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  • Question 1 - A 12-year-old girl presents to the clinic with complaints of anterior knee pain...

    Incorrect

    • A 12-year-old girl presents to the clinic with complaints of anterior knee pain for a few weeks, which worsens while walking downstairs. During the examination, a positive shrug test is observed, and she has a valgus knee deformity.
      What is the most probable diagnosis?

      Your Answer: Osgood-Schlatter disease

      Correct Answer: Chondromalacia patellae

      Explanation:

      Common Causes of Knee Pain in Adolescents and Young Adults

      Knee pain is a common complaint among adolescents and young adults. There are several conditions that can cause knee pain, including chondromalacia patellae, osteoarthritis, Osgood-Schlatter disease, osteochondritis dissecans, and patellar subluxation.

      Chondromalacia patellae is characterized by abnormal softening of the cartilage on the underside of the patella. It is more common in females, those with valgus knee deformity, and those who are flat-footed. Patients may experience anterior knee pain that worsens with prolonged sitting or activities such as walking down stairs, jumping, running, or climbing. Treatment involves physiotherapy to alter patella-femoral alignment, along with analgesics and ice for symptom relief.

      Osteoarthritis is a disease of older patients caused by cartilage breakdown in weight-bearing joints. Osgood-Schlatter disease is a common cause of knee pain in young adolescents, particularly sporty boys, and is caused by overuse of quadriceps. Osteochondritis dissecans is caused by separation of subchondral bone articular cartilage from the joint surface and tends to present in teenagers and young adults with vague and achy joint pain. Patellar subluxation describes the temporary but recurring lateral subluxation of the patella, which can cause anterior patellar pain and joint stiffness.

      It is important to note that knee pain in children could be due to hip pathology, such as slipped upper femoral epiphysis. Diagnosis and treatment for these conditions may involve clinical examination, radiographs, and MRI. Treatment may include physiotherapy, analgesics, ice packs, knee braces, and in some cases, surgery.

    • This question is part of the following fields:

      • Musculoskeletal
      29
      Seconds
  • Question 2 - A 65-year-old man was diagnosed with angina after experiencing chest pain during physical...

    Incorrect

    • A 65-year-old man was diagnosed with angina after experiencing chest pain during physical activity. He underwent an exercise test at the cardiology clinic and was prescribed aspirin, bisoprolol, atorvastatin, and a glyceryl trinitrate (GTN) spray.
      After six months, he returned with an increase in the frequency of anginal episodes, which were relieved by GTN spray and did not occur at rest.
      What medication would be the most suitable addition to his current treatment?

      Your Answer: Diltiazem

      Correct Answer: Amlodipine

      Explanation:

      If a beta-blocker is not effective in controlling angina, it is recommended to add a longer-acting dihydropyridine calcium channel blocker such as amlodipine. Diltiazem and verapamil should not be used in combination with a beta-blocker due to the risk of life-threatening bradycardia and heart failure. Ivabradine and nicorandil can be used as alternatives if a dihydropyridine CCB is not suitable, but should only be initiated under specialist advice.

      Angina pectoris is a condition that can be managed through various methods, including lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. The first-line medication should be either a beta-blocker or a calcium channel blocker, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If the initial treatment is not effective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, other drugs such as long-acting nitrates, ivabradine, nicorandil, or ranolazine can be considered. Nitrate tolerance is a common issue, and patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. This effect is not seen in patients who take once-daily modified-release isosorbide mononitrate. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.

    • This question is part of the following fields:

      • Cardiovascular
      84.2
      Seconds
  • Question 3 - A 75 year old man with congestive cardiac failure is seen in cardiology...

    Incorrect

    • A 75 year old man with congestive cardiac failure is seen in cardiology clinic. He reports persistent shortness of breath with minimal activity. His current medications consist of furosemide, ramipril, bisoprolol, and spironolactone. An ECHO reveals an ejection fraction of 30%, while an ECG shows sinus rhythm with a QRS duration of 150ms. What is the optimal approach to enhance mortality?

      Your Answer: Increase furosemide dose

      Correct Answer: Cardiac resynchronisation therapy

      Explanation:

      Heart failure patients with a left ventricular ejection fraction of less than or equal to 40% and symptoms no more severe than class III according to the New York Heart Association functional classification may benefit from digoxin in terms of reducing hospitalization. However, it does not have an impact on mortality. While increasing the dosage of furosemide may provide relief from fluid overload symptoms, it does not affect mortality.

      Non-Drug Management for Chronic Heart Failure

      Chronic heart failure is a condition that requires long-term management to improve symptoms and reduce hospitalization. While medication is often the first line of treatment, non-drug management options are also available. Two such options are cardiac resynchronization therapy and exercise training.

      Cardiac resynchronization therapy involves biventricular pacing for patients with heart failure and wide QRS. This therapy has been shown to improve symptoms and reduce hospitalization in patients with NYHA class III heart failure. By synchronizing the heart’s contractions, this therapy can improve the heart’s pumping ability and reduce symptoms such as shortness of breath and fatigue.

      Exercise training is another non-drug management option for chronic heart failure. While it may not reduce hospitalization or mortality rates, it has been shown to improve symptoms. Exercise can help improve the heart’s ability to pump blood and increase overall fitness levels. This can lead to a reduction in symptoms such as fatigue and shortness of breath, allowing patients to engage in daily activities with greater ease.

      Overall, non-drug management options such as cardiac resynchronization therapy and exercise training can be effective in managing chronic heart failure. These options can improve symptoms and quality of life for patients, reducing the need for hospitalization and improving overall health outcomes.

    • This question is part of the following fields:

      • Cardiovascular
      209.6
      Seconds
  • Question 4 - A 38-year-old man presents to you with complaints of a persistent sensation of...

    Incorrect

    • A 38-year-old man presents to you with complaints of a persistent sensation of mucus in the back of his throat. He also reports a chronic cough for the past 6 months and frequently experiences bad breath, particularly in the mornings. He admits to smoking 10 cigarettes daily but otherwise feels fine. On examination, his ears appear normal, and his throat shows slight redness with no swelling of the tonsils. What is the most probable diagnosis?

      Your Answer: Smoker's cough

      Correct Answer: Postnasal drip

      Explanation:

      Nasal tumors can cause symptoms such as nosebleeds, a persistent blocked nose, blood-stained mucus draining from the nose, and a decreased sense of smell. A chronic cough in smokers, known as a smoker’s cough, is caused by damage and destruction of the protective cilia in the respiratory tract. Nasal polyps can result in symptoms such as nasal obstruction, sneezing, rhinorrhea, and a poor sense of taste and smell. If symptoms are unilateral or accompanied by bleeding, it may be a sign of a more serious condition. Nasal foreign bodies, which are commonly found in children, can include items such as peas, beads, buttons, seeds, and sweets.

      Understanding Post-Nasal Drip

      Post-nasal drip is a condition that arises when the nasal mucosa produces an excessive amount of mucus. This excess mucus then accumulates in the back of the nose or throat, leading to a chronic cough and unpleasant breath. Essentially, post-nasal drip occurs when the body produces more mucus than it can handle, resulting in a buildup that can cause discomfort and irritation. This condition can be caused by a variety of factors, including allergies, sinus infections, and even certain medications. Understanding the causes and symptoms of post-nasal drip can help individuals seek appropriate treatment and alleviate their discomfort.

