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Question 1
Correct
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A 21 year old college student comes to the emergency department complaining of feeling unwell, having a fever, and experiencing a severe sore throat. After evaluating the patient, you inform them that you suspect they may have contracted infectious mononucleosis. The patient inquires if it is possible to have caught this by kissing someone a week ago.
What is the usual duration of the incubation period for infectious mononucleosis?Your Answer: 4-8 weeks
Explanation:Glandular fever, also known as infectious mononucleosis or mono, is a clinical syndrome characterized by symptoms such as sore throat, fever, and swollen lymph nodes. It is primarily caused by the Epstein-Barr virus (EBV), with other viruses and infections accounting for the remaining cases. Glandular fever is transmitted through infected saliva and primarily affects adolescents and young adults. The incubation period is 4-8 weeks.
The majority of EBV infections are asymptomatic, with over 95% of adults worldwide having evidence of prior infection. Clinical features of glandular fever include fever, sore throat, exudative tonsillitis, lymphadenopathy, and prodromal symptoms such as fatigue and headache. Splenomegaly (enlarged spleen) and hepatomegaly (enlarged liver) may also be present, and a non-pruritic macular rash can sometimes occur.
Glandular fever can lead to complications such as splenic rupture, which increases the risk of rupture in the spleen. Approximately 50% of splenic ruptures associated with glandular fever are spontaneous, while the other 50% follow trauma. Diagnosis of glandular fever involves various investigations, including viral serology for EBV, monospot test, and liver function tests. Additional serology tests may be conducted if EBV testing is negative.
Management of glandular fever involves supportive care and symptomatic relief with simple analgesia. Antiviral medication has not been shown to be beneficial. It is important to identify patients at risk of serious complications, such as airway obstruction, splenic rupture, and dehydration, and provide appropriate management. Patients can be advised to return to normal activities as soon as possible, avoiding heavy lifting and contact sports for the first month to reduce the risk of splenic rupture.
Rare but serious complications associated with glandular fever include hepatitis, upper airway obstruction, cardiac complications, renal complications, neurological complications, haematological complications, chronic fatigue, and an increased risk of lymphoproliferative cancers and multiple sclerosis.
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This question is part of the following fields:
- Infectious Diseases
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Question 2
Incorrect
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A 32 year old woman arrives at the emergency department complaining of abdominal pain, fever, and yellowing of her skin and eyes. Upon examination, it is evident that she is clinically jaundiced. The patient has a history of intravenous drug use. You suspect she may have acute hepatitis B infection. Which of the following serology results would best support this diagnosis?
Your Answer: HBsAg positive and anti-HBc IgM negative
Correct Answer: HBsAg positive and anti-HBc IgM positive
Explanation:The presence of serum HBsAg for more than 6 months indicates chronic HBV infection. HBeAg can be detected in the serum during the early stages of acute infection and some chronic infections. Higher levels of virus replication are usually associated with the presence of HBeAg, making individuals with chronic HBV more infectious. If HBeAg is cleared, anti-HBe is typically detected, indicating lower infectivity. The presence of anti-HBe, along with a decline in HBV-DNA, suggests control of viral replication and the likelihood of resolving acute hepatitis B. The presence of anti-HBc indicates current or past HBV infection, appearing at the onset of symptoms in acute infection and persisting for life. However, it may be absent in the early stages of acute infection. Anti-HBc IgM indicates recent HBV infection within the last six months and can help differentiate between acute and chronic infection. Over time, it is gradually replaced by IgG anti-HBc. IgG anti-HBc generally persists for life and indicates past infection. Anti-HBs indicates recovery from and immunity to HBV. If anti-HBs is present without anti-HBc, it suggests immunization. The quantification of anti-HBs is used to measure the response to vaccination.
Further Reading:
Hepatitis B is a viral infection that is transmitted through exposure to infected blood or body fluids. It can also be passed from mother to child during childbirth. The incubation period for hepatitis B is typically 6-20 weeks. Common symptoms of hepatitis B include fever, jaundice, and elevated liver transaminases.
Complications of hepatitis B infection can include chronic hepatitis, which occurs in 5-10% of cases, fulminant liver failure, hepatocellular carcinoma, glomerulonephritis, polyarteritis nodosa, and cryoglobulinemia.
Immunization against hepatitis B is recommended for various at-risk groups, including healthcare workers, intravenous drug users, sex workers, close family contacts of infected individuals, and those with chronic liver disease or kidney disease. The vaccine contains HBsAg adsorbed onto an aluminum hydroxide adjuvant and is prepared using recombinant DNA technology. Most vaccination schedules involve three doses of the vaccine, with a booster recommended after 5 years.
Around 10-15% of adults may not respond adequately to the vaccine. Risk factors for poor response include age over 40, obesity, smoking, alcohol excess, and immunosuppression. Testing for anti-HBs levels is recommended for healthcare workers and patients with chronic kidney disease. Interpretation of anti-HBs levels can help determine the need for further vaccination or testing for infection.
In terms of serology, the presence of HBsAg indicates acute disease if present for 1-6 months, and chronic disease if present for more than 6 months. Anti-HBs indicates immunity, either through exposure or immunization. Anti-HBc indicates previous or current infection, with IgM anti-HBc appearing during acute or recent infection and IgG anti-HBc persisting. HbeAg is a marker of infectivity.
Management of hepatitis B involves notifying the Health Protection Unit for surveillance and contact tracing. Patients should be advised to avoid alcohol and take precautions to minimize transmission to partners and contacts. Referral to a gastroenterologist or hepatologist is recommended for all patients. Symptoms such as pain, nausea, and itch can be managed with appropriate drug treatment. Pegylated interferon-alpha and other antiviral medications like tenofovir and entecavir may be used to suppress viral replication in chronic carriers.
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This question is part of the following fields:
- Infectious Diseases
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Question 3
Incorrect
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A 40-year-old man comes in with abdominal cramps and severe bloody diarrhoea due to a gastrointestinal infection.
What is the MOST LIKELY single causative organism?Your Answer: Giardia lamblia
Correct Answer: Entamoeba histolytica
Explanation:Infectious causes of bloody diarrhea include Campylobacter spp., Shigella spp., Salmonella spp., Clostridium difficile, Enterohaemorrhagic Escherichia coli, Yersinia spp., Schistosomiasis, and Amoebiasis (Entamoeba histolytica). Enterotoxigenic E.coli is a non-invasive strain that does not cause inflammation or bloody diarrhea. Instead, it typically presents with profuse watery diarrhea and is not usually associated with abdominal cramping. The other organisms mentioned in this question are associated with watery diarrhea, but not bloody diarrhea.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 4
Incorrect
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You organize a teaching session for the junior doctors on the syndrome of inappropriate antidiuretic hormone secretion. Which of the following biochemical abnormalities is typical of SIADH?
