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Question 1
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A 55-year-old man with a chronic medical condition has had two recent upper respiratory tract infections that have been prolonged and complicated with sinusitis and bronchitis. His general practitioner is concerned that the patient may have a secondary immunodeficiency due to the chronic medical condition (rather than being caused by the medication used to treat his condition).
Which of the following conditions is most likely to cause a secondary immunodeficiency?Your Answer: Chronic kidney disease
Explanation:Understanding Immunodeficiency in Various Medical Conditions
Immunodeficiency is a condition where the immune system is weakened, making individuals more susceptible to infections. While some medical conditions are directly associated with immunodeficiency, others are not. Chronic kidney disease, particularly end-stage disease requiring dialysis, is linked to secondary immunodeficiency, making patients vulnerable to infections such as sepsis, peritonitis, influenza, tuberculosis, and pneumonia. Similarly, some disease-modifying drugs used in the treatment of multiple sclerosis have immunomodulatory and immunosuppressive effects, increasing the risk of infection. Asthma and psoriasis are not typically associated with immunodeficiency, but long-term use of oral corticosteroids and certain medications used to treat severe psoriasis can increase the risk of infection. Rheumatoid arthritis is not a direct cause of immunodeficiency, but disease-modifying drugs used in its treatment can increase the risk. Overall, drug treatment is a common cause of secondary immunodeficiency, with cancer treatment being a significant concern. Other causes include HIV, surgery or trauma, and malnutrition. Understanding the relationship between various medical conditions and immunodeficiency is crucial in managing patient care and preventing infections.
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This question is part of the following fields:
- Allergy And Immunology
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Question 2
Correct
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A 25-year-old woman comes to her General Practitioner complaining of bilateral erythematous palms. She reports itching and the presence of some vesicles. She has observed this developing quickly at work, where she has just begun a new job as a hairdresser.
What is the most probable diagnosis?Your Answer: Allergic contact dermatitis
Explanation:Skin Conditions: Allergic Contact Dermatitis, Atopic Eczema, Scabies, Hand, Foot and Mouth Disease, and Ringworm
Skin conditions can vary in their causes and symptoms. Allergic contact dermatitis is a delayed hypersensitivity reaction that occurs upon contact with an allergen, such as nickel, hair dyes, bleaches, perfumes, fragrances, and rubber antioxidants in gloves. Atopic eczema is a chronic skin condition that presents with red, itchy skin localized to the flexor surfaces and doesn’t normally develop vesicles. Scabies is a contagious skin condition caused by exposure to mites, which is very itchy and often starts between the fingers, but it would not normally flare up while at work. Hand, foot and mouth disease is a common childhood condition caused by the Coxsackievirus, characterized by a vesicular rash on the hands, feet, and mouth. Ringworm is a fungal skin infection that is usually circular with a silver scale and can be itchy, but it would be unlikely to cause bilateral hand symptoms and doesn’t cause the vesicular rash described here.
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This question is part of the following fields:
- Allergy And Immunology
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Question 3
Incorrect
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A 27-year-old male patient complains of bloating and changes in his bowel movements. He has been maintaining a food diary and suspects that his symptoms may be due to a food allergy. Laboratory results reveal normal full blood count, ESR, and thyroid function tests. Anti-endomysial antibodies are negative. What is the most appropriate test to explore the possibility of a food allergy?
Your Answer:
Correct Answer: Skin prick test
Explanation:Skin prick testing is the preferred initial approach as it is cost-effective and can assess a wide range of allergens. Although IgE testing is useful in food allergy, it is specific IgE antibodies that are measured rather than total IgE levels.
Types of Allergy Tests
Allergy tests are used to determine the specific allergens that trigger an individual’s allergic reactions. There are several types of allergy tests available, each with its own advantages and limitations. The most commonly used test is the skin prick test, which is easy to perform and inexpensive. Drops of diluted allergen are placed on the skin, and a needle is used to pierce the skin. If a patient has an allergy, a wheal will typically develop. This test is useful for food allergies and pollen allergies.
Another type of allergy test is the radioallergosorbent test (RAST), which determines the amount of IgE that reacts specifically with suspected or known allergens. Results are given in grades from 0 (negative) to 6 (strongly positive). This test is useful for food allergies, inhaled allergens (such as pollen), and wasp/bee venom.
Skin patch testing is another type of allergy test that is useful for contact dermatitis. Around 30-40 allergens are placed on the back, and irritants may also be tested for. The patches are removed 48 hours later, and the results are read by a dermatologist after a further 48 hours.
Blood tests may be used when skin prick tests are not suitable, for example if there is extensive eczema or if the patient is taking antihistamines. Overall, the choice of allergy test depends on the individual’s specific needs and circumstances.