    • This question is part of the following fields:

      • ENT
      632.5
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  • Question 5 - A 14-year-old patient presents to the emergency department with a cut sustained while...

    Correct

    • A 14-year-old patient presents to the emergency department with a cut sustained while helping her mother with gardening. The wound appears superficial and is closed with skin glue. During examination, her vital signs are recorded as a temperature of 36.9ºC, heart rate of 86 bpm, blood pressure of 115/87 mmHg, respiratory rate of 16/min, and oxygen saturation of 98% on room air. The patient's mother is concerned about the need for a tetanus booster as she cannot recall if her daughter received the full course of vaccinations during childhood. How should the patient be managed?

      Your Answer: Tetanus booster vaccine and immunoglobulin

      Explanation:

      If a patient’s tetanus vaccination history is uncertain and the wound is not minor and less than 6 hours old, they should receive a booster vaccine and immunoglobulin. In this case, the patient is 13 years old and should have received 4 or 5 vaccinations against tetanus under the standard UK vaccination schedule. Antibiotics are not necessary if the wound is clean and not deep. It is more efficient to administer the booster while the patient is in the department rather than asking the GP to follow up, which could result in the patient being lost to follow up. The term tetanus level is incorrect as there is no such test.

      Tetanus Vaccination and Management of Wounds

      The tetanus vaccine is a purified toxin that is given as part of a combined vaccine. In the UK, it is given as part of the routine immunisation schedule at 2, 3, and 4 months, 3-5 years, and 13-18 years, providing a total of 5 doses for long-term protection against tetanus.

      When managing wounds, the first step is to classify them as clean, tetanus-prone, or high-risk tetanus-prone. Clean wounds are less than 6 hours old and have negligible tissue damage, while tetanus-prone wounds include puncture-type injuries acquired in a contaminated environment or wounds containing foreign bodies. High-risk tetanus-prone wounds include wounds or burns with systemic sepsis, certain animal bites and scratches, heavy contamination with material likely to contain tetanus spores, wounds or burns with extensive devitalised tissue, and wounds or burns that require surgical intervention.

      If the patient has had a full course of tetanus vaccines with the last dose less than 10 years ago, no vaccine or tetanus immunoglobulin is required regardless of the wound severity. If the patient has had a full course of tetanus vaccines with the last dose more than 10 years ago, a reinforcing dose of vaccine is required for tetanus-prone wounds, and a reinforcing dose of vaccine plus tetanus immunoglobulin is required for high-risk wounds. If the vaccination history is incomplete or unknown, a reinforcing dose of vaccine is required regardless of the wound severity, and a reinforcing dose of vaccine plus tetanus immunoglobulin is required for tetanus-prone and high-risk wounds.

      Overall, proper vaccination and wound management are crucial in preventing tetanus infection.

    • This question is part of the following fields:

      • Paediatrics
      34.3
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  • Question 6 - A 56-year-old man is recuperating after experiencing his initial bout of gout. He...

    Incorrect

    • A 56-year-old man is recuperating after experiencing his initial bout of gout. He continues to experience some persistent discomfort in his big toe. He has no predisposing factors for gout and no signs of gouty tophi upon examination. At what point would it be appropriate to initiate uric acid-lowering treatment?

      Your Answer: If one further attack of gout in the next 12 months

      Correct Answer: Once his symptoms of acute gout have resolved

      Explanation:

      It is now recommended to offer allopurinol to all patients after their first gout attack, without delay. However, it is advised to wait until the inflammation has subsided before discussing urate-lowering therapy with the patient. If the attacks are too frequent, allopurinol can be considered even before the inflammation has completely settled. These recommendations are provided by the 2017 British Society for Rheumatology and NICE Clinical Knowledge Summaries.

      Gout is caused by chronic hyperuricaemia and is managed acutely with NSAIDs or colchicine. Urate-lowering therapy (ULT) is recommended for patients with >= 2 attacks in 12 months, tophi, renal disease, uric acid renal stones, or prophylaxis if on cytotoxics or diuretics. Allopurinol is first-line ULT, with an initial dose of 100 mg od and titrated to aim for a serum uric acid of < 300 µmol/l. Lifestyle modifications include reducing alcohol intake, losing weight if obese, and avoiding high-purine foods. Consideration should be given to stopping precipitating drugs and losartan may be suitable for patients with coexistent hypertension.

    • This question is part of the following fields:

      • Musculoskeletal
      41.9
      Seconds
  • Question 7 - A mother brings her 6-week-old infant to your clinic suspecting that the baby...

    Incorrect

    • A mother brings her 6-week-old infant to your clinic suspecting that the baby may have a squint. She has observed that the baby's eyes do not always appear to be looking in the same direction. However, she reports that the baby is developing well and there are no concerns regarding their vision.
      What would be the most suitable course of action in this situation?

      Your Answer: Urgent referral to ophthalmology

      Correct Answer: Reassure dad that intermittent squint in newborns is normal

      Explanation:

      It is considered normal for newborns under 3 months to have intermittent squint due to their underdeveloped eye muscles. Therefore, there is no need for investigation. However, if the squint persists or there are concerns about the newborn’s vision, referral to secondary care is recommended. In older children, eye patches may be used to prevent lazy eye.

      Squint, also known as strabismus, is a condition where the visual axes are misaligned. There are two types of squints: concomitant and paralytic. Concomitant squints are more common and are caused by an imbalance in the extraocular muscles. On the other hand, paralytic squints are rare and are caused by the paralysis of extraocular muscles. It is important to detect squints early on as they can lead to amblyopia, where the brain fails to process inputs from one eye and favours the other eye over time.

      To detect a squint, a corneal light reflection test can be performed by holding a light source 30cm from the child’s face to see if the light reflects symmetrically on the pupils. The cover test is also used to identify the nature of the squint. This involves asking the child to focus on an object, covering one eye, and observing the movement of the uncovered eye. The test is then repeated with the other eye covered.

      If a squint is detected, it is important to refer the child to secondary care. Eye patches may also be used to help prevent amblyopia.

    • This question is part of the following fields:

      • Ophthalmology
      30.8
      Seconds
  • Question 8 - A 68-year-old woman presents with a 4-month history of heaviness and discomfort in...

    Incorrect

    • A 68-year-old woman presents with a 4-month history of heaviness and discomfort in her upper legs, which is present after walking for more than 5 minutes. She used to enjoy walking regularly, but now finds it difficult to participate. However, she is still able to drive to her part-time job as a receptionist. She has a history of hypertension and was recently started on medication. She quit smoking 3 years ago. On examination, her blood pressure is 150/85 mmHg. Her pulse is 64 and regular. Her peripheral pulses are palpable, but the capillary return in her toes is slow. Neurological examination of her arms and legs is normal, except for diminished ankle jerks and reduced vibration sense distally.
      Which of the following is the most likely diagnosis?

