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Question 1
Incorrect
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A 28-year-old man comes to the Emergency Department complaining of pain in his left testicle that has been gradually increasing over the past 72 hours. He appears to be in discomfort but is able to walk. Upon examination, his left testicle is tender to firm palpation. His vital signs are normal, and there is no redness or swelling. His abdominal examination is unremarkable. He reports dysuria and has recently started a new sexual relationship.
What is the most suitable course of action?Your Answer: Treat with ciprofloxacin orally for 10 days
Correct Answer: Treat with ceftriaxone 500 mg intramuscular (im) plus doxycycline 100 mg twice daily for 10–14 days
Explanation:Treatment Options for Epididymo-orchitis: Choosing the Right Antibiotics
Epididymo-orchitis is a condition that causes inflammation of the epididymis and testicles. It is most commonly caused by sexually transmitted infections such as Chlamydia trachomatis or Neisseria gonorrhoeae. When treating this condition, it is important to choose the right antibiotics based on the suspected causative organism.
In the case of a sexually transmitted infection, ceftriaxone 500 mg intramuscular (im) plus doxycycline 100 mg twice daily for 10–14 days is the recommended treatment. However, if an enteric organism is suspected, ciprofloxacin may be preferred.
It is important to note that pain relief alone is not sufficient and empirical treatment with antibiotics is advised. Additionally, immediate involvement of a urologist is necessary to rule out testicular torsion.
While hospital admission and intravenous antibiotics may be necessary in severe cases, stable patients with epididymo-orchitis do not require this level of intervention. By choosing the appropriate antibiotics and involving a urologist when necessary, patients can receive effective treatment for this condition.
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This question is part of the following fields:
- Urology
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Question 2
Correct
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A 65-year-old man presents to clinic with a three month history of worsening lower urinary tract symptoms and nocturnal enuresis. Upon examination, he has a painless distended bladder and a smoothly enlarged prostate on digital rectal examination. Bladder scan reveals 1.5L residual and ultrasound kidney, ureter, bladder (US KUB) shows bilateral hydronephrosis. His blood results are as follows:
Na+ 136 mmol/L (135 - 145)
K+ 4.5 mmol/L (3.5 - 5.0)
Bicarbonate 28 mmol/L (22 - 29)
Urea 6.5 mmol/L (2.0 - 7.0)
Creatinine 310 µmol/L (55 - 120)
What is the most likely diagnosis?Your Answer: Chronic high pressure urinary retention
Explanation:Chronic urinary retention is considered high pressure if it leads to impaired renal function or hydronephrosis. A painless distended bladder containing over 1 L of urine is a common symptom of chronic urinary retention, usually caused by bladder outflow obstruction. In this case, the patient’s elevated creatinine levels (290) and bilateral hydronephrosis visible on US KUB indicate high pressure chronic retention. Low pressure chronic urinary retention, on the other hand, does not cause hydronephrosis or renal impairment. Acute urinary retention typically presents with supra-pubic tenderness and a palpable bladder, but does not usually result in a painless distended bladder. Catheterisation typically drains less than 1 L of urine. Given the patient’s painless distended bladder and 1.2L urine volume, acute urinary retention is unlikely.
Understanding Chronic Urinary Retention
Chronic urinary retention is a condition that develops gradually and is usually painless. It can be classified into two types: high pressure retention and low pressure retention. High pressure retention is often caused by bladder outflow obstruction and can lead to impaired renal function and bilateral hydronephrosis. On the other hand, low pressure retention does not affect renal function and does not cause hydronephrosis.
When chronic urinary retention is diagnosed, catheterisation may be necessary to relieve the pressure in the bladder. However, this can lead to decompression haematuria, which is a common side effect. This occurs due to the rapid decrease in pressure in the bladder and usually does not require further treatment.
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This question is part of the following fields:
- Surgery
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Question 3
Correct
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A 22-year-old male patient complains of inadequate pubertal development. Upon examination, he has small testes on both sides, scanty pubic and facial hair, long arms and legs, and large hands and feet. What is the probable karyotype?
Your Answer: 47, XXY
Explanation:Klinefelter Syndrome and its Cytogenetic Studies
Klinefelter syndrome is a genetic disorder that affects males. It is characterized by the presence of an extra X chromosome, resulting in a karyotype of 47,XXY in 80-90% of cases. However, about 10% of patients have mosaicism, which can include various karyotypes such as 46,XY/47,XXY, 46,XY/48,XXXY, and 47,XXY/48,XXXY. Other variants include 48,XXYY, 48,XXXY, 49,XXXYY, and 49,XXXXY.
