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Question 1
Incorrect
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An 82-year-old man arrives at the emergency department with haematemesis that began 45 minutes ago. He has a history of chronic back pain and takes ibuprofen, as well as warfarin for his atrial fibrillation. The medical team initiates resuscitation and places two large-bore cannulas. What is the appropriate management for this patient in an acute setting?
Your Answer: IV proton pump inhibitors and fresh frozen plasma
Correct Answer: IV prothrombin complex concentrate
Explanation:There is insufficient evidence to support the use of PPIs in stopping bleeding, as in most cases, bleeding ceases without their administration. Administering IV proton pump inhibitors and fresh frozen plasma prior to endoscopy is incorrect, as PPIs should not be given and fresh frozen plasma should only be given to patients with specific blood clotting abnormalities.
Acute upper gastrointestinal bleeding is a common and significant medical issue that can be caused by various conditions, with oesophageal varices and peptic ulcer disease being the most common. The clinical features of this condition include haematemesis, melena, and a raised urea level due to the protein meal of the blood. The differential diagnosis for acute upper gastrointestinal bleeding includes oesophageal, gastric, and duodenal causes.
The management of acute upper gastrointestinal bleeding involves risk assessment using the Glasgow-Blatchford score, which helps clinicians decide whether patients can be managed as outpatients or not. Resuscitation is also necessary, including ABC, wide-bore intravenous access, and platelet transfusion if actively bleeding platelet count is less than 50 x 10*9/litre. Endoscopy should be offered immediately after resuscitation in patients with a severe bleed, and all patients should have endoscopy within 24 hours.
For non-variceal bleeding, proton pump inhibitors (PPIs) should not be given before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding. However, PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy. If further bleeding occurs, options include repeat endoscopy, interventional radiology, and surgery. For variceal bleeding, terlipressin and prophylactic antibiotics should be given to patients at presentation, and band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices. Transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 2
Correct
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A 23-year-old female patient visits the ophthalmologist complaining of painful red eyes. Upon examination, the ophthalmologist diagnoses her with bilateral anterior uveitis. During the medical history, the patient reveals that she has been experiencing a persistent dry cough and has visited her GP several times. The ophthalmologist orders blood tests and a chest x-ray, which reveal elevated angiotensin-converting enzyme levels and bilateral hilar lymphadenopathy. What is the underlying cause of uveitis in this patient?
Your Answer: Sarcoidosis
Explanation:Sarcoidosis may present as bilateral anterior uveitis in young adults, making it an important early consideration. Recurrent uveitis in both eyes, along with a history of pulmonary issues, should prompt investigation for sarcoidosis. The other options, which do not involve a dry cough, are not relevant. Rheumatoid arthritis affects small joints in the hands, feet, and wrists, while ankylosing spondylitis primarily affects the spine with symptoms of back pain and stiffness, neither of which are mentioned in this scenario.
Anterior uveitis, also known as iritis, is a type of inflammation that affects the iris and ciliary body in the front part of the uvea. It is a common cause of red eye and is associated with HLA-B27, which may also be linked to other conditions. Symptoms of anterior uveitis include sudden onset of eye discomfort and pain, small or irregular pupils, intense sensitivity to light, blurred vision, redness, tearing, and the presence of pus and inflammatory cells in the front part of the eye. This condition may be associated with ankylosing spondylitis, reactive arthritis, ulcerative colitis, Crohn’s disease, Behcet’s disease, and sarcoidosis. Urgent review by an ophthalmologist is necessary, and treatment may involve the use of cycloplegics and steroid eye drops.
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This question is part of the following fields:
- Ophthalmology
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Question 3
Correct
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You are evaluating a 23-year-old man who reports experiencing auditory hallucinations that have been occurring more frequently, now happening every day. Based on his history, which of the following factors is the most significant risk factor for psychotic disorders?
Your Answer: Having a parent with schizophrenia
Explanation:The most significant risk factor for psychotic disorders is a person’s family history.
Understanding the Epidemiology of Schizophrenia
Schizophrenia is a psychotic disorder that affects a significant portion of the population. The strongest risk factor for developing this condition is having a family history of the disorder. Individuals with a parent who has schizophrenia have a relative risk of 7.5. Additionally, monozygotic twins have a 50% chance of developing schizophrenia, while siblings have a 10% chance. In contrast, individuals with no relatives with schizophrenia have a 1% chance of developing the disorder.
Aside from family history, other factors can increase the risk of developing schizophrenia. Black Caribbean ethnicity has a relative risk of 5.4, while migration and living in an urban environment have relative risks of 2.9 and 2.4, respectively. Cannabis use also increases the risk of developing schizophrenia, with a relative risk of 1.4.
Understanding the epidemiology of schizophrenia is crucial in identifying individuals who may be at risk of developing the disorder. By recognizing these risk factors, healthcare professionals can provide early interventions and support to prevent or manage the onset of schizophrenia.
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This question is part of the following fields:
- Psychiatry
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Question 4
Correct
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A 50-year-old female comes to the doctor's office complaining of progressive paraesthesia in her fingers, toes, and peri-oral area for the past two weeks. She also experiences muscle cramps and spasms. The patient had a thyroidectomy for Graves' disease recently but has no other health issues or drug allergies. What can be expected from this patient's ECG results, considering the probable diagnosis?
Your Answer: Isolated QTc elongation
Explanation:Following thyroid surgery, a patient is experiencing paraesthesia, cramps, and spasms, which are likely due to hypocalcemia resulting from damage to the parathyroid glands. The most common ECG change associated with this condition is isolated QTc elongation, while dysrhythmias are rare. Alternating QRS amplitude is not associated with this condition and is instead linked to pericardial effusion. Isolated QTc shortening is also incorrect as it is typically associated with hypercalcemia, which can be caused by hyperparathyroidism and malignancy. The combination of T wave inversion, QTc prolongation, and visible U waves is associated with hypokalemia, which can be caused by vomiting, thiazide use, and Cushing’s syndrome. Similarly, the combination of tall, peaked T waves, QTc shortening, and ST-segment depression is associated with hyperkalemia, which can be caused by Addison’s disease, rhabdomyolysis, acute kidney injury, and potassium-sparing diuretics.
Complications of Thyroid Surgery: An Overview
Thyroid surgery is a common procedure that involves the removal of all or part of the thyroid gland. While the surgery is generally safe, there are potential complications that can arise. These complications can be anatomical, such as damage to the recurrent laryngeal nerve, which can result in voice changes or difficulty swallowing. Bleeding is another potential complication, which can be particularly dangerous in the confined space of the neck and can lead to respiratory problems due to swelling. Additionally, damage to the parathyroid glands, which are located near the thyroid, can result in hypocalcaemia, a condition in which the body has low levels of calcium. It is important for patients to be aware of these potential complications and to discuss them with their healthcare provider before undergoing thyroid surgery.
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This question is part of the following fields:
- ENT
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Question 5
Incorrect
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A 45-year-old woman is recuperating in the hospital after a coronary angiogram for unstable angina. Two days after the procedure, she reports experiencing intense pain in her left foot. Upon examination, her left lower limb peripheral pulses are normal. There is tissue loss on the medial three toes on the left foot and an area of livedo reticularis on the same foot.
