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  • Question 1 - A 35-year-old woman experiences a sudden and severe headache followed by collapse. Imaging...

    Incorrect

    • A 35-year-old woman experiences a sudden and severe headache followed by collapse. Imaging reveals a subarachnoid hemorrhage, but there are no signs of increased intracranial pressure. What medication should be given?

      Your Answer: Mannitol

      Correct Answer: Nimodipine

      Explanation:

      To prevent vasospasm in aneurysmal subarachnoid haemorrhages, nimodipine is utilized. This medication is a calcium channel blocker that lessens cerebral vasospasm and enhances results. It is given to the majority of subarachnoid haemorrhage cases.

      A subarachnoid haemorrhage (SAH) is a type of bleeding that occurs within the subarachnoid space of the meninges in the brain. It can be caused by head injury or occur spontaneously. Spontaneous SAH is often caused by an intracranial aneurysm, which accounts for around 85% of cases. Other causes include arteriovenous malformation, pituitary apoplexy, and mycotic aneurysms. The classic symptoms of SAH include a sudden and severe headache, nausea and vomiting, meningism, coma, seizures, and ECG changes.

      The first-line investigation for SAH is a non-contrast CT head, which can detect acute blood in the basal cisterns, sulci, and ventricular system. If the CT is normal within 6 hours of symptom onset, a lumbar puncture is not recommended. However, if the CT is normal after 6 hours, a lumbar puncture should be performed at least 12 hours after symptom onset to check for xanthochromia and other CSF findings consistent with SAH. If SAH is confirmed, referral to neurosurgery is necessary to identify the underlying cause and provide urgent treatment.

      Management of aneurysmal SAH involves supportive care, such as bed rest, analgesia, and venous thromboembolism prophylaxis. Vasospasm is prevented with oral nimodipine, and intracranial aneurysms require prompt intervention to prevent rebleeding. Most aneurysms are treated with a coil by interventional neuroradiologists, but some require a craniotomy and clipping by a neurosurgeon. Complications of aneurysmal SAH include re-bleeding, hydrocephalus, vasospasm, and hyponatraemia. Predictive factors for SAH include conscious level on admission, age, and amount of blood visible on CT head.

    • This question is part of the following fields:

      • Surgery
      26.5
      Seconds
  • Question 2 - A mother brings her 12-year-old boy into the Emergency Department. She is concerned...

    Correct

    • A mother brings her 12-year-old boy into the Emergency Department. She is concerned as he has started to limp over the last few days and is in pain. There is no history of trauma; he has no temperature and is otherwise well. You notice he is overweight for his age.
      Which is the most likely diagnosis?

      Your Answer: Slipped femoral epiphysis

      Explanation:

      Pediatric Hip Conditions: Slipped Femoral Epiphysis, Perthes’ Disease, Septic Arthritis, and Juvenile Idiopathic Arthritis

      Hip conditions in children can present with a variety of symptoms and causes. One common condition is slipped femoral epiphysis, which typically affects boys aged 10-16 who are overweight. Symptoms include a painful limp, limited internal rotation, and displacement of the femoral head on X-ray. Treatment involves surgical fixation.

      Another condition is Perthes’ disease, which is avascular necrosis of the femoral head and typically affects younger children aged 4-10, more commonly in boys. Symptoms include an intermittent limp and limited joint movement. Treatment can be medical or surgical, but surgery may result in limb shortening and a permanent limp.

      Septic arthritis presents with an acutely painful, inflamed, and swollen joint, often with fever. It is more common in patients with underlying joint disease or a history of trauma. Musculoskeletal back pain is unlikely in this scenario.

      Juvenile idiopathic arthritis is an autoimmune inflammatory joint disease seen in children under 16. It presents with joint swelling, morning pain, limping, lethargy, reduced activity, and poor appetite, and is associated with anterior uveitis and spiking fevers. However, it is unlikely in this scenario due to the chronicity of symptoms and the child’s overall health.

      In conclusion, pediatric hip conditions can have various causes and symptoms, and proper diagnosis and treatment are crucial for optimal outcomes.

    • This question is part of the following fields:

      • Paediatrics
      10.5
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  • Question 3 - A 45-year-old man underwent a renal transplant four weeks ago. The transplant was...