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This question is part of the following fields:
- Allergy And Immunology
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Question 4
Incorrect
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A 30-year-old woman visits her General Practitioner during the summer. She has suffered from mild asthma for many years, controlled with an inhaled short-acting beta-agonist (SABA). She has started working at a construction site and has noticed that her asthma is much worse, with daily symptoms. She has to use her current inhaler several times a day.
On examination, her chest is clear. Her best peak expiratory flow rate (PEFR) is 480 l/min. Today, her PEFR is 430 l/min.
What is the most appropriate next step in this patient's management?Your Answer:
Correct Answer: Start an inhaled corticosteroid
Explanation:Managing Worsening Asthma Symptoms: Starting Inhaled Corticosteroids
This patient’s asthma symptoms have worsened, likely due to exposure to allergens at the stable. While her chest is clear and her PEFR has only mildly dropped, her daily symptoms and use of SABA indicate poorly controlled asthma. The first step in managing her symptoms is to start an inhaled corticosteroid as part of the stepwise approach to asthma management. Urgent allergy testing or a home allergy testing kit are not necessary at this stage, and oral steroids are not yet indicated. Instead, allergen avoidance measures can be discussed. It is not necessary for the patient to stop working at the stable at this time.
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This question is part of the following fields:
- Allergy And Immunology
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Question 5
Incorrect
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A 54-year-old man comes to the general practice clinic to discuss his aftercare: he was discharged from hospital six weeks ago after a successful liver transplant. He is being treated by the local liver unit and has a medical history of hypertension, hyperlipidaemia, and liver cirrhosis caused by alcohol consumption. He is also a smoker. He has some concerns about his ongoing care and would like some guidance on lifestyle issues and managing his blood pressure. What is the best advice to give this patient?
Your Answer:
Correct Answer: The use of nicotine patches is safe post liver transplant
Explanation:Post-Liver Transplant Patient Care: Important Considerations
Liver transplant patients require specialized care to ensure optimal outcomes. Here are some important considerations:
Encourage smoking cessation: Smoking can promote fibrosis and increase the risk of hepatoma development. Nicotine replacement therapy is a safe option.
Limit alcohol intake: For non-alcohol indications, maintaining alcohol intake below 14 units/week is appropriate to prevent significant relapse and graft damage.
Encourage exercise: Exercise can provide cardiovascular benefits and reduce the risk of osteoporosis. Strenuous exercise should be avoided for the first 12 months after transplant.
Consider statins: Pravastatin and atorvastatin are safe and effective for managing hypertriglyceridaemia following a liver transplant.
Use calcium channel blockers for hypertension: These drugs have minimal side effects and do not interact with calcineurin inhibitors like tacrolimus.
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This question is part of the following fields:
- Allergy And Immunology
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Question 6
Incorrect
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A 35-year-old woman has recently developed symmetrical polyarthritis affecting the small joints of the hands and feet.
Which of the following tests is most likely to contribute to a definitive diagnosis in this patient?
Your Answer:
Correct Answer: Rheumatoid factor
Explanation:Autoantibodies and their Association with Autoimmune Diseases
Autoantibodies are antibodies that target the body’s own tissues and cells. They are often associated with autoimmune diseases, which occur when the immune system mistakenly attacks healthy cells and tissues. Here are some common autoantibodies and their association with autoimmune diseases:
1. Rheumatoid factor: This autoantibody is found in 60-70% of patients with rheumatoid arthritis (RA) and in 5% of the general population. It may also be elevated in other autoimmune diseases. Testing for rheumatoid factor is recommended in people with suspected RA who have synovitis on clinical examination.
2. Antinuclear antibody: This autoantibody binds to the contents of the cell nucleus. It is present in almost all people with systemic lupus erythematosus and is also found in patients with other autoimmune diseases such as rheumatoid arthritis, scleroderma, Sjögren’s syndrome, polymyositis, and certain forms of chronic active hepatitis.
3. Antimitochondrial antibody: This autoantibody is present in 90-95% of patients with autoimmune liver disease, primary biliary cholangitis, and also in 0.5% of the general population. It is also found in about 35% of patients with primary biliary cirrhosis.
4. Antiphospholipid antibodies: These autoantibodies are associated with antiphospholipid syndrome, an autoimmune, hypercoagulable state that can cause arterial and venous thrombosis as well as pregnancy-related complications such as miscarriage, stillbirth, preterm delivery, and severe preeclampsia.
5. HLA-B27 antigen: This antigen is strongly associated with ankylosing spondylitis, as well as other diseases such as psoriasis, reactive arthritis, and inflammatory bowel disease. Its prevalence varies in the general population according to racial type.
In conclusion, autoantibodies can provide important diagnostic and prognostic information in autoimmune diseases. Testing for these antibodies can help healthcare providers make accurate diagnoses and develop effective treatment plans.
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This question is part of the following fields:
- Allergy And Immunology
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Question 7
Incorrect
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A 48-year-old woman with known breast cancer is undergoing chemotherapy at the local hospital. She has been feeling tired and emotional throughout her course of chemotherapy so far, but presents to the Duty Clinic as today, she is feeling more tired than usual, with no appetite and she has been feeling hot and cold at home and struggling to get comfortable.