What is the most probable diagnosis?Your Answer: Arterial thromboembolism
Correct Answer: Cholesterol embolisation
Explanation:Differentiating Vascular Conditions: Causes and Symptoms
Cholesterol embolisation occurs when cholesterol crystals from a ruptured atherosclerotic plaque block small or medium arteries, often following an intervention like coronary angiography. This results in microvascular ischemia, which typically does not affect blood pressure or larger vessels, explaining the normal peripheral pulses in affected patients. Livedo reticularis, a purplish discoloration, may also occur due to microvascular ischemia.
Arterial thromboembolism is a common condition, especially in patients with established cardiovascular disease or risk factors like hypertension, hyperlipidemia, and smoking. It tends to affect larger vessels than cholesterol embolism, leading to the absence of peripheral pulses and gangrenous toes.
Buerger’s disease, also known as thromboangiitis obliterans, is a vasculitis that mainly affects young men who smoke. It presents with claudication of the arms or legs, with or without ulcers or gangrene. However, the acute onset of symptoms following an intervention makes cholesterol embolism a more likely diagnosis.
Deep vein thrombosis typically presents with a swollen, painful calf and does not display signs of arterial insufficiency like gangrene and livedo reticularis.
Takayasu’s arteritis is a rare form of large vessel vasculitis that mainly affects the aorta. It is more common in women and tends to present below the age of 30 years old with pulseless arms. However, this patient’s history is not typical for Takayasu’s arteritis.
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This question is part of the following fields:
- Cardiovascular
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Question 6
Incorrect
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A 67-year-old man presents to the Emergency Department with pleuritic chest pain that started two hours ago. He has a history of lung cancer with bony metastases and has recently started treatment with erlotinib.
His vital signs are as follows: temperature 37.2ºC; oxygen saturation 92% on room air; respiratory rate 20 breaths per minute; heart rate 98 beats per minute; blood pressure 140/86 mmHg.
A chest X-ray is performed, which shows no abnormalities. He is started on supplemental oxygen therapy, and a CT pulmonary angiogram (CTPA) is ordered.
While waiting for the CTPA results, what is the most appropriate next step in management?Your Answer: Commence prophylactic dose low molecular weight heparin (LMWH)
Correct Answer: Commence rivaroxaban
Explanation:The recommended initial management for patients with suspected pulmonary embolism (PE) is to ensure they are haemodynamically stable before starting anticoagulation. According to the latest NICE Guidelines (2020), a direct oral anticoagulant (DOAC) such as apixaban or rivaroxaban should be started unless there are contraindications. In this case, the patient is stable and can be started on rivaroxaban. It is important to note that starting prophylactic dose LMWH is not appropriate for suspected PE, and commencing warfarin at loading dose is also not recommended due to its delayed anticoagulant effects. Thrombolytic agents such as alteplase are only appropriate for haemodynamically unstable patients. Dabigatran is an alternative option for patients who cannot take apixaban or rivaroxaban, but it too requires a bridging dose of LMWH.
Management of Pulmonary Embolism: NICE Guidelines
Pulmonary embolism (PE) is a serious condition that requires prompt management. The National Institute for Health and Care Excellence (NICE) updated their guidelines on the management of venous thromboembolism (VTE) in 2020, with some key changes. One of the significant changes is the recommendation to use direct oral anticoagulants (DOACs) as the first-line treatment for most people with VTE, including those with active cancer. Another change is the increasing use of outpatient treatment for low-risk PE patients, determined by a validated risk stratification tool.
Anticoagulant therapy is the cornerstone of VTE management, and the guidelines recommend using apixaban or rivaroxaban as the first-line treatment following the diagnosis of a PE. If neither of these is suitable, LMWH followed by dabigatran or edoxaban or LMWH followed by a vitamin K antagonist (VKA) can be used. For patients with active cancer, DOACs are now recommended instead of LMWH. The length of anticoagulation is determined by whether the VTE was provoked or unprovoked, with treatment typically stopped after 3-6 months for provoked VTE and continued for up to 6 months for unprovoked VTE.
In cases of haemodynamic instability, thrombolysis is recommended as the first-line treatment for massive PE with circulatory failure. Patients who have repeat pulmonary embolisms, despite adequate anticoagulation, may be considered for inferior vena cava (IVC) filters. However, the evidence base for IVC filter use is weak.
Overall, the updated NICE guidelines provide clear recommendations for the management of PE, including the use of DOACs as first-line treatment and outpatient management for low-risk patients. The guidelines also emphasize the importance of individualized treatment based on risk stratification and balancing the risks of VTE recurrence and bleeding.
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This question is part of the following fields:
- Respiratory Medicine
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Question 7
Correct
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A 28-year-old male patient visits his GP with complaints of progressive tunnel vision and difficulty seeing at night for the past year. He recalls his grandfather experiencing similar symptoms but is unsure of the cause. During fundus examination, bone-spicule pigmentation is observed in the peripheral retina. What is the probable diagnosis?
Your Answer: Retinitis pigmentosa
Explanation:The presence of black bone-spicule pigmentation on fundoscopy is a classic sign of retinitis pigmentosa, an inherited retinal disorder that causes tunnel vision and night blindness by affecting the peripheral retina.
Understanding Retinitis Pigmentosa
Retinitis pigmentosa is a condition that primarily affects the peripheral retina, leading to tunnel vision. The initial sign of this condition is often night blindness, which can progress to a loss of peripheral vision. Fundoscopy, a diagnostic test, reveals black bone spicule-shaped pigmentation in the peripheral retina and mottling of the retinal pigment epithelium. Retinitis pigmentosa is often associated with other diseases such as Refsum disease, Usher syndrome, abetalipoproteinemia, Lawrence-Moon-Biedl syndrome, Kearns-Sayre syndrome, and Alport’s syndrome.
To better understand retinitis pigmentosa, it is important to know that it is a genetic disorder that affects the retina’s ability to respond to light. This condition can lead to the death of photoreceptor cells in the retina, which are responsible for detecting light and transmitting visual information to the brain. As a result, individuals with retinitis pigmentosa may experience difficulty seeing in low light conditions, loss of peripheral vision, and, in severe cases, complete blindness.
In summary, retinitis pigmentosa is a genetic condition that primarily affects the peripheral retina, leading to tunnel vision. It is often associated with other diseases and can cause night blindness, loss of peripheral vision, and, in severe cases, complete blindness. Early diagnosis and management are crucial in preventing further vision loss.
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This question is part of the following fields:
- Ophthalmology
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Question 8
Incorrect
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John is a 35-year-old male who has been detained by the police under a section of the Mental Health Act. He was seen running in and out of traffic in a public area, openly responding to unseen stimuli and avoiding social interaction.
Regarding the section he has likely been placed under, which of the following is true?Your Answer: Treatment can be given without consent
Correct Answer: It lasts up to 24 hours
Explanation:The police can utilize Section 136 to transport individuals who may be exhibiting indications of mental illness and pose a danger to themselves or others to a secure location. This section is only valid for a maximum of 24 hours, during which time a Mental Health Act Assessment can be scheduled. In rare cases, it may be extended by an additional 12 hours. It is only applicable to individuals in public areas, not in their own or someone else’s residence – Section 135 is required for this. It does not authorize involuntary treatment. A secure location can be a hospital, the individual’s home or a friend’s home, or, if no other option is available, a police station.