      Your Answer: Abdominal aortic stenosis

      Correct Answer: Lumbar canal stenosis

      Explanation:

      Differential Diagnosis of Progressive Exertional Leg Pain: A Review of Possible Conditions

      Progressive exertional leg pain can be a symptom of various medical conditions. In this article, we will review some of the possible differential diagnoses for this symptom.

      Lumbar Canal Stenosis
      Lumbar canal stenosis is a degenerative condition associated with the ageing spine, resulting in narrowing of the central spinal canal, lateral recess or neural foramina. It is usually due to progressive hypertrophy of the facet joints and disc degeneration. It is a syndrome of buttock or leg pain, with or without back pain, associated with a narrow space available for the neural and vascular elements in the lumbar spine.

      Metabolic Muscle Disease
      This is a diverse group of hereditary muscle disorders caused by specific enzymatic defects due to defective genes. Disorders of muscle energy metabolism result in skeletal muscle dysfunction. Most metabolic myopathies are considered primary inborn errors of metabolism and are associated with enzymatic defects that affect the ability of muscle fibres to maintain energy and adenosine triphosphate (ATP) concentrations. These include abnormalities of glycogen, lipid, purine or mitochondrial biochemistry.

      Idiopathic Parkinson’s Disease
      Idiopathic Parkinson’s disease (IPD) commonly presents with tremor, stiffness, slowness and balance/gait issues. In addition, PD classically displays a unilateral onset. This patient has no resting symptoms suggestive of IPD.

      Hypothyroid Muscle Disease
      Hypothyroidism is associated with proximal myopathy. There is commonly proximal muscle weakness and raised creatine kinase (CK). Patients may suffer muscle cramping, proximal symmetrical muscle weakness, muscle stiffness and exercise intolerance. Reduced reflexes/ankle reflexes are commonly seen.

      Abdominal Aortic Stenosis
      This refers to narrowing of the aorta during its course in the abdomen. This would produce bilateral vascular claudication symptoms, due to reduced blood flow distal to the stenosis. The progressive exertional leg pain described here could be in keeping with vascular claudication.

    • This question is part of the following fields:

      • Neurology
      58
      Seconds
  • Question 9 - A 55-year-old rancher presents to the ER with his spouse. He is experiencing...

    Correct

    • A 55-year-old rancher presents to the ER with his spouse. He is experiencing a high fever and excessive sweating. During the examination, multiple black blisters are observed, which are producing a malodorous discharge. What is the typical microorganism linked to this ailment?

      Your Answer: Clostridium perfringens

      Explanation:

      Gas gangrene is a severe bacterial infection that can lead to muscle necrosis, sepsis, gas production, and ultimately, death. The infection can occur in two ways: through traumatic or surgical inoculation of a wound with bacteria, or spontaneously, which is often observed in immunocompromised patients. While there are multiple causes of gas gangrene, clostridium perfringens, a type of clostridia species, is frequently implicated. The condition typically begins with pain and progresses to systemic symptoms such as fever and dehydration. Skin changes, including blisters that can burst and produce a foul-smelling discharge, are also common. Movement may produce a crackling sound known as crepitus.

      Clostridia: Gram-Positive Anaerobic Bacilli

      Clostridia are a group of gram-positive, obligate anaerobic bacilli. There are several species of Clostridia, each with their own unique features and pathologies. C. perfringens produces α-toxin, a lecithinase, which can cause gas gangrene and haemolysis. Symptoms of gas gangrene include tender, oedematous skin with haemorrhagic blebs and bullae, and crepitus may be present on palpation. C. botulinum is typically found in canned foods and honey and can cause flaccid paralysis by preventing the release of acetylcholine. C. difficile is known for causing pseudomembranous colitis, which is often seen after the use of broad-spectrum antibiotics. This species produces both an exotoxin and a cytotoxin. Finally, C. tetani produces an exotoxin called tetanospasmin, which prevents the release of glycine from Renshaw cells in the spinal cord, leading to spastic paralysis.

    • This question is part of the following fields:

      • Infectious Diseases
      12.7
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  • Question 10 - A 61-year-old Caucasian man presents for a routine health check. He has a...

    Correct

    • A 61-year-old Caucasian man presents for a routine health check. He has a medical history of asthma and type 2 diabetes mellitus. His most recent HbA1c is 56 mmol/mol (7.3%). During the check-up, his blood pressure is measured at 160/80 mmHg. Subsequently, ambulatory blood pressure monitoring is conducted, which shows an average daytime blood pressure of 150/90 mmHg. What is the appropriate next step in management?

      Your Answer: Ramipril

      Explanation:

      For the treatment of hypertension in diabetic patients, the first-line medication should be ACE inhibitors such as ramipril. However, this may not be suitable for individuals of Afro-Caribbean descent or women who may become pregnant. In case of a cough developing with ACE inhibitors, an angiotensin-II receptor antagonist like losartan should be prescribed. If the patient is not diabetic, calcium channel blockers like amlodipine or diuretics such as indapamide would be the preferred initial treatment. Beta blockers like propranolol are not typically the first choice for hypertension treatment, but may be considered for young patients who cannot tolerate ACE inhibitors or women attempting to conceive.

      NICE released updated guidelines in 2019 for the management of hypertension, building on previous guidelines from 2011. These guidelines aimed to classify hypertension into stages and recommend the use of ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) to accurately diagnose hypertension. This is important because some patients experience white coat hypertension, where their blood pressure rises in a clinical setting, leading to potential overdiagnosis of hypertension. ABPM and HBPM allow for a more accurate assessment of a patient’s overall blood pressure and can prevent overdiagnosis.

      NICE recommends measuring blood pressure in both arms when considering a diagnosis of hypertension and repeating measurements if there is a difference of more than 20 mmHg between arms. If the blood pressure is >= 140/90 mmHg, NICE suggests offering ABPM or HBPM to confirm the diagnosis. If the blood pressure is >= 180/120 mmHg, referral for specialist assessment is recommended if there are signs of retinal haemorrhage or papilloedema or life-threatening symptoms. If target organ damage is identified, antihypertensive drug treatment may be started immediately.

      ABPM involves taking at least 2 measurements per hour during the person’s usual waking hours and using the average value of at least 14 measurements. If ABPM is not tolerated, HBPM should be offered. HBPM involves taking two consecutive measurements at least 1 minute apart, twice daily for at least 4 days, and using the average value of all remaining measurements.

      Interpreting the results of ABPM/HBPM is important for determining treatment. If the average blood pressure is >= 135/85 mmHg (stage 1 hypertension), treatment may be considered for patients under 80 years of age with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. In 2019, NICE also recommended considering antihypertensive drug treatment for adults under 60 with stage 1 hypertension and an estimated 10-year risk below 10%. If the average blood pressure is >= 150/95 mmHg (stage 2 hypertension), drug treatment should be offered regardless of age.

    • This question is part of the following fields:

      • Cardiovascular
      28.1
      Seconds
  • Question 11 - A 75-year-old man is prescribed oral alendronate after a hip fracture. Can you...

    Incorrect

    • A 75-year-old man is prescribed oral alendronate after a hip fracture. Can you provide instructions on how to take the tablet?

