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  • Question 1 - A 50-year-old patient has discovered a lump in her neck and another one...

    Correct

    • A 50-year-old patient has discovered a lump in her neck and another one in her groin. She has been experiencing feverish symptoms for several months and has had to change her bedclothes twice in the last week. Upon examination, smooth, firm, enlarged lymph nodes are noted at both sites. The patient's GP is concerned about the possibility of an underlying lymphoma and has referred her to secondary care for further investigations. A CT scan has not revealed any other lymph nodes. What is the most appropriate diagnosis and staging for this patient?

      Your Answer: On biopsy the malignant lymphoid cells would be likely to have many of the characteristics of their parent cells

      Explanation:

      Lymphomas and their Staging

      Malignancies that arise from lymphocytes can spread to different lymph node groups due to their ability to retain adhesion and signalling receptors. Lymphomas can present at various sites, including bone marrow, gut, and spleen, as normal trafficking of lymphoid cells occurs through these places. Interestingly, higher-grade lymphomas are easier to cure than lower grade lymphomas, despite initially being associated with a higher mortality rate. On the other hand, low-grade lymphomas may not require immediate treatment, but the disease progresses over time, leading to a poorer prognosis.

      To diagnose lymphoma, a biopsy of the affected area, such as a lymph node or bone marrow, is necessary. The Ann Arbor staging system is used to stage lymphomas, with Stage I indicating disease in a single lymph node group and Stage IV indicating extra-nodal involvement other than the spleen. The addition of a ‘B’ signifies the presence of ‘B’ symptoms, which are associated with a poorer prognosis for each disease stage.

      From the examination findings, it is evident that the disease is present on both sides of the diaphragm, indicating at least Stage III lymphoma. the staging of lymphomas is crucial in determining the appropriate treatment plan and predicting the patient’s prognosis.

    • This question is part of the following fields:

      • Haematology And Oncology
      8268.3
      Seconds
  • Question 2 - Which of the following hinders the production of insulin secretion? ...

    Correct

    • Which of the following hinders the production of insulin secretion?

      Your Answer: Adrenaline

      Explanation:

      The release of insulin can be inhibited by alpha adrenergic drugs, beta blockers, and sympathetic nerves.

      Insulin is a hormone produced by the pancreas that plays a crucial role in regulating the metabolism of carbohydrates and fats in the body. It works by causing cells in the liver, muscles, and fat tissue to absorb glucose from the bloodstream, which is then stored as glycogen in the liver and muscles or as triglycerides in fat cells. The human insulin protein is made up of 51 amino acids and is a dimer of an A-chain and a B-chain linked together by disulfide bonds. Pro-insulin is first formed in the rough endoplasmic reticulum of pancreatic beta cells and then cleaved to form insulin and C-peptide. Insulin is stored in secretory granules and released in response to high levels of glucose in the blood. In addition to its role in glucose metabolism, insulin also inhibits lipolysis, reduces muscle protein loss, and increases cellular uptake of potassium through stimulation of the Na+/K+ ATPase pump.

    • This question is part of the following fields:

      • Endocrine System
      12.6
      Seconds
  • Question 3 - A research group evaluating the effectiveness of a new exercise program in reducing...

    Incorrect

    • A research group evaluating the effectiveness of a new exercise program in reducing blood pressure. A group of 200 volunteers was recruited. Half of the volunteers were over the age of 50 and were given the exercise program. The other half of the volunteers were under the age of 50 and were not given the exercise program.

      The group was followed-up over the next 6 months. Blood pressure readings were taken at the beginning and end of the study. Results were divided into 2 categories: volunteers who had a decrease in blood pressure and volunteers who did not have a decrease in blood pressure.

      At the end of the study, the results obtained were as follows:

      Outcome Exercise program No exercise program
      Decrease in blood pressure (over 50 years old) 25 10
      Decrease in blood pressure (under 50 years old) 20 15
      No decrease in blood pressure (over 50 years old) 10 15
      No decrease in blood pressure (under 50 years old) 30 30

      The researchers are unsure of the significance of the results obtained.

      Which of the following statistical tests would be most appropriate?

      Your Answer: Paired t-test

      Correct Answer: Pearson's chi-square test

      Explanation:

      The paired t-test is a statistical test used to compare the means of two related groups, such as before and after measurements of the same individuals. It is appropriate when the data is continuous and normally distributed.

      Types of Significance Tests

      Significance tests are used to determine whether the results of a study are statistically significant or simply due to chance. The type of significance test used depends on the type of data being analyzed. Parametric tests are used for data that can be measured and are usually normally distributed, while non-parametric tests are used for data that cannot be measured in this way.

      Parametric tests include the Student’s t-test, which can be paired or unpaired, and Pearson’s product-moment coefficient, which is used for correlation analysis. Non-parametric tests include the Mann-Whitney U test, which compares ordinal, interval, or ratio scales of unpaired data, and the Wilcoxon signed-rank test, which compares two sets of observations on a single sample. The chi-squared test is used to compare proportions or percentages, while Spearman and Kendall rank are used for correlation analysis.

      It is important to choose the appropriate significance test for the type of data being analyzed in order to obtain accurate and reliable results. By understanding the different types of significance tests available, researchers can make informed decisions about which test to use for their particular study.

    • This question is part of the following fields:

      • General Principles
      25.3
      Seconds
  • Question 4 - A 68-year-old man arrives at the Emergency Department complaining of sharp and stabbing...

    Correct

    • A 68-year-old man arrives at the Emergency Department complaining of sharp and stabbing central chest pain that radiates to his back, neck, and left shoulder. He reports feeling feverish and states that sitting forward relieves the pain while lying down worsens it. The patient also mentions a recent hospitalization for a heart attack three weeks ago. During auscultation at the left sternal border, a scratchy sound is heard while the patient leans forward and holds his breath. His ECG shows widespread ST-segment saddle elevation and PR-segment depression. Can you identify the nerve responsible for his shoulder pain?

      Your Answer: Phrenic nerve

      Explanation:

      The referred pain to the shoulder in this case is likely caused by Dressler’s syndrome, a type of pericarditis that occurs after a heart attack. The scratchy sound heard during auscultation is a pericardial friction rub, which is a common characteristic of pericarditis. The phrenic nerve, which supplies the pericardium, travels from the neck down through the thoracic cavity and can cause referred pain to the shoulder in cases of pericarditis.

      The axillary nerve is responsible for innervating the teres minor and deltoid muscles, and dysfunction of this nerve can result in loss of sensation or movement in the shoulder area.

      While the accessory nerve does innervate muscles in the neck that attach to the shoulder, it has a purely motor function and is not responsible for sensory input. Additionally, the referred pain in this case is not typical of musculoskeletal pain, but rather a result of pericarditis.

      Injuries involving the long thoracic nerve often result in winging of the scapula and are commonly caused by axillary surgery.

      Although the vagus nerve does supply parasympathetic innervation to the heart, it is not responsible for the referred pain in this case, as the pericardium is innervated by the phrenic nerve.

      The Phrenic Nerve: Origin, Path, and Supplies

      The phrenic nerve is a crucial nerve that originates from the cervical spinal nerves C3, C4, and C5. It supplies the diaphragm and provides sensation to the central diaphragm and pericardium. The nerve passes with the internal jugular vein across scalenus anterior and deep to the prevertebral fascia of the deep cervical fascia.

      The right phrenic nerve runs anterior to the first part of the subclavian artery in the superior mediastinum and laterally to the superior vena cava. In the middle mediastinum, it is located to the right of the pericardium and passes over the right atrium to exit the diaphragm at T8. On the other hand, the left phrenic nerve passes lateral to the left subclavian artery, aortic arch, and left ventricle. It passes anterior to the root of the lung and pierces the diaphragm alone.

      Understanding the origin, path, and supplies of the phrenic nerve is essential in diagnosing and treating conditions that affect the diaphragm and pericardium.

    • This question is part of the following fields:

      • Respiratory System
      45.4
      Seconds
  • Question 5 - A 50-year-old female patient presents with a lump in her groin that appears...

    Correct

    • A 50-year-old female patient presents with a lump in her groin that appears and disappears. Upon consultation, it is determined that the hernia is protruding between the pectineal (Cooper's) ligament, lacunar ligament, and femoral vein. What type of hernia is being described by the consultant?

      Your Answer: Femoral

      Explanation:

      Types of Hernias and their Borders

      Hernias are a medical condition where an organ or tissue protrudes through a weak spot in the surrounding muscle or tissue. One type of hernia is the Femoral hernia, which protrudes through the femoral canal. This type of hernia is more common in women due to their pelvic structure and childbirth. The femoral ring is narrow, making it more likely for these hernias to become strangulated.

      Another type of hernia is the inguinal hernia, which protrudes through the inguinal canal. Petit’s hernia protrudes through the inferior lumbar triangle, Grynfeltt’s through the superior lumbar triangle, and obturator hernias through the obturator foramen. Each type of hernia has its own unique borders and characteristics.

    • This question is part of the following fields:

      • Clinical Sciences
      36.7
      Seconds
  • Question 6 - A 25-year-old man is stabbed in the chest about 10cm below the left...

    Correct

    • A 25-year-old man is stabbed in the chest about 10cm below the left nipple. Upon arrival at the emergency department, an abdominal ultrasound scan reveals a significant amount of intraperitoneal bleeding. Which of the following statements regarding the probable location of the injury is false?