Sectioning under the Mental Health Act is a legal process used for individuals who refuse voluntary admission. This process excludes patients who are under the influence of drugs or alcohol. There are several sections under the Mental Health Act that allow for different types of admission and treatment.
Section 2 allows for admission for assessment for up to 28 days, which is not renewable. An Approved Mental Health Professional (AMHP) or the nearest relative (NR) can make the application on the recommendation of two doctors, one of whom should be an approved consultant psychiatrist. Treatment can be given against the patient’s wishes.
Section 3 allows for admission for treatment for up to 6 months, which can be renewed. An AMHP and two doctors, both of whom must have seen the patient within the past 24 hours, can make the application. Treatment can also be given against the patient’s wishes.
Section 4 is used as an emergency 72-hour assessment order when a section 2 would involve an unacceptable delay. A GP and an AMHP or NR can make the application, which is often changed to a section 2 upon arrival at the hospital.
Section 5(2) allows a doctor to legally detain a voluntary patient in hospital for 72 hours, while section 5(4) allows a nurse to detain a voluntary patient for 6 hours.
Section 17a allows for Supervised Community Treatment (Community Treatment Order) and can be used to recall a patient to the hospital for treatment if they do not comply with the conditions of the order in the community, such as taking medication.
Section 135 allows for a court order to be obtained to allow the police to break into a property to remove a person to a Place of Safety. Section 136 allows for someone found in a public place who appears to have a mental disorder to be taken by the police to a Place of Safety. This section can only be used for up to 24 hours while a Mental Health Act assessment is arranged.
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This question is part of the following fields:
- Psychiatry
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Question 9
Correct
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A 62-year-old woman visits the clinic complaining of unpleasant breath and gurgling sounds while swallowing. She reports no other symptoms or changes in her health.
What is the MOST probable diagnosis?Your Answer: Pharyngeal pouch
Explanation:Pharyngeal Pouch and Hiatus Hernia: Two Common Causes of Oesophageal Symptoms
Pharyngeal pouch and hiatus hernia are two common conditions that can cause symptoms related to the oesophagus. A pharyngeal pouch is a diverticulum that forms in the posterior aspect of the oesophagus due to herniation between two muscles that constrict the inferior part of the pharynx. This pouch can trap food and cause halitosis, regurgitation of food or gurgling noises, and sometimes a palpable lump on the side of the neck. Treatment involves surgery to correct the herniation or sometimes to close the diverticulum.
Hiatus hernia, on the other hand, occurs when part of the stomach protrudes through the diaphragm into the chest cavity, leading to a retrosternal burning sensation, gastro-oesophageal reflux, and dysphagia. This condition is more common in older people and those with obesity or a history of smoking. Treatment may involve lifestyle changes, such as weight loss and avoiding trigger foods, as well as medications to reduce acid production or strengthen the lower oesophageal sphincter.
Other possible causes of oesophageal symptoms include gastro-oesophageal reflux disease (GORD), oesophageal candidiasis, and oesophageal carcinoma. GORD is a chronic condition that involves reflux of gastric contents into the oesophagus, causing symptoms of heartburn and acid regurgitation. Oesophageal candidiasis is a fungal infection that usually affects people with weakened immune systems. Oesophageal carcinoma is a type of cancer that can develop in the lining of the oesophagus, often with symptoms such as weight loss, dysphagia, abdominal pain, and dyspepsia. However, based on the history provided, pharyngeal pouch and hiatus hernia are more likely causes of the patient’s symptoms.
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This question is part of the following fields:
- ENT
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Question 10
Correct
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A 54-year-old man with a history of hypertension comes in for a check-up. During his annual health assessment, he undergoes a U&E, HbA1c, and cholesterol test. The results are as follows:
His blood pressure today is 128/78 mmHg. He takes ramipril 5mg od as his only regular medication.
Na+ 142 mmol/l
K+ 4.6 mmol/l
Urea 5.2 mmol/l
Creatinine 88 µmol/l
Total cholesterol 5.2 mmol/l
HbA1c 45 mmol/mol (6.3%)
His 10-year QRISK2 score is 7%. What is the most appropriate course of action based on these findings?Your Answer: Arrange a fasting glucose sample
Explanation:There is no need to take any action regarding his cholesterol as it is under control. Additionally, his blood pressure is also well managed. However, his HbA1c level is in the pre-diabetes range (42-47 mmol/mol) and requires further investigation. It is important to note that a HbA1c reading alone cannot rule out diabetes, and a fasting sample should be arranged for confirmation.
Type 2 diabetes mellitus can be diagnosed through a plasma glucose or HbA1c sample. The diagnostic criteria vary depending on whether the patient is experiencing symptoms or not. If the patient is symptomatic, a fasting glucose level of 7.0 mmol/l or higher or a random glucose level of 11.1 mmol/l or higher (or after a 75g oral glucose tolerance test) indicates diabetes. If the patient is asymptomatic, the same criteria apply but must be demonstrated on two separate occasions.
In 2011, the World Health Organization released supplementary guidance on the use of HbA1c for diagnosing diabetes. A HbA1c level of 48 mmol/mol (6.5%) or higher is diagnostic of diabetes mellitus. However, a HbA1c value of less than 48 mmol/mol (6.5%) does not exclude diabetes and may not be as sensitive as fasting samples for detecting diabetes. For patients without symptoms, the test must be repeated to confirm the diagnosis. It is important to note that increased red cell turnover can cause misleading HbA1c results.
There are certain conditions where HbA1c cannot be used for diagnosis, such as haemoglobinopathies, haemolytic anaemia, untreated iron deficiency anaemia, suspected gestational diabetes, children, HIV, chronic kidney disease, and people taking medication that may cause hyperglycaemia (such as corticosteroids).
Impaired fasting glucose (IFG) is defined as a fasting glucose level of 6.1 mmol/l or higher but less than 7.0 mmol/l. Impaired glucose tolerance (IGT) is defined as a fasting plasma glucose level less than 7.0 mmol/l and an OGTT 2-hour value of 7.8 mmol/l or higher but less than 11.1 mmol/l. People with IFG should be offered an oral glucose tolerance test to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person does not have diabetes but does have IGT.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 11
Correct
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A 72-year-old man presents to your clinic complaining of left nostril blockage and frequent nosebleeds for the past 4 weeks. He has a medical history of well-controlled diabetes and hypertension and has a smoking history of 20 cigarettes per day since he was 18. He used to work in construction. During the examination, you observe a nasal polyp on the left side. What would be the most suitable course of action?
Your Answer: 2 week-wait referral
Explanation:Unilateral nasal polyps are a cause for concern and should be promptly referred to an ENT specialist as they may indicate nasal cancer. However, they can also be caused by other factors such as nose picking, foreign bodies, misapplication of nasal spray or cystic fibrosis. Treatment with antibiotics, oral steroids, nasal drops or cautery is unlikely to be effective and may delay the diagnosis of a serious condition.
Understanding Nasal Polyps
Nasal polyps are a relatively uncommon condition affecting around 1% of adults in the UK. They are more commonly seen in men and are not typically found in children or the elderly. There are several associations with nasal polyps, including asthma (particularly late-onset asthma), aspirin sensitivity, infective sinusitis, cystic fibrosis, Kartagener’s syndrome, and Churg-Strauss syndrome. When asthma, aspirin sensitivity, and nasal polyposis occur together, it is known as Samter’s triad.
