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  • Question 1 - A 55-year-old woman presents following a fall. She reports pain and weakness in...

    Incorrect

    • A 55-year-old woman presents following a fall. She reports pain and weakness in her hands for several months, stiff legs and slurred speech and has bilateral wasting of the small muscles of her hands. Reflexes in the upper limbs are absent. Tongue atrophy and fasciculations are present and both legs show increased tone, pyramidal weakness and hyper-reflexia with extensor plantars. Pain and temperature sensation is impaired in the upper limbs.
      Which of the following is the most likely diagnosis?

      Your Answer: Syringomyelia

      Correct Answer: Syringobulbia

      Explanation:

      The patient is showing signs of a spinal cord lesion, with LMN signs in the arms and UMN signs in the legs. There is also a loss of thermal and pain sensation, indicating involvement of the spinothalamic tracts but not the posterior columns. This is typical of a syrinx, which is a fluid-filled hole in the spinal cord. The patient is experiencing dysesthetic pain in the hands, which is a common symptom of syringomyelia/syringobulbia. The presence of twelfth nerve atrophy and slurred speech indicates that the lesion extends into the brainstem, ruling out syringomyelia. Cervical spondylosis can produce similar symptoms, but there should also be neck pain. Motor neurone disease is unlikely due to the sensory involvement, and multiple sclerosis is not a likely explanation given the other clinical features.

    • This question is part of the following fields:

      • Neurology
      135.3
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  • Question 2 - A 3-year-old male presents with fever, nausea, and painful urination at the clinic....

    Correct

    • A 3-year-old male presents with fever, nausea, and painful urination at the clinic. What is the best method to collect a urine sample?

      Your Answer: Clean-catch urine

      Explanation:

      The advice given in the NICE guidelines regarding urine collection has been criticised for being impractical.

      Urinary Tract Infection in Children: Symptoms, Diagnosis, and Treatment

      Urinary tract infections (UTIs) are more common in boys until 3 months of age, after which the incidence is substantially higher in girls. At least 8% of girls and 2% of boys will have a UTI in childhood. The presentation of UTIs in childhood depends on age. Infants may experience poor feeding, vomiting, and irritability, while younger children may have abdominal pain, fever, and dysuria. Older children may experience dysuria, frequency, and haematuria. Features that may suggest an upper UTI include a temperature of over 38ºC and loin pain or tenderness.

      According to NICE guidelines, a urine sample should be checked in a child if there are any symptoms or signs suggestive of a UTI, with unexplained fever of 38°C or higher (test urine after 24 hours at the latest), or with an alternative site of infection but who remain unwell (consider urine test after 24 hours at the latest). A clean catch is the preferable method for urine collection. If not possible, urine collection pads should be used. Invasive methods such as suprapubic aspiration should only be used if non-invasive methods are not possible.

      Infants less than 3 months old should be referred immediately to a paediatrician. Children aged more than 3 months old with an upper UTI should be considered for admission to the hospital. If not admitted, oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days. Children aged more than 3 months old with a lower UTI should be treated with oral antibiotics for 3 days according to local guidelines, usually trimethoprim, nitrofurantoin, cephalosporin, or amoxicillin. Parents should be asked to bring the children back if they remain unwell after 24-48 hours. Antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs.

    • This question is part of the following fields:

      • Children And Young People
      50.4
      Seconds
  • Question 3 - You come across a 30-year-old accountant who has been diagnosed with Crohn's disease...

    Incorrect

    • You come across a 30-year-old accountant who has been diagnosed with Crohn's disease after experiencing abdominal pain, loose stools and a microcytic anaemia. The individual is seeking further information on the condition.

      Which of the following statements is accurate regarding Crohn's disease?

      Your Answer: Smoking is not a risk factor for Crohn's disease

      Correct Answer: Osteoporosis occurs in up to 30% of patients with inflammatory bowel disease

      Explanation:

      Upon diagnosis, approximately 66% of individuals with inflammatory bowel disease exhibit anaemia. Crohn’s disease is typically diagnosed at a median age of 30 years. The global incidence and prevalence of Crohn’s disease are on the rise.