Your Answer: Elevated plasma osmolality
Correct Answer: Hyponatraemia
Explanation:SIADH is characterized by hyponatremia, which is a condition where there is a low level of sodium in the blood. This occurs because the body is unable to properly excrete excess water, leading to a dilution of sodium levels. SIADH is specifically classified as euvolemic, meaning that there is a normal amount of fluid in the body, and hypotonic, indicating that the concentration of solutes in the blood is lower than normal.
Further Reading:
Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition characterized by low sodium levels in the blood due to excessive secretion of antidiuretic hormone (ADH). ADH, also known as arginine vasopressin (AVP), is responsible for promoting water and sodium reabsorption in the body. SIADH occurs when there is impaired free water excretion, leading to euvolemic (normal fluid volume) hypotonic hyponatremia.
There are various causes of SIADH, including malignancies such as small cell lung cancer, stomach cancer, and prostate cancer, as well as neurological conditions like stroke, subarachnoid hemorrhage, and meningitis. Infections such as tuberculosis and pneumonia, as well as certain medications like thiazide diuretics and selective serotonin reuptake inhibitors (SSRIs), can also contribute to SIADH.
The diagnostic features of SIADH include low plasma osmolality, inappropriately elevated urine osmolality, urinary sodium levels above 30 mmol/L, and euvolemic. Symptoms of hyponatremia, which is a common consequence of SIADH, include nausea, vomiting, headache, confusion, lethargy, muscle weakness, seizures, and coma.
Management of SIADH involves correcting hyponatremia slowly to avoid complications such as central pontine myelinolysis. The underlying cause of SIADH should be treated if possible, such as discontinuing causative medications. Fluid restriction is typically recommended, with a daily limit of around 1000 ml for adults. In severe cases with neurological symptoms, intravenous hypertonic saline may be used. Medications like demeclocycline, which blocks ADH receptors, or ADH receptor antagonists like tolvaptan may also be considered.
It is important to monitor serum sodium levels closely during treatment, especially if using hypertonic saline, to prevent rapid correction that can lead to central pontine myelinolysis. Osmolality abnormalities can help determine the underlying cause of hyponatremia, with increased urine osmolality indicating dehydration or renal disease, and decreased urine osmolality suggesting SIADH or overhydration.
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This question is part of the following fields:
- Endocrinology
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Question 5
Correct
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A fourth-year medical student is studying subarachnoid hemorrhages (SAH).
Which of the following statements is accurate regarding subarachnoid hemorrhage?Your Answer: SAH is associated with polycystic kidneys
Explanation:A subarachnoid haemorrhage (SAH) occurs when there is spontaneous bleeding into the subarachnoid space and is often a catastrophic event. The incidence of SAH is 9 cases per 100,000 people per year, and it typically affects individuals between the ages of 35 and 65.
The majority of SAH cases (80%) are caused by the rupture of berry (saccular) aneurysms, while 15% are caused by arteriovenous malformations (AVM). In less than 5% of cases, no specific cause can be found. Berry aneurysms are associated with polycystic kidneys, Ehlers-Danlos Syndrome, and coarctation of the aorta.
There are several risk factors for SAH, including smoking, hypertension, bleeding disorders, alcohol misuse, mycotic aneurysm, and a family history of the condition.
Patients with SAH typically experience a sudden and severe occipital headache, often described as the worst headache of my life. This may be accompanied by vomiting, collapse, seizures, and coma. Clinical signs of SAH include neck stiffness, a positive Kernig’s sign, and focal neurological abnormalities. Fundoscopy may reveal subhyaloid retinal haemorrhages in approximately 25% of patients.
Re-bleeding occurs in 30-40% of patients who survive the initial episode, with the highest risk occurring between 7 and 14 days after the initial event.
Untreated SAH has a mortality rate of nearly 50% within the first eight weeks following presentation. Prolonged coma is associated with a 100% mortality rate.
The first-line investigation for SAH is a CT head scan, which can detect over 95% of cases if performed within the first 24 hours. The sensitivity of the CT scan increases to nearly 100% if performed within 6 hours of symptom onset. If the CT scan is negative and there are no contraindications, a lumbar puncture (LP) should be performed at least 12 hours after the onset of headache to diagnose SAH. Approximately 3% of patients with a negative CT scan will be confirmed to have had an SAH following an LP.
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This question is part of the following fields:
- Neurology
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Question 6
Incorrect
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You evaluate a 35-year-old male patient who has been diagnosed with an anal fissure. He has been undergoing treatment for the last two months, which includes lactulose, senna, topical creams with local anesthetics, and topical GTN ointment. However, his symptoms continue to persist, and he describes the pain during bowel movements as intolerable.
What would be the most suitable next step in managing this patient's condition?Your Answer: Topical diltiazem
Correct Answer: Botulinum toxin injection
Explanation:An anal fissure is a tear in the wall of the anal mucosa that exposes the circular muscle layer. The majority of these tears occur in the posterior midline. The most common cause is the passage of a large, hard stool after a period of constipation. If multiple fissures are present, it may indicate an underlying condition such as Crohn’s disease or tuberculosis.
Both men and women are equally affected by anal fissures, and they are most commonly seen in individuals in their thirties. The typical symptoms of an anal fissure include intense, sharp pain during bowel movements, which can last up to an hour after passing stool. Additionally, there may be spots of bright red blood on the toilet paper when wiping, and a history of constipation.
The initial management of an anal fissure involves non-operative measures such as using stool softeners and bulking agents. To alleviate the intense anal pain, analgesics and topical local anesthetics may be prescribed. According to a recent meta-analysis, first-line therapy should involve the use of topical GTN or diltiazem, with botulinum toxin being used as a rescue treatment if necessary (Modern perspectives in the treatment of chronic anal fissures. Ann R Coll Surg Engl. 2007 Jul;89(5):472-8.)
Sphincterotomy, a surgical procedure, should be reserved for fissures that do not heal and has a success rate of 90%. Anal dilatation, also known as Lord’s procedure, is rarely used nowadays due to the high risk of subsequent fecal incontinence.