The symptoms of nasal polyps include nasal obstruction, rhinorrhoea, sneezing, and a poor sense of taste and smell. It is important to note that any unusual symptoms, such as unilateral symptoms or bleeding, require further investigation. If nasal polyps are suspected, patients should be referred to an ear, nose, and throat (ENT) specialist for a full examination.
The management of nasal polyps typically involves the use of topical corticosteroids, which can shrink polyp size in around 80% of patients. Overall, understanding nasal polyps and their associations can help with early detection and appropriate management.
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This question is part of the following fields:
- ENT
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Question 12
Correct
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A 25-year-old man comes to his General Practitioner complaining of an itchy rash on both his wrists that has been present for 1 week. Upon examination, the doctor notes small purplish papules on the flexural aspect of both wrists with a flat top and small white lines on the surface. The patient also has areas of hyperpigmentation on the inner aspect of his elbows. What is the most probable diagnosis?
Your Answer: Lichen planus
Explanation:The patient’s symptoms and medical history suggest a diagnosis of lichen planus, a skin condition with an unknown cause that is likely immune-mediated. The rash is typically itchy and appears as papules with a shiny, purplish color in areas such as the palms, soles, genitalia, and flexor surfaces of the arms. The rash often has a polygonal shape and may have white lines known as Wickham’s striae. Over time, the papules flatten and are replaced by hyperpigmentation. Oral involvement is common, with a white-lace pattern on the buccal mucosa. Management usually involves topical steroids, but more severe cases may require oral steroids or immunosuppressants. Atopic eczema, irritant eczema, molluscum contagiosum, and psoriasis are different skin conditions that do not fit the patient’s symptoms.
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This question is part of the following fields:
- Dermatology
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Question 13
Incorrect
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A 42-year-old woman is admitted to hospital with left-sided weakness. She takes warfarin for deep vein thrombosis and her international normalised ratio (INR) is usually in the therapeutic range of 2–3. Her INR is measured on admission to hospital and is 1.1. She has recently started a new medication.
Which of the following medications is this patient most likely to have recently started?
Your Answer: Ketoconazole
Correct Answer: Carbamazepine
Explanation:Cytochrome P450 Enzyme Inducers and Inhibitors and their Effects on Warfarin Metabolism
Warfarin is a commonly used anticoagulant medication that requires careful monitoring of the international normalized ratio (INR) to ensure therapeutic efficacy and prevent bleeding complications. However, certain medications can affect the metabolism of warfarin by inducing or inhibiting cytochrome P450 enzymes in the liver.
One example of a cytochrome P450 enzyme inducer is carbamazepine, which can increase warfarin metabolism and reduce its effectiveness. This can result in a decreased INR and potentially increase the risk of blood clots. On the other hand, cytochrome P450 enzyme inhibitors such as cimetidine, erythromycin, ketoconazole, and sulfamethoxazole can reduce warfarin metabolism and increase its potency, leading to an increased INR and higher risk of bleeding complications.
To remember these medications, a helpful mnemonic is PC BRAS for enzyme inducers and SICKFACES.COM for enzyme inhibitors. Patients starting these medications should be closely monitored for changes in their INR and warfarin dosages may need to be adjusted accordingly.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 14
Correct
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A 30-year-old female presents to her GP after a missed period and a positive pregnancy test. She is thrilled to be pregnant but is worried about her epilepsy medication. What medications are safe for epileptics during pregnancy?
Your Answer: Lamotrigine
Explanation:The use of anti-epileptic medication during pregnancy is a complex issue due to the risk of severe congenital defects. Therefore, it is important to provide good contraceptive advice and planning to women of childbearing age who are taking these medications. However, in cases where a woman becomes pregnant while on anti-epileptic medication, it is crucial to seek medical advice as soon as possible.
According to recent guidelines from MBRRACE-UK and NICE, lamotrigine is the preferred medication for most women with epilepsy who are of childbearing age. In some cases, a dose increase may be necessary during pregnancy. Other medications such as phenytoin, phenobarbitone, and sodium valproate are known to have adverse effects on cognitive abilities and are generally avoided unless absolutely necessary.
For pregnant women with epilepsy, lamotrigine, carbamazepine, and levetiracetam are considered to have the least impact on the developing fetus. However, it is important for all pregnant women with epilepsy to receive specialist care and guidance throughout their pregnancy.
Pregnancy and breastfeeding can be a concern for women with epilepsy. It is generally recommended that women continue taking their medication during pregnancy, as the risks of uncontrolled seizures outweigh the potential risks to the fetus. However, it is important for women to take folic acid before pregnancy to reduce the risk of neural tube defects. The use of antiepileptic medication during pregnancy can increase the risk of congenital defects, but this risk is still relatively low. It is recommended to aim for monotherapy and there is no need to monitor drug levels. Sodium valproate is associated with neural tube defects, while carbamazepine is considered the least teratogenic of the older antiepileptics. Phenytoin is associated with cleft palate, and lamotrigine may require a dose increase during pregnancy. Breastfeeding is generally safe for mothers taking antiepileptics, except for barbiturates. Pregnant women taking phenytoin should be given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn.
A warning has been issued about the use of sodium valproate during pregnancy and in women of childbearing age. New evidence suggests a significant risk of neurodevelopmental delay in children following maternal use of this medication. Therefore, it should only be used if clearly necessary and under specialist neurological or psychiatric advice. It is important for women with epilepsy to discuss their options with their healthcare provider and make informed decisions about their treatment during pregnancy and breastfeeding.
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This question is part of the following fields:
- Neurology
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Question 15
Incorrect
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A 75-year-old male has two episodes of weakness affecting the right arm and leg each lasting ten minutes, both within the space of 2 days. He did not attend the emergency department after the first episode. His only significant past medical history is hypertension, for which he takes amlodipine 5mg OD. He has experienced one similar episode to this one year ago, but did not seek medical attention. His son is present who informs you that the patient has lost a significant amount of weight in the last year. On further questioning, he reports some haemoptysis lately. His blood pressure in the department was 170/90 mmHg initially.
His bloods reveal:
Hb 115 g/l
Platelets 149 * 109/l
WBC 13.1 * 109/l
Na+ 132 mmol/l
K+ 5.3 mmol/l
Creatinine 111 µmol/l
CRP 15 mg/l
ECG: Sinus tachycardia, rate 104/min
What is the most appropriate management for this gentleman?Your Answer: Aspirin + transient ischaemic attack (TIA) clinic referral
Correct Answer: Admit for CT head + aspirin
Explanation:This question assesses the candidate’s understanding of TIA risk stratification. The individual meets the criteria for crescendo TIAs, having experienced two TIAs within a week. This necessitates prompt evaluation and imaging. Admission is recommended for any patient with a score of more than 4 on the ABCD2 scale or crescendo TIA.
A transient ischaemic attack (TIA) is a brief period of neurological deficit caused by a vascular issue, lasting less than an hour. The original definition of a TIA was based on time, but it is now recognized that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new ’tissue-based’ definition is now used. The clinical features of a TIA are similar to those of a stroke, but the symptoms resolve within an hour. Possible features include unilateral weakness or sensory loss, aphasia or dysarthria, ataxia, vertigo, or loss of balance, visual problems, and sudden transient loss of vision in one eye (amaurosis fugax).