On examination, you find she has a temperature of 38.5 oC, but no focal symptoms, and her respiratory and pulse rates and blood pressure are all within normal limits.
What is the most appropriate course of action?Your Answer:
Correct Answer: Emergency transfer to a local hospital for medical review
Explanation:Emergency Management of Neutropenic Sepsis in a Chemotherapy Patient
Neutropenic sepsis is a potentially life-threatening complication of neutropenia, commonly seen in patients undergoing chemotherapy. In a patient with fever and neutropenia, neutropenic sepsis should be suspected, and emergency transfer to a local hospital for medical review is necessary. Prescribing broad-spectrum antibiotics or offering emotional support is not the appropriate management in this situation. The patient requires inpatient monitoring and treatment, as per the ‘sepsis six’ bundle of care, to avoid the risk of sudden deterioration. It is crucial to recognize the urgency of this situation and act promptly to ensure the best possible outcome for the patient.
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This question is part of the following fields:
- Allergy And Immunology
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Question 8
Incorrect
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A 26-year-old woman is 18 weeks pregnant. She works as a kindergarten teacher, and two children in the kindergarten have developed Chickenpox. Her own mother is certain that she had Chickenpox as a child.
What is the most appropriate piece of advice to give in order to reassure this woman that her baby is not at risk from this Chickenpox contact?
Your Answer:
Correct Answer: The patient is at low risk of developing an infection as she is sure she had a previous Chickenpox infection
Explanation:Understanding Chickenpox Serology Results in Pregnancy
Chickenpox infection during pregnancy can have serious consequences for both the mother and the fetus. Therefore, it is important to determine a woman’s immunity status before she is exposed to the virus. Serology testing can help determine if a woman has been previously infected or vaccinated against Chickenpox. Here are the possible results and their implications:
– Negative IgG and negative IgM serology: This indicates that the woman has not been previously exposed to the virus and is not immune. She should avoid exposure and receive immunoglobulin if she has significant exposure. She should also be vaccinated postpartum.
– Positive IgG and negative IgM serology: This indicates that the woman has been previously infected or vaccinated and has protective immunity against re-infection. This is the desired result if the woman has no history of Chickenpox.
– Positive IgG and positive IgM serology: This suggests recent infection, but should not be used alone to diagnose infection. Clinical presentation should also be considered. If the woman develops Chickenpox, she should receive acyclovir.
– No serology testing needed: If the woman has a definite history of Chickenpox, she is considered immune and doesn’t need serology testing.It is important to note that a history of Chickenpox may not be a reliable predictor of immunity in women from overseas, and serology testing may be necessary. The NICE guidance on Chickenpox infection in pregnancy provides further recommendations.
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This question is part of the following fields:
- Allergy And Immunology
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Question 9
Incorrect
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A 35-year-old man presents with chronic diarrhoea, unexplained weight loss, and low levels of iron in his blood. You suspect coeliac disease and want to investigate further.
Choose from the options below the immunoglobulin that may be deficient in individuals with coeliac disease.Your Answer:
Correct Answer: IgA
Explanation:Coeliac Disease and Selective IgA Deficiency
Coeliac disease is more common in individuals with selective IgA deficiency, which affects 0.4% of the general population and 2.6% of coeliac disease patients. Diagnosis of coeliac disease relies on detecting IgA antibodies to transglutaminase or anti-endomysial antibody. However, it is crucial to check total serum IgA levels before ruling out the diagnosis based on serology. For those with confirmed IgA deficiency, IgG tTGA and/or IgG EMA are the appropriate serological tests.
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This question is part of the following fields:
- Allergy And Immunology
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Question 10
Incorrect
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You have a female patient aged 30 who works in a factory producing latex products. She has developed asthma and you have referred her to the respiratory unit for further investigation into the possibility of occupational asthma. She wants to know what tests she may need.
Which test is of proven value in diagnosing occupational asthma?Your Answer:
Correct Answer: Serial peak flow measurements
Explanation:Diagnosis of Occupational Asthma
Investigations that have been proven valuable in diagnosing occupational asthma include serial peak flow measurements at and away from work, specific IgE assay or skin prick testing, and specific inhalation testing. To accurately measure peak flow, it should be measured more than four times a day at and away from work for three weeks. Results should be plotted as daily minimum, mean, and maximum values, and intraday variability should be calculated as a percentage of either the mean or highest value (normal upper value is 20%).
Occupational asthma can be confirmed if there is a consistent fall in peak flow values with increased intraday variability on working days, and improvement on days away from work. Computer-based analysis may be necessary. It is important to note that these investigations are only useful when the patient is still in the job with exposure to the suspected agent.
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This question is part of the following fields:
- Allergy And Immunology
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