      Your Answer: The quadrate lobe is contained within the functional right lobe.

      Explanation:

      The most probable location of injury in the liver is the right lobe. Hence, option B is the correct answer as the quadrate lobe is considered as a functional part of the left lobe. The liver is mostly covered by peritoneum, except for the bare area at the back. The right lobe of the liver has the largest bare area and is also bigger than the left lobe.

      Structure and Relations of the Liver

      The liver is divided into four lobes: the right lobe, left lobe, quadrate lobe, and caudate lobe. The right lobe is supplied by the right hepatic artery and contains Couinaud segments V to VIII, while the left lobe is supplied by the left hepatic artery and contains Couinaud segments II to IV. The quadrate lobe is part of the right lobe anatomically but functionally is part of the left, and the caudate lobe is supplied by both right and left hepatic arteries and lies behind the plane of the porta hepatis. The liver lobules are separated by portal canals that contain the portal triad: the hepatic artery, portal vein, and tributary of bile duct.

      The liver has various relations with other organs in the body. Anteriorly, it is related to the diaphragm, esophagus, xiphoid process, stomach, duodenum, hepatic flexure of colon, right kidney, gallbladder, and inferior vena cava. The porta hepatis is located on the postero-inferior surface of the liver and transmits the common hepatic duct, hepatic artery, portal vein, sympathetic and parasympathetic nerve fibers, and lymphatic drainage of the liver and nodes.

      The liver is supported by ligaments, including the falciform ligament, which is a two-layer fold of peritoneum from the umbilicus to the anterior liver surface and contains the ligamentum teres (remnant of the umbilical vein). The ligamentum venosum is a remnant of the ductus venosus. The liver is supplied by the hepatic artery and drained by the hepatic veins and portal vein. Its nervous supply comes from the sympathetic and parasympathetic trunks of the coeliac plexus.

    • This question is part of the following fields:

      • Gastrointestinal System
      226.3
      Seconds
  • Question 7 - You are the physician attending to a 32-year-old expectant mother who is experiencing...

    Correct

    • You are the physician attending to a 32-year-old expectant mother who is experiencing discomfort in her thumb and index finger. She reports paraesthesia in the palmar region of her thumb and index finger, which worsens at night.

      What nerve is likely to be impacted?

      Your Answer: Median

      Explanation:

      The patient is experiencing pins and needles and pain in the thumb and index finger, which worsens at night. These symptoms are indicative of carpal tunnel syndrome, which occurs when the median nerve is compressed due to increased pressure in the carpal tunnel. The distribution of the patient’s symptoms aligns with the area supplied by the median nerve.

      The inferior lateral cutaneous nerve does not innervate the thumb and index finger, so it cannot explain the patient’s symptoms. Damage to the musculocutaneous nerve would cause weakness in the upper arm flexors and impaired sensation in the lateral forearm, but not in the thumb and index finger.

      The radial nerve is responsible for wrist extension, and damage to it would result in wrist drop and altered sensation in the dorsum of the hand. The ulnar nerve causes clawing of the hand and paraesthesia in the medial two fingers when damaged, which is not consistent with the patient’s symptoms.

      Upper limb anatomy is a common topic in examinations, and it is important to know certain facts about the nerves and muscles involved. The musculocutaneous nerve is responsible for elbow flexion and supination, and typically only injured as part of a brachial plexus injury. The axillary nerve controls shoulder abduction and can be damaged in cases of humeral neck fracture or dislocation, resulting in a flattened deltoid. The radial nerve is responsible for extension in the forearm, wrist, fingers, and thumb, and can be damaged in cases of humeral midshaft fracture, resulting in wrist drop. The median nerve controls the LOAF muscles and can be damaged in cases of carpal tunnel syndrome or elbow injury. The ulnar nerve controls wrist flexion and can be damaged in cases of medial epicondyle fracture, resulting in a claw hand. The long thoracic nerve controls the serratus anterior and can be damaged during sports or as a complication of mastectomy, resulting in a winged scapula. The brachial plexus can also be damaged, resulting in Erb-Duchenne palsy or Klumpke injury, which can cause the arm to hang by the side and be internally rotated or associated with Horner’s syndrome, respectively.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      64.2
      Seconds
  • Question 8 - A 35-year-old woman arrives at the Emergency Department with a sudden onset of...

    Correct

    • A 35-year-old woman arrives at the Emergency Department with a sudden onset of painless left-sided facial weakness, along with difficulty speaking and a drooping mouth. She expresses concern about having a stroke, but her medical history is unremarkable. Upon further examination, you rule out a stroke and suspect that she may be experiencing Bell's palsy, an unexplained paralysis of the facial nerve.

      What signs would you anticipate discovering during the examination?

      Your Answer: Taste impairment of the anterior tongue

      Explanation:

      The facial nerve’s chorda tympani branch is responsible for providing taste sensation to the anterior two-thirds of the tongue. Bell’s palsy is a condition characterized by unilateral facial nerve weakness or paralysis, which can result in impaired taste sensation in the anterior tongue.

      Upper motor neuron lesions typically spare the forehead, as alternative nerve routes can still provide innervation. In contrast, lower motor neuron lesions like Bell’s palsy can cause forehead paralysis.

      While ptosis may occur in Bell’s palsy, it typically presents unilaterally rather than bilaterally.

      Although patients with Bell’s palsy may complain of tearing eyes, tear production is actually decreased due to loss of control of the eyelids and facial muscles.

      The facial nerve controls the motor aspect of the corneal reflex, so an abnormal corneal reflex may be observed in Bell’s palsy.

      Nerve Supply of the Tongue

      The tongue is a complex organ that plays a crucial role in speech and taste. It is innervated by three different cranial nerves, each responsible for different functions. The anterior two-thirds of the tongue receive general sensation from the lingual branch of the mandibular division of the trigeminal nerve (CN V3) and taste sensation from the chorda tympani branch of the facial nerve (CN VII). On the other hand, the posterior one-third of the tongue receives both general sensation and taste sensation from the glossopharyngeal nerve (CN IX).

      In terms of motor function, the hypoglossal nerve (CN XII) is responsible for controlling the movements of the tongue. It is important to note that the tongue’s nerve supply is essential for proper functioning, and any damage to these nerves can result in speech and taste disorders.

    • This question is part of the following fields:

      • Gastrointestinal System
      106.3
      Seconds
  • Question 9 - The initial root of the brachial plexus typically emerges at what level? ...

    Correct

    • The initial root of the brachial plexus typically emerges at what level?

      Your Answer: C5

      Explanation:

      The nerve plexus originates from the level of C5 and consists of 5 primary nerve roots. It ultimately gives rise to a total of 15 nerves, including the major nerves that innervate the upper limb such as the axillary, radial, ulnar, musculocutaneous, and median nerves.

      Understanding the Brachial Plexus and Cutaneous Sensation of the Upper Limb

      The brachial plexus is a network of nerves that originates from the anterior rami of C5 to T1. It is divided into five sections: roots, trunks, divisions, cords, and branches. To remember these sections, a common mnemonic used is Real Teenagers Drink Cold Beer.

      The roots of the brachial plexus are located in the posterior triangle and pass between the scalenus anterior and medius muscles. The trunks are located posterior to the middle third of the clavicle, with the upper and middle trunks related superiorly to the subclavian artery. The lower trunk passes over the first rib posterior to the subclavian artery. The divisions of the brachial plexus are located at the apex of the axilla, while the cords are related to the axillary artery.

      The branches of the brachial plexus provide cutaneous sensation to the upper limb. This includes the radial nerve, which provides sensation to the posterior arm, forearm, and hand; the median nerve, which provides sensation to the palmar aspect of the thumb, index, middle, and half of the ring finger; and the ulnar nerve, which provides sensation to the palmar and dorsal aspects of the fifth finger and half of the ring finger.

      Understanding the brachial plexus and its branches is important in diagnosing and treating conditions that affect the upper limb, such as nerve injuries and neuropathies. It also helps in understanding the cutaneous sensation of the upper limb and how it relates to the different nerves of the brachial plexus.

    • This question is part of the following fields:

      • Neurological System
      26
      Seconds
  • Question 10 - What is the term used to describe a drug that binds to the...

    Correct

    • What is the term used to describe a drug that binds to the same receptor as an agonist but is unable to produce a comparable effect even with increasing doses?

      Your Answer: Partial agonist

      Explanation:

      Agonists, Antagonists, and Partial Agonists

      Agonists, antagonists, and partial agonists are terms used to describe drugs that interact with receptors in the body. Competitive antagonists work by binding to the same receptor site as the agonist, preventing it from binding and producing its effect. However, increasing the concentration of the agonist can overcome this effect.

      Allosteric drugs, on the other hand, act at a site separate from the receptor site of the agonist. This can either enhance or inhibit the effect of the agonist. Partial agonists, like buprenorphine, produce a weaker effect than a full agonist. When combined with a full agonist, like morphine, the overall effect is decreased, leading to poor pain control.

      the differences between agonists, antagonists, and partial agonists is important in the development and use of drugs for various medical conditions. By targeting specific receptors in the body, these drugs can produce a desired effect or block unwanted effects. Proper dosing and combination of these drugs can lead to effective treatment and management of various conditions.

