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Question 1
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A 42-year-old accountant comes to see you for a follow-up review 2 weeks after presenting with symptoms suggesting low mood. He had felt ‘down’ for several weeks, no longer enjoyed work or seeing friends and was sleeping more than usual. Despite this, he had a normal appetite, a strong sense of self-worth, denied any thoughts of self-harm or suicide and came across as reasonably active and lively. He says that he feels very anxious on Sunday evenings before going to work on a Monday and is getting increasingly ‘short and snappy’ with his colleagues. However, he says that work is otherwise going well and he is managing to get through the day. He does not feel any better at today’s consultation and is requesting advice about treatment options. He says he is ‘not a tablet person’.
What should you advise?Your Answer: A trial of computer-based cognitive behavioural therapy (CBT) or peer support
Explanation:For a patient with mild depression symptoms, the recommended first-line treatment is low-intensity psychosocial interventions such as computer-based CBT, group-based CBT, or peer support groups performing physical activity programs. If the patient prefers non-pharmacological treatment, antidepressants should not be used as first-line. Benzodiazepines should be avoided due to their addictive potential and side-effect profile. In the presence of both depression and anxiety, depression should be treated first according to NICE guidelines.
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This question is part of the following fields:
- Psychiatry
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Question 2
Incorrect
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A 42-year-old man comes to the clinic complaining of gynaecomastia.
What is the most probable reason for his gynaecomastia?Your Answer: Hypopituitarism
Correct Answer: Seminoma
Explanation:The causes of Gynaecomastia are varied and can be indicative of underlying health issues. This condition is characterized by the enlargement of male breast tissue, which is caused by an imbalance in the testosterone to oestradiol ratio. It is important to note that hyperprolactinaemia and hypopituitarism do not affect this ratio and are not commonly associated with gynaecomastia.
It is also important to note that hypothyroidism and CAH are not known to cause this condition. However, gynaecomastia can be a symptom of seminoma, a type of testicular cancer, due to the secretion of human chorionic gonadotropin (HCG). Therefore, seeking medical attention if gynaecomastia is present is crucial.
Prolactinoma, on the other hand, is a benign tumour of the pituitary gland that is typically asymptomatic. It is not known to cause gynaecomastia, but it is important to monitor its growth and seek medical attention if any symptoms arise. Understanding the causes of gynaecomastia can help individuals identify potential health issues and seek appropriate treatment.
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This question is part of the following fields:
- Endocrinology
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Question 3
Incorrect
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You are observing an antenatal clinic and your next patient is a 26-year-old woman who is 16 weeks pregnant with her first child. Take a brief history of this patient.
The patient has a past medical history of coeliac disease and hypothyroidism. She takes no regular medications and has no known drug allergies. Her family history is relevant for her father has type 1 diabetes. She has never smoked and since pregnancy, has stopped drinking alcohol.
What additional tests, if any, should be arranged for this patient based on her medical history?Your Answer: No further tests required
Correct Answer: Oral glucose tolerance test at 24-28 weeks
Explanation:Pregnant women with a first-degree relative with diabetes should be screened for gestational diabetes with an OGTT at 24-28 weeks. No further tests are required, but thyroid function tests should be done in each trimester for those with an existing diagnosis of hypothyroidism. OGTT should not be done at 18-22 weeks.
Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.
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This question is part of the following fields:
- Obstetrics
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Question 4
Incorrect
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A 54-year-old woman presents with back and flank pain affecting both sides. She has been diagnosed some years ago with antiphospholipid antibody syndrome and has suffered from a previous deep vein thrombosis. On assessment, temperature is 36.7oC, heart rate is 76 bpm, blood pressure 128/80 mmHg and she is still passing urine.
