

    • An 80-year-old man with aortic stenosis came for his annual check-up. During the visit, his blood pressure was measured at 110/90 mmHg and his carotid pulse was slow-rising. What is the most severe symptom that indicates a poor prognosis in aortic stenosis?

      Your Answer: Orthostatic dizziness

      Correct Answer: Syncope

      Explanation:

      Symptoms and Mortality Risk in Aortic Stenosis

      Aortic stenosis is a serious condition that can lead to decreased cerebral perfusion and potentially fatal outcomes. Here are some common symptoms and their associated mortality risks:

      – Syncope: This is a major concern and indicates the need for valve replacement, regardless of valve area.
      – Chest pain: While angina can occur due to reduced diastolic coronary perfusion time and increased left ventricular mass, it is not as significant as syncope in predicting mortality.
      – Cough: Aortic stenosis typically does not cause coughing.
      – Palpitations: Unless confirmed to be non-sustained ventricular tachycardia, palpitations do not increase mortality risk.
      – Orthostatic dizziness: Mild decreased cerebral perfusion can cause dizziness upon standing, but this symptom alone does not confer additional mortality risk.

      It is important to be aware of these symptoms and seek medical attention if they occur, as aortic stenosis can be a life-threatening condition.

    • This question is part of the following fields:

      • Cardiology
      31.6
      Seconds
  • Question 8 - A 50-year-old woman comes to the doctor complaining of muscle weakness and a...

    Incorrect

    • A 50-year-old woman comes to the doctor complaining of muscle weakness and a rash that has been developing over the past month. Upon examination, the doctor notes symmetrical weakness in the shoulders and hips, as well as red papules on the proximal interphalangeal joints. What skin manifestation is likely being described in this case?

      Your Answer: Heliotrope rash

      Correct Answer: Gottron's papules

      Explanation:

      The correct answer is Gottron’s papules, which are roughened red papules mainly seen over the knuckles in patients with dermatomyositis. In this case, the patient’s symmetrical proximal muscle weakness and skin involvement indicate dermatomyositis. Gottron’s papules are small violaceous papules that can also be seen on the proximal interphalangeal and metacarpophalangeal joints. While Gottron’s sign is also associated with dermatomyositis, it refers to violaceous macules over the knees and elbows and is not being described in this case. The heliotrope rash, a violaceous or dusky red rash surrounding the eye, is another highly characteristic sign of dermatomyositis, but it is not present in this case. Similarly, a malar rash, which is a butterfly-shaped rash over the cheeks and nose commonly seen in patients with SLE, is not relevant to this case.

      Dermatomyositis is a condition that causes inflammation and muscle weakness, as well as distinct skin lesions. It can occur on its own or be associated with other connective tissue disorders or underlying cancers, particularly ovarian, breast, and lung cancer. Screening for cancer is often done after a diagnosis of dermatomyositis. Polymyositis is a variant of the disease that does not have prominent skin manifestations.

      The skin features of dermatomyositis include a photosensitive macular rash on the back and shoulders, a heliotrope rash around the eyes, roughened red papules on the fingers’ extensor surfaces (known as Gottron’s papules), extremely dry and scaly hands with linear cracks on the fingers’ palmar and lateral aspects (known as mechanic’s hands), and nail fold capillary dilation. Other symptoms may include proximal muscle weakness with tenderness, Raynaud’s phenomenon, respiratory muscle weakness, interstitial lung disease (such as fibrosing alveolitis or organizing pneumonia), dysphagia, and dysphonia.

      Investigations for dermatomyositis typically involve testing for ANA antibodies, which are positive in around 80% of patients. Approximately 30% of patients have antibodies to aminoacyl-tRNA synthetases, including antibodies against histidine-tRNA ligase (also called Jo-1), antibodies to signal recognition particle (SRP), and anti-Mi-2 antibodies.

    • This question is part of the following fields:

      • Musculoskeletal
      24.8
      Seconds
  • Question 9 - You are the FY1 working on a pediatric ward. You overhear the nurses...

    Incorrect

    • You are the FY1 working on a pediatric ward. You overhear the nurses speaking about the son of one of your patients in a derogatory way. This upsets you as you have built a good rapport with the patient and his family.
      Which of the following is the most appropriate action?

      Your Answer: Inform the patients family immediately and ask them to request a ward change

      Correct Answer: Speak to the nurses quietly at a later time

      Explanation:

      Appropriate Actions in Response to Overhearing Inappropriate Conversation Among Nurses

      When overhearing inappropriate conversation among nurses on the ward, it is important to respond in a professional and appropriate manner. One should not interrupt the nurses and tell them to keep quiet or start shouting at them. Instead, the most appropriate action is to speak to the nurses quietly at a later time when things have calmed down. Confronting them in the moment may lead to further tension and conflict. Informing the patient’s family immediately and asking for a ward change is also not recommended as it may create mistrust and ill feeling towards the nursing staff. Speaking to the Ward Sister is an option, but it may cause a delay in addressing the issue. Therefore, it is better to approach the nurses directly and share concerns in a calm and professional manner.

    • This question is part of the following fields:

      • Ethics And Legal
      48
      Seconds
  • Question 10 - You come across an 11-year-old boy with asthma who has been using a...

    Incorrect

    • You come across an 11-year-old boy with asthma who has been using a salbutamol inhaler for the past year. He reports needing it when he plays sports outside, especially in colder weather. His mother is worried as he has been using it more frequently in the last 6 months and has had to use it at night. She has also noticed that he sometimes wakes up coughing and his wheezing is worse in the morning. On average, he uses his inhaler 3-4 times a week. After examining the patient and finding no abnormalities, what would be the most appropriate next step to step up his treatment?

      Your Answer:

      Correct Answer: Start a paediatric low-dose inhaled corticosteroid

      Explanation:

      Managing Asthma in Children: NICE Guidelines

      Asthma management in children has been updated by NICE in 2017, following the 2016 BTS guidelines. The new guidelines for children aged 5-16 are similar to those for adults, with a stepwise approach for treatment. For newly-diagnosed asthma, short-acting beta agonist (SABA) is recommended. If symptoms persist, a combination of SABA and paediatric low-dose inhaled corticosteroid (ICS) is used. Leukotriene receptor antagonist (LTRA) is added if symptoms still persist, followed by long-acting beta agonist (LABA) if necessary. Maintenance and reliever therapy (MART) is used as a combination of ICS and LABA for daily maintenance therapy and symptom relief. For children under 5 years old, clinical judgement plays a greater role in diagnosis. The stepwise approach is similar to that for older children, with an 8-week trial of paediatric moderate-dose ICS before adding LTRA. If symptoms persist, referral to a paediatric asthma specialist is recommended.

      It should be noted that NICE does not recommend changing treatment for well-controlled asthma patients simply to adhere to the latest guidelines. The definitions of low, moderate, and high-dose ICS have also changed, with different definitions for adults and children. For children, <= 200 micrograms budesonide or equivalent is considered a paediatric low dose, 200-400 micrograms is a moderate dose, and > 400 micrograms is a high dose. Overall, the new NICE guidelines provide a clear and concise approach to managing asthma in children.

    • This question is part of the following fields:

      • Paediatrics
      0
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SESSION STATS - PERFORMANCE PER SPECIALTY

Pharmacology (1/1) 100%
Surgery (1/1) 100%
Psychiatry (0/1) 0%
Palliative Care (1/1) 100%
Gastroenterology (0/1) 0%
Neurology (1/1) 100%
Musculoskeletal (0/1) 0%
Ethics And Legal (0/1) 0%
Paediatrics (1/1) 100%
Passmed