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This question is part of the following fields:
- Surgical Emergencies
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Question 7
Incorrect
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A 60-year-old woman comes in with a red, hot, swollen great toe. The diagnosis is acute gout. You decide to start her on a non-steroidal anti-inflammatory drug (NSAID). Her husband was recently diagnosed with a peptic ulcer after an endoscopy, and she is worried about the potential side effects of NSAIDs.
Which of the following NSAIDs has the lowest occurrence of side effects?Your Answer:
Correct Answer: Ibuprofen
Explanation:The differences in anti-inflammatory activity among NSAIDs are minimal, but there is significant variation in how individuals respond to and tolerate these drugs. Approximately 60% of patients will experience a positive response to any NSAID, and those who do not respond to one may find relief with another. Pain relief typically begins shortly after taking the first dose, and a full analgesic effect is usually achieved within a week. However, it may take up to 3 weeks to see an anti-inflammatory effect, which may not be easily assessed. If desired results are not achieved within these timeframes, it is recommended to try a different NSAID.
NSAIDs work by reducing the production of prostaglandins through the inhibition of the enzyme cyclo-oxygenase. Different NSAIDs vary in their selectivity for inhibiting different types of cyclo-oxygenase. Selective inhibition of cyclo-oxygenase-2 is associated with a lower risk of gastrointestinal intolerance. Other factors also play a role in susceptibility to gastrointestinal effects, so the choice of NSAID should consider the incidence of gastrointestinal and other side effects.
Ibuprofen, a propionic acid derivative, possesses anti-inflammatory, analgesic, and antipyretic properties. It generally has fewer side effects compared to other non-selective NSAIDs, but its anti-inflammatory properties are weaker. For rheumatoid arthritis, doses of 1.6 to 2.4 g daily are required, and it may not be suitable for conditions where inflammation is prominent, such as acute gout.
Naproxen is often a preferred choice due to its combination of good efficacy and low incidence of side effects. However, it does have a higher occurrence of side effects compared to ibuprofen.
Ketoprofen and diclofenac have similar anti-inflammatory properties to ibuprofen but are associated with more side effects.
Indometacin has an action that is equal to or superior to naproxen, but it also has a high incidence of side effects, including headache, dizziness, and gastrointestinal disturbances.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 8
Incorrect
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A 60-year-old woman presents with intense pain in her left eye and sudden vision loss in the same eye. She has experienced multiple episodes of vomiting. After conducting a comprehensive examination and measuring the intraocular pressure, you diagnose her with acute closed-angle glaucoma. You provide analgesics and administer IV acetazolamide as the initial treatment.
What other treatment option could potentially benefit this patient?Your Answer:
Correct Answer: Topical pilocarpine
Explanation:This patient has presented with acute closed-angle glaucoma, which is a serious eye condition requiring immediate medical attention. It occurs when the iris pushes forward and blocks the fluid access to the trabecular meshwork, leading to increased pressure within the eye and damage to the optic nerve.
The main symptoms of acute closed-angle glaucoma include severe eye pain, decreased vision, redness around the cornea, swelling of the cornea, a fixed semi-dilated pupil, nausea, vomiting, and episodes of blurred vision or seeing haloes.
To confirm the diagnosis, tonometry is performed to measure the intraocular pressure. Normal pressure ranges from 10 to 21 mmHg, but in acute closed-angle glaucoma, it is often higher than 30 mmHg. Goldmann’s applanation tonometer is commonly used in hospitals for this purpose.
Management of acute closed-angle glaucoma involves providing pain relief, such as morphine, and antiemetics if the patient is experiencing vomiting. Intravenous acetazolamide is administered to reduce intraocular pressure. Additionally, a topical miotic medication like pilocarpine is started about an hour after initiating other treatments to help constrict the pupil, as it may initially be paralyzed and unresponsive.
Overall, acute closed-angle glaucoma is a medical emergency that requires prompt intervention to alleviate symptoms and prevent further damage to the eye.
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This question is part of the following fields:
- Ophthalmology
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Question 9
Incorrect
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A 35-year-old patient with a history of exhaustion and weariness has a complete blood count scheduled. The complete blood count reveals the presence of macrocytic anemia.
What is the most probable underlying diagnosis?Your Answer:
Correct Answer: Liver disease
Explanation:Anaemia can be categorized based on the size of red blood cells. Microcytic anaemia, characterized by a mean corpuscular volume (MCV) of less than 80 fl, can be caused by various factors such as iron deficiency, thalassaemia, anaemia of chronic disease (which can also be normocytic), sideroblastic anaemia (which can also be normocytic), lead poisoning, and aluminium toxicity (although this is now rare and mainly affects haemodialysis patients).
On the other hand, normocytic anaemia, with an MCV ranging from 80 to 100 fl, can be attributed to conditions like haemolysis, acute haemorrhage, bone marrow failure, anaemia of chronic disease (which can also be microcytic), mixed iron and folate deficiency, pregnancy, chronic renal failure, and sickle-cell disease.
Lastly, macrocytic anaemia, characterized by an MCV greater than 100 fl, can be caused by factors such as B12 deficiency, folate deficiency, hypothyroidism, reticulocytosis, liver disease, alcohol abuse, myeloproliferative disease, myelodysplastic disease, and certain drugs like methotrexate, hydroxyurea, and azathioprine.
It is important to understand the different causes of anaemia based on red cell size as this knowledge can aid in the diagnosis and management of this condition.
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This question is part of the following fields:
- Haematology
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Question 10
Incorrect
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A 45-year-old woman presents with a 6-month history of lower back pain and rib pain. She has been brought to your clinic today by her husband, who is concerned about her confusion over the past few days. She has also had difficulty passing urine today. On examination, she appears pale and has tenderness over her lumbar spine and lower ribs. Fundoscopy reveals retinal haemorrhages. Her most recent blood results are shown below:
Hb 8.4 g/dl (13-17 g/dl)
MCV 102.6 fl (80-100 fl)
Platelets 114 x 109/l (150-400 x 109/l)
WCC 3.4 x 109/l (4-11 x 109/l)
Normal differential
Sodium 140 mmol/l (135-145 mmol/l)
Potassium 4.6 mmol/l (3.5-5.0 mmol/l)
Calcium 2.94 mmol/l (2.05-2.60 mmol/l)
Creatinine 193 mmol/l (60-110 mmol/l)
Urea 11.2 mmol/l (3-7 mmol/l)
Total protein 88 g/l (60-85 g/l)
Albumin 23 g/l (36-52 g/l)
ESR 132 mm/hr (30 mm/hr)
Which is the SINGLE most likely diagnosis?Your Answer:
Correct Answer: Multiple myeloma
Explanation:Multiple myeloma is a cancerous growth of plasma cells, a type of white blood cell responsible for producing antibodies. It is more prevalent in men and typically occurs in individuals over the age of 60.