NICE recommends immediate antithrombotic therapy with aspirin 300 mg unless the patient has a bleeding disorder or is taking an anticoagulant. If the patient has had more than one TIA or has a suspected cardioembolic source or severe carotid stenosis, specialist review is necessary. Urgent assessment is required within 24 hours for patients who have had a suspected TIA in the last 7 days. Referral for specialist assessment is necessary as soon as possible within 7 days for patients who have had a suspected TIA more than a week previously. Neuroimaging and carotid imaging are recommended, and antithrombotic therapy is necessary. Carotid artery endarterectomy should only be considered if the carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.
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This question is part of the following fields:
- Neurology
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Question 16
Correct
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A 72-year-old man undergoing evaluation in the Medical Outpatient Department for complaints of joint pain is found to have weakly positive serum antinuclear antibodies (ANAs). All his other blood tests are within normal limits.
What is the most probable cause of this patient's ANA positivity?Your Answer: Age related
Explanation:Understanding the Relationship Between ANAs and Various Medical Conditions
As individuals age, the level of anti-nuclear antibodies (ANAs) in their blood tends to increase, particularly in those over 65 years old. Therefore, a weakly positive ANA sample in an older patient with normal blood results is likely due to age-related factors.
Chronic fatigue syndrome (CFS) is not associated with ANA positivity. This diagnosis is made only after ruling out all other possibilities and finding no biochemical evidence to support it.
Ankylosing spondylitis (AS) is not linked to any known antibodies. While patients with AS may have elevated levels of non-specific inflammatory markers, such as C-reactive protein and erythrocyte sedimentation rate, genetic testing for human leukocyte antigen (HLA)-B27 may aid in diagnosis.
Primary antiphospholipid (APL) antibody syndrome does not typically involve ANA positivity. If ANAs are present in a patient with APL syndrome, it suggests a secondary form of the condition associated with a connective tissue disorder. APL syndrome is usually characterized by anti-cardiolipin antibodies and abnormal clotting studies.
Myasthenia gravis, a condition characterized by fatiguability and weakness induced by repeated actions, is not related to ANAs. Instead, it is caused by antibodies targeting the nicotinic acetylcholine receptor.
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This question is part of the following fields:
- Immunology/Allergy
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Question 17
Correct
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A 55-year-old woman presents to the Emergency Department with a sudden-onset blurring of vision in both eyes as well as light sensitivity. She is a known type II diabetic with blood sugars well maintained with medication.
On examination, her temperature is 36.8 oC, while her blood pressure (BP) is 180/110 mmHg. Her pulse is 70 beats per minute. Her respiratory rate is 18 breaths per minute, and her oxygen saturations are 98% on room air.
On dilated fundoscopy, both optic discs are swollen with widespread flame-shaped haemorrhages and cotton-wool spots.
What is the most appropriate first-line management of this condition?Your Answer: Intravenous (IV) labetalol
Explanation:Misconceptions about Treatment for Hypertensive Retinopathy
Hypertensive retinopathy is a condition that occurs when high blood pressure damages the blood vessels in the retina. However, there are several misconceptions about the treatment for this condition.
Firstly, in a hypertensive emergency with retinopathy, it is important to lower blood pressure slowly to avoid brain damage. Intravenous labetalol is a suitable medication for this purpose, with the aim of reducing diastolic blood pressure to 100 mmHg or reducing it by 20-25 mmHg per day, whichever is less.
Secondly, oral calcium channel blockers like amlodipine are not useful in an acute setting of hypertensive emergency. They are not effective in treating hypertensive retinopathy.
Thirdly, intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection is not a treatment for hypertensive retinopathy. It is used to treat wet age-related macular degeneration.
Fourthly, pan-retinal photocoagulation or any laser treatment for the eye is not a treatment for hypertensive retinopathy. It is a treatment for proliferative diabetic retinopathy.
Lastly, sublingual glyceryl trinitrate (GTN) spray is not a suitable treatment for hypertensive retinopathy. It is typically used in patients with angina and acute coronary syndrome.
In conclusion, it is important to understand the appropriate treatments for hypertensive retinopathy to avoid misconceptions and ensure proper care for patients.
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This question is part of the following fields:
- Ophthalmology
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Question 18
Correct
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A 30-year-old woman comes to her General Practitioner complaining of fatigue and sudden shortness of breath. An urgent full blood count is performed and the patient is diagnosed with acute lymphoblastic leukemia (ALL).
What is the most probable first-line treatment option for this patient's leukemia?Your Answer: Chemotherapy
Explanation:Treatment Options for Acute Leukaemia: Chemotherapy, Stem-Cell Transplant, Blood Transfusion, Intravenous Immunoglobulins, and Radiotherapy
Acute leukaemias, such as acute lymphoblastic leukaemia (ALL), are characterized by an increase in primitive undifferentiated blast cells in the bone marrow and blood, leading to marrow failure. The traditional treatment for ALL involves four components: induction, consolidation, maintenance, and central nervous system (CNS) prophylaxis. The first-line therapy for ALL is combination chemotherapy, which aims to eradicate the blast cells. Once remission is induced, maintenance chemotherapy is given to eliminate the disease that cannot be detected under the microscope.
Stem-cell transplants can be used to treat ALL once remission is induced using chemotherapy. This treatment can be allogeneic (the patient receives stem cells from a matched or partially mismatched related or unrelated donor) or autologous (the patient receives their own stem cells). The goal of a stem-cell transplant is to restore the body’s ability to produce normal blood cells. While it can be a curative treatment for patients with this disease, it is not used as a first-line treatment.
Blood transfusions are not a treatment for acute leukaemia, but they may be necessary to treat anaemia or platelet deficiency. Patients with leukaemia are at risk of graft-versus-host disease, so they are typically given irradiated blood components. Intravenous immunoglobulins are not used to treat acute leukaemia but may be used prophylactically against infection in patients with hypogammaglobulinaemia due to cancer treatment.
Radiotherapy is not a first-line treatment for acute leukaemia, but it may be used to treat the brain or spinal cord if the disease has spread there. Total body radiotherapy may also be used before a stem-cell transplant to suppress the immune system and reduce the risk of transplant rejection.
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This question is part of the following fields:
- Haematology/Oncology
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Question 19
Correct
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You assess a 45-year-old male with Marfan's syndrome. What is the probable reason for mortality in individuals with this condition?
Your Answer: Aortic dissection
Explanation:Aortic dissection may be more likely to occur in individuals with Marfan’s syndrome due to the dilation of the aortic sinuses.
Understanding Marfan’s Syndrome
Marfan’s syndrome is a genetic disorder that affects the connective tissue in the body. It is caused by a defect in the FBN1 gene on chromosome 15, which codes for the protein fibrillin-1. This disorder is inherited in an autosomal dominant pattern, meaning that a person only needs to inherit one copy of the defective gene from one parent to develop the condition. Marfan’s syndrome affects approximately 1 in 3,000 people.
The features of Marfan’s syndrome include a tall stature with an arm span to height ratio greater than 1.05, a high-arched palate, arachnodactyly (long, slender fingers), pectus excavatum (sunken chest), pes planus (flat feet), and scoliosis (curvature of the spine). In addition, individuals with Marfan’s syndrome may experience cardiovascular problems such as dilation of the aortic sinuses, mitral valve prolapse, and aortic aneurysm. They may also have lung issues such as repeated pneumothoraces. Eye problems are also common, including upwards lens dislocation, blue sclera, and myopia. Finally, dural ectasia, or ballooning of the dural sac at the lumbosacral level, may also occur.