    Incorrect

    • A 45-year-old man underwent a renal transplant four weeks ago. The transplant was complicated by delayed graft function, which required haemodialysis on days one and three post-surgery due to hyperkalaemia. By day six, the transplant began to function, and he was discharged on day 10 with decreasing creatinine levels. He is currently taking immunosuppressants (tacrolimus, azathioprine, prednisolone), prophylaxis against opportunistic infections (co-trimoxazole, valganciclovir), aspirin, and amlodipine. Despite regular clinic visits, his potassium levels remain persistently high at 6.5 mmol/l. Which medication is likely causing this issue?

      Your Answer: Azathioprine

      Correct Answer: Co-trimoxazole

      Explanation:

      Co-trimoxazole and its Side Effects

      Co-trimoxazole is a medication that is commonly used to treat and prevent Pneumocystis jiroveci pneumonia, which is more prevalent in immunocompromised individuals. It is a combination of two drugs, trimethoprim and sulfamethoxazole, and is known to cause side effects such as gastrointestinal discomfort, rashes, and hyperkalaemia. Hyperkalaemia is a condition where there is an excess of potassium in the blood, and it is a well-known side effect of co-trimoxazole. This is because the medication inhibits sodium channels in the distal nephron, similar to the potassium-sparing diuretic amiloride.

      Although co-trimoxazole is generally safe, it can cause rare but serious side effects such as Stevens-Johnson syndrome, bone marrow depression, and agranulocytosis. Patients who have documented allergies to either component of the medication should avoid it and use pentamidine nebulisers as an alternative. Additionally, co-trimoxazole may be teratogenic, meaning it can cause harm to a developing fetus, so female patients should be advised to use contraception and stop taking the medication if they plan to become pregnant. Overall, co-trimoxazole is an effective medication for treating and preventing Pneumocystis jiroveci pneumonia, but patients should be aware of its potential side effects.

    • This question is part of the following fields:

      • Nephrology
      51.2
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  • Question 4 - An 85-year-old woman presents in the Emergency Department with a 3-week history of...

    Incorrect

    • An 85-year-old woman presents in the Emergency Department with a 3-week history of increasing confusion and falls. Routine investigations reveal:
      FBC: Hb 123 g/l, MCV 86 fl, WCC 7.9 × 109/l, platelets 478 × 109/l
      U&Es: Na+ 109 mmol/l, K+ 4.9 mmol/l, urea 5.2 mmol/l, creatinine 76 μmol/l
      Which of the following would clinically exclude a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH)?

      Your Answer: Blood pressure (BP) = 120/70 mm Hg sitting; BP = 133/74 mm Hg standing

      Correct Answer: Gross peripheral oedema and ascites

      Explanation:

      Understanding the Exclusion Criteria for SIADH: Causes of Hyponatremia in the Elderly

      Hyponatremia is a common incidental finding in the unwell elderly, and its causes can be understood by knowing the exclusion criteria for SIADH. SIADH secretion should not be diagnosed in the presence of hypovolemia, hypotension, Addison’s disease, signs of fluid overload (such as effusions, ascites, and peripheral edema), hypothyroidism, or drugs that cause hyponatremia. Once these are excluded or corrected, the diagnosis is confirmed by sending paired serum and urinary specimens for sodium and osmolality measurements. SIADH is confirmed when one has hyponatremia and a low measured serum osmolality, with measurable urinary sodium and a relatively concentrated urinary osmolality. Causes are found in the chest and in the head, so all patients with unexplained hyponatremia should have a chest X-ray and, if this is normal, a computed tomography brain scan.

      Understanding the Exclusion Criteria for SIADH: Causes of Hyponatremia in the Elderly

    • This question is part of the following fields:

      • Clinical Biochemistry
      61.2
      Seconds
  • Question 5 - A 30-year-old man comes to see his GP complaining of headaches, nausea, and...

    Incorrect

    • A 30-year-old man comes to see his GP complaining of headaches, nausea, and anxiety that have been ongoing for the past year. He has sought medical attention from various healthcare providers and was prescribed codeine pain relief, which he has now finished. Upon examination, there are no notable findings, and private investigations including a CT and MRI of the head have come back normal. Despite being reassured multiple times, he remains convinced that he has a brain tumour and requests further testing and pain relief. His paternal grandfather died from a brain tumour. What is the most probable diagnosis?