    • This question is part of the following fields:

      • Pharmacology
      11.1
      Seconds
  • Question 11 - A 32-year-old man with a history of psoriasis visits his doctor complaining of...

    Correct

    • A 32-year-old man with a history of psoriasis visits his doctor complaining of new lesions on his back. He mentions that he has only ever had lesions on his knees and elbows before and is worried. Upon further inquiry, the patient discloses that he recently got a tattoo on his back, which is only a week old. He also notes that the new lesions appeared shortly after getting the tattoo. The doctor considers a phenomenon in which new psoriatic lesions develop after skin trauma in patients with psoriasis. What is the term for this phenomenon?

      Your Answer: Koebner

      Explanation:

      The Koebner phenomenon is a term used to describe the appearance of skin lesions at the site of injury. Patients with a history of psoriasis and recent skin trauma are at risk of developing this phenomenon, which can also occur in individuals with other skin conditions like warts and vitiligo. Lichen planus is another condition where the Koebner phenomenon is observed. In contrast, the Nikolsky phenomenon is a dermatological phenomenon seen in pemphigus vulgaris, where the epidermis can be moved over the dermis upon palpation. Psoriatic arthritis is a type of arthritis that affects some individuals with psoriasis, causing joint inflammation, pain, stiffness, and swelling.

      The Koebner Phenomenon: Skin Lesions at the Site of Injury

      The Koebner phenomenon refers to the occurrence of skin lesions at the site of injury. This phenomenon is commonly observed in various skin conditions such as psoriasis, vitiligo, warts, lichen planus, lichen sclerosus, and molluscum contagiosum. In other words, if a person with any of these skin conditions experiences trauma or injury to their skin, they may develop new lesions in the affected area.

      This phenomenon is named after Heinrich Koebner, a German dermatologist who first described it in 1876. The exact mechanism behind the Koebner phenomenon is not fully understood, but it is believed to be related to the immune system’s response to injury. In some cases, the injury may trigger an autoimmune response, leading to the development of new lesions.

      The Koebner phenomenon can be a frustrating and challenging aspect of managing skin conditions. It is important for individuals with these conditions to take precautions to avoid injury to their skin, such as wearing protective clothing or avoiding activities that may cause trauma. Additionally, prompt treatment of any new lesions that develop can help prevent further spread of the condition.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      193
      Seconds
  • Question 12 - A 65-year-old woman visits her doctor complaining of consistent abdominal bloating over the...

    Incorrect

    • A 65-year-old woman visits her doctor complaining of consistent abdominal bloating over the past 3 months. She reports no other symptoms and her physical examination appears normal. However, she is anxious as her acquaintance experienced comparable symptoms before being diagnosed with an advanced gynecological cancer. What diagnostic test should be conducted to assess her likelihood of having ovarian cancer?

      Your Answer: Diagnostic laparotomy

      Correct Answer: CA125

      Explanation:

      The patient’s symptom is non-specific and could have various causes. However, given her age and the fact that she has lost a friend to ovarian cancer, it is reasonable to perform a simple test to rule out this possibility and alleviate her concerns. It is important to note that the patient does not exhibit any other common symptoms associated with ovarian cancer, such as weight loss.

      CA-125 is a tumour marker for ovarian cancer, while CA19-9 is associated with pancreatic cancer. CEA is a marker for bowel cancer, and colonoscopy may be considered if the patient presents with additional symptoms that suggest gastrointestinal disease.

      Understanding Ovarian Cancer: Risk Factors, Symptoms, and Management

      Ovarian cancer is a type of cancer that affects women, with the peak age of incidence being 60 years. It is the fifth most common malignancy in females and carries a poor prognosis due to late diagnosis. Around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas. Interestingly, recent studies suggest that the distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancers.

      There are several risk factors associated with ovarian cancer, including a family history of mutations of the BRCA1 or the BRCA2 gene, early menarche, late menopause, and nulliparity. Clinical features of ovarian cancer are notoriously vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms, early satiety, and diarrhea.

      To diagnose ovarian cancer, a CA125 test is usually done initially. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 should not be used for screening for ovarian cancer in asymptomatic women. Diagnosis is difficult and usually involves diagnostic laparotomy.

      Management of ovarian cancer usually involves a combination of surgery and platinum-based chemotherapy. The prognosis for ovarian cancer is poor, with 80% of women having advanced disease at presentation and the all stage 5-year survival being 46%. It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. However, recent evidence suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies.

    • This question is part of the following fields:

      • Reproductive System
      141
      Seconds
  • Question 13 - A 58-year-old man is having a superficial parotidectomy for a pleomorphic adenoma. What...

    Incorrect

    • A 58-year-old man is having a superficial parotidectomy for a pleomorphic adenoma. What is the most superficially located structure encountered during the dissection of the parotid?

      Your Answer: Retromandibular vein

      Correct Answer: Facial nerve

      Explanation:

      The facial nerve is situated at the surface of the parotid gland, followed by the retromandibular vein at a slightly deeper level, and the arterial layer at the deepest level.

      The parotid gland is located in front of and below the ear, overlying the mandibular ramus. Its salivary duct crosses the masseter muscle, pierces the buccinator muscle, and drains adjacent to the second upper molar tooth. The gland is traversed by several structures, including the facial nerve, external carotid artery, retromandibular vein, and auriculotemporal nerve. The gland is related to the masseter muscle, medial pterygoid muscle, superficial temporal and maxillary artery, facial nerve, stylomandibular ligament, posterior belly of the digastric muscle, sternocleidomastoid muscle, stylohyoid muscle, internal carotid artery, mastoid process, and styloid process. The gland is supplied by branches of the external carotid artery and drained by the retromandibular vein. Its lymphatic drainage is to the deep cervical nodes. The gland is innervated by the parasympathetic-secretomotor, sympathetic-superior cervical ganglion, and sensory-greater auricular nerve. Parasympathetic stimulation produces a water-rich, serous saliva, while sympathetic stimulation leads to the production of a low volume, enzyme-rich saliva.

    • This question is part of the following fields:

      • Gastrointestinal System
      68.5
      Seconds
  • Question 14 - A 35-year-old woman presents to the medical assessment unit with sudden onset shortness...

    Incorrect

    • A 35-year-old woman presents to the medical assessment unit with sudden onset shortness of breath. She reports no cough or fever and has no other associated symptoms. She recently returned from a hiking trip in France and takes the oral contraceptive pill but no other regular medications. She smokes 10 cigarettes a day but drinks no alcohol. On examination, she is tachypnoeic and tachycardic with an elevated JVP. Her calves are soft and non-tender with no pitting oedema. Initial blood tests show a positive D-dimer and elevated CRP. What is the appropriate treatment for this patient?

      Your Answer: Urgent thrombolysis with alteplase

      Correct Answer: Low molecular weight heparin

      Explanation:

      Treatment for Suspected Pulmonary Embolism

      When a patient presents with risk factors for pulmonary embolism (PE) such as recent travel and oral contraceptive pill use, along with symptoms like tachypnea, tachycardia, and hypoxia, it is important to consider the possibility of a significant PE. In such cases, treatment with low molecular weight heparin should be given promptly to prevent further complications. A low-grade fever is also common in venothromboembolic disease. Elevated JVP signifies significant right heart strain due to a significant PE, but maintained blood pressure is a positive sign.

      The most common ECG finding in PE is an isolated sinus tachycardia, while the CXR may be clear, but prominent pulmonary arteries reflect pulmonary hypertension due to clot load in the pulmonary tree. A D-dimer test is recommended if the Wells score for PE is less than 4.

      According to NICE guidelines on venous thromboembolic diseases, low molecular weight heparin is the appropriate initial treatment for suspected PE. It is important not to delay treatment to await CTPA unless it can be performed immediately. There is no evidence of pneumonia to warrant IV antibiotics. Unfractionated heparin may be considered for patients with an eGFR of less than 30, high risk of bleeding, or those undergoing thrombolysis, but this is not the case with this patient. Thrombolysis is not indicated unless there is haemodynamic instability, even in suspected large PEs.

      In summary, prompt treatment with low molecular weight heparin is crucial in suspected cases of PE, and other treatment options should be considered based on individual patient factors.

    • This question is part of the following fields:

      • Respiratory System
      80.8
      Seconds
  • Question 15 - A 27-year-old man with Von Willebrand's disease is scheduled for an intravenous infusion...

    Correct

    • A 27-year-old man with Von Willebrand's disease is scheduled for an intravenous infusion of desmopressin acetate. The medication works by triggering the release of von Willebrand factor from cells, which enhances factor VIII and the creation of the platelet plug in clotting. What substance is responsible for maintaining blood solubility and preventing platelet activation in individuals without clotting disorders?

      Your Answer: Prostacyclin

      Explanation:

      Understanding the coagulation cascade is crucial, but it’s also important to know the substances that the body secretes to maintain normal blood vessel function and prevent excessive clotting. In primary haemostasis, the formation of a platelet plug is a critical step, and several substances in the blood vessels work against platelet activation to keep the blood flowing smoothly.

      Prostacyclin, which is produced from arachidonic acid, inhibits platelet activation. Nitric oxide prevents platelet adhesion to the vessel wall and also dilates blood vessels to increase blood flow. Endothelial ADPase inhibits ADP, which is a platelet activator.