In the past, the life expectancy of individuals with Marfan’s syndrome was around 40-50 years. However, with regular echocardiography monitoring and the use of beta-blockers and ACE inhibitors, this has improved significantly in recent years. Despite these improvements, aortic dissection and other cardiovascular problems remain the leading cause of death in individuals with Marfan’s syndrome.
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This question is part of the following fields:
- Musculoskeletal
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Question 20
Incorrect
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A 35-year-old woman presents with a gradual loss of night vision over the past few months. On examination, she has also lost peripheral vision. She reports that her mother had a similar problem and became blind in her early 40s.
What is the most probable diagnosis? Choose ONE answer only.Your Answer: Leber's congenital amaurosis
Correct Answer: Retinitis pigmentosa
Explanation:Retinitis pigmentosa (RP) is a group of inherited disorders that cause progressive peripheral vision loss and difficulty seeing in low light, which can eventually lead to central vision loss. RP is often diagnosed based on the hallmark symptom of night blindness, and can be inherited in different ways. While there is no cure for RP, patients can receive low-vision evaluations and medications such as vitamins and calcium-channel blockers to help manage their symptoms. Glaucoma is another eye disease that can cause vision loss, particularly in older adults, but the patient’s symptoms and age do not suggest a diagnosis of primary open-angle glaucoma. Leber’s congenital amaurosis is a rare eye disorder that affects infants and young children, and is characterized by severe visual impairment, photophobia, and nystagmus, which is not consistent with the patient’s symptoms. Multiple sclerosis is an immune-mediated disease that can cause optic neuritis, but the patient’s symptoms do not match those typically associated with this condition. Vitreous hemorrhage is a condition where blood leaks into the vitreous body of the eye, causing visual disturbances such as floaters and cloudy vision, but the patient’s symptoms do not suggest this diagnosis either.
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This question is part of the following fields:
- Ophthalmology
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Question 21
Correct
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A woman contacts the local psychiatry crisis team, worried about her daughter - who has previously been diagnosed with schizophrenia - becoming more isolated and paranoid about her surroundings. She reports that her daughter is increasingly concerned about her neighbors eavesdropping on her conversations. Her symptoms were previously well managed on daily risperidone. When the woman visited her daughter, she discovered unopened boxes of her medication on the counter.
What would be a suitable course of treatment for this patient?Your Answer: Depot risperidone injections
Explanation:Considering the patient’s increasing symptoms of psychosis, it is possible that non-compliance with their risperidone medication is an issue. In such cases, it is recommended to consider once monthly IM antipsychotic depot injections for patients with poor oral compliance. However, the patient’s risperidone dose would need to be re-titrated to their previous level.
Clozapine is typically used for treatment-resistant psychosis after trying two other antipsychotics. However, there is no evidence of the patient having tried multiple antipsychotics, and it appears that risperidone was effectively controlling their symptoms. If risperidone is not effective, quetiapine could be tried before considering Clozapine, provided there are no contraindications.
While cognitive behavioural therapy (CBT) can be helpful in reducing symptoms of psychosis, it is less likely to be effective than monthly depot injections.
Based on the patient’s history, there is no indication that they pose a risk to themselves or others that would warrant admission. Therefore, efforts should be made to manage the patient in the community.
Atypical antipsychotics are now recommended as the first-line treatment for patients with schizophrenia, as per the 2005 NICE guidelines. These medications have the advantage of significantly reducing extrapyramidal side-effects. However, they can also cause adverse effects such as weight gain, hyperprolactinaemia, and in the case of clozapine, agranulocytosis. The Medicines and Healthcare products Regulatory Agency has issued warnings about the increased risk of stroke and venous thromboembolism when antipsychotics are used in elderly patients. Examples of atypical antipsychotics include clozapine, olanzapine, risperidone, quetiapine, amisulpride, and aripiprazole.
Clozapine, one of the first atypical antipsychotics, carries a significant risk of agranulocytosis and requires full blood count monitoring during treatment. Therefore, it should only be used in patients who are resistant to other antipsychotic medication. The BNF recommends introducing clozapine if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs, one of which should be a second-generation antipsychotic drug, each for at least 6-8 weeks. Adverse effects of clozapine include agranulocytosis, neutropaenia, reduced seizure threshold, constipation, myocarditis, and hypersalivation. Dose adjustment of clozapine may be necessary if smoking is started or stopped during treatment.
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This question is part of the following fields:
- Psychiatry
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Question 22
Correct
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A floppy four-week-old neonate presents with vomiting, weight loss and circulatory collapse. Blood tests demonstrate hyponatraemia and hyperkalaemia. Further tests confirm metabolic acidosis and hypoglycaemia. The paediatrician notices that the penis was enlarged and the scrotum pigmented. The child was treated with both a glucocorticoid and a mineralocorticoid.
What is the most likely underlying diagnosis?Your Answer: Congenital adrenal hyperplasia
Explanation:Endocrine Disorders: Congenital Adrenal Hyperplasia, Conn Syndrome, Addisonian Crisis, Cushing Syndrome, and Thyrotoxic Crisis
Endocrine disorders are conditions that affect the production and regulation of hormones in the body. Here are five different endocrine disorders and their characteristics:
Congenital Adrenal Hyperplasia (CAH) is a group of autosomal recessive conditions caused by mutations in the enzymes involved in the production of steroids and hormones from the adrenal glands. It can affect both men and women equally, and symptoms include ambiguous genitalia at birth for women and hyperpigmentation and penile enlargement for men. Treatment involves hormone replacement therapy.
Conn Syndrome is a condition associated with primary hyperaldosteronism, which presents with hypernatraemia and hypokalaemia. It is more commonly seen in adult patients, but there are cases reported in childhood.
Addisonian Crisis occurs due to glucocorticoid and mineralocorticoid deficiency, usually occurring in adulthood. It is a potentially fatal episode that presents with hyponatraemia, hyperkalaemia, hypoglycaemia, and hypercalcaemia. Urgent intravenous administration of glucocorticoids is necessary for management.
Cushing Syndrome is due to cortisol excess, either exogenous or endogenous, and is usually diagnosed in adulthood. Symptoms include weight gain, hypertension, oedema, hyperglycaemia, hypokalaemia, and pigmentation of the skin in the axillae and neck.
Thyrotoxic Crisis, also known as a thyroid storm, is a life-threatening condition associated with excessive production of thyroid hormones. It can be the first presentation of undiagnosed hyperthyroidism in neonates and children. Symptoms include tachycardia, hypertension, fever, poor feeding, weight loss, diarrhoea, nausea, vomiting, seizures, and coma. Prompt treatment is necessary to prevent acute congestive heart failure, shock, and death.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 23
Incorrect
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A 79-year-old woman visits her GP complaining of a painless leg ulcer that has been present for a few weeks. Upon examination, the GP observes a superficial erythematous oval-shaped ulcer above her medial malleolus, with hyperpigmentation of the surrounding skin. The patient's ankle-brachial pressure index (ABPI) is 0.95. What is the initial management strategy that should be employed?