When a patient over 60 presents with an elevated ESR, unexplained anemia, hypercalcemia, renal impairment, and bone pain, the initial diagnosis is usually multiple myeloma until proven otherwise.
The most common symptoms of multiple myeloma include:
1. Anemia: This is caused by the infiltration of the bone marrow and suppression of blood cell production. It is typically normocytic and normochromic, but can also be macrocytic.
2. Bone pain: Approximately 70% of patients experience bone pain, which commonly affects the spine and ribs. Localized pain and tenderness may indicate a pathological fracture, and vertebral fractures can lead to spinal cord compression.
3. Renal failure: Acute or chronic renal failure occurs in about one-third of patients. This is generally due to the effects of light chains on the tubules.
4. Neurological symptoms: Hypercalcemia can cause weakness, lethargy, and confusion, while hyperviscosity can result in headaches and retinopathy. Amyloid infiltration can lead to peripheral neuropathies, with carpal tunnel syndrome being the most common.
5. Infection: The most common infections seen in multiple myeloma patients are pyelonephritis and pneumonia.
In addition to the routine blood tests already conducted, a suspected diagnosis of multiple myeloma should prompt further investigations, including:
– Plasma viscosity measurement
– Urinary protein electrophoresis to detect Bence-Jones proteins
– Serum electrophoresis to identify the type of paraprotein
– Quantitative immunoglobulin level testing
– Skeletal survey to look for lytic lesions
– Bone marrow aspirate and possibly biopsyA diagnosis of multiple myeloma is confirmed by the presence of a monoclonal protein in the serum or urine, lytic lesions on X-ray, and an increased number of plasma cells in the bone marrow.
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This question is part of the following fields:
- Haematology
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Question 11
Incorrect
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A 35-year-old West Indian woman with a past medical history of bilateral wrist and hand pain comes to the clinic complaining of a red rash on her cheeks and nose.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Systemic lupus erythematosus
Explanation:Systemic lupus erythematosus (SLE) is a connective tissue disorder that affects multiple systems in the body. It is characterized by skin rashes, joint pain, and the presence of antibodies against double-stranded DNA. SLE is more commonly seen in young women, with a ratio of 10 females to 1 male. It is also more prevalent in West Indian populations.
One of the classic signs of SLE is the presence of a butterfly rash. This rash appears as redness over the bridge of the nose and cheeks. It is often worsened by exposure to sunlight and can occur before other symptoms of SLE develop.
Joint involvement is common in SLE and can affect both large and small joints. The knee, proximal interphalangeal, wrist, and metacarpophalangeal joints are most frequently affected.
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This question is part of the following fields:
- Dermatology
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Question 12
Incorrect
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A 60-year-old individual comes in with an arthropathy impacting the metatarsophalangeal joint on their left foot. Gout is suspected, and a joint aspirate is sent for laboratory analysis.
What type of crystals would be anticipated in the presence of gout?Your Answer:
Correct Answer: Negatively birefringent needle-shaped crystals
Explanation:Gout and pseudogout are both characterized by the presence of crystal deposits in the joints that are affected. Gout occurs when urate crystals are deposited, while pseudogout occurs when calcium pyrophosphate crystals are deposited. Under a microscope, these crystals can be distinguished by their appearance. Urate crystals are needle-shaped and negatively birefringent, while calcium pyrophosphate crystals are brick-shaped and positively birefringent.
Gout can affect any joint in the body, but it most commonly manifests in the hallux metatarsophalangeal joint, which is the joint at the base of the big toe. This joint is affected in approximately 50% of gout cases. On the other hand, pseudogout primarily affects the larger joints, such as the knee.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 13
Incorrect
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A 42-year-old woman is brought in by ambulance following a high-speed car accident. There was a prolonged extraction at the scene, and a full trauma call is placed. She is disoriented and slightly restless. Her vital signs are as follows: heart rate 125, blood pressure 83/45, oxygen saturation 98% on high-flow oxygen, respiratory rate 31, temperature 36.1°C. Her capillary refill time is 5 seconds, and her extremities appear pale and cool to the touch. Her cervical spine is triple immobilized. The airway is clear, and her chest examination is normal. Two large-bore needles have been inserted in her antecubital fossa, and a complete set of blood tests have been sent to the laboratory, including a request for a cross-match. She experiences significant suprapubic tenderness upon abdominal palpation, and there is noticeable bruising around her pelvis. A pelvic X-ray reveals a vertical shear type pelvic fracture.
What type of shock is she experiencing?Your Answer:
Correct Answer: Class III
Explanation:This patient is currently experiencing moderate shock, classified as class III. This level of shock corresponds to a loss of 30-40% of their circulatory volume, which is equivalent to a blood loss of 1500-2000 mL.
Hemorrhage can be categorized into four classes based on physiological parameters and clinical signs. These classes are classified as class I, class II, class III, and class IV.
In class I hemorrhage, the blood loss is up to 750 mL or up to 15% of the blood volume. The pulse rate is less than 100 beats per minute, and the systolic blood pressure is normal. The pulse pressure may be normal or increased, and the respiratory rate is within the range of 14-20 breaths per minute. The urine output is greater than 30 mL per hour, and the patient’s CNS/mental status is slightly anxious.
In class II hemorrhage, the blood loss ranges from 750-1500 mL or 15-30% of the blood volume. The pulse rate is between 100-120 beats per minute, and the systolic blood pressure is still normal. The pulse pressure is decreased, and the respiratory rate increases to 20-30 breaths per minute. The urine output decreases to 20-30 mL per hour, and the patient may experience mild anxiety.
In class III hemorrhage, like the case of this patient, the blood loss is between 1500-2000 mL or 30-40% of the blood volume. The pulse rate further increases to 120-140 beats per minute, and the systolic blood pressure decreases. The pulse pressure continues to decrease, and the respiratory rate rises to 30-40 breaths per minute. The urine output significantly decreases to 5-15 mL per hour, and the patient becomes anxious and confused.
In class IV hemorrhage, the blood loss exceeds 2000 mL or more than 40% of the blood volume. The pulse rate is greater than 140 beats per minute, and the systolic blood pressure is significantly decreased. The pulse pressure is further decreased, and the respiratory rate exceeds 40 breaths per minute. The urine output becomes negligible, and the patient’s CNS/mental status deteriorates to a state of confusion and lethargy.