Compared to a normal male with a karyotype of 46,XY and Turner’s syndrome with a karyotype of 45,X, individuals with Klinefelter syndrome may exhibit physical and medical features such as delayed speech and language skills, learning disabilities, and increased height. However, most males with 47,XYY syndrome, which is a variant of Klinefelter syndrome, have normal sexual development and are able to conceive children.
In summary, Klinefelter syndrome is a genetic disorder that affects males and is characterized by an extra X chromosome. Cytogenetic studies have shown various karyotypes, including mosaicism and other variants. While individuals with Klinefelter syndrome may exhibit certain physical and medical features, most males with 47,XYY syndrome have normal sexual development and fertility.
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This question is part of the following fields:
- Clinical Sciences
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Question 4
Correct
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A 58-year-old accountant undergoes a transurethral resection of the prostate (TURP) that lasted for 45 minutes. The ST2 notifies you that the patient is restless. His heart rate is 100 bpm, and his blood pressure is 160/95 mmHg. He is experiencing fluid overload, and his blood test shows a sodium level of 122 mmol/l. What is the probable reason for these symptoms?
Your Answer: Transurethral resection of the prostate (TURP) syndrome
Explanation:TURP can lead to several complications, including Tur syndrome, urethral stricture/UTI, retrograde ejaculation, and perforation of the prostate. Tur syndrome occurs when irrigation fluid enters the bloodstream, causing dilutional hyponatremia, fluid overload, and glycine toxicity. Treatment involves managing the associated complications and restricting fluid intake.
Understanding Post-Prostatectomy Syndromes
Transurethral prostatectomy is a widely used procedure for treating benign prostatic hyperplasia. It involves the insertion of a resectoscope through the urethra to remove strips of prostatic tissue using diathermy. During the procedure, the bladder and prostate are irrigated with fluids, which can lead to electrolyte imbalances. Complications may arise, such as haemorrhage, urosepsis, and retrograde ejaculation.
Post-prostatectomy syndromes are a common occurrence after transurethral prostatectomy. These syndromes can cause discomfort and pain, and may include urinary incontinence, erectile dysfunction, and bladder neck contracture. Patients may also experience a decrease in semen volume and a change in the sensation of orgasm. It is important for patients to discuss any concerns or symptoms with their healthcare provider to determine the best course of treatment. With proper care and management, post-prostatectomy syndromes can be effectively managed.
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This question is part of the following fields:
- Surgery
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Question 5
Correct
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An 81-year-old patient is admitted with dysuria and confusion. She is diagnosed with a urinary tract infection (UTI) and treated with ciprofloxacin. After 3 days, she develops a profuse offensive diarrhoea. Her pulse is 82 bpm, blood pressure 140/78 mmHg and temperature 37.4 °C. Her abdomen is mildly tender throughout, but no guarding. Bloods show a white cell count of 28.7 × 109/l (was 11.6).
What is the most likely cause of her symptoms?Your Answer: Clostridium difficile diarrhoea
Explanation:Differential Diagnosis for a Patient with Diarrhoea: Clostridium difficile, Ulcerative Colitis, Pyelonephritis, Quinolone-resistant UTI, and Overflow Diarrhoea
When a patient presents with diarrhoea, it is important to consider various differential diagnoses. In the case of a patient who recently started antibiotics and developed profuse diarrhoea, Clostridium difficile infection is the most likely cause. This infection is characterized by foul-smelling diarrhoea, a tender abdomen, fever, and vomiting, along with a raised white cell count.
While ulcerative colitis can also present with similar symptoms, it typically has a longer history of gastrointestinal issues and does not occur acutely after starting antibiotics. Pyelonephritis, on the other hand, can cause fever, vomiting, and abdominal pain, but it does not typically cause diarrhoea. Quinolone-resistant UTI may cause continued fevers and UTI symptoms, but it would not cause diarrhoea. Finally, overflow diarrhoea is a possible diagnosis in elderly patients, but it would not typically present with foul-smelling diarrhoea and a raised white cell count.
In summary, when a patient presents with diarrhoea, it is important to consider various differential diagnoses, including Clostridium difficile, ulcerative colitis, pyelonephritis, quinolone-resistant UTI, and overflow diarrhoea.