Your Answer: Urgent referral to vascular surgery
Correct Answer: Compression bandaging
Explanation:The recommended treatment for venous ulceration is compression bandaging, which is appropriate for this patient who exhibits typical signs of the condition such as hyperpigmentation and an ulcer located above the medial malleolus. Before initiating compression treatment, an ABPI was performed to rule out arterial disease, which was normal. Hydrocolloid dressings have limited benefit for venous ulceration, while flucloxacillin is used to treat cellulitis. Diabetic foot ulcers are painless and tend to occur on pressure areas, while arterial ulcers have distinct characteristics and are associated with an abnormal ABPI.
Venous Ulceration and its Management
Venous ulceration is a type of ulcer that is commonly seen above the medial malleolus. To assess for poor arterial flow that could impair healing, an ankle-brachial pressure index (ABPI) is important in non-healing ulcers. A normal ABPI is usually between 0.9 – 1.2, while values below 0.9 indicate arterial disease. Interestingly, values above 1.3 may also indicate arterial disease, particularly in diabetics, due to false-negative results caused by arterial calcification.
The only treatment that has been shown to be of real benefit for venous ulceration is compression bandaging, usually four-layer. Oral pentoxifylline, a peripheral vasodilator, can also improve the healing rate. There is some small evidence supporting the use of flavonoids, but little evidence to suggest benefit from hydrocolloid dressings, topical growth factors, ultrasound therapy, and intermittent pneumatic compression. Proper management of venous ulceration is crucial to promote healing and prevent complications.
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This question is part of the following fields:
- Dermatology
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Question 24
Incorrect
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Liam, 35, is admitted to the Emergency Department after a fall down the stairs at home. Upon examination, it is observed that he has bruising around the eyes and behind the ears. What does this indicate?
Your Answer: Orbital fracture
Correct Answer: Basilar skull fracture
Explanation:The classic signs associated with basilar skull fractures are periorbital bruising, which is bruising around the eye also known as Raccoon eyes, and post-auricular bruising, which is bruising of the mastoid also known as Battle’s sign. Therefore, the correct answer for this question is basilar skull fracture.
NICE Guidelines for Investigating Head Injuries in Adults
Head injuries can be serious and require prompt medical attention. The National Institute for Health and Care Excellence (NICE) has provided clear guidelines for healthcare professionals to determine which adult patients need further investigation with a CT head scan. Patients who require immediate CT head scans include those with a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment, suspected open or depressed skull fractures, signs of basal skull fractures, post-traumatic seizures, focal neurological deficits, and more than one episode of vomiting.
For patients with any loss of consciousness or amnesia since the injury, a CT head scan within 8 hours is recommended for those who are 65 years or older, have a history of bleeding or clotting disorders, experienced a dangerous mechanism of injury, or have more than 30 minutes of retrograde amnesia of events immediately before the head injury. Additionally, patients on warfarin who have sustained a head injury with no other indications for a CT head scan should also receive a scan within 8 hours of the injury.
It is important for healthcare professionals to follow these guidelines to ensure that patients receive appropriate and timely care for their head injuries. By identifying those who require further investigation, healthcare professionals can provide the necessary treatment and support to prevent further complications and improve patient outcomes.
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This question is part of the following fields:
- Neurology
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Question 25
Incorrect
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A 65-year-old woman is referred to the general medical clinic with a history of about 10 attacks of pins and needles in her right arm and leg over a period of 4 weeks. Her GP is concerned that this patient will soon have a completed stroke despite already being on aspirin. Typical attacks lasted for about 5 min and there were no additional symptoms. On closer enquiry she said that the sensation started in her right foot and then, over a period of about 1 min, spread ‘like water running up my leg’ to involve her whole leg and arm. Each attack was identical. Her past medical history includes hypertension and diabetes, for which she already takes aspirin. There are no abnormalities on neurological examination, but her blood pressure is 180/100 mmHg.
Which of the following is the most likely diagnosis?
Your Answer: TIAs affecting the right hemisphere
Correct Answer: Partial epileptic seizure affecting the right hemisphere
Explanation:Differential Diagnosis for Recurrent Neurological Symptoms
Recurrent neurological symptoms can be caused by a variety of conditions, and a thorough differential diagnosis is necessary to determine the underlying cause. In the case of a patient experiencing march-like progression of symptoms affecting the left side of the body, several possibilities must be considered.
A partial epileptic seizure affecting the right hemisphere is a likely cause, as the positive sensory symptoms and stereotyped nature of the episodes are typical of epilepsy. The rapid progression of symptoms over seconds to a minute is also characteristic of seizure activity.
Transient ischaemic attacks (TIAs) affecting the right hemisphere are less likely, as the march-like progression of symptoms and positive sensory symptoms are not typical of a vascular cause. TIAs are more likely to present with loss of sensation rather than abnormal sensations.
Recurrent, deep, white-matter microhaemorrhages are a possibility due to the patient’s risk factors, but the stereotyped nature of the attacks and positive sensory symptoms make this diagnosis less likely. Microhaemorrhages would typically present with numbness affecting the entire left side at onset.
Migraine equivalent is a rare possibility, but the rapid progression of symptoms and frequency of episodes make this diagnosis unlikely. Migraine aura without headache typically spreads over 20-30 minutes and is more common in patients with a history of previous migraine.
Cerebral venous thrombosis is also unlikely, as the absence of headache makes this diagnosis less probable. CVT typically presents with headache and other neurological symptoms.
In conclusion, the positive sensory features, stereotyped nature, and march of symptoms suggest epilepsy as the most likely cause of the patient’s recurrent neurological symptoms.
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This question is part of the following fields:
- Neurology
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Question 26
Correct
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A 68-year-old man presents with complaints of weight loss and fatigue that have been ongoing for several months. Upon examination, the only notable finding is pallor. A blood film reveals the presence of immature blasts, and genetic testing shows the presence of a chromosomal translocation t(9;22) - the Philadelphia chromosome. Further investigations reveal the following results: Hb of 95 g/l (normal range: 135-175 g/l), leukocytes of 62 × 109/l (normal range: 4.0-11.0 × 109/l), and PLT of 101 × 109/l (normal range: 150-400 × 109/l). What is the most likely diagnosis?
Your Answer: Chronic myeloid leukaemia (CML)
Explanation:Chronic myeloid leukaemia (CML) is a rare form of cancer that occurs due to the abnormal growth of myeloid precursors or blasts. This leads to an increase in white blood cells and a decrease in the normal functions of the bone marrow, resulting in anaemia and thrombocytopenia. CML is most commonly seen in people between the ages of 60 and 70 and has a slow onset that can last for months or even years. The majority of cases are caused by a genetic mutation called the Philadelphia chromosome, which produces a protein that promotes the growth of cancer cells. Symptoms of CML include fatigue, weight loss, night sweats, abdominal distension, and left upper quadrant pain. Treatment for CML involves inhibiting the genetic mutation with a drug called imatinib.
Acute lymphocytic leukaemia (ALL) is a type of cancer that occurs due to the abnormal growth of immature lymphocytes, which replace the normal cells of the bone marrow and lead to a decrease in blood cell production. ALL is most commonly seen in children and presents with symptoms such as anaemia, fever, and abdominal pain. Diagnosis is made through bone marrow biopsy and genetic analysis, which can reveal chromosomal abnormalities associated with the disease.