      Fibrinogen, a large and soluble compound, is the precursor to fibrin, which forms an insoluble mesh to trap blood cells and platelets within a clot. This is the final step of the coagulation cascade, and the clot is further strengthened by fibrin-stabilising factor. Thromboxane, produced by activated platelets, increases platelet activation and constricts blood vessels, making it another thrombotic agent. Aggregated platelets produce ADP, which further enhances platelet aggregation.

      The Coagulation Cascade: Two Pathways to Fibrin Formation

      The coagulation cascade is a complex process that leads to the formation of a blood clot. There are two pathways that can lead to fibrin formation: the intrinsic pathway and the extrinsic pathway. The intrinsic pathway involves components that are already present in the blood and has a minor role in clotting. It is initiated by subendothelial damage, such as collagen, which leads to the formation of the primary complex on collagen by high-molecular-weight kininogen (HMWK), prekallikrein, and Factor 12. This complex activates Factor 11, which in turn activates Factor 9. Factor 9, along with its co-factor Factor 8a, forms the tenase complex, which activates Factor 10.

      The extrinsic pathway, on the other hand, requires tissue factor released by damaged tissue. This pathway is initiated by tissue damage, which leads to the binding of Factor 7 to tissue factor. This complex activates Factor 9, which works with Factor 8 to activate Factor 10. Both pathways converge at the common pathway, where activated Factor 10 causes the conversion of prothrombin to thrombin. Thrombin hydrolyses fibrinogen peptide bonds to form fibrin and also activates factor 8 to form links between fibrin molecules.

      Finally, fibrinolysis occurs, which is the process of clot resorption. Plasminogen is converted to plasmin to facilitate this process. It is important to note that certain factors are involved in both pathways, such as Factor 10, and that some factors are vitamin K dependent, such as Factors 2, 7, 9, and 10. The intrinsic pathway can be assessed by measuring the activated partial thromboplastin time (APTT), while the extrinsic pathway can be assessed by measuring the prothrombin time (PT).

    • This question is part of the following fields:

      • Haematology And Oncology
      27.1
      Seconds
  • Question 16 - A 28-year-old mother brings her newborn son to the GP for his six-week...

    Incorrect

    • A 28-year-old mother brings her newborn son to the GP for his six-week check-up. She mentions that her son had vitamin K deficiency bleeding at three days old but has since recovered and is receiving vitamin K replacement. Which clotting factor is reliant on this vitamin?

      Your Answer: Clotting factor XII

      Correct Answer: Clotting factor II

      Explanation:

      Vitamin K plays a crucial role as a cofactor in the carboxylation process of clotting factors II, VII, IX, and X. Additionally, vitamin K is essential for the formation of protein C, S, and Z.

      Although previously known as the haemorrhage disease of the newborn, Vitamin K deficiency bleeding (VKDB) is now the preferred term. While rare in the UK, VKDB can occur in breastfed babies whose parents have refused prophylaxis.

      Furthermore, vitamin K is a fat-soluble vitamin, and its levels may decrease in conditions that affect fat absorption, such as cystic fibrosis and short bowel syndrome.

      Understanding Vitamin K

      Vitamin K is a type of fat-soluble vitamin that plays a crucial role in the carboxylation of clotting factors such as II, VII, IX, and X. This vitamin acts as a cofactor in the process, which is essential for blood clotting. In clinical settings, vitamin K is used to reverse the effects of warfarinisation, a process that inhibits blood clotting. However, it may take up to four hours for the INR to change after administering vitamin K.

      Vitamin K deficiency can occur in conditions that affect fat absorption since it is a fat-soluble vitamin. Additionally, prolonged use of broad-spectrum antibiotics can eliminate gut flora, leading to a deficiency in vitamin K. It is essential to maintain adequate levels of vitamin K to ensure proper blood clotting and prevent bleeding disorders.

    • This question is part of the following fields:

      • General Principles
      36.3
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  • Question 17 - A 30-year-old woman has recently been diagnosed with epilepsy and is planning to...

    Incorrect

    • A 30-year-old woman has recently been diagnosed with epilepsy and is planning to start a family soon. She has come to see you, her GP, to discuss the treatment options for epilepsy and which medications are safe to take during pregnancy.

      Which of the following drugs poses the highest risk of causing neural tube defects?

      Your Answer: Phenobarbital

      Correct Answer: Sodium valproate

      Explanation:

      Women of childbearing potential should not be prescribed sodium valproate due to its high association with neural tube defects, as well as craniofacial abnormalities and distal digit hypoplasia. Among antiepileptics, it has the highest rate of causing these defects.

      Harmful Drugs and Medical Conditions for Developing Fetuses

      During pregnancy, certain drugs and medical conditions can harm the developing fetus. These harmful substances and conditions are known as teratogens. Some examples of teratogens include ACE inhibitors, alcohol, aminoglycosides, carbamazepine, chloramphenicol, cocaine, diethylstilbesterol, lithium, maternal diabetes mellitus, smoking, tetracyclines, thalidomide, and warfarin.

      ACE inhibitors can cause renal dysgenesis and craniofacial abnormalities in the fetus. Alcohol consumption during pregnancy can lead to craniofacial abnormalities. Aminoglycosides can cause ototoxicity. Carbamazepine can result in neural tube defects and craniofacial abnormalities. Chloramphenicol can cause grey baby syndrome. Cocaine use during pregnancy can lead to intrauterine growth retardation and preterm labor. Diethylstilbesterol can cause vaginal clear cell adenocarcinoma. Lithium can result in Ebstein’s anomaly, which is an atrialized right ventricle. Maternal diabetes mellitus can cause macrosomia, neural tube defects, polyhydramnios, preterm labor, and caudal regression syndrome. Smoking during pregnancy can lead to preterm labor and intrauterine growth retardation. Tetracyclines can cause discolored teeth. Thalidomide can result in limb reduction defects. Valproate can cause neural tube defects and craniofacial abnormalities. Warfarin can lead to craniofacial abnormalities in the fetus.

      It is important for pregnant women to avoid exposure to these harmful substances and conditions to ensure the healthy development of their fetus.

    • This question is part of the following fields:

      • General Principles
      24.2
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  • Question 18 - A 25-year-old man gets into a brawl and receives a cut on the...

    Correct

    • A 25-year-old man gets into a brawl and receives a cut on the back of his right arm, about 2 cm above the olecranon process. Upon examination at the ER, he is unable to straighten his elbow. Which tendon is the most probable one to have been severed?

      Your Answer: Triceps

      Explanation:

      The elbow joint is extended by the triceps muscle, while the remaining muscles listed are responsible for flexion of the elbow joint.

      Anatomy of the Triceps Muscle

      The triceps muscle is a large muscle located on the back of the upper arm. It is composed of three heads: the long head, lateral head, and medial head. The long head originates from the infraglenoid tubercle of the scapula, while the lateral head originates from the dorsal surface of the humerus, lateral and proximal to the groove of the radial nerve. The medial head originates from the posterior surface of the humerus on the inferomedial side of the radial groove and both of the intermuscular septae.

      All three heads of the triceps muscle insert into the olecranon process of the ulna, with some fibers inserting into the deep fascia of the forearm and the posterior capsule of the elbow. The triceps muscle is innervated by the radial nerve and supplied with blood by the profunda brachii artery.

      The primary action of the triceps muscle is elbow extension. The long head can also adduct the humerus and extend it from a flexed position. The radial nerve and profunda brachii vessels lie between the lateral and medial heads of the triceps muscle. Understanding the anatomy of the triceps muscle is important for proper diagnosis and treatment of injuries or conditions affecting this muscle.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      23
      Seconds
  • Question 19 - A teenage boy is in a car crash and experiences a spinal cord...

    Correct

    • A teenage boy is in a car crash and experiences a spinal cord injury resulting in a hemisection of his spinal cord. What clinical features will he exhibit on examination below the level of injury?

      Your Answer: Weakness and loss of light touch sensation on the same side and loss of pain on the opposite side

      Explanation:

      When a hemisection of the spinal cord occurs, it results in a condition known as Brown-Sequard syndrome. This condition is characterized by sensory and motor loss on the same side of the injury, as well as pain loss on the opposite side. The loss of motor function on the same side is due to damage to the corticospinal tract, which does not cross over within the spinal cord but instead decussates in the brainstem. Similarly, the loss of light touch on the same side is due to damage to the dorsal column, which also decussates in the brainstem. In contrast, the loss of pain on the opposite side is due to damage to the spinothalamic tract, which decussates at the level of sensory input. As a result, pain signals are always carried on the opposite side of the spinal cord, while motor and light touch signals are carried on the same side as the injury.

      Understanding Brown-Sequard Syndrome

      Brown-Sequard syndrome is a condition that occurs when there is a lateral hemisection of the spinal cord. This condition is characterized by a combination of symptoms that affect the body’s ability to sense and move. Individuals with Brown-Sequard syndrome experience weakness on the same side of the body as the lesion, as well as a loss of proprioception and vibration sensation on that side. On the opposite side of the body, there is a loss of pain and temperature sensation.

      It is important to note that the severity of Brown-Sequard syndrome can vary depending on the location and extent of the spinal cord injury. Some individuals may experience only mild symptoms, while others may have more severe impairments. Treatment for Brown-Sequard syndrome typically involves a combination of physical therapy, medication, and other supportive measures to help manage symptoms and improve overall quality of life.