      Your Answer: Take it on a full stomach to minimise gastric irritation and avoid lying down for 30 minutes afterwards

      Correct Answer: Take at least 30 minutes before breakfast with plenty of water + sit-upright for 30 minutes following

      Explanation:

      Bisphosphonates: Uses and Adverse Effects

      Bisphosphonates are drugs that mimic the action of pyrophosphate, a molecule that helps prevent bone demineralization. They work by inhibiting osteoclasts, which are cells that break down bone tissue. This reduces the risk of bone fractures and can be used to treat conditions such as osteoporosis, hypercalcemia, Paget’s disease, and pain from bone metastases.

      However, bisphosphonates can have adverse effects, including oesophageal reactions such as oesophagitis and ulcers, osteonecrosis of the jaw, and an increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate. Patients may also experience an acute phase response, which can cause fever, myalgia, and arthralgia. Hypocalcemia, or low calcium levels, can also occur due to reduced calcium efflux from bone, but this is usually not clinically significant.

      To minimize the risk of adverse effects, patients taking oral bisphosphonates should swallow the tablets whole with plenty of water while sitting or standing. They should take the medication on an empty stomach at least 30 minutes before breakfast or other oral medications and remain upright for at least 30 minutes after taking the tablet. Hypocalcemia and vitamin D deficiency should be corrected before starting bisphosphonate treatment, and calcium supplements should only be prescribed if dietary intake is inadequate. The duration of bisphosphonate treatment varies depending on the patient’s level of risk, and some authorities recommend stopping treatment after five years for low-risk patients with a femoral neck T-score of > -2.5.

    • This question is part of the following fields:

      • Musculoskeletal
      20.3
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  • Question 12 - A 29-year-old woman visits the genitourinary medicine clinic with four fleshy, pigmented lesions...

    Incorrect

    • A 29-year-old woman visits the genitourinary medicine clinic with four fleshy, pigmented lesions on her vulva after starting a new relationship. What is the best initial course of action?

      Your Answer: Topical salicylic acid

      Correct Answer: Topical podophyllum

      Explanation:

      For the treatment of genital warts, topical podophyllum is recommended for multiple, non-keratinised warts, while cryotherapy is recommended for solitary, keratinised warts. Cryotherapy can also be used as an initial treatment for genital warts.

      Understanding Genital Warts

      Genital warts, also known as condylomata accuminata, are a common reason for visits to genitourinary clinics. These warts are caused by various types of the human papillomavirus (HPV), with types 6 and 11 being the most common culprits. It is important to note that HPV, particularly types 16, 18, and 33, can increase the risk of cervical cancer.

      The warts themselves are small, fleshy protrusions that are typically 2-5mm in size and may be slightly pigmented. They can cause discomfort, itching, and even bleeding. Treatment options for genital warts include topical podophyllum or cryotherapy, depending on the location and type of lesion. Topical agents are generally used for multiple, non-keratinised warts, while solitary, keratinised warts respond better to cryotherapy. Imiquimod, a topical cream, is often used as a second-line treatment. It is important to note that genital warts can be resistant to treatment, and recurrence is common. However, most anogenital HPV infections clear up on their own within 1-2 years without intervention.

    • This question is part of the following fields:

      • Reproductive Medicine
      36.6
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  • Question 13 - An 80-year-old man presents to you with a complaint of blurred vision that...

    Correct

    • An 80-year-old man presents to you with a complaint of blurred vision that has been worsening over the past 3 months. He has a medical history of type 2 diabetes and takes metformin. During the examination, you observe a shadow in the red reflex. What is the most probable diagnosis?

      Your Answer: Cataract

      Explanation:

      Understanding Cataracts: Causes, Symptoms, and Management

      A cataract is a common eye condition that affects the lens of the eye, causing it to become cloudy and reducing the amount of light that reaches the retina. This can lead to blurred or reduced vision, making it difficult to see clearly. Cataracts are more common in women and tend to increase in incidence with age. While the normal ageing process is the most common cause, other factors such as smoking, alcohol consumption, trauma, diabetes, and long-term corticosteroid use can also contribute to the development of cataracts.

      Symptoms of cataracts include reduced vision, faded colour vision, glare, and halos around lights. A defect in the red reflex is also a sign of cataracts. Diagnosis is typically made through ophthalmoscopy and slit-lamp examination, which can reveal the presence of a visible cataract.

      In the early stages, age-related cataracts can be managed conservatively with stronger glasses or contact lenses and brighter lighting. However, surgery is the only effective treatment for cataracts and involves removing the cloudy lens and replacing it with an artificial one. Referral for surgery should be based on the presence of visual impairment, impact on quality of life, and patient choice. Complications following surgery can include posterior capsule opacification, retinal detachment, posterior capsule rupture, and endophthalmitis.

      Overall, cataracts are a common and treatable eye condition that can significantly impact a person’s vision. Understanding the causes, symptoms, and management options can help individuals make informed decisions about their eye health.

    • This question is part of the following fields:

      • Ophthalmology
      58.2
      Seconds
  • Question 14 - A 68-year-old man came to your GP clinic complaining of stiffness and pain...

    Correct

    • A 68-year-old man came to your GP clinic complaining of stiffness and pain in his knee joints, painful urination, and a red eye with circumcorneal redness, hypopyon, and photophobia. What is the most probable reason for his red eye?

      Your Answer: Iritis

      Explanation:

      When dealing with reactive arthritis, it is important to keep in mind that anterior uveitis may also be present in addition to conjunctivitis.

      Since reactive arthritis is linked to HLA-B27, it is important to consider the possibility of iritis or anterior uveitis, even though conjunctivitis is more commonly seen as part of the triad of symptoms. The specific description of a red eye with circumcorneal redness and hypopyon suggests iritis rather than conjunctivitis. Conjunctivitis typically causes a more generalized redness of the eye and hypopyon is not commonly observed. Corneal ulceration is unlikely in this case as there is no mention of increased fluorescein uptake on the cornea or a visible ulcer. Scleritis can be ruled out as it does not present with circumcorneal redness or hypopyon. While scleritis is associated with systemic conditions such as rheumatoid arthritis and other collagen/vascular disorders like Wegener’s granulomatosis, polyarteritis nodosa, and systemic lupus erythematosus, it is not associated with reactive arthritis. Blepharitis is also an incorrect diagnosis as there were no eyelid symptoms and blepharitis does not typically cause a red eye with photophobic symptoms.

      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.

    • This question is part of the following fields:

      • Ophthalmology
      47
      Seconds
  • Question 15 - After expressing discomfort in their chest, a 75-year-old patient suddenly collapses on the...

    Correct

    • After expressing discomfort in their chest, a 75-year-old patient suddenly collapses on the surgical ward with no detectable pulse. The medical team initiates cardiopulmonary resuscitation (CPR) and calls for immediate assistance.
      Once the defibrillator is connected, the team pauses to check the rhythm. Although there is organised electrical activity, there is still no pulse or signs of life.
      In addition to continuing CPR with a ratio of 30 compressions to 2 breaths, what other actions should the team take at this stage?