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This question is part of the following fields:
- Trauma
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Question 14
Incorrect
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A 62-year-old woman presents with a persistent cough that has been ongoing for several months. She reports that the cough occasionally produces a small amount of phlegm, especially in the morning. She has experienced a significant weight loss of 28 pounds over the past six months and constantly feels fatigued. Even with minimal physical activity, she becomes short of breath. She has no significant medical history and is a non-smoker. She enjoys keeping and racing pigeons as a hobby. Upon examination, bilateral fine end-inspiratory crackles are heard.
What is the SINGLE most likely diagnosis?Your Answer:
Correct Answer: Extrinsic allergic alveolitis
Explanation:This patient is likely to have pigeon fancier’s lung, which is a type of extrinsic allergic alveolitis (EAA) caused by chronic exposure to avian antigens found in bird droppings. This condition leads to hypersensitivity pneumonitis and the formation of granulomas in the lungs.
While his presentation could also be consistent with idiopathic pulmonary fibrosis, the fact that he keeps and races pigeons makes EAA more likely in this case.
EAA can manifest as either an acute or chronic condition. The acute form typically presents with flu-like symptoms such as fever, cough, chest tightness, and breathlessness occurring 4 to 6 hours after exposure.
The clinical features of chronic pigeon fancier’s lung include a productive cough, progressive breathlessness, weight loss, anorexia, fatigue, and malaise.
Other forms of EAA include farmer’s lung (caused by exposure to Saccharopolyspora rectivirgula from wet hay), malt-worker’s lung (caused by exposure to Aspergillus clavatus from moldy malt), cheese-worker’s lung (caused by exposure to Penicillium casei from moldy cheese), chemical worker’s lung (caused by exposure to trimetallic anhydride, diisocyanate, and methylene diisocyanate), mushroom worker’s lung (caused by exposure to thermophilic actinomycetes in mushroom compost), and hot tub lung (caused by exposure to Mycobacterium avium from poorly maintained hot tubs).
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This question is part of the following fields:
- Respiratory
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Question 15
Incorrect
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A 45-year-old man presents with a history of feeling generally unwell and having experienced fevers at home. He has a history of lung cancer for which he is currently receiving radiation therapy. His observations are as follows: HR 92 bpm, BP 130/80, SaO2 98% on air, temperature 38.9°C. A diagnosis of neutropenic sepsis is suspected.
According to the current NICE guidelines what is the cut off point for the neutrophil count for a diagnosis of neutropenic sepsis to be made?Your Answer:
Correct Answer: 0.5 x 109 per litre or lower
Explanation:Neutropenic sepsis is a serious complication that can arise when a person has low levels of neutrophils, which are a type of white blood cell. This condition can be life-threatening and is commonly seen in individuals undergoing treatments such as cytotoxic chemotherapy or taking immunosuppressive drugs. Other causes of neutropenia include infections, bone marrow disorders like aplastic anemia and myelodysplastic syndromes, as well as nutritional deficiencies.
To diagnose neutropenic sepsis, doctors look for specific criteria in patients receiving anticancer treatment. These criteria include having a neutrophil count of 0.5 x 109 per liter or lower, along with either a body temperature higher than 38°C or other signs and symptoms that indicate a clinically significant sepsis.
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This question is part of the following fields:
- Oncological Emergencies
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Question 16
Incorrect
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A 32-year-old woman who is 39-weeks pregnant is brought to the Emergency Department due to severe headaches, visual disturbances, and abdominal pain. Shortly after arrival, she experiences a seizure and collapses. Her husband mentions that she has been receiving treatment for hypertension during the pregnancy.
What is the most suitable initial treatment in this case?Your Answer:
Correct Answer: IV magnesium sulphate
Explanation:Eclampsia is the most likely diagnosis in this case. It is characterized by the occurrence of one or more convulsions on top of pre-eclampsia. To control seizures in eclampsia, the recommended treatment is magnesium sulphate. The Collaborative Eclampsia Trial regimen should be followed for administering magnesium sulphate. Initially, a loading dose of 4 g should be given intravenously over 5 to 15 minutes. This should be followed by a continuous infusion of 1 g per hour for 24 hours. If the woman experiences another eclamptic seizure, the infusion should be continued for an additional 24 hours after the last seizure. In case of recurrent seizures, a further dose of 2-4 g should be administered intravenously over 5 to 15 minutes. It is important to note that the only cure for eclampsia is the delivery of the fetus and placenta. Once the patient is stabilized, she should be prepared for an emergency caesarean section.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 17
Incorrect
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A 16 year old male is brought into the emergency department as he has become disoriented and lethargic over the past day. Initial tests suggest a diagnosis of diabetic ketoacidosis. A blue 20g cannula has been inserted to administer intravenous fluids. What is the estimated maximum rate of flow through a 20g cannula?
Your Answer:
Correct Answer: 60 ml/minute
Explanation:The size of the cannula used for IV fluid infusion determines the maximum flow rate. For a 20g cannula, the maximum flow rate is around 60 ml per minute. As a result, the fastest infusion time through a 20g cannula is approximately 15 minutes for a maximum volume of 1000 ml.
Further Reading:
Peripheral venous cannulation is a procedure that should be performed following established guidelines to minimize the risk of infection, injury, extravasation, and early failure of the cannula. It is important to maintain good hand hygiene, use personal protective equipment, ensure sharps safety, and employ an aseptic non-touch technique during the procedure.
According to the National Institute for Health and Care Excellence (NICE), the skin should be disinfected with a solution of 2% chlorhexidine gluconate and 70% alcohol before inserting the catheter. It is crucial to allow the disinfectant to completely dry before inserting the cannula.
The flow rates of IV cannulas can vary depending on factors such as the gauge, color, type of fluid used, presence of a bio-connector, length of the cannula, and whether the fluid is drained under gravity or pumped under pressure. However, the following are typical flow rates for different gauge sizes: 14 gauge (orange) has a flow rate of 270 ml/minute, 16 gauge (grey) has a flow rate of 180 ml/minute, 18 gauge (green) has a flow rate of 90 ml/minute, 20 gauge (pink) has a flow rate of 60 ml/minute, and 22 gauge (blue) has a flow rate of 36 ml/minute. These flow rates are based on infusing 1000 ml of normal saline under ideal circumstances, but they may vary in practice.