    • This question is part of the following fields:

      • Neurological System
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  • Question 20 - A 16-year-old boy presents to the hospital with suspected appendicitis. Upon examination, he...

    Correct

    • A 16-year-old boy presents to the hospital with suspected appendicitis. Upon examination, he exhibits maximum tenderness at McBurney's point. Can you identify the location of McBurney's point?

      Your Answer: 2/3rds laterally along the line between the umbilicus and the anterior superior iliac spine

      Explanation:

      To locate McBurney’s point, one should draw an imaginary line from the umbilicus to the anterior superior iliac spine on the right-hand side and then find the point that is 2/3rds of the way along this line. The other choices do not provide the correct location for this anatomical landmark.

      Acute appendicitis is a common condition that requires surgery and can occur at any age, but is most prevalent in young people aged 10-20 years. The pathogenesis of acute appendicitis involves lymphoid hyperplasia or a faecolith, which leads to obstruction of the appendiceal lumen. This obstruction causes gut organisms to invade the appendix wall, resulting in oedema, ischaemia, and possibly perforation.

      The most common symptom of acute appendicitis is abdominal pain, which is typically peri-umbilical and radiates to the right iliac fossa due to localised peritoneal inflammation. Other symptoms include mild pyrexia, anorexia, and nausea. Examination may reveal generalised or localised peritonism, rebound and percussion tenderness, guarding and rigidity, and classical signs such as Rovsing’s sign and psoas sign.

      Diagnosis of acute appendicitis is typically based on raised inflammatory markers and compatible history and examination findings. Imaging may be used in certain cases, such as ultrasound in females where pelvic organ pathology is suspected. Management of acute appendicitis involves appendicectomy, which can be performed via an open or laparoscopic approach. Patients with perforated appendicitis require copious abdominal lavage, while those without peritonitis who have an appendix mass should receive broad-spectrum antibiotics and consideration given to performing an interval appendicectomy. Intravenous antibiotics alone have been trialled as a treatment for appendicitis, but evidence suggests that this is associated with a longer hospital stay and up to 20% of patients go on to have an appendicectomy within 12 months.

    • This question is part of the following fields:

      • Gastrointestinal System
      62.4
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  • Question 21 - What is the apoptotic event that occurs just before the formation of an...

    Incorrect

    • What is the apoptotic event that occurs just before the formation of an apoptosome?

      Your Answer: Activation of caspase-9

      Correct Answer: Release of cytochrome c from mitochondria

      Explanation:

      Apoptosis and the Role of the Apoptosome

      Apoptosis, also known as programmed cell death, is a natural process that occurs in all multicellular organisms. It involves a series of changes in cell morphology, including membrane blebbing, cell shrinkage, nuclear fragmentation, chromatin condensation, and chromosomal DNA fragmentation. The formation of the apoptosome is a crucial part of the apoptosis cascade. It is a large protein structure that is triggered by the release of cytochrome c from the mitochondria in response to various stimuli, such as DNA damage, infections, or developmental signals.

      The apoptosome is formed when cytochrome c binds to Apaf-1, a cytosolic protein, in a 1:1 ratio. This triggers the recruitment and activation of the initiator pro-caspase-9, which then activates effector caspases, a family of apoptotic proteases, to initiate the apoptotic cascade. It is important to note that the activation of caspase-9 occurs only after the formation of the apoptosome.

      In summary, apoptosis is a natural process that occurs in multicellular organisms, and the apoptosome plays a crucial role in triggering the apoptotic cascade. the mechanisms behind apoptosis and the formation of the apoptosome can provide insights into various diseases and developmental processes.

    • This question is part of the following fields:

      • Basic Sciences
      33.3
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  • Question 22 - A 16-year-old girl complains of pain in her right iliac fossa and is...

    Incorrect

    • A 16-year-old girl complains of pain in her right iliac fossa and is diagnosed with acute appendicitis. You bring her to the operating room for a laparoscopic appendectomy. While performing the procedure, you are distracted by the scrub nurse and accidentally tear the appendicular artery, causing significant bleeding. Which vessel is likely to be the primary source of the hemorrhage?

      Your Answer: Superior mesenteric artery

      Correct Answer: Ileo-colic artery

      Explanation:

      The ileocolic artery gives rise to the appendicular artery.

      Appendix Anatomy and Location

      The appendix is a small, finger-like projection located at the base of the caecum. It can be up to 10cm long and is mainly composed of lymphoid tissue, which can sometimes lead to confusion with mesenteric adenitis. The caecal taenia coli converge at the base of the appendix, forming a longitudinal muscle cover over it. This convergence can aid in identifying the appendix during surgery, especially if it is retrocaecal and difficult to locate. The arterial supply to the appendix comes from the appendicular artery, which is a branch of the ileocolic artery. It is important to note that the appendix is intra-peritoneal.

      McBurney’s Point and Appendix Positions

      McBurney’s point is a landmark used to locate the appendix during physical examination. It is located one-third of the way along a line drawn from the Anterior Superior Iliac Spine to the Umbilicus. The appendix can be found in six different positions, with the retrocaecal position being the most common at 74%. Other positions include pelvic, postileal, subcaecal, paracaecal, and preileal. It is important to be aware of these positions as they can affect the presentation of symptoms and the difficulty of locating the appendix during surgery.

    • This question is part of the following fields:

      • Gastrointestinal System
      47.3
      Seconds
  • Question 23 - A 68-year-old woman arrives at the emergency department with a complaint of a...

    Correct

    • A 68-year-old woman arrives at the emergency department with a complaint of a painful, red toe. The pain began a few hours ago and has been getting worse. Upon examination, her 1st metatarsophalangeal joint is inflamed, erythematous, and tender to the touch.

      What are the joint aspiration findings that would confirm a gout flare diagnosis?

      Your Answer: Negatively birefringent needle-shaped monosodium urate crystals

      Explanation:

      Joint aspiration is a valuable diagnostic tool for differentiating between various causes of joint swelling, including septic arthritis and pseudogout. In the case of gout, joint aspiration will reveal needle-shaped monosodium urate crystals that are negatively birefringent under polarised light. These crystals form when uric acid levels remain persistently high and deposit in tissues, leading to the characteristic inflammatory response seen in gout.

      It is important to note that a green-colored aspirate with a positive gram stain for Staphylococcus aureus is not indicative of gout, but rather suggests septic arthritis. In this case, the aspirate may have a raised white cell count and appear yellow or green.

      Similarly, the presence of negatively birefringent needle-shaped calcium oxalate crystals is not associated with gout, but rather with kidney stones. These crystals form when there are high concentrations of calcium oxalate in the urine and are typically octahedral or envelope-shaped.

      Finally, positively birefringent rhomboid-shaped calcium pyrophosphate crystals are not seen in gout, but rather in pseudogout. Pseudogout presents with similar symptoms to gout and more commonly affects the knee joint.

      Understanding Gout: Symptoms and Diagnosis

      Gout is a type of arthritis that causes inflammation and pain in the joints. Patients experience episodes of intense pain that can last for several days, followed by periods of no symptoms. The acute episodes usually reach their peak within 12 hours and can affect various joints, with the first metatarsophalangeal joint being the most commonly affected. Swelling and redness are also common symptoms of gout.

      If left untreated, repeated acute episodes of gout can lead to joint damage and chronic joint problems. To diagnose gout, doctors may perform synovial fluid analysis to look for needle-shaped, negatively birefringent monosodium urate crystals under polarised light. Uric acid levels may also be checked once the acute episode has subsided, as they can be high, normal, or low during the attack.

      Radiological features of gout include joint effusion, well-defined punched-out erosions with sclerotic margins, and eccentric erosions. Unlike rheumatoid arthritis, gout does not cause periarticular osteopenia. Soft tissue tophi may also be visible.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      28.2
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  • Question 24 - A 72-year-old man who had mitral valve surgery three months ago comes in...

    Correct

    • A 72-year-old man who had mitral valve surgery three months ago comes in with worsening dyspnea. An echocardiogram reveals vegetations on the anterior leaflet of the mitral valve. What is the probable causative agent?

      Your Answer: Staphylococcus aureus

      Explanation:

      Endocarditis and Common Causative Organisms

      Endocarditis is a condition where the inner lining of the heart, particularly the valves, becomes infected. Staphylococcus aureus is the most frequent cause of endocarditis within six months of cardiac surgery. A woman who presents with cardiac failure due to acute endocarditis can be diagnosed through echocardiography, which shows vegetation, and other clinical parameters. However, blood cultures are also necessary to identify the organism responsible for the infection. Given the recent history of valvular surgery, Staphylococcus aureus contamination during the operation is the most likely cause. Coagulase negative Staphylococcus should also be considered. Streptococcus pyogenes is the second most common cause of infective endocarditis, but it tends to cause subacute disease with symptoms such as fever, weight loss, general malaise, and anemia. Although all other organisms can cause infective endocarditis, they are less common causes.

    • This question is part of the following fields:

      • Clinical Sciences
      22.4
      Seconds
  • Question 25 - What is the more commonly recognized name for the compound referred to as...

    Correct

    • What is the more commonly recognized name for the compound referred to as vitamin E?