      Your Answer: Give intravenous adrenaline

      Explanation:

      In the case of pulseless electrical activity, which is a non-shockable rhythm, the ALS algorithm requires the administration of adrenaline as soon as intravascular access is achieved. This should be done immediately after the rhythm check, following two more minutes of CPR. The recommended dose is 1mg IV, which should be repeated every 3-5 minutes. It is important to note that intramuscular adrenaline is not appropriate for cardiac arrest, and IV amiodarone is not indicated for non-shockable rhythms. While it is correct to avoid shocking the patient, it is incorrect to delay drug administration until the next rhythm check. The most recent Resuscitation Council Guidelines (2021) support the immediate administration of adrenaline in non-shockable rhythms.

      The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.

    • This question is part of the following fields:

      • Cardiovascular
      67.5
      Seconds
  • Question 16 - A 45-year-old woman presents to the Dermatology Clinic for regular follow-up of her...

    Correct

    • A 45-year-old woman presents to the Dermatology Clinic for regular follow-up of her psoriasis. This had previously been well controlled after phototherapy six months ago; however, she has recently deteriorated.
      Her current treatment regime includes topical calcipotriol (Dovonex), topical coal tar ointment and topical hydromol ointment, in addition to amoxicillin for a recent respiratory infection. She is otherwise fit and well.
      On examination, she has an erythematous rash covering much of her back, with widespread patches on her arms and legs. The rash is tender and warm, though she appears to be shivering. There are no oral lesions. Her pulse is 98 beats per minute, while her blood pressure (BP) is 95/50 mmHg and her temperature is 38.2 °C.
      What is the most important next step in this woman's treatment?

      Your Answer: Arrange hospital admission

      Explanation:

      Urgent Hospital Admission Required for Erythrodermic Psoriasis

      Erythrodermic psoriasis is a severe dermatological emergency that requires urgent hospital admission. This is evident in a patient who presents with a drop in blood pressure, tachycardia, borderline pyrexia, and rigors. While the patient’s psoriasis needs more intensive management, it is not appropriate to manage erythroderma in the community.

      The treatment for erythrodermic psoriasis includes supportive care, such as intravenous fluids, cool, wet dressings, and a systemic agent. The choice of a systemic agent depends on the patient and may involve rapid-acting therapies like ciclosporin or slower agents like methotrexate. However, it is important to note that starting any systemic agent requires investigations, including baseline blood tests and a viral screen, to ensure it is not contraindicated.

      It is crucial to differentiate erythrodermic psoriasis from other dermatological emergencies like Stevens-Johnson syndrome/toxic epidermal necrolysis (TEN), which is a severe drug reaction associated with amoxicillin and anti-epileptic therapies. However, in this case, the patient’s history features a slow deterioration of pre-existing psoriasis, and the rash is not desquamating, and there are no oral lesions. Therefore, hospital admission is required for erythrodermic psoriasis.

      It is essential to avoid repeating phototherapy in a patient with erythrodermic psoriasis as it can worsen the condition. In a well patient, phototherapy would not be reattempted six months after a poor response, and an alternate approach would most likely be sought.

    • This question is part of the following fields:

      • Dermatology
      47.6
      Seconds
  • Question 17 - What is the most probable adverse effect experienced by patients who are taking...

    Correct

    • What is the most probable adverse effect experienced by patients who are taking gliclazide?

      Your Answer: Weight gain

      Explanation:

      Weight gain is the most frequent side-effect observed in patients who take sulfonylureas, although they may experience all of the aforementioned side-effects.

      Sulfonylureas are a type of medication used to treat type 2 diabetes mellitus. They work by increasing the amount of insulin produced by the pancreas, but they are only effective if the pancreas is functioning properly. Sulfonylureas bind to a specific channel on the cell membrane of pancreatic beta cells, which helps to increase insulin secretion. However, there are some potential side effects associated with these drugs.

      One of the most common side effects of sulfonylureas is hypoglycaemia, which can be more likely to occur with long-acting preparations like chlorpropamide. Weight gain is another possible side effect. In rare cases, sulfonylureas can cause hyponatraemia, which is a condition where the body retains too much water and sodium levels become too low. Other rare side effects include bone marrow suppression, hepatotoxicity (liver damage), and peripheral neuropathy. It is important to note that sulfonylureas should not be used during pregnancy or while breastfeeding.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      40.1
      Seconds
  • Question 18 - A 54-year-old man with a history of untreated hypertension had a heart attack...

    Incorrect

    • A 54-year-old man with a history of untreated hypertension had a heart attack and received coronary stenting. He was prescribed multiple medications and his blood test results showed:
      Na+ 140 mmol/l
      K+ 6.2 mmol/l
      Which of the following antihypertensive drugs could be causing this result?

      Your Answer: Bumetanide

      Correct Answer: Enalapril

      Explanation:

      Hyperkalaemia is caused by ACE inhibitor.

      Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. These inhibitors are also used to treat diabetic nephropathy and for secondary prevention of ischaemic heart disease. The mechanism of action of ACE inhibitors is to inhibit the conversion of angiotensin I to angiotensin II. They are metabolized in the liver through phase 1 metabolism.

      ACE inhibitors may cause side effects such as cough, which occurs in around 15% of patients and may occur up to a year after starting treatment. This is thought to be due to increased bradykinin levels. Angioedema may also occur up to a year after starting treatment. Hyperkalaemia and first-dose hypotension are other potential side effects, especially in patients taking diuretics. ACE inhibitors should be avoided during pregnancy and breastfeeding, and caution should be exercised in patients with renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema.

      Patients receiving high-dose diuretic therapy (more than 80 mg of furosemide a day) are at an increased risk of hypotension when taking ACE inhibitors. Before initiating treatment, urea and electrolytes should be checked, and after increasing the dose, a rise in creatinine and potassium may be expected. Acceptable changes include an increase in serum creatinine up to 30% from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment. The current NICE guidelines provide a flow chart for the management of hypertension.

    • This question is part of the following fields:

      • Cardiovascular
      40.3
      Seconds
  • Question 19 - A 27-year-old man has come back from a vacation at the beach in...

    Incorrect

    • A 27-year-old man has come back from a vacation at the beach in Tenerife with a fresh rash on his neck and arms. The rash consists of patches that are coppery brown in color and lighter than the surrounding skin. There is no itching or pain associated with the rash. When examined with a Wood's light, the affected areas show yellow-green fluorescence.

      What is the recommended initial treatment for this skin condition?

      Your Answer: Emollient

      Correct Answer: Ketoconazole shampoo

      Explanation:

      Ketoconazole shampoo is the recommended first-line therapy for treating pityriasis versicolor, a fungal infection caused by Malassezia furfur that commonly affects the trunk, neck, and arms following sun exposure. While the rash is usually asymptomatic, an emollient may help with any associated itch or irritation, but it is not sufficient to treat the underlying fungal infection. Oral antifungals like itraconazole may be necessary for extensive or unresponsive cases, but for limited non-extensive disease, ketoconazole shampoo is the preferred treatment. Topical steroids and vitamin D analogues are not effective in treating pityriasis versicolor.