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This question is part of the following fields:
- Pharmacology
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Question 6
Incorrect
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A 70-year-old man visits a neurovascular clinic for a check-up. He had a stroke caused by a lack of blood flow to the brain four weeks ago but has since made a remarkable recovery. However, the patient experienced severe abdominal discomfort and diarrhea when he switched from taking 300mg of aspirin daily to 75 mg of clopidogrel. Consequently, he stopped taking clopidogrel, and his symptoms have subsided.
What would be the most suitable medication(s) to recommend for preventing a secondary stroke?Your Answer: Ticagrelor
Correct Answer: Aspirin 75 mg plus modified release dipyridamole
Explanation:When clopidogrel cannot be used, the recommended treatment for secondary stroke prevention is a combination of aspirin 75 mg and modified-release dipyridamole. Studies have shown that this combination is more effective than taking either medication alone. Ticagrelor is not currently recommended for this purpose by NICE, and prasugrel is contraindicated due to the risk of bleeding. Oral anticoagulants like warfarin are generally not used for secondary stroke prevention, with antiplatelets being the preferred treatment.
The Royal College of Physicians (RCP) and NICE have published guidelines on the diagnosis and management of patients following a stroke. The management of acute stroke includes maintaining normal levels of blood glucose, hydration, oxygen saturation, and temperature. Blood pressure should not be lowered in the acute phase unless there are complications. Aspirin should be given as soon as possible if a haemorrhagic stroke has been excluded. Anticoagulants should not be started until brain imaging has excluded haemorrhage. Thrombolysis with alteplase should only be given if administered within 4.5 hours of onset of stroke symptoms and haemorrhage has been definitively excluded. Mechanical thrombectomy is a new treatment option for patients with an acute ischaemic stroke. NICE recommends thrombectomy for people who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography or magnetic resonance angiography. Secondary prevention includes the use of clopidogrel and dipyridamole. Carotid artery endarterectomy should only be considered if carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.
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This question is part of the following fields:
- Medicine
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Question 7
Correct
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A 32-year-old woman and her 34-year-old partner visit the general practice clinic as they have been unsuccessful in conceiving after 14 months of trying. She reports having regular menstrual cycles every 28 days.
What is the most appropriate test to determine if she is ovulating?Your Answer: Day 21 progesterone level
Explanation:Fertility Testing Methods
When it comes to fertility testing, there are several methods available to determine a female’s ovulatory status. One of the easiest tests is the day 21 progesterone level. If the results are greater than 30 nmol/l in two cycles, then the patient is said to be ovulating.
Another method is the cervical fern test, which involves observing the formation of ferns in the cervical mucous under the influence of estrogen. However, measuring progesterone levels is a more accurate test as estrogen levels can vary.
Basal body temperature estimation is also commonly used, as the basal body temperature typically increases after ovulation. However, measuring progesterone levels is still considered the most accurate way to determine ovulation.
It’s important to note that day 2 luteinising hormone (LH) and follicle-stimulating hormone (FSH) are not reliable markers of ovulation. Additionally, endometrial biopsy is not a test used in fertility testing.
In conclusion, there are several methods available for fertility testing, but measuring progesterone levels is the most accurate way to determine ovulatory status.
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This question is part of the following fields:
- Gynaecology
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Question 8
Incorrect
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As a junior doctor on a surgical ward, you are tasked with admitting a 65-year-old woman with cholecystitis. She is scheduled for emergency surgery to remove her gallbladder the next day and is the first on the list. The patient has a history of type 2 diabetes mellitus and takes metformin 1g twice daily. Her recent HbA1c has come back elevated at 95 mmol/mol, but she has not yet seen her GP to discuss this. Her admission bloods show normal renal function. The ward nurse asks for guidance on how to manage the patient's diabetes mellitus during the perioperative period. What is the most appropriate management plan?
Your Answer: The patient should omit metformin from the evening before the operation
Correct Answer: A variable rate insulin infusion should be started
Explanation:Patients with diabetes who are on insulin and are either undergoing major surgery or have poorly controlled diabetes will typically require a variable rate intravenous insulin infusion (VRIII). However, if the patient is only missing one meal and is on oral antidiabetic treatment, medication manipulation on the day of surgery may suffice. It is important to check hospital guidelines and discuss the patient with the surgical and anaesthetic team.
If the patient’s recent HbA1c shows poorly controlled type 2 diabetes mellitus, a VRIII is likely necessary. The decision to omit metformin in the peri-operative period depends on the risk of acute kidney injury. If the patient has a low risk and is only missing one meal, they can continue their metformin, but should omit the lunchtime dose if taken three times a day. If there is a higher risk or the patient is missing more than one meal, metformin should be omitted from the time they start fasting.