      Your Answer: Somatisation disorder

      Correct Answer: Hypochondriasis

      Explanation:

      The correct diagnosis for this patient is hypochondriasis, also known as illness anxiety disorder. This is characterized by a persistent belief in the presence of a serious underlying disease, such as cancer, despite negative test results and reassurance from healthcare providers. It is helpful to remember that hypochondriasis is worrying about cancer, as both words contain the letter C and cancer is an example of a serious underlying disease.

      Conversion disorder, factitious disorder, and malingering are all incorrect diagnoses for this patient. Conversion disorder involves functional neurological symptoms without clear cause, often traced back to a psychological trigger. Factitious disorder, also known as Munchausen’s syndrome, involves intentionally producing physical or psychological problems to assume a sick role or deceive healthcare providers. Malingering involves fraudulently simulating or exaggerating symptoms for financial or other gains. None of these diagnoses fit the patient’s symptoms and concerns, as they are not consciously feigning symptoms, seeking material gain, or assuming a sick role. The patient is genuinely worried about a serious underlying condition being missed.

      Psychiatric Terms for Unexplained Symptoms

      There are various psychiatric terms used to describe patients who exhibit symptoms for which no organic cause can be found. One such disorder is somatisation disorder, which involves the presence of multiple physical symptoms for at least two years, and the patient’s refusal to accept reassurance or negative test results. Another disorder is illness anxiety disorder, which is characterized by a persistent belief in the presence of an underlying serious disease, such as cancer, despite negative test results.

      Conversion disorder is another condition that involves the loss of motor or sensory function, and the patient does not consciously feign the symptoms or seek material gain. Patients with this disorder may be indifferent to their apparent disorder, a phenomenon known as la belle indifference. Dissociative disorder, on the other hand, involves the process of ‘separating off’ certain memories from normal consciousness, and may manifest as amnesia, fugue, or stupor. Dissociative identity disorder (DID) is the most severe form of dissociative disorder and was previously known as multiple personality disorder.

      Factitious disorder, also known as Munchausen’s syndrome, involves the intentional production of physical or psychological symptoms. Finally, malingering is the fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain. Understanding these psychiatric terms can help healthcare professionals better diagnose and treat patients with unexplained symptoms.

    • This question is part of the following fields:

      • Psychiatry
      47.5
      Seconds
  • Question 6 - A 3-year-old boy was brought to his GP by his mother, who had...

    Correct

    • A 3-year-old boy was brought to his GP by his mother, who had noticed a slight squint in his left eye. During the examination, the GP observed that the red reflex was absent.
      What is the most accurate description of this child's condition?

      Your Answer: There is a significant risk for secondary malignancy in survivors

      Explanation:

      Retinoblastoma: A Rare Eye Cancer with High Survival Rate but Risk of Secondary Malignancy

      Retinoblastoma is a rare type of eye cancer that primarily affects children under the age of 5. It is characterized by an abnormal reflection in the pupil, appearing white instead of red, known as leucocoria. Most cases are caused by mutations in the retinoblastoma 1 (RB1) gene, located on chromosome 13, with one-third of cases being inherited in an autosomal dominant pattern. Surgical removal of the tumor, usually through enucleation, is the standard treatment, and the 5-year survival rate is almost 100% if diagnosed and treated promptly.

      However, survivors of retinoblastoma are at risk of developing secondary non-ocular tumors, including malignant melanoma, sarcoma, brain tumors, leukemia, and osteosarcoma. Therefore, regular monitoring throughout life is necessary. Most cases are diagnosed before the age of 5, with 90% of cases being diagnosed before the child’s fifth birthday. It is important to note that retinoblastoma is not a recessive condition, and the RB1 gene is located on chromosome 13, not 16.

    • This question is part of the following fields:

      • Paediatrics
      26
      Seconds
  • Question 7 - A 26-year-old transgender male (assigned female at birth) patient presents to your clinic...

    Correct

    • A 26-year-old transgender male (assigned female at birth) patient presents to your clinic seeking advice on contraception. He is currently receiving testosterone therapy and is being monitored by the gender identity clinic. Although he plans to undergo surgery in the future, he has not done so yet. He is in good health overall.