      Understanding Pityriasis Versicolor

      Pityriasis versicolor, also known as tinea versicolor, is a fungal infection that affects the skin’s surface. It is caused by Malassezia furfur, which was previously known as Pityrosporum ovale. This condition is characterized by patches that may be hypopigmented, pink, or brown, and it is most commonly found on the trunk. The patches may become more noticeable following a suntan, and scaling is a common symptom. Mild pruritus may also occur.

      Pityriasis versicolor can affect healthy individuals, but it is more likely to occur in those who are immunosuppressed, malnourished, or have Cushing’s syndrome. Treatment typically involves the use of topical antifungal medications, with ketoconazole shampoo being the recommended option due to its cost-effectiveness for larger areas. If topical treatment fails, alternative diagnoses should be considered, and oral itraconazole may be prescribed. Scrapings may also be sent for confirmation of the diagnosis. Understanding the features, predisposing factors, and management of pityriasis versicolor can help individuals recognize and effectively treat this common fungal infection.

    • This question is part of the following fields:

      • Dermatology
      39.2
      Seconds
  • Question 20 - A 27-year-old female patient visits the genitourinary medicine clinic seeking treatment for recurring...

    Correct

    • A 27-year-old female patient visits the genitourinary medicine clinic seeking treatment for recurring genital warts. Which virus is the most probable cause of this condition?

      Your Answer: Human papilloma virus 6 & 11

      Explanation:

      Understanding Genital Warts

      Genital warts, also known as condylomata accuminata, are a common reason for visits to genitourinary clinics. These warts are caused by various types of the human papillomavirus (HPV), with types 6 and 11 being the most common culprits. It is important to note that HPV, particularly types 16, 18, and 33, can increase the risk of cervical cancer.

      The warts themselves are small, fleshy protrusions that are typically 2-5mm in size and may be slightly pigmented. They can cause discomfort, itching, and even bleeding. Treatment options for genital warts include topical podophyllum or cryotherapy, depending on the location and type of lesion. Topical agents are generally used for multiple, non-keratinised warts, while solitary, keratinised warts respond better to cryotherapy. Imiquimod, a topical cream, is often used as a second-line treatment. It is important to note that genital warts can be resistant to treatment, and recurrence is common. However, most anogenital HPV infections clear up on their own within 1-2 years without intervention.

    • This question is part of the following fields:

      • Reproductive Medicine
      8.4
      Seconds
  • Question 21 - Which of the following statements about the correlation between the menstrual cycle and...

    Incorrect

    • Which of the following statements about the correlation between the menstrual cycle and body temperature is accurate?

      Your Answer: Body temperature rises just before ovulation

      Correct Answer: Body temperature rises following ovulation

      Explanation:

      The increase in body temperature after ovulation is utilized in certain cases of natural family planning.

      Phases of the Menstrual Cycle

      The menstrual cycle is a complex process that can be divided into four phases: menstruation, follicular phase, ovulation, and luteal phase. During the follicular phase, a number of follicles develop in the ovaries, with one follicle becoming dominant around the mid-follicular phase. At the same time, the endometrium begins to proliferate. This phase is characterized by a rise in follicle-stimulating hormone (FSH), which results in the development of follicles that secrete oestradiol.

      During ovulation, the mature egg is released from the dominant follicle and triggers the acute release of luteinizing hormone (LH). This phase occurs on day 14 of the menstrual cycle. Following ovulation, the luteal phase begins, during which the corpus luteum secretes progesterone. This hormone causes the endometrium to change into a secretory lining. If fertilization does not occur, the corpus luteum will degenerate, and progesterone levels will fall.

      The cervical mucus also changes throughout the menstrual cycle. Following menstruation, the mucus is thick and forms a plug across the external os. Just prior to ovulation, the mucus becomes clear, acellular, and low viscosity. It also becomes ‘stretchy’ – a quality termed spinnbarkeit. Under the influence of progesterone, it becomes thick, scant, and tacky.

      Basal body temperature is another indicator of the menstrual cycle. It falls prior to ovulation due to the influence of oestradiol and rises following ovulation in response to higher progesterone levels. Understanding the different phases of the menstrual cycle can help individuals track their fertility and plan for pregnancy.

    • This question is part of the following fields:

      • Reproductive Medicine
      7.8
      Seconds
  • Question 22 - You are conducting an infant assessment. What are the clinical manifestations of a...

    Incorrect

    • You are conducting an infant assessment. What are the clinical manifestations of a clubfoot?

      Your Answer: Inverted + dorsiflexed foot + pes planus which is not passively correctable

      Correct Answer: Inverted + plantar flexed foot which is not passively correctable

      Explanation:

      Talipes Equinovarus: A Common Foot Deformity in Newborns

      Talipes equinovarus, also known as club foot, is a foot deformity characterized by an inward turning and plantar flexed foot. It is a common condition that affects 1 in 1,000 newborns, with a higher incidence in males. In about 50% of cases, the deformity is present in both feet. While the cause of talipes equinovarus is often unknown, it can be associated with conditions such as spina bifida, cerebral palsy, and oligohydramnios.

      Diagnosis of talipes equinovarus is typically made during the newborn exam, and imaging is not usually necessary. The deformity is not passively correctable, and the diagnosis is based on clinical examination.

      In recent years, there has been a shift towards conservative management of talipes equinovarus, with the Ponseti method being the preferred approach. This method involves manipulation and progressive casting of the foot, starting soon after birth. The deformity is usually corrected within 6-10 weeks, and an Achilles tenotomy may be required in some cases. Night-time braces are then used until the child is 4 years old to prevent relapse, which occurs in about 15% of cases.

      Overall, talipes equinovarus is a common foot deformity in newborns that can be effectively managed with conservative methods such as the Ponseti method.

    • This question is part of the following fields:

      • Musculoskeletal
      26.8
      Seconds
  • Question 23 - A 70-year-old man visits his primary care physician complaining of increasing shortness of...

    Correct

    • A 70-year-old man visits his primary care physician complaining of increasing shortness of breath, especially during physical activity. He has also been experiencing a persistent dry cough for the past 8 weeks. The doctor suspects pulmonary fibrosis and orders spirometry testing.

      The patient's predicted spirometry values are as follows:
      FEV1 4.25L
      FVC 5.10L
      Transfer capacity (TLCO) Normal

      What are the probable spirometry findings for this individual?

      Your Answer: FEV1 = 2.79, FVC = 3.34, TLCO = Decreased

      Explanation:

      Once the predicted values are obtained, the FEV1:FVC ratio can be evaluated. If this ratio is less than 70, it indicates a potential issue.

      Understanding Idiopathic Pulmonary Fibrosis

      Idiopathic pulmonary fibrosis (IPF) is a chronic lung condition that causes progressive fibrosis of the interstitium of the lungs. Unlike other causes of lung fibrosis, IPF has no underlying cause. It is typically seen in patients aged 50-70 years and is more common in men.

      The symptoms of IPF include progressive exertional dyspnoea, dry cough, clubbing, and bibasal fine end-inspiratory crepitations on auscultation. Diagnosis is made through spirometry, impaired gas exchange tests, and imaging such as chest x-rays and high-resolution CT scans.

      Management of IPF includes pulmonary rehabilitation, but very few medications have been shown to be effective. Some evidence suggests that pirfenidone, an antifibrotic agent, may be useful in selected patients. Many patients will eventually require supplementary oxygen and a lung transplant.