Investigations:
Investigation Result Normal value
Sodium (Na+) 141 mmol/l 135–145 mmol/l
Potassium (K+) 6.3 mmol/l 3.5–5.0 mmol/l
Urea 17.3 mmol/l 2.5–6.5 mmol/l
Creatinine 325 μmol/l 50–120 µmol/l
Urine proteinuria +++
Which of the following diagnoses fits best with this clinical scenario?Your Answer: Bilateral ureteric obstruction
Correct Answer: Bilateral renal vein thrombosis
Explanation:Possible Causes of Bilateral Flank Pain, Renal Failure, and Proteinuria
Bilateral flank pain, renal failure, and marked proteinuria can be caused by various conditions. One possible diagnosis is bilateral renal vein thrombosis, especially if the patient has a history of antiphospholipid antibody syndrome and previous deep vein thrombosis. Other causes of renal vein thrombosis include extrinsic compression of the renal vein by a tumour or a retroperitoneal mass, invasion of the renal vein or inferior vena cava by a tumour, or nephrotic syndrome that increases coagulability. Abdominal ultrasound and angiography can help diagnose renal vein thrombosis, and anticoagulation is the main treatment.
Bilateral ureteric obstruction can cause anuria, while bilateral pyelonephritis can cause sepsis and leukocytes and nitrites in the urine. Medullary sponge kidney, a congenital disorder that causes cystic dilation of the collecting ducts in one or both kidneys, may present with haematuria or nephrocalcinosis but does not affect renal function. Bilateral renal artery stenosis can cause uncontrollable hypertension and reduced renal function but not pain. Therefore, a thorough evaluation is necessary to determine the underlying cause of the patient’s symptoms.
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This question is part of the following fields:
- Renal
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Question 5
Incorrect
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A 72-year-old man presents to the emergency department after being referred by his primary care physician due to experiencing abdominal distension and difficulty passing stool or flatus for the past four days. The patient denies any nausea or vomiting, but reports irregular bowel movements with occasional bleeding and recent weight loss. During the examination, tinkling bowel sounds are heard and a digital rectal exam reveals the presence of hard feces. The patient also mentions that his mother had a history of recurrent bowel adhesions requiring multiple surgeries. What is the most probable cause of the patient's symptoms?
Your Answer: Paralytic ileus
Correct Answer: Large bowel obstruction
Explanation:The patient’s presentation suggests a large bowel obstruction, as indicated by the abdominal distension, inability to pass stool or flatus, and presence of hard faeces on digital rectal examination. The history of rectal bleeding and weight loss further support this diagnosis. Acute mesenteric ischemia is unlikely due to the absence of severe pain and nausea/vomiting. Paralytic ileus is a possibility, but the presence of bowel sounds suggests a mechanical obstruction. A small bowel obstruction is unlikely given the patient’s family history and lack of vomiting.
Understanding Large Bowel Obstruction
Large bowel obstruction occurs when the passage of food, fluids, and gas through the large intestines is blocked. The most common cause of this condition is a tumor, accounting for 60% of cases. Colonic malignancy is often the initial presenting complaint in approximately 30% of cases, particularly in more distal colonic and rectal tumors. Other causes include volvulus and diverticular disease.
Clinical features of large bowel obstruction include abdominal pain, distention, and absence of passing flatus or stool. Nausea and vomiting may suggest a more proximal lesion, while peritonism may be present if there is associated bowel perforation. It is important to consider the underlying causes, such as any recent symptoms suggestive of colorectal cancer.
Abdominal x-ray is still commonly used as a first-line investigation, with a diameter greater than the normal limits being diagnostic of obstruction. CT scan has a high sensitivity and specificity for identifying obstruction and its underlying cause.
Initial management includes NBM, IV fluids, and nasogastric tube with free drainage. Conservative management for up to 72 hours can be trialed if the cause of obstruction does not require surgery. Around 75% of cases will eventually require surgery. IV antibiotics will be given if perforation is suspected or surgery is planned. Emergency surgery is necessary if there is any overt peritonitis or evidence of bowel perforation, which may involve irrigation of the abdominal cavity, resection of perforated segment and ischaemic bowel, and addressing the underlying cause of the obstruction.