      During the consultation, he reveals that he is sexually active with a male partner and they do not use protection during vaginal intercourse. As he still has a uterus, he is worried about the possibility of pregnancy and wants to avoid it for the time being.

      What recommendations would you provide to him?

      Your Answer: The intrauterine copper device is a safe option

      Explanation:

      The only accurate statement among the given options is that the intrauterine copper device is a safe contraceptive option for transgender males. This is because it is non-hormonal and does not interfere with testosterone therapy, although it may worsen menstrual bleeding. Condoms are also a viable option, but not the only safe one. Testosterone therapy does not prevent pregnancy and can even cause birth defects if the patient becomes pregnant. The combined oral contraceptive pill and vaginal ring are not recommended as they contain estrogen, which can counteract the effects of testosterone therapy. However, progesterone-only methods such as injections, the intrauterine system, and the progesterone-only pill are suitable options.

      Contraceptive and Sexual Health Guidance for Transgender and Non-Binary Individuals

      The Faculty of Sexual & Reproductive Healthcare has released guidance on contraceptive choices and sexual health for transgender and non-binary individuals. The guidance emphasizes the importance of sensitive communication and offering options that consider personal preferences, co-morbidities, and current medications or therapies.

      For individuals engaging in vaginal sex where there may be a risk of pregnancy and/or sexually transmitted infections, condoms and dental dams are recommended. Cervical screening and human papillomavirus vaccinations should also be offered to sexually active individuals with a uterus. Those engaging in anal sex and rimming should be advised of the risk of hepatitis A & B and offered vaccinations. Individuals at risk of HIV transmission should be advised of the availability of pre-exposure prophylaxis and post-exposure prophylaxis as required.

      For patients seeking permanent contraception, a fallopian tube occlusion or a vasectomy may be the most appropriate solution and neither would be affected by hormonal therapy. Testosterone therapy does not provide protection against pregnancy, and oestrogen-containing regimes are not recommended in patients undergoing testosterone therapy. Progesterone-only contraceptives are considered safe, and the intrauterine system and injections may also suspend menstruation. Non-hormonal intrauterine devices do not interact with hormonal regimes but can exacerbate menstrual bleeding.

      In patients assigned male at birth, there may be a reduction or cessation of sperm production with certain therapies, but the variability of effects means they cannot be relied upon as a method of contraception. Condoms should be recommended in those patients engaging in vaginal sex wishing to avoid the risk of pregnancy. Emergency contraception may be required in patients assigned female at birth following unprotected vaginal intercourse, and either of the available oral emergency contraceptive options may be considered. The non-hormonal intrauterine device may also be an option, but it may have unacceptable side effects in some patients.

      Overall, the guidance stresses the importance of individualized care and communication in contraceptive and sexual health decisions for transgender and non-binary individuals.

    • This question is part of the following fields:

      • Gynaecology
      47.9
      Seconds
  • Question 8 - A nervous 23-year-old man with a rapid breathing rate presents with the following...

    Incorrect

    • A nervous 23-year-old man with a rapid breathing rate presents with the following arterial blood gas findings:
      pH 7.27 (7.36-7.44)
      PCO2 2.6 KPa (4.7-6.0)
      Base excess −12 mmol/L
      What is his acid-base status?

      Your Answer: Combined metabolic and respiratory alkalosis

      Correct Answer: Metabolic acidosis with some compensatory respiratory alkalosis

      Explanation:

      Metabolic Acidosis

      Metabolic acidosis is a condition characterized by a low pH level and base deficit, indicating an excess of acid in the body. This can be caused by a variety of factors, including lactic acidosis, ketoacidosis, poisoning, and renal tubular acidosis. Additionally, loss of bicarbonate due to conditions such as diarrhea, biliary/pancreatic/small bowel fistulae, urinary diversion surgery, and cholestyramine can also contribute to metabolic acidosis.

      One of the physiological responses to metabolic acidosis is respiratory compensation, which involves the body attempting to normalize pH by clearing out the acidic gas CO2. This can result in a low CO2 level. It is important to identify the underlying cause of metabolic acidosis in order to provide appropriate treatment and prevent further complications.