      The prognosis for IPF is poor, with an average life expectancy of around 3-4 years. CT scans can show advanced pulmonary fibrosis, including honeycombing. While there is no cure for IPF, early diagnosis and management can help improve quality of life and potentially prolong survival.

    • This question is part of the following fields:

      • Respiratory Medicine
      49
      Seconds
  • Question 24 - A 50-year-old woman presents to dermatology after being referred by her physician for...

    Correct

    • A 50-year-old woman presents to dermatology after being referred by her physician for lesions on both shins. Upon examination, symmetrical erythematous lesions with an orange peel texture are observed. What is the probable diagnosis?

      Your Answer: Pretibial myxoedema

      Explanation:

      Pretibial myxoedema is a condition characterized by orange peel-like lesions on the skin of the shins, often associated with Grave’s disease.

      Understanding Shin Lesions: Differential Diagnosis and Characteristic Features

      Shin lesions can be caused by a variety of conditions, and it is important to differentiate between them in order to provide appropriate treatment. The four most common conditions that can cause shin lesions are erythema nodosum, pretibial myxoedema, pyoderma gangrenosum, and necrobiosis lipoidica diabeticorum.

      Erythema nodosum is characterized by symmetrical, tender, erythematous nodules that heal without scarring. It is often caused by streptococcal infections, sarcoidosis, inflammatory bowel disease, or certain medications such as penicillins, sulphonamides, or oral contraceptive pills.

      Pretibial myxoedema, on the other hand, is seen in Graves’ disease and is characterized by symmetrical, erythematous lesions that give the skin a shiny, orange peel appearance.

      Pyoderma gangrenosum initially presents as a small red papule, which later develops into deep, red, necrotic ulcers with a violaceous border. It is idiopathic in 50% of cases, but may also be seen in inflammatory bowel disease, connective tissue disorders, and myeloproliferative disorders.

      Finally, necrobiosis lipoidica diabeticorum is characterized by shiny, painless areas of yellow/red skin typically found on the shin of diabetics. It is often associated with telangiectasia.

      In summary, understanding the differential diagnosis and characteristic features of shin lesions can help healthcare professionals provide appropriate treatment and improve patient outcomes.

    • This question is part of the following fields:

      • Dermatology
      9.3
      Seconds
  • Question 25 - A 23-year-old woman contacts her doctor to request a referral for antenatal care....

    Incorrect

    • A 23-year-old woman contacts her doctor to request a referral for antenatal care. She has been attempting to conceive for the past year and has recently received a positive pregnancy test result. Her LMP was 5 weeks ago, which prompted her to take the test. The patient is in good health with no underlying medical conditions, does not smoke, and abstains from alcohol. Her BMI is 34 kg/m².

      What is the advised folic acid consumption for this patient?

      Your Answer: Folic acid 400mcg daily, continue until end of pregnancy

      Correct Answer: Folic acid 5mg daily, continue until end of 1st trimester

      Explanation:

      Pregnant women who have a BMI of 30 kg/m² or higher should be given a daily dose of 5mg folic acid until the 13th week of their pregnancy. Folic acid is crucial during the first trimester as it helps prevent neural tube defects (NTD). Typically, a daily dose of 400mcg is sufficient for most pregnant women during the first 12 weeks of pregnancy. However, those with a BMI of over 30 kg/m², as well as those with diabetes, sickle cell disease (SCD), thalassaemia trait, coeliac disease, on anti-epileptic medication, personal or family history of NTD, or who have previously given birth to a baby with an NTD, should be prescribed a daily dose of 5mg folic acid. It is recommended that folic acid be taken while trying to conceive to further reduce the risk of NTD. Additionally, NICE advises all pregnant women to take a daily dose of 10mcg (400 units) of vitamin D throughout their entire pregnancy.

      Pregnancy and Obesity: Risks and Management

      Obesity during pregnancy can lead to various complications for both the mother and the unborn child. A BMI of 30 kg/m² or higher at the first antenatal visit is considered obese. Maternal risks include miscarriage, venous thromboembolism, gestational diabetes, pre-eclampsia, dysfunctional and induced labour, postpartum haemorrhage, wound infections, and a higher rate of caesarean section. Fetal risks include congenital anomaly, prematurity, macrosomia, stillbirth, increased risk of developing obesity and metabolic disorders in childhood, and neonatal death.

      It is important to inform women with a BMI of 30 or more at the booking appointment about the risks associated with obesity during pregnancy. They should not attempt to reduce the risk by dieting while pregnant, and healthcare professionals will manage the risk during their pregnancy.

      Management of obesity during pregnancy includes taking 5mg of folic acid instead of 400mcg, screening for gestational diabetes with an oral glucose tolerance test (OGTT) at 24-28 weeks, giving birth in a consultant-led obstetric unit if the BMI is 35 kg/m² or higher, and having an antenatal consultation with an obstetric anaesthetist and a plan made if the BMI is 40 kg/m² or higher. It is important to manage obesity during pregnancy to reduce the risks and ensure the health of both the mother and the unborn child.

    • This question is part of the following fields:

      • Reproductive Medicine
      21
      Seconds
  • Question 26 - A 32-year-old female with rheumatoid arthritis visits her GP for advice on starting...

    Incorrect

    • A 32-year-old female with rheumatoid arthritis visits her GP for advice on starting a family. She and her partner are eager to conceive and she has been taking folic acid for the past four weeks. The patient has no other medical history and is currently taking methotrexate, paracetamol, ibuprofen, and lansoprazole. She is aware that her sister had to stop some of her rheumatoid arthritis medications before getting pregnant and wants to know if she needs to do the same.

      What is the appropriate management advice for this patient?

      Your Answer: Stop methotrexate at least three months before conception

      Correct Answer: Stop methotrexate at least six months before conception

      Explanation:

      When it comes to methotrexate, it is important to discontinue the drug at least six months before attempting to conceive, regardless of gender. This is because methotrexate can potentially harm sperm in males and cause early abortion in females. By allowing for a full wash-out period, the risk of DNA changes in both gametes can be minimized. While some studies suggest that paternal exposure to methotrexate within 90 days before pregnancy may not lead to congenital malformations, stillbirths, or preterm births, current guidelines recommend avoiding the drug for six months to ensure proper folic acid repletion. Therefore, options suggesting stopping methotrexate for only one or three months before conception are incorrect.

      Managing Rheumatoid Arthritis During Pregnancy

      Rheumatoid arthritis (RA) is a condition that commonly affects women of reproductive age, making issues surrounding conception and pregnancy a concern. While there are no official guidelines for managing RA during pregnancy, expert reviews suggest that patients with early or poorly controlled RA should wait until their disease is more stable before attempting to conceive.

      During pregnancy, RA symptoms tend to improve for most patients, but only a small minority experience complete resolution. After delivery, patients often experience a flare-up of symptoms. It’s important to note that certain medications used to treat RA are not safe during pregnancy, such as methotrexate and leflunomide. However, sulfasalazine and hydroxychloroquine are considered safe.