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This question is part of the following fields:
- Surgery
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Question 6
Incorrect
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A 49-year-old woman with a history of type 2 diabetes for three years comes in for her annual check-up. Despite optimizing her oral hypoglycemic therapy, she has gained around 5 kg in weight over the past year and her HbA1c has worsened. She is also taking ramipril, bendroflumethiazide, and amlodipine, but her blood pressure remains difficult to control, with a reading of 172/102 mmHg. During the examination, she has developed abdominal striae, thin skin with bruising, and proximal weakness. The doctor suspects Cushing's syndrome. What is the most appropriate test for this patient?
Your Answer: CT scan adrenals
Correct Answer: 24 hour urine free cortisol concentration
Explanation:Screening Tests for Cushing’s Syndrome
Cushing’s syndrome is a condition caused by excessive levels of cortisol in the body. To diagnose this condition, appropriate screening tests are necessary. The preferred test is the 1 mg overnight dexamethasone suppression test, where 1 mg of dexamethasone is given at 11 pm, and cortisol levels are measured at 9 am the following morning. A cortisol concentration less than 50 nmol/L after this test is considered normal.
Another effective test is a 24-hour urine collection to measure free cortisol in the urine. An elevated cortisol level, usually above 250 nmol/day, indicates Cushing’s syndrome. However, random cortisol or 9 am cortisol tests do not provide any diagnostic information.
In investigating the possible cause of Cushing’s syndrome, chest x-rays and adrenal CT scans are useful. These tests can help identify the underlying cause of the condition. It is important to perform appropriate screening tests to diagnose Cushing’s syndrome and determine the best course of treatment.
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This question is part of the following fields:
- Endocrinology
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Question 7
Correct
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A 45-year-old patient presents after trauma and exhibits a lack of sensation in the anatomical snuff box. Which nerve is likely responsible for this sensory loss?
Your Answer: Radial nerve
Explanation:Common Nerve Injuries and Their Effects
Radial nerve injury causes a condition known as wrist drop, which is characterized by the inability to extend the wrist and fingers. This injury also results in varying degrees of sensory loss, with the anatomical snuffbox being a common area affected.
On the other hand, median nerve injury leads to the loss of sensation in the thumb, index, middle, and lateral half of the ring finger. This condition can also cause weakness in the muscles that control the thumb, leading to difficulty in grasping objects.
Lastly, ulnar nerve injury results in a claw hand deformity, where the fingers are flexed and cannot be straightened. This injury also causes a loss of sensation over the medial half of the ring finger and little finger.
In summary, nerve injuries can have significant effects on the function and sensation of the hand. It is important to seek medical attention if any of these symptoms are experienced to prevent further damage.
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This question is part of the following fields:
- Neurology
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Question 8
Incorrect
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A 7-year-old girl is brought to the emergency department by her mother. The mother reports that her daughter has been running a fever for the past 5 days and has been acting differently. Despite giving her paracetamol, the fever has not subsided.
During the examination, the girl presents with cracked, bright red lips, conjunctival injection, palpable lymph nodes in the cervical area, and redness on the palms of her hands and soles of her feet.
What medication should be given based on the probable diagnosis?Your Answer: Benzylpenicillin
Correct Answer: High-dose aspirin
Explanation:Kawasaki disease requires the use of high-dose aspirin, despite it being generally not recommended for children due to the risk of Reye’s syndrome. This is because the child presents with a persistent fever lasting more than 5 days, along with other characteristic symptoms such as injected conjunctiva, swollen mucosal linings around the mouth, and red, swollen hands and feet. Intravenous immunoglobulin is also recommended for treatment.