Hodgkin’s lymphoma (HL) is a type of cancer that typically presents with enlarged lymph nodes and is associated with the presence of Reed-Sternberg cells, which are abnormal B cells. Multiple myeloma (MM) is a cancer that affects plasma cells in the bone marrow, leading to a decrease in blood cell production and other symptoms such as hypercalcemia and kidney dysfunction. Non-Hodgkin’s lymphoma (NHL) is a type of cancer that arises from the abnormal growth of B cells, T cells, or natural killer cells and can be caused by genetic mutations, infections, or chronic inflammation. Symptoms of NHL include enlarged lymph nodes throughout the body.
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This question is part of the following fields:
- Haematology/Oncology
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Question 27
Correct
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A 65-year-old man comes to your clinic complaining of progressive slurred speech over the past few months. He is embarrassed because he frequently gives presentations for work and some people have joked that he sounds drunk. Upon examination, there is no droop or drooling in his head and face, but he struggles to articulate certain phrases and has difficulty swallowing. His tongue also appears to fasciculate when he sticks it out. In addition, there is mild weakness and hypotonia in his limbs, but his knees and ankles have slight hyperreflexia. What is the most likely cause of his symptoms?
Your Answer: Motor neurone disease
Explanation:The presence of fasciculations, along with upper and lower motor neurone signs, strongly suggests motor neuron disease as the underlying condition. The patient’s difficulty with speech and swallowing may be due to bulbar palsy, which is commonly associated with this disease. A stroke, which typically presents with sudden onset of symptoms, is unlikely to be the cause of the patient’s progressive symptoms over weeks or months. While a cerebellar tumour may cause slurred speech, it would typically be accompanied by other symptoms such as ataxia, vertigo, and difficulty with basic movements. Multiple sclerosis is an uncommon diagnosis in late-middle-aged men and is an upper motor neurone disease, whereas this patient has a combination of upper and lower motor neurone signs. There is no evidence of tremor or bradykinesia in this case.
Understanding Motor Neuron Disease: Signs and Diagnosis
Motor neuron disease is a neurological condition that affects both upper and lower motor neurons. It is a rare condition that usually presents after the age of 40 and can manifest in different patterns such as amyotrophic lateral sclerosis, progressive muscular atrophy, and bulbar palsy. The diagnosis of motor neuron disease is based on clinical features, including the presence of fasciculations, the absence of sensory signs, and the combination of upper and lower motor neuron signs. Wasting of the small hand muscles and tibialis anterior is also common.
Other features that can help diagnose motor neuron disease include the absence of external ocular muscle involvement, the absence of cerebellar signs, and preserved abdominal reflexes. Sphincter dysfunction, if present, is usually a late feature. While vague sensory symptoms may occur early in the disease, sensory signs are typically absent.
Nerve conduction studies can help exclude a neuropathy, while electromyography shows a reduced number of action potentials with increased amplitude. MRI is usually performed to exclude other conditions such as cervical cord compression and myelopathy. Understanding the signs and diagnosis of motor neuron disease is crucial for early detection and management of the condition.
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This question is part of the following fields:
- Neurology
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Question 28
Correct
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As a junior doctor on the neonatal ward, you are called to a forceps delivery. During the delivery, the midwives notice shoulder dystocia in a newborn. What is the initial management approach for shoulder dystocia in a neonate?
Your Answer: McRoberts manoeuvre (hyperflexion of the legs)
Explanation:The McRoberts maneuver involves hyperflexing the legs.
Shoulder dystocia is a complication that can occur during vaginal delivery when the body of the fetus cannot be delivered after the head has already been delivered. This is usually due to the anterior shoulder of the fetus becoming stuck on the mother’s pubic bone. Shoulder dystocia can cause harm to both the mother and the fetus. Risk factors for shoulder dystocia include fetal macrosomia, high maternal body mass index, diabetes mellitus, and prolonged labor.
If shoulder dystocia is identified, it is important to call for senior help immediately. The McRoberts’ maneuver is often performed, which involves flexing and abducting the mother’s hips to increase the angle of the pelvis and facilitate delivery. An episiotomy may be performed to provide better access for internal maneuvers, but it will not relieve the bony obstruction. Symphysiotomy and the Zavanelli maneuver are not recommended as they can cause significant maternal morbidity. Oxytocin administration is not indicated for shoulder dystocia.
Complications of shoulder dystocia can include postpartum hemorrhage and perineal tears for the mother, and brachial plexus injury and neonatal death for the fetus. It is important to manage shoulder dystocia promptly and appropriately to minimize the risk of these complications.
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This question is part of the following fields:
- Paediatrics
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Question 29
Incorrect
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A 62-year-old woman comes to the Emergency Department with acute abdominal pain. She is experiencing severe pain in the epigastric region that radiates to her back and is vomiting excessively. When questioned, she confesses to having had too many drinks at a bachelorette party the night before. Her serum amylase level is 1190 u/l. What is the most suitable initial management step?
Your Answer: Urgent computerised tomography (CT) of the abdomen
Correct Answer: Fluid resuscitation
Explanation:Treatment and Diagnosis of Acute Pancreatitis
Acute pancreatitis can lead to systemic inflammatory response syndrome and multiple organ dysfunction syndromes. The mainstay of treatment is supportive measures such as fluid resuscitation and oxygen supplementation. Abdominal ultrasound can be useful to identify gallstones as the cause of pancreatitis, but fluid resuscitation takes priority. IV antibiotics are not indicated unless complications occur. Enteral feeding is preferred over nil by mouth, and parenteral feeding should be considered if enteral feeding is not tolerated. Urgent CT of the abdomen is not necessary in the acute stage unless complications are suspected. However, for severe pancreatitis, contrast-enhanced CT may be indicated four days after initial symptoms to assess for complications.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 30
Incorrect
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A client is observed to have a missing triceps reflex. To which nerve root does this correspond?
Your Answer: C6-C7
Correct Answer: C7-C8
Explanation:Understanding Common Reflexes
Reflexes are automatic responses of the body to certain stimuli. These responses are controlled by the nervous system and do not require conscious thought. Common reflexes include the ankle reflex, knee reflex, biceps reflex, and triceps reflex. Each reflex is associated with a specific root in the spinal cord.
The ankle reflex is associated with the S1-S2 root, which is located in the lower part of the spinal cord. This reflex is elicited by tapping the Achilles tendon with a reflex hammer. The resulting contraction of the calf muscle indicates the integrity of the spinal cord and the peripheral nerves.
The knee reflex is associated with the L3-L4 root, which is located in the middle part of the spinal cord. This reflex is elicited by tapping the patellar tendon with a reflex hammer. The resulting contraction of the quadriceps muscle indicates the integrity of the spinal cord and the peripheral nerves.
The biceps reflex is associated with the C5-C6 root, which is located in the upper part of the spinal cord. This reflex is elicited by tapping the biceps tendon with a reflex hammer. The resulting contraction of the biceps muscle indicates the integrity of the spinal cord and the peripheral nerves.
The triceps reflex is associated with the C7-C8 root, which is located in the upper part of the spinal cord. This reflex is elicited by tapping the triceps tendon with a reflex hammer. The resulting contraction of the triceps muscle indicates the integrity of the spinal cord and the peripheral nerves.
Understanding these common reflexes can help healthcare professionals diagnose and treat various neurological conditions. By testing these reflexes, they can determine if there is any damage or dysfunction in the nervous system.
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This question is part of the following fields:
- Neurology
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