    • This question is part of the following fields:

      • Emergency Medicine
      44.9
      Seconds
  • Question 9 - A 27-year-old is brought to the on-call psychiatry team at a hospital after...

    Incorrect

    • A 27-year-old is brought to the on-call psychiatry team at a hospital after being found wandering aimlessly on the streets. The patient had a breakdown in a local convenience store where they were caught stealing cigarettes and had a violent outburst when confronted by the store clerk. When asked about their behavior, they state that they do not care about the consequences of their actions and that they have stolen many times before. They also admit to enjoying hurting others in the past and have a history of animal cruelty. Although they report self-harming in the past, there are no visible scars.

      Which of the following characteristics would be more indicative of a diagnosis of antisocial personality disorder rather than borderline personality disorder?

      Your Answer: The presence of psychotic symptoms

      Correct Answer: Male gender

      Explanation:

      Men are more commonly affected by antisocial personality disorder, while borderline personality disorder is more frequently diagnosed in young women. However, there can be some overlap in the symptoms of both disorders, such as impulsivity. Borderline personality disorder is characterized by unstable emotions, fluctuating self-image, and recurrent thoughts of self-harm or suicide. On the other hand, antisocial personality disorder is marked by a repeated failure to follow social norms or rules, reckless behavior that endangers oneself and others, and a lack of remorse for these actions. If there are persistent mood changes or psychotic symptoms present, it may indicate a different primary diagnosis than a personality disorder.

      Personality disorders are a set of personality traits that are maladaptive and interfere with normal functioning in life. It is estimated that around 1 in 20 people have a personality disorder, which are typically categorized into three clusters: Cluster A, which includes Odd or Eccentric disorders such as Paranoid, Schizoid, and Schizotypal; Cluster B, which includes Dramatic, Emotional, or Erratic disorders such as Antisocial, Borderline (Emotionally Unstable), Histrionic, and Narcissistic; and Cluster C, which includes Anxious and Fearful disorders such as Obsessive-Compulsive, Avoidant, and Dependent.

      Paranoid individuals exhibit hypersensitivity and an unforgiving attitude when insulted, a reluctance to confide in others, and a preoccupation with conspiratorial beliefs and hidden meanings. Schizoid individuals show indifference to praise and criticism, a preference for solitary activities, and emotional coldness. Schizotypal individuals exhibit odd beliefs and magical thinking, unusual perceptual disturbances, and inappropriate affect. Antisocial individuals fail to conform to social norms, deceive others, and exhibit impulsiveness, irritability, and aggressiveness. Borderline individuals exhibit unstable interpersonal relationships, impulsivity, and affective instability. Histrionic individuals exhibit inappropriate sexual seductiveness, a need to be the center of attention, and self-dramatization. Narcissistic individuals exhibit a grandiose sense of self-importance, lack of empathy, and excessive need for admiration. Obsessive-compulsive individuals are occupied with details, rules, and organization to the point of hampering completion of tasks. Avoidant individuals avoid interpersonal contact due to fears of criticism or rejection, while dependent individuals have difficulty making decisions without excessive reassurance from others.

      Personality disorders are difficult to treat, but a number of approaches have been shown to help patients, including psychological therapies such as dialectical behavior therapy and treatment of any coexisting psychiatric conditions.

    • This question is part of the following fields:

      • Psychiatry
      34.1
      Seconds
  • Question 10 - An 80-year-old female visits her GP complaining of muscle weakness that has been...

    Correct

    • An 80-year-old female visits her GP complaining of muscle weakness that has been gradually worsening for the past year. She is unable to stand or walk for extended periods of time. Additionally, she has a purple rash on her eyelids, red nodules on her knees and elbows, and painful cracked skin on her fingers. Which autoantibody is the probable cause of these symptoms?

      Your Answer: Antinuclear (ANA)

      Explanation:

      AMA (Anti-mitochondrial antibodies)

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

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

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

    • This question is part of the following fields:

      • Musculoskeletal
      15.9
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Surgery (0/1) 0%
Paediatrics (2/2) 100%
Nephrology (0/1) 0%
Clinical Biochemistry (0/1) 0%
Psychiatry (0/2) 0%
Gynaecology (1/1) 100%
Emergency Medicine (0/1) 0%
Musculoskeletal (1/1) 100%
Passmed