      Your Answer: Alpha tocopherol

      Explanation:

      Vitamin E and Other Essential Nutrients

      Vitamin E is a group of compounds that includes alpha tocopherol, beta tocopherol, gamma tocopherol, and delta tocopherol. While each of these compounds contains vitamin E activity, alpha tocopherol is the most biologically active and abundant form of vitamin E in the diet. Vitamin E plays a crucial role in protecting cells and proteins from oxidative damage by removing free radicals. It also has antithrombotic effects, which means it impairs the action of thromboxane and thrombin, reducing blood clotting and platelet aggregation.

      Adults are recommended to consume at least 15 mg of vitamin E daily, but larger quantities may also be beneficial. Good sources of vitamin E in the diet include sunflower oil, wheatgerm, and unprocessed cereals. In addition to vitamin E, other essential nutrients include alpha 1 antitrypsin, which prevents alveolar damage and lung dysfunction, beta carotene, which is responsible for vision development, boron, which is important for bone health, and thiamine, which can lead to polyneuropathy and heart failure if deficient. these essential nutrients and their roles in the body can help individuals make informed decisions about their diet and overall health.

    • This question is part of the following fields:

      • Clinical Sciences
      18.5
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  • Question 26 - A 27-year-old man, who has a history of epilepsy, attends a follow-up appointment...

    Correct

    • A 27-year-old man, who has a history of epilepsy, attends a follow-up appointment at neurology outpatients. He reports experiencing a prodrome of aura before having floaters in his vision and unusual flashes of color during the ictal phase. The patient has no other notable symptoms or medical history. Which region of the brain is linked to the symptoms described by this patient?

      Your Answer: Occipital lobe

      Explanation:

      Occipital lobe seizures are associated with visual disturbances such as floaters and flashes. The cerebellum is not typically associated with epilepsy, although recent research has potentially implicated this area in refractory epilepsy. Seizures in the frontal lobe can cause random hand and leg movements and abnormal posturing, while seizures in the parietal lobe can cause sensory disturbances such as paraesthesia.

      Localising Features of Focal Seizures in Epilepsy

      Focal seizures in epilepsy can be localised based on the specific location of the brain where they occur. Temporal lobe seizures are common and may occur with or without impairment of consciousness or awareness. Most patients experience an aura, which is typically a rising epigastric sensation, along with psychic or experiential phenomena such as déjà vu or jamais vu. Less commonly, hallucinations may occur, such as auditory, gustatory, or olfactory hallucinations. These seizures typically last around one minute and are often accompanied by automatisms, such as lip smacking, grabbing, or plucking.

      On the other hand, frontal lobe seizures are characterised by motor symptoms such as head or leg movements, posturing, postictal weakness, and Jacksonian march. Parietal lobe seizures, on the other hand, are sensory in nature and may cause paraesthesia. Finally, occipital lobe seizures may cause visual symptoms such as floaters or flashes. By identifying the specific location and type of seizure, doctors can better diagnose and treat epilepsy in patients.

    • This question is part of the following fields:

      • Neurological System
      24.5
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  • Question 27 - A 35-year-old motorcyclist is in a road traffic collision resulting in a severely...

    Incorrect

    • A 35-year-old motorcyclist is in a road traffic collision resulting in a severely displaced humerus fracture. During surgical repair, the surgeon observes an injury to the radial nerve. Which of the following muscles is most likely to be unaffected by this injury?

      Your Answer: Abductor pollicis longus

      Correct Answer: None of the above

      Explanation:

      BEST

      The Radial Nerve: Anatomy, Innervation, and Patterns of Damage

      The radial nerve is a continuation of the posterior cord of the brachial plexus, with root values ranging from C5 to T1. It travels through the axilla, posterior to the axillary artery, and enters the arm between the brachial artery and the long head of triceps. From there, it spirals around the posterior surface of the humerus in the groove for the radial nerve before piercing the intermuscular septum and descending in front of the lateral epicondyle. At the lateral epicondyle, it divides into a superficial and deep terminal branch, with the deep branch crossing the supinator to become the posterior interosseous nerve.

      The radial nerve innervates several muscles, including triceps, anconeus, brachioradialis, and extensor carpi radialis. The posterior interosseous branch innervates supinator, extensor carpi ulnaris, extensor digitorum, and other muscles. Denervation of these muscles can lead to weakness or paralysis, with effects ranging from minor effects on shoulder stability to loss of elbow extension and weakening of supination of prone hand and elbow flexion in mid prone position.

      Damage to the radial nerve can result in wrist drop and sensory loss to a small area between the dorsal aspect of the 1st and 2nd metacarpals. Axillary damage can also cause paralysis of triceps. Understanding the anatomy, innervation, and patterns of damage of the radial nerve is important for diagnosing and treating conditions that affect this nerve.

    • This question is part of the following fields:

      • Neurological System
      51.9
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  • Question 28 - A 75-year-old man is scheduled for an arterial bypass surgery to treat foot...

    Correct

    • A 75-year-old man is scheduled for an arterial bypass surgery to treat foot ulceration and claudication. The distal arterial anastomosis will be formed using the anterior tibial artery. Which of the following structures is not in close proximity to it?

      Your Answer: Tibialis posterior

      Explanation:

      The anterior tibial artery is closely associated with the tibialis anterior muscle as it serves as one of the main arteries in the anterior compartment.

      The anterior tibial artery starts opposite the lower border of the popliteus muscle and ends in front of the ankle, where it continues as the dorsalis pedis artery. As it descends, it runs along the interosseous membrane, the distal part of the tibia, and the front of the ankle joint. The artery passes between the tendons of the extensor digitorum and extensor hallucis longus muscles as it approaches the ankle. The deep peroneal nerve is closely related to the artery, lying anterior to the middle third of the vessel and lateral to it in the lower third.

    • This question is part of the following fields:

      • Cardiovascular System
      35.2
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  • Question 29 - A 12-year-old girl is experiencing intense pain around her belly button that is...

    Correct

    • A 12-year-old girl is experiencing intense pain around her belly button that is spreading to her right iliac fossa. She has a fever and is vomiting on and off. The medical team has decided to perform a laparoscopic removal of her appendix. Can you identify the most frequent location of the appendix in the pelvis?

      Your Answer: Retrocaecal

      Explanation:

      Anatomy of the Appendix

      The appendix is a tube that is approximately 10 cm long and can be found in different positions in the body depending on the individual. It is most commonly located behind the caecum, which is retrocaecal, in about 65% of people. However, it can also be found in the pelvic area in around 30% of individuals. Other variations include being located below the caecum, which is subcaecal, or in front of the terminal ileum, which is pre-ileal. Additionally, it can be found behind the ileum, which is post-ileal. The position of the appendix can vary greatly from person to person, and it is important for medical professionals to be aware of these variations when diagnosing and treating conditions related to the appendix.

    • This question is part of the following fields:

      • Clinical Sciences
      101.8
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  • Question 30 - A 2-month-old boy is admitted to the neonatal intensive care unit with microcephaly....

    Correct

    • A 2-month-old boy is admitted to the neonatal intensive care unit with microcephaly. He is in the 5th percentile for weight and length, and his head circumference is <3rd percentile for his age. Upon physical examination, his lungs are clear and there are no audible murmurs, but his liver edge is palpable at the level of the umbilicus. Further investigations reveal ventriculomegaly with periventricular calcifications on a CT scan of the head. What is the most likely cause of this congenital infection?

      Your Answer: Cytomegalovirus

      Explanation:

      Congenital CMV infection can lead to various symptoms such as hearing loss, low birth weight, petechial rash, microcephaly, and seizures. This condition is typically acquired during pregnancy, and if the fetus is exposed to CMV during the first trimester, it may result in intrauterine growth retardation and central nervous system damage, leading to hearing and sight impairments.

      Infectious mononucleosis caused by Epstein-Barr virus is an uncommon cause of congenital defects. Herpes simplex virus may cause skin rashes and microcephaly, but it is not typically associated with calcifications and hepatomegaly. Toxoplasmosis often presents with macrocephaly and diffuse parenchymal calcifications rather than periventricular calcifications. Congenital syphilis can result in various symptoms such as sensorineural deafness, mulberry molars, bone lesions, saddle nose, and Hutchinson’s teeth.

      Congenital Infections: Rubella, Toxoplasmosis, and Cytomegalovirus

      Congenital infections are infections that are present at birth and can cause various health problems for the newborn. The three most common congenital infections encountered in medical examinations are rubella, toxoplasmosis, and cytomegalovirus. Of these, cytomegalovirus is the most common in the UK, and maternal infection is usually asymptomatic.

      Each of these infections can cause different characteristic features in newborns. Rubella can cause sensorineural deafness, congenital cataracts, congenital heart disease, glaucoma, cerebral calcification, chorioretinitis, hydrocephalus, low birth weight, and purpuric skin lesions. Toxoplasmosis can cause growth retardation, hepatosplenomegaly, purpuric skin lesions, ‘salt and pepper’ chorioretinitis, microphthalmia, cerebral palsy, anaemia, and microcephaly. Cytomegalovirus can cause visual impairment, learning disability, encephalitis/seizures, pneumonitis, hepatosplenomegaly, anaemia, jaundice, and cerebral palsy.

      It is important for healthcare professionals to be aware of these congenital infections and their potential effects on newborns. Early detection and treatment can help prevent or minimize the health problems associated with these infections.

    • This question is part of the following fields:

      • General Principles
      40
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  • Question 31 - A 55-year-old man, who has a history of type 2 diabetes, is prescribed...