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This question is part of the following fields:
- Resus
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Question 18
Incorrect
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A 42-year-old woman comes in with a painful, red left eye and sensitivity to light. She also reports seeing floaters and experiencing a dull, throbbing headache. She is currently being evaluated by the rheumatology team for persistent pain and stiffness in her upper back and discomfort in her buttocks and thighs. Her eye appears red, and a hypopyon is visible.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Anterior uveitis
Explanation:The most probable diagnosis in this case is anterior uveitis, which refers to inflammation of the iris. It typically presents with symptoms such as a painful and red eye, sensitivity to light, excessive tearing, and decreased visual clarity. The photo above shows a possible indication of this condition, with the presence of pus in the front chamber of the eye, known as hypopyon.
Anterior uveitis can have various causes, including idiopathic cases where no specific cause is identified. Other potential triggers include trauma, chronic joint diseases like spondyloarthropathies and juvenile chronic arthritis, inflammatory bowel disease, psoriasis, sarcoidosis, and infections such as Lyme disease, tuberculosis, leptospirosis, herpes simplex virus (HSV), and varicella-zoster virus (VZV). Additionally, certain malignancies like non-Hodgkin lymphoma, ocular melanoma, and retinoblastoma can be associated with anterior uveitis.
It is worth noting that there is a strong link between the HLA-B27 genotype and anterior uveitis, with approximately 50% of patients having this genetic marker. In this particular case, the likely underlying diagnosis is ankylosing spondylitis, a condition characterized by chronic pain and stiffness in the mid-spine area and sacroiliitis. It is important to mention that around 30% of men with unilateral uveitis will be found to have ankylosing spondylitis.
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This question is part of the following fields:
- Ophthalmology
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Question 19
Incorrect
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A 42-year-old left-handed history teacher presents with a sudden onset of difficulty in recalling historical facts. A CT scan of her head reveals a right parietal lobe infarct.
Which SINGLE clinical feature is most likely to also be present?Your Answer:
Correct Answer: Agraphia
Explanation:The parietal lobes can be divided into two functional areas. One area is responsible for sensation and perception, while the other integrates sensory input primarily from the visual pathways. These lobes play a crucial role in cognition and spatial awareness.
Typically, the left parietal lobe is dominant, and if there are lesions in this area, it can lead to a condition known as Gerstmann’s Syndrome. This syndrome encompasses several difficulties, including problems with writing (agraphia or dysgraphia), arithmetic (acalculia or dyscalculia), and identifying fingers (finger agnosia). Additionally, individuals may experience left-right disorientation and some form of aphasia or dysphasia, affecting their ability to express themselves or understand others.
On the other hand, lesions in the right parietal lobe, which is the non-dominant side, can result in neglecting a part of the body. This can make tasks like dressing and washing challenging.
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This question is part of the following fields:
- Neurology
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Question 20
Incorrect
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A 45-year-old man is brought into the Emergency Department by his wife after taking an overdose of paracetamol. The patient claims that he wants to end it all and refuses to stay in the hospital for treatment. His wife insists that he must be treated because he is not thinking clearly.
Which medication is the primary treatment for paracetamol overdose in an inpatient setting?Your Answer:
Correct Answer: Acetylcysteine
Explanation:Paracetamol overdose is the most common overdose in the U.K. and is also the leading cause of acute liver failure. The liver damage occurs due to a metabolite of paracetamol called N-acetyl-p-benzoquinoneimine (NAPQI), which depletes the liver’s glutathione stores and directly harms liver cells. Severe liver damage and even death can result from an overdose of more than 12 g or > 150 mg/kg body weight.
The clinical manifestations of paracetamol overdose can be divided into four stages:
Stage 1 (0-24 hours): Patients may not show any symptoms, but common signs include nausea, vomiting, and abdominal discomfort.
Stage 2 (24-48 hours): Right upper quadrant pain and tenderness develop, along with the possibility of hypoglycemia and reduced consciousness.
Stage 3 (48-96 hours): Hepatic failure begins, characterized by jaundice, coagulopathy, and encephalopathy. Loin pain, haematuria, and proteinuria may indicate early renal failure.
Stage 4 (> 96 hours): Hepatic failure worsens progressively, leading to cerebral edema, disseminated intravascular coagulation (DIC), and ultimately death.
The earliest and most sensitive indicator of liver damage is a prolonged INR, which starts to rise approximately 24 hours after the overdose. Liver function tests (LFTs) typically remain normal until 18 hours after the overdose. However, AST and ALT levels then sharply increase and can exceed 10,000 units/L by 72-96 hours. Bilirubin levels rise more slowly and peak around 5 days.
The primary treatment for paracetamol overdose is acetylcysteine. Acetylcysteine is a highly effective antidote, but its efficacy diminishes rapidly if administered more than 8 hours after a significant ingestion. Ingestions exceeding 75 mg/kg are considered significant.
Acetylcysteine should be given based on a 4-hour level or administered empirically if the presentation occurs more than 8 hours after a significant overdose. If the overdose is staggered or the timing is uncertain, empirical treatment is also recommended. The treatment regimen is as follows:
– First dose: 150 mg/kg in 200 mL 5% glucose over 1 hour
– Second dose 50 mg/kg in 500 mL 5% glucose over 4 hours
– Third dose 100 mg/kg in 1000 mL 5% glucose over 16 hours -
This question is part of the following fields:
- Pharmacology & Poisoning
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Question 21
Incorrect
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A 4-year-old child is brought in by ambulance. He has been experiencing seizures for the past 35 minutes. He has received two doses of IV lorazepam. His bowel movement is normal, and he is not taking any medication.
According to the current APLS guidelines, what would be the most suitable next course of action in managing his condition?Your Answer:
Correct Answer: Set up phenytoin infusion
Explanation:The current algorithm for the treatment of a convulsing child, known as APLS, is as follows:
Step 1 (5 minutes after the start of convulsion):
If a child has been convulsing for 5 minutes or more, the initial dose of benzodiazepine should be administered. This can be done by giving Lorazepam at a dose of 0.1 mg/kg intravenously (IV) or intraosseously (IO) if vascular access is available. Alternatively, buccal midazolam at a dose of 0.5 mg/kg or rectal diazepam at a dose of 0.5 mg/kg can be given if vascular access is not available.Step 2 (10 minutes after the start of Step 1):
If the convulsion continues for a further 10 minutes, a second dose of benzodiazepine should be given. It is also important to summon senior help at this point.Step 3 (10 minutes after the start of Step 2):
At this stage, it is necessary to involve senior help to reassess the child and provide guidance on further management. The recommended approach is as follows:
– If the child is not already on phenytoin, a phenytoin infusion should be initiated. This involves administering 20 mg/kg of phenytoin intravenously over a period of 20 minutes.