Benzylpenicillin (penicillin G) is not indicated for this child as they do not exhibit symptoms of meningitis or endocarditis. Ibuprofen is also not appropriate for Kawasaki disease, as it is typically used for other conditions such as juvenile idiopathic arthritis and soft-tissue injuries. Low-dose aspirin may be given to low-risk patients who present more than 10 days after symptom onset and have normal ESR/CRP results and initial echocardiogram results.Understanding Kawasaki Disease
Kawasaki disease is a rare type of vasculitis that primarily affects children. It is important to identify this disease early on as it can lead to serious complications, such as coronary artery aneurysms. The disease is characterized by a high-grade fever that lasts for more than five days and is resistant to antipyretics. Other symptoms include conjunctival injection, bright red, cracked lips, strawberry tongue, cervical lymphadenopathy, and red palms and soles that later peel.
Diagnosis of Kawasaki disease is based on clinical presentation as there is no specific diagnostic test available. Management of the disease involves high-dose aspirin, which is one of the few indications for aspirin use in children. Intravenous immunoglobulin is also used as a treatment option. Echocardiogram is the initial screening test for coronary artery aneurysms, rather than angiography.
Complications of Kawasaki disease can be serious, with coronary artery aneurysm being the most common. It is important to recognize the symptoms of Kawasaki disease early on and seek medical attention promptly to prevent potential complications.
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This question is part of the following fields:
- Paediatrics
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Question 9
Incorrect
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In pharmacokinetics, how is the rate of elimination or metabolism of an active drug from the body calculated?
Your Answer: Bioactivity
Correct Answer: Clearance
Explanation:Pharmacokinetics: How the Body Processes Drugs
Pharmacokinetics refers to the processes involved in how the body processes drugs. It involves four main processes: absorption, distribution, metabolism, and excretion. Metabolism and excretion are responsible for removing active drugs from the body. Metabolism converts drugs into inactive metabolites, while excretion removes the drug or its metabolite from the body. Renal excretion is the most common method of drug excretion, but some drugs may also be excreted in the bile or faeces.
Clearance is the rate at which active drugs are removed from the circulation. It involves both renal excretion and hepatic metabolism, but in practice, clearance usually measures only the renal excretion of a drug. The glomerular filtration rate affects drug clearance, but even individuals with normal kidney function can have widely varying rates of drug clearance. The structure and distribution of a drug can also affect its clearance.
In summary, pharmacokinetics is the study of how the body processes drugs, involving absorption, distribution, metabolism, and excretion. Clearance is the rate at which active drugs are removed from the circulation, and it involves both renal excretion and hepatic metabolism. The glomerular filtration rate and drug structure and distribution can affect drug clearance.
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This question is part of the following fields:
- Pharmacology
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Question 10
Correct
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A 42-year-old man presents to A&E with sudden onset of severe epigastric pain and bright red blood in his vomit. He has a long history of heavy alcohol consumption. On examination, he has guarding over the epigastric region and cool extremities. He also has a distended abdomen with ascites and spider naevi on his neck and cheek. The patient is unstable hemodynamically, and fluid resuscitation is initiated. What is the most crucial medication to begin given the probable diagnosis?
Your Answer: Terlipressin
Explanation:Medications for Oesophageal Variceal Bleeds
Oesophageal variceal bleeds are a serious medical emergency that require prompt treatment. The most important medication to administer in this situation is terlipressin, which reduces bleeding by constricting the mesenteric arterial circulation and decreasing portal venous inflow. Clopidogrel, an antiplatelet medication, should not be used as it may worsen bleeding. Propranolol, a beta-blocker, can be used prophylactically to prevent variceal bleeding but is not the most important medication to start in an acute setting. Omeprazole, a proton pump inhibitor, is not recommended before endoscopy in the latest guidelines but is often used in hospital protocols. Tranexamic acid can aid in the treatment of acute bleeding but is not indicated for oesophageal variceal bleeds. Following terlipressin administration, band ligation should be performed, and if bleeding persists, TIPS should be considered.
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This question is part of the following fields:
- Gastroenterology
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