    Incorrect

    • A 55-year-old man, who has a history of type 2 diabetes, is prescribed losartan for his hypertension due to the development of a dry cough from ramipril. Losartan works by inhibiting the activity of a substance that acts on the AT1 receptor.

      What accurately characterizes the function of this substance?

      Your Answer: Activate aquaporin in the kidney collecting duct

      Correct Answer: Increases filtration fraction through vasoconstriction of the efferent arteriole of the glomerulus to preserve GFR

      Explanation:

      Angiotensin II is responsible for increasing the filtration fraction by constricting the efferent arteriole of the glomerulus, which helps to maintain the glomerular filtration rate (GFR). This mechanism has been found to slow down the progression of diabetic nephropathy. AT1 receptor blockers such as azilsartan, candesartan, and olmesartan can also block the action of Ang II. Desmopressin activates aquaporin, which is mainly located in the collecting duct of the kidneys. Norepinephrine and epinephrine, not Ang II, can cause vasoconstriction of the afferent arteriole of the glomerulus.

      The renin-angiotensin-aldosterone system is a complex system that regulates blood pressure and fluid balance in the body. The adrenal cortex is divided into three zones, each producing different hormones. The zona glomerulosa produces mineralocorticoids, mainly aldosterone, which helps regulate sodium and potassium levels in the body. Renin is an enzyme released by the renal juxtaglomerular cells in response to reduced renal perfusion, hyponatremia, and sympathetic nerve stimulation. It hydrolyses angiotensinogen to form angiotensin I, which is then converted to angiotensin II by angiotensin-converting enzyme in the lungs. Angiotensin II has various actions, including causing vasoconstriction, stimulating thirst, and increasing proximal tubule Na+/H+ activity. It also stimulates aldosterone and ADH release, which causes retention of Na+ in exchange for K+/H+ in the distal tubule.

    • This question is part of the following fields:

      • Renal System
      177.4
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  • Question 32 - A 56-year-old male is admitted to the hospital with increasing fatigue and difficulty...

    Correct

    • A 56-year-old male is admitted to the hospital with increasing fatigue and difficulty exercising. After undergoing various tests, including echocardiography and right heart catheterization, it is determined that he has pulmonary arterial hypertension (PAH) with a mean pulmonary artery pressure of 35 mmhg and a pulmonary capillary wedge pressure of 8mmhg. One of the medications prescribed for him is ambrisentan. What is the mechanism of action of this drug?

      Your Answer: Endothelin-1 receptor antagonist

      Explanation:

      Ambrisentan is an antagonist of endothelin-1 receptors, which are involved in vasoconstriction. In pulmonary arterial hypertension (PAH), the expression of endothelin-1 is increased, leading to constriction of blood vessels. Ambrisentan selectively targets ETA receptors found in vascular smooth muscle, reducing morbidity and mortality in PAH patients. Common side effects include peripheral edema, sinusitis, flushing, and nasal congestion. Prostacyclins like PGI2 can also be used to manage PPH by dilating blood vessels and inhibiting platelet aggregation. PGE2, an inflammatory mediator, is not used in PAH treatment. PDE inhibitors like sildenafil increase cGMP levels in pulmonary vessels, relaxing vascular smooth muscle and reducing pulmonary artery pressure.

      Pulmonary arterial hypertension (PAH) is a condition where the resting mean pulmonary artery pressure is equal to or greater than 25 mmHg. The pathogenesis of PAH is thought to involve endothelin. It is more common in females and typically presents between the ages of 30-50 years. PAH is diagnosed in the absence of chronic lung diseases such as COPD, although certain factors increase the risk. Around 10% of cases are inherited in an autosomal dominant fashion.

      The classical presentation of PAH is progressive exertional dyspnoea, but other possible features include exertional syncope, exertional chest pain, peripheral oedema, and cyanosis. Physical examination may reveal a right ventricular heave, loud P2, raised JVP with prominent ‘a’ waves, and tricuspid regurgitation.

      Management of PAH should first involve treating any underlying conditions. Acute vasodilator testing is central to deciding on the appropriate management strategy. If there is a positive response to acute vasodilator testing, oral calcium channel blockers may be used. If there is a negative response, prostacyclin analogues, endothelin receptor antagonists, or phosphodiesterase inhibitors may be used. Patients with progressive symptoms should be considered for a heart-lung transplant.

    • This question is part of the following fields:

      • Cardiovascular System
      26.4
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  • Question 33 - Sophie, a 35-year-old female, is brought to the Emergency Department by ambulance after...

    Correct

    • Sophie, a 35-year-old female, is brought to the Emergency Department by ambulance after being involved in a car accident.

      Upon conducting several tests, an X-ray reveals that she has sustained a mid shaft humeral fracture.

      What is the structure that is typically most vulnerable to injury in cases of mid shaft humeral fractures?

      Your Answer: Radial nerve

      Explanation:

      The humerus is a long bone that runs from the shoulder blade to the elbow joint. It is mostly covered by muscle but can be felt throughout its length. The head of the humerus is a smooth, rounded surface that connects to the body of the bone through the anatomical neck. The surgical neck, located below the head and tubercles, is the most common site of fracture. The greater and lesser tubercles are prominences on the upper end of the bone, with the supraspinatus and infraspinatus tendons inserted into the greater tubercle. The intertubercular groove runs between the two tubercles and holds the biceps tendon. The posterior surface of the body has a spiral groove for the radial nerve and brachial vessels. The lower end of the humerus is wide and flattened, with the trochlea, coronoid fossa, and olecranon fossa located on the distal edge. The medial epicondyle is prominent and has a sulcus for the ulnar nerve and collateral vessels.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      66.7
      Seconds
  • Question 34 - You are giving a lecture to a group of nursing students on aspirin...

    Incorrect

    • You are giving a lecture to a group of nursing students on aspirin overdose and its characteristics.

      As you discuss the pathophysiology of the metabolic acidosis observed in patients with aspirin overdose, you address the root cause of the metabolic acidosis in these individuals.

      Your Answer: Increased breakdown of lactate

      Correct Answer: Uncoupling of the electron transport chain in the mitochondria leading to reduced ATP production

      Explanation:

      Inhibiting the electron transport chain in mitochondria, aspirin overdose leads to a decline in ATP production. This decrease in ATP is counterbalanced by an upsurge in anaerobic respiration, which generates lactate – an acidic byproduct. The accumulation of lactate leads to a decrease in pH, resulting in metabolic acidosis.

      Salicylate overdose can cause a combination of respiratory alkalosis and metabolic acidosis. The respiratory center is initially stimulated, leading to hyperventilation and respiratory alkalosis. However, the direct acid effects of salicylates, combined with acute renal failure, can later cause metabolic acidosis. In children, metabolic acidosis tends to be more prominent. Other symptoms of salicylate overdose include tinnitus, lethargy, sweating, pyrexia, nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.

      The treatment for salicylate overdose involves general measures such as airway, breathing, and circulation support, as well as administering activated charcoal. Urinary alkalinization with intravenous sodium bicarbonate can help eliminate aspirin in the urine. In severe cases, hemodialysis may be necessary. Indications for hemodialysis include a serum concentration of over 700 mg/L, metabolic acidosis that is resistant to treatment, acute renal failure, pulmonary edema, seizures, and coma.

      Salicylates can also cause the uncoupling of oxidative phosphorylation, which leads to decreased adenosine triphosphate production, increased oxygen consumption, and increased carbon dioxide and heat production. It is important to recognize the symptoms of salicylate overdose and seek prompt medical attention to prevent serious complications.

    • This question is part of the following fields:

      • General Principles
      77.1
      Seconds
  • Question 35 - A 16-year-old competitive swimmer visits the paediatric clinic after experiencing palpitations during races...

    Incorrect

    • A 16-year-old competitive swimmer visits the paediatric clinic after experiencing palpitations during races or intense training. She has never had shortness of breath or chest pain, but one persistent episode led her to the emergency department where an ECG was taken. Based on the shortening of one of the ECG intervals, a provisional diagnosis of Wolff-Parkinson-White syndrome was made. What does this abnormal section of the ECG represent in terms of electrical activity?

      Your Answer: Ventricular depolarisation alone

      Correct Answer: The time between atrial depolarisation and ventricular depolarisation

      Explanation:

      The PR interval on an ECG represents the duration between atrial depolarisation and ventricular depolarisation. In Wolff-Parkinson-White syndrome, an accessory pathway called the Bundle of Kent exists between the atrium and ventricle, allowing electrical signals to bypass the atrioventricular node and potentially leading to tachyarrhythmias. This results in a shorter PR interval on the ECG. Atrial repolarisation is not visible on the ECG, while the depolarisation of the sinoatrial node is represented by the p wave. The QT interval on the ECG represents the time between ventricular depolarisation and repolarisation, while the QRS complex represents ventricular depolarisation, not the PR interval.

      Understanding the Normal ECG

      The electrocardiogram (ECG) is a diagnostic tool used to assess the electrical activity of the heart. The normal ECG consists of several waves and intervals that represent different phases of the cardiac cycle. The P wave represents atrial depolarization, while the QRS complex represents ventricular depolarization. The ST segment represents the plateau phase of the ventricular action potential, and the T wave represents ventricular repolarization. The Q-T interval represents the time for both ventricular depolarization and repolarization to occur.