– If the child is already taking phenytoin, phenobarbitone can be used as an alternative. The recommended dose is 20 mg/kg administered intravenously over 20 minutes.
– In the meantime, rectal paraldehyde can be considered at a dose of 0.8 ml/kg of the 50:50 mixture while preparing the infusion.Step 4 (20 minutes after the start of Step 3):
If the child is still experiencing convulsions at this stage, it is crucial to have an anaesthetist present. A rapid sequence induction with thiopental is recommended for further management.Please note that this algorithm is subject to change based on individual patient circumstances and the guidance of medical professionals.
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This question is part of the following fields:
- Neurology
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Question 22
Incorrect
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A 25-year-old is brought into the emergency department after being discovered unresponsive in a neighbor's backyard. It is suspected that the patient had consumed alcohol at a nearby club and opted to walk home in the snowy conditions. The patient's temperature is documented as 27.8ºC. The nurse connects leads to conduct a 12-lead ECG. Which of the subsequent ECG alterations is most closely linked to hypothermia?
Your Answer:
Correct Answer: Osborn waves
Explanation:Hypothermia can cause various changes in an electrocardiogram (ECG). These changes include a slower heart rate (bradycardia), the presence of Osborn Waves (also known as J waves), a prolonged PR interval, a widened QRS complex, and a prolonged QT interval. Additionally, the ECG may show artifacts caused by shivering, as well as the presence of ventricular ectopics. In severe cases, hypothermia can lead to cardiac arrest, which may manifest as ventricular tachycardia (VT), ventricular fibrillation (VF), or asystole.
Further Reading:
Hypothermia is defined as a core temperature below 35ºC and can be graded as mild, moderate, severe, or profound based on the core temperature. When the core temperature drops, the basal metabolic rate decreases and cell signaling between neurons decreases, leading to reduced tissue perfusion. This can result in decreased myocardial contractility, vasoconstriction, ventilation-perfusion mismatch, and increased blood viscosity. Symptoms of hypothermia progress as the core temperature drops, starting with compensatory increases in heart rate and shivering, and eventually leading to bradyarrhythmias, prolonged PR, QRS, and QT intervals, and cardiac arrest.
In the management of hypothermic cardiac arrest, ALS should be initiated with some modifications. The pulse check during CPR should be prolonged to 1 minute due to difficulty in obtaining a pulse. Rewarming the patient is important, and mechanical ventilation may be necessary due to stiffness of the chest wall. Drug metabolism is slowed in hypothermic patients, so dosing of drugs should be adjusted or withheld. Electrolyte disturbances are common in hypothermic patients and should be corrected.
Frostbite refers to a freezing injury to human tissue and occurs when tissue temperature drops below 0ºC. It can be classified as superficial or deep, with superficial frostbite affecting the skin and subcutaneous tissues, and deep frostbite affecting bones, joints, and tendons. Frostbite can be classified from 1st to 4th degree based on the severity of the injury. Risk factors for frostbite include environmental factors such as cold weather exposure and medical factors such as peripheral vascular disease and diabetes.
Signs and symptoms of frostbite include skin changes, cold sensation or firmness to the affected area, stinging, burning, or numbness, clumsiness of the affected extremity, and excessive sweating, hyperemia, and tissue gangrene. Frostbite is diagnosed clinically and imaging may be used in some cases to assess perfusion or visualize occluded vessels. Management involves moving the patient to a warm environment, removing wet clothing, and rapidly rewarming the affected tissue. Analgesia should be given as reperfusion is painful, and blisters should be de-roofed and aloe vera applied. Compartment syndrome is a risk and should be monitored for. Severe cases may require surgical debridement of amputation.
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This question is part of the following fields:
- Cardiology
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Question 23
Incorrect
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A 35-year-old construction worker presents with hematemesis. He consumed excessive alcohol with his colleagues the previous night and began vomiting towards the end of the evening. After forcefully retching and vomiting multiple times, he observed traces of blood in his vomit. He vomited once again this morning and is extremely worried as there was still blood present.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Mallory-Weiss syndrome
Explanation:Mallory-Weiss syndrome is a condition characterized by a tear in the lining of the esophagus, specifically near the junction where the esophagus meets the stomach. This tear is typically caused by forceful retching and vomiting and is often associated with behaviors such as binge drinking, eating disorders, and hyperemesis gravidarum. Fortunately, the bleeding usually stops within 24-48 hours and invasive procedures like endoscopy are rarely necessary.
It is important to note that Mallory-Weiss syndrome should not be confused with Boerhaave’s syndrome, which is the spontaneous rupture of a healthy esophagus, usually following intense vomiting. Patients with Boerhaave’s syndrome experience respiratory collapse, subcutaneous emphysema, and acute abdominal pain. While Boerhaave’s syndrome is rare, it is more commonly observed in individuals who abuse alcohol.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 24
Incorrect
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You review a child with a history of attention deficit hyperactivity disorder (ADHD) who is currently experiencing severe symptoms. He hands you a note to read that expresses his thoughts about his condition. However, you struggle to comprehend it as it is excessively verbose and highly disorganized.
Which ONE of the following cognitive impairments is he exhibiting?Your Answer:
Correct Answer: Graphorrhea
Explanation:Graphorrhoea is a communication disorder characterized by an excessive use of words and a tendency to ramble in written work. It is similar to word salad, but specifically occurs in written form. This condition is often observed in individuals with schizophrenia.
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This question is part of the following fields:
- Mental Health
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Question 25
Incorrect
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A 22-year-old patient arrives at the Emergency Department a few hours after being discharged from the day surgery unit following a tonsillectomy. The patient is experiencing bleeding in the surgical area, and you are having trouble controlling it. You urgently page the on-call ENT team.
Which of the following blood vessels is most likely causing the bleeding?Your Answer:
Correct Answer: External palatine vein
Explanation:Recurrent or chronic tonsillitis is a clear indication for tonsillectomy, which is the surgical removal of the palatine tonsils. One common complication of this procedure is bleeding, which occurs in approximately 0.5-2% of cases. The bleeding that occurs after tonsillectomy is typically venous in nature and most frequently originates from the external palatine vein. This vein drains the lateral tonsillar region and ultimately empties into the facial vein. Additionally, bleeding can also arise from the tonsillar branch of the facial artery, which supplies the inferior pole of the palatine tonsil.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 26
Incorrect
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You review a 30-year-old man who presents with an acute exacerbation of asthma and consider ordering a chest X-ray.