Leaving poorly controlled diabetes untreated during surgery increases the risk of complications such as wound and respiratory infections and post-operative kidney injury. Therefore, a VRIII is the safer option. Long-term insulin treatment can be assessed by the patient’s community team once the patient is medically stable.
If the patient is listed for emergency surgery, managing their diabetes peri-operatively is appropriate to prevent their condition from worsening. However, if the surgery is elective, it may be best to wait until the diabetes is better managed.
Preparation for surgery varies depending on whether the patient is undergoing an elective or emergency procedure. For elective cases, it is important to address any medical issues beforehand through a pre-admission clinic. Blood tests, urine analysis, and other diagnostic tests may be necessary depending on the proposed procedure and patient fitness. Risk factors for deep vein thrombosis should also be assessed, and a plan for thromboprophylaxis formulated. Patients are advised to fast from non-clear liquids and food for at least 6 hours before surgery, and those with diabetes require special management to avoid potential complications. Emergency cases require stabilization and resuscitation as needed, and antibiotics may be necessary. Special preparation may also be required for certain procedures, such as vocal cord checks for thyroid surgery or bowel preparation for colorectal cases.
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This question is part of the following fields:
- Surgery
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Question 9
Incorrect
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A 3-year-old girl is brought to the Emergency Department by her father following a 2-day history of a non-productive cough. Her father denies any recent viral illness.
On examination, the patient has no accessory muscle usage and is afebrile. On auscultation, she is noted to have a left-sided wheeze without crepitations. The patient has been developing normally and has never had any respiratory problems before. She has no significant past medical or family history. Her immunisation records are up to date.
What is the most likely cause of her symptoms?Your Answer: Asthma
Correct Answer: Inhaled foreign body
Explanation:Differential Diagnosis for a Child with Respiratory Symptoms
When a child presents with respiratory symptoms, it is important to consider various differential diagnoses. In the case of a short duration of non-productive cough, an audible wheeze, and unilateral wheeze on auscultation, an inhaled foreign body should be considered as a possible cause. Other potential diagnoses include croup, bronchiolitis, pneumonia, and asthma.
Croup, caused by a virus such as the parainfluenza virus, is characterized by a barking-seal-like cough and may be accompanied by stridor. Bronchiolitis, on the other hand, typically follows a coryzal period of cough and/or cold and causes respiratory distress as evidenced by accessory muscle usage, nasal flare, and tachypnea. It is also characterized by widespread inspiratory crepitations.
Pneumonia should also be included in the differential diagnosis, but the lack of respiratory distress and fever, as well as the absence of a productive cough, make it less likely. Asthma, which is rarely diagnosed in children of this age, would present with sudden onset respiratory distress and widespread wheezing.
In summary, a thorough evaluation of the patient’s symptoms and clinical findings is necessary to arrive at an accurate diagnosis and appropriate treatment plan.
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This question is part of the following fields:
- Paediatrics
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Question 10
Incorrect
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A 38-year-old woman comes to the emergency department with a complaint of unequal pupil size. Upon examination, there is an anisocoria of >1mm. The anisocoria appears to be more pronounced when a light is shone on the patient's face compared to when the room is darkened. The patient's eye movements are normal, and a slit-lamp examination reveals no evidence of synechiae. What possible condition could be responsible for these findings?
Your Answer: Horner syndrome
Correct Answer: Adie's tonic pupil
Explanation:When a patient presents with anisocoria, it is important to determine whether the issue lies with dilation or constriction. In this case, the anisocoria is exacerbated by bright light, indicating a problem with the parasympathetic innervation and the affected pupil’s inability to constrict. Adie’s tonic pupil is a likely cause, as it involves dysfunction of the ciliary ganglion. Horner syndrome and oculomotor nerve palsy are unlikely causes, as they would result in different symptoms. Physiological anisocoria and pilocarpine are also incorrect answers.
Mydriasis, which is the enlargement of the pupil, can be caused by various factors. These include third nerve palsy, Holmes-Adie pupil, traumatic iridoplegia, pheochromocytoma, and congenital conditions. Additionally, certain drugs can also cause mydriasis, such as topical mydriatics like tropicamide and atropine, sympathomimetic drugs like amphetamines and cocaine, and anticholinergic drugs like tricyclic antidepressants. It’s important to note that anisocoria, which is when one pupil is larger than the other, can also result in the appearance of mydriasis.
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This question is part of the following fields:
- Ophthalmology
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