      The P-R interval represents the time between the onset of atrial depolarization and the onset of ventricular depolarization. The duration of the QRS complex is normally 0.06 to 0.1 seconds, while the duration of the P wave is 0.08 to 0.1 seconds. The Q-T interval ranges from 0.2 to 0.4 seconds depending upon heart rate. At high heart rates, the Q-T interval is expressed as a ‘corrected Q-T (QTc)’ by taking the Q-T interval and dividing it by the square root of the R-R interval.

      Understanding the normal ECG is important for healthcare professionals to accurately interpret ECG results and diagnose cardiac conditions. By analyzing the different waves and intervals, healthcare professionals can identify abnormalities in the electrical activity of the heart and provide appropriate treatment.

    • This question is part of the following fields:

      • Cardiovascular System
      45.5
      Seconds
  • Question 36 - A 78-year-old woman is diagnosed with a femoral hernia and requires surgery. What...

    Correct

    • A 78-year-old woman is diagnosed with a femoral hernia and requires surgery. What structure forms the posterior wall of the femoral canal?

      Your Answer: Pectineal ligament

      Explanation:

      Understanding the Femoral Canal

      The femoral canal is a fascial tunnel located at the medial aspect of the femoral sheath. It contains both the femoral artery and femoral vein, with the canal lying medial to the vein. The borders of the femoral canal include the femoral vein laterally, the lacunar ligament medially, the inguinal ligament anteriorly, and the pectineal ligament posteriorly.

      The femoral canal plays a significant role in allowing the femoral vein to expand, which facilitates increased venous return to the lower limbs. However, it can also be a site of femoral hernias, which occur when abdominal contents protrude through the femoral canal. The relatively tight neck of the femoral canal places these hernias at high risk of strangulation, making it important to understand the anatomy and function of this structure. Overall, understanding the femoral canal is crucial for medical professionals in diagnosing and treating potential issues related to this area.

    • This question is part of the following fields:

      • Gastrointestinal System
      7.8
      Seconds
  • Question 37 - A patient in their 60s presents to surgical outpatients with diffuse abdominal pain....

    Incorrect

    • A patient in their 60s presents to surgical outpatients with diffuse abdominal pain. As a second-line imaging investigation, a CT scan is requested. The radiologist looks through the images to write the report. Which of the following would they expect to find at the level of the transpyloric plane (L1)?

      Your Answer: Body of the pancreas

      Correct Answer: Hila of the kidneys

      Explanation:

      The hila of the kidneys are at the level of the transpyloric plane, with the left kidney slightly higher than the right. The adrenal glands sit just above the kidneys at the level of T12. The neck of the pancreas, not the body, is at the level of the transpyloric plane. The coeliac trunk originates at the level of T12 and the inferior mesenteric artery originates at L3.

      The Transpyloric Plane and its Anatomical Landmarks

      The transpyloric plane is an imaginary horizontal line that passes through the body of the first lumbar vertebrae (L1) and the pylorus of the stomach. It is an important anatomical landmark used in clinical practice to locate various organs and structures in the abdomen.

      Some of the structures that lie on the transpyloric plane include the left and right kidney hilum (with the left one being at the same level as L1), the fundus of the gallbladder, the neck of the pancreas, the duodenojejunal flexure, the superior mesenteric artery, and the portal vein. The left and right colic flexure, the root of the transverse mesocolon, and the second part of the duodenum also lie on this plane.

      In addition, the upper part of the conus medullaris (the tapered end of the spinal cord) and the spleen are also located on the transpyloric plane. Knowing the location of these structures is important for various medical procedures, such as abdominal surgeries and diagnostic imaging.

      Overall, the transpyloric plane serves as a useful reference point for clinicians to locate important anatomical structures in the abdomen.

    • This question is part of the following fields:

      • Respiratory System
      69.5
      Seconds
  • Question 38 - A 70-year-old woman is admitted to the cardiology ward with a 4-day history...

    Incorrect

    • A 70-year-old woman is admitted to the cardiology ward with a 4-day history of increasing shortness of breath and difficulty sleeping due to breathlessness when lying flat. Her medical history includes ischaemic heart disease and chronic heart failure. She was recently started on a new medication by her GP.

      Upon examination, diffuse crackles are heard loudest at the bases. Her JVP is elevated, and there is pitting oedema to the knees bilaterally.

      Brain natriuretic peptide 5500 pg/mL (< 300)

      Which medication is most likely to have caused this presentation?

      Your Answer: Amlodipine

      Correct Answer: Verapamil

      Explanation:

      Calcium channel blockers are a class of drugs commonly used to treat cardiovascular disease. These drugs target voltage-gated calcium channels found in myocardial cells, cells of the conduction system, and vascular smooth muscle. The different types of calcium channel blockers have varying effects on these areas, making it important to differentiate their uses and actions.

      Verapamil is used to treat angina, hypertension, and arrhythmias. It is highly negatively inotropic and should not be given with beta-blockers as it may cause heart block. Side effects include heart failure, constipation, hypotension, bradycardia, and flushing.

      Diltiazem is used to treat angina and hypertension. It is less negatively inotropic than verapamil, but caution should still be exercised when patients have heart failure or are taking beta-blockers. Side effects include hypotension, bradycardia, heart failure, and ankle swelling.

      Nifedipine, amlodipine, and felodipine are dihydropyridines used to treat hypertension, angina, and Raynaud’s. They affect peripheral vascular smooth muscle more than the myocardium, which means they do not worsen heart failure but may cause ankle swelling. Shorter acting dihydropyridines like nifedipine may cause peripheral vasodilation, resulting in reflex tachycardia. Side effects include flushing, headache, and ankle swelling.

      According to current NICE guidelines, the management of hypertension involves a flow chart that takes into account various factors such as age, ethnicity, and comorbidities. Calcium channel blockers may be used as part of the treatment plan depending on the individual patient’s needs.

    • This question is part of the following fields:

      • General Principles
      86.6
      Seconds
  • Question 39 - A 30-year-old male presents with a recurrent history of chest infections. During the...

    Incorrect

    • A 30-year-old male presents with a recurrent history of chest infections. During the examination, it is observed that there is an absence of palpable vas deferens, but both testes are present in the scrotum. What is the probable underlying disease association?

      Your Answer: Gardners syndrome

      Correct Answer: Cystic fibrosis

      Explanation:

      Understanding Absence of the Vas Deferens

      Absence of the vas deferens is a condition that can occur either unilaterally or bilaterally. In 40% of cases, the cause is due to mutations in the CFTR gene, which is associated with cystic fibrosis. However, in some non-CF cases, the absence of the vas deferens is due to unilateral renal agenesis. Despite this condition, assisted conception may still be possible through sperm harvesting.

      It is important to understand the underlying causes of absence of the vas deferens, as it can impact fertility and the ability to conceive. While the condition may be associated with cystic fibrosis, it can also occur independently. However, with advancements in assisted reproductive technologies, individuals with this condition may still have options for starting a family. By seeking medical advice and exploring available options, individuals can make informed decisions about their reproductive health.

    • This question is part of the following fields:

      • Reproductive System
      22.7
      Seconds
  • Question 40 - A 73-year-old man is undergoing an open abdominal aortic aneurysm repair. The aneurysm...

    Incorrect

    • A 73-year-old man is undergoing an open abdominal aortic aneurysm repair. The aneurysm is located in a juxtarenal location and surgical access to the neck of aneurysm is difficult. Which one of the following structures may be divided to improve access?

      Your Answer: Coeliac axis

      Correct Answer: Left renal vein

      Explanation:

      During juxtarenal aortic surgery, the neck of the aneurysm can cause stretching of the left renal vein, which may lead to its division. This can worsen the nephrotoxic effects of the surgery, especially when a suprarenal clamp is also used. However, intentionally dividing the Cisterna Chyli will not enhance access and can result in chyle leakage. Similarly, dividing the transverse colon is not beneficial and can increase the risk of graft infection. Lastly, dividing the SMA is unnecessary for a juxtarenal procedure.

      The abdominal aorta is a major blood vessel that originates from the 12th thoracic vertebrae and terminates at the fourth lumbar vertebrae. It is located in the abdomen and is surrounded by various organs and structures. The posterior relations of the abdominal aorta include the vertebral bodies of the first to fourth lumbar vertebrae. The anterior relations include the lesser omentum, liver, left renal vein, inferior mesenteric vein, third part of the duodenum, pancreas, parietal peritoneum, and peritoneal cavity. The right lateral relations include the right crus of the diaphragm, cisterna chyli, azygos vein, and inferior vena cava (which becomes posterior distally). The left lateral relations include the fourth part of the duodenum, duodenal-jejunal flexure, and left sympathetic trunk. Overall, the abdominal aorta is an important blood vessel that supplies oxygenated blood to various organs in the abdomen.

    • This question is part of the following fields:

      • Gastrointestinal System
      62.7
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Haematology And Oncology (2/2) 100%
Endocrine System (1/1) 100%
General Principles (1/6) 17%
Respiratory System (1/3) 33%
Clinical Sciences (4/4) 100%
Gastrointestinal System (4/7) 57%
Musculoskeletal System And Skin (5/5) 100%
Neurological System (3/4) 75%
Pharmacology (1/1) 100%
Reproductive System (0/2) 0%
Basic Sciences (0/1) 0%
Cardiovascular System (2/3) 67%
Renal System (0/1) 0%
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