Which of the following is NOT a reason to perform a chest X-ray in the evaluation of acute asthma?Your Answer:
Correct Answer: Acute severe asthma
Explanation:Chest X-rays are not typically recommended as a routine investigation for acute asthma. However, they may be necessary in specific situations. These situations include suspected pneumomediastinum or consolidation, as well as cases of life-threatening asthma. Additionally, if a patient fails to respond adequately to treatment or requires ventilation, a chest X-ray may be performed. It is important to note that these circumstances warrant the use of chest X-rays, but they are not routinely indicated for the investigation of acute asthma.
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This question is part of the following fields:
- Respiratory
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Question 27
Incorrect
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A middle-aged patient experiences a stroke that leads to impairment in Wernicke’s area.
What consequences can be expected from damage to Wernicke’s area?Your Answer:
Correct Answer: Receptive aphasia
Explanation:Wernicke’s area is situated in the dominant cerebral hemisphere temporal lobe. Specifically, it can be found in the posterior section of the superior temporal gyrus.
This area is responsible for comprehending both written and spoken language. It allows individuals to read a sentence, understand its meaning, and articulate it verbally.
When Wernicke’s area is damaged, patients may be able to string words together fluently, but the resulting phrases lack coherence and meaning. This condition is known as receptive aphasia or Wernicke’s aphasia.
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This question is part of the following fields:
- Neurology
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Question 28
Incorrect
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A 35-year-old woman is given a medication for a medical condition during her pregnancy. As a result, the newborn experiences multiple significant birth defects, such as neural tube, craniofacial, and limb abnormalities.
Which of the following medications is the most probable culprit for these anomalies?Your Answer:
Correct Answer: Sodium valproate
Explanation:Sodium valproate is considered the most high-risk anti-epileptic drug during pregnancy. A recent review found that up to 40% of children born to women who took sodium valproate while pregnant experienced some form of adverse effect. These effects include a 1.5% risk of neural tube defects and an increased risk of cardiac, craniofacial, and limb defects. Additionally, there is a significant risk of neurodevelopmental problems in childhood.
Here is a list outlining the commonly encountered drugs that have adverse effects during pregnancy:
ACE inhibitors (e.g. ramipril): If given in the second and third trimester, these drugs can cause hypoperfusion, renal failure, and the oligohydramnios sequence.
Aminoglycosides (e.g. gentamicin): These drugs can cause ototoxicity and deafness in the fetus.
Aspirin: High doses of aspirin can lead to first-trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) do not pose a significant risk.
Benzodiazepines (e.g. diazepam): When given late in pregnancy, these drugs can cause respiratory depression and a neonatal withdrawal syndrome.
Calcium-channel blockers: If given in the first trimester, these drugs can cause phalangeal abnormalities. If given in the second and third trimester, they can lead to fetal growth retardation.
Carbamazepine: This drug can cause hemorrhagic disease of the newborn and neural tube defects.
Chloramphenicol: Use of this drug can result in gray baby syndrome.
Corticosteroids: If given in the first trimester, corticosteroids may cause orofacial clefts in the fetus.
Danazol: If given in the first trimester, this drug can cause masculinization of the female fetuses genitals.
Finasteride: Pregnant women should avoid handling finasteride as crushed or broken tablets can be absorbed through the skin and affect male sex organ development.
Haloperidol: If given in the first trimester, this drug may cause limb malformations. If given in the third trimester, there is an increased risk of extrapyramidal symptoms in the neonate.
Heparin: Maternal bleeding and thrombocytopenia are potential adverse outcomes.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 29
Incorrect
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A child presents with a severe acute asthma attack. After a poor response to the initial salbutamol nebulizer, you administer another nebulizer that also contains ipratropium bromide.
What is the most common side effect experienced with ipratropium bromide?Your Answer:
Correct Answer: Dry mouth
Explanation:Ipratropium bromide commonly leads to dry mouth as a side effect. Additionally, it may result in constipation, cough, sudden bronchospasm, headache, nausea, and palpitations. In patients with prostatic hyperplasia and bladder outflow obstruction, it can cause urinary retention. Furthermore, susceptible individuals may experience acute closed-angle glaucoma as a result of using this medication.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 30
Incorrect
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A 45-year-old man comes in with a 4-day history of sudden pain in his left scrotum and a high body temperature. During the examination, the epididymis is swollen and tender, and the skin covering the scrotum is red and warm to the touch. Lifting the scrotum provides relief from the pain.
What is the most probable organism responsible for this condition?Your Answer:
Correct Answer: Escherichia coli
Explanation:Epididymo-orchitis refers to the inflammation of the epididymis and/or testicle. It typically presents with sudden pain, swelling, and inflammation in the affected area. This condition can also occur chronically, which means that the pain and inflammation last for more than six months.
The causes of epididymo-orchitis vary depending on the age of the patient. In men under 35 years old, the infection is usually sexually transmitted and caused by Chlamydia trachomatis or Neisseria gonorrhoeae. In men over 35 years old, the infection is usually non-sexually transmitted and occurs as a result of enteric organisms that cause urinary tract infections, with Escherichia coli being the most common. However, there can be some overlap between these groups, so it is important to obtain a thorough sexual history in all age groups.
Mumps should also be considered as a potential cause of epididymo-orchitis in the 15 to 30 age group, as mumps orchitis occurs in around 40% of post-pubertal boys with mumps.
While most cases of epididymo-orchitis are infective, non-infectious causes can also occur. These include genito-urinary surgery, vasectomy, urinary catheterization, Behcet’s disease, sarcoidosis, and drug-induced cases such as those caused by amiodarone.
Patients with epididymo-orchitis typically present with unilateral scrotal pain and swelling that develops relatively quickly. The affected testis will be tender to touch, and there is usually a palpable swelling of the epididymis that starts at the lower pole of the testis and spreads towards the upper pole. The testis itself may also be involved, and there may be redness and/or swelling of the scrotum on the affected side. Patients may experience fever and urethral discharge as well.
The most important differential diagnosis to consider is testicular torsion, which requires immediate medical attention within 6 hours of onset to save the testicle. Testicular torsion is more likely in men under the age of 20, especially if the pain is very severe and sudden. It typically presents around four hours after onset. In this case, the patient’s age, longer history of symptoms, and the presence of fever are more indicative of epididymo-orchitis.
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This question is part of the following fields:
- Urology
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