      Interestingly, studies have shown that the use of TNF-α blockers during pregnancy does not significantly increase adverse outcomes. However, many patients in these studies stopped taking the medication once they found out they were pregnant. Low-dose corticosteroids may also be used to control symptoms during pregnancy.

      NSAIDs can be used until 32 weeks, but should be withdrawn after that due to the risk of early closure of the ductus arteriosus. Patients with RA should also be referred to an obstetric anaesthetist due to the risk of atlanto-axial subluxation. Overall, managing RA during pregnancy requires careful consideration and consultation with healthcare professionals.

    • This question is part of the following fields:

      • Reproductive Medicine
      57.6
      Seconds
  • Question 27 - Breast cancer is a disease that affects many women. What is true about...

    Incorrect

    • Breast cancer is a disease that affects many women. What is true about breast cancer? Choose one statement from the options provided.

      Your Answer: Incidence in the UK equates to a 1 in 25 lifetime risk for each woman.

      Correct Answer: It is the second most common cancer in women.

      Explanation:

      Breast cancer is the second most common cancer in women and the leading cause of cancer death among women worldwide. Tamoxifen is a drug that can be used to treat breast cancer that requires estrogen to grow. It works by either blocking estrogen receptors or blocking the production of estrogen. For women with estrogen receptor-positive breast cancer, continuing tamoxifen for 10 years instead of stopping at 5 years can further reduce the risk of recurrence and mortality. However, tamoxifen does not affect the risk of breast cancer recurrence. The risk of endometrial cancer is slightly increased with tamoxifen treatment. Screening modalities include breast self-examination, clinical breast examination, mammography, ultrasonography, and magnetic resonance imaging. Early detection is crucial in preventing breast cancer, and screening intervals may need to be shortened to prevent more deaths. Physical examination and biopsy are also important diagnostic approaches. Treatment for breast cancer typically involves surgery, radiation therapy, and adjuvant hormone or chemotherapy when necessary.

    • This question is part of the following fields:

      • Reproductive Medicine
      34.1
      Seconds
  • Question 28 - A 75-year-old man presented to the eye clinic with double vision. He has...

    Correct

    • A 75-year-old man presented to the eye clinic with double vision. He has been experiencing this for the past few weeks. During examination, it was observed that he had horizontal diplopia and slight limitation of one of the extraocular muscles in his left eye. The patient has a medical history of hypertension and prostate cancer. Brain imaging revealed a metastatic lesion in the clivus that surrounds the cavernous sinus and carotid artery. Which cranial nerve palsy is responsible for the diplopia in this patient?

      Your Answer: Left sixth cranial nerve (CN6) palsy

      Explanation:

      Understanding the 12 Cranial Nerves and their Functions

      The human body has 12 pairs of cranial nerves that originate from the brainstem and control various functions such as movement, sensation, and reflexes. Each nerve has a specific function and pathway, and damage to any of these nerves can result in various clinical symptoms.

      Some of the important functions of these nerves include smell (olfactory nerve), sight (optic nerve), eye movement (oculomotor, trochlear, and abducens nerves), facial sensation and mastication (trigeminal nerve), facial movement and taste (facial nerve), hearing and balance (vestibulocochlear nerve), taste and swallowing (glossopharyngeal nerve), phonation and innervation of viscera (vagus nerve), head and shoulder movement (accessory nerve), and tongue movement (hypoglossal nerve).

      In addition to their primary functions, some of these nerves also play a role in various reflexes such as the corneal reflex, jaw jerk reflex, gag reflex, carotid sinus reflex, pupillary light reflex, and lacrimation reflex. Understanding the functions and pathways of these cranial nerves is essential for diagnosing and treating various neurological conditions.

    • This question is part of the following fields:

      • Neurology
      34.3
      Seconds
  • Question 29 - A 67-year-old man attending the respiratory clinic receives a suspected diagnosis of chronic...

    Correct

    • A 67-year-old man attending the respiratory clinic receives a suspected diagnosis of chronic obstructive pulmonary disease.
      Which of the following is the most appropriate investigation to confirm diagnosis?

      Your Answer: Spirometry

      Explanation:

      Investigations for COPD: Spirometry is Key

      COPD is a chronic obstructive airway disease that is diagnosed through a combination of clinical history, signs, and investigations. While several investigations may be used to support a diagnosis of COPD, spirometry is the most useful and important tool. A spirometer is used to measure functional lung volumes, including forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC). The FEV1:FVC ratio provides an estimate of the severity of airflow obstruction, with a normal ratio being 75-80%. In patients with COPD, the ratio is typically <0.7 and FEV1 <80% predicted. Spirometry is essential for establishing a baseline for disease severity, monitoring disease progression, and assessing the effects of treatment. Other investigations, such as echocardiography, chest radiography, ECG, and peak flow, may be used to exclude other pathologies or assess comorbidities, but spirometry remains the key investigation for diagnosing and managing COPD.

    • This question is part of the following fields:

      • Respiratory Medicine
      13.4
      Seconds
  • Question 30 - A 29-year-old woman with a four year history of ulcerative colitis is prescribed...

    Incorrect

    • A 29-year-old woman with a four year history of ulcerative colitis is prescribed azathioprine to prevent relapses. What vaccine should she avoid during this treatment?

      Your Answer: Rabies

      Correct Answer: Yellow fever

      Explanation:

      Patients who are immunosuppressed, such as those taking azathioprine, should not receive live attenuated vaccines including BCG, MMR, oral polio, yellow fever, and oral typhoid.

      Types of Vaccines and Their Characteristics

      Vaccines are essential in preventing the spread of infectious diseases. However, it is crucial to understand the different types of vaccines and their characteristics to ensure their safety and effectiveness. Live attenuated vaccines, such as BCG, MMR, and oral polio, may pose a risk to immunocompromised patients. In contrast, inactivated preparations, including rabies and hepatitis A, are safe for everyone. Toxoid vaccines, such as tetanus, diphtheria, and pertussis, use inactivated toxins to generate an immune response. Subunit and conjugate vaccines, such as pneumococcus, haemophilus, meningococcus, hepatitis B, and human papillomavirus, use only part of the pathogen or link bacterial polysaccharide outer coats to proteins to make them more immunogenic. Influenza vaccines come in different types, including whole inactivated virus, split virion, and sub-unit. Cholera vaccine contains inactivated strains of Vibrio cholerae and recombinant B-subunit of the cholera toxin. Hepatitis B vaccine contains HBsAg adsorbed onto aluminium hydroxide adjuvant and is prepared from yeast cells using recombinant DNA technology. Understanding the different types of vaccines and their characteristics is crucial in making informed decisions about vaccination.

    • This question is part of the following fields:

      • Immunology/Allergy
      12.3
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Musculoskeletal (0/4) 0%
Cardiovascular (2/5) 40%
ENT (0/1) 0%
Paediatrics (1/1) 100%
Ophthalmology (2/3) 67%
Neurology (1/2) 50%
Infectious Diseases (1/1) 100%
Reproductive Medicine (1/6) 17%
Dermatology (2/3) 67%
Endocrinology/Metabolic Disease (1/1) 100%
Respiratory Medicine (2/2) 100%
Immunology/Allergy (0/1) 0%
Passmed