      Osteoporosis is a condition that is more prevalent in women and increases with age. However, there are many other risk factors and secondary causes of osteoporosis. Some of the most significant risk factors include a history of glucocorticoid use, rheumatoid arthritis, alcohol excess, parental hip fracture history, low body mass index, and current smoking. Other risk factors include a sedentary lifestyle, premature menopause, certain ethnicities, endocrine disorders, gastrointestinal disorders, chronic kidney disease, and certain genetic disorders. Additionally, certain medications such as SSRIs, antiepileptics, and proton pump inhibitors may worsen osteoporosis.

      If a patient is diagnosed with osteoporosis or has a fragility fracture, further investigations may be necessary to identify the cause of osteoporosis and assess the risk of subsequent fractures. Recommended investigations include a history and physical examination, blood tests such as a full blood count, urea and electrolytes, liver function tests, bone profile, CRP, and thyroid function tests. Other procedures may include bone densitometry, lateral radiographs, protein immunoelectrophoresis, and urinary Bence-Jones proteins. Additionally, markers of bone turnover and urinary calcium excretion may be assessed. By identifying the cause of osteoporosis and contributory factors, healthcare providers can select the most appropriate form of treatment.

    • This question is part of the following fields:

      • Gastroenterology
      175.2
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  • Question 4 - What type of prescribing error is the most frequently occurring? ...

    Incorrect

    • What type of prescribing error is the most frequently occurring?

      Your Answer: Interaction with another medication

      Correct Answer: Incomplete information on the prescription

      Explanation:

      GMC Study Reveals High Rate of Prescription Errors

      A recent study conducted by the General Medical Council (GMC) has found that almost 5% of the 6,000 prescriptions assessed had some form of prescribing or monitoring error. The most common error identified was incomplete information on the prescription, accounting for a third of all errors.

      This study highlights the importance of accurate and complete information when prescribing medication. Such errors can have serious consequences for patients, including adverse reactions and ineffective treatment. It is crucial that healthcare professionals take the time to ensure that all necessary information is included on prescriptions and that they are monitored appropriately. By doing so, they can help to reduce the risk of errors and improve patient safety.

    • This question is part of the following fields:

      • Improving Quality, Safety And Prescribing
      103
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  • Question 5 - An 88-year-old female patient of yours has multiple medical problems.

    She takes aspirin, paracetamol,...

    Incorrect

    • An 88-year-old female patient of yours has multiple medical problems.

      She takes aspirin, paracetamol, bisoprolol, ramipril, codeine, omeprazole and nifedipine. She says she tries to remember to take her tablets but she doesn't attend for repeat prescriptions as often as she should. When compliant, she is stable and well.

      Which one of the following regarding this lady's treatment is correct?

      Your Answer:

      Correct Answer: You should give 'once daily' regimens where possible

      Explanation:

      Factors to Consider in Drug Treatments for MRCGP Exam

      For the MRCGP exam, it is important to have a good understanding of the factors associated with drug treatments. This includes knowledge of drug metabolism, absorption, and excretion. Candidates should also be aware of multiple prescribing, non-compliance by patients, and iatrogenic disease.

      In this scenario, it is important to consider the patient’s medication regimen and the possibility of non-compliance. While it may be premature to talk about stopping medications, it is recommended to give ‘once daily’ regimens where possible. Admitting the patient to residential care solely for medication compliance is extreme and likely unnecessary.

      To further enhance knowledge on medication compliance, the BMJ offers evidence and tips on the use of medication compliance aids. Additionally, the ABC of monitoring drug therapy provides a comprehensive guide on patient compliance.

    • This question is part of the following fields:

      • Older Adults
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  • Question 6 - A 54-year-old woman with Rheumatoid arthritis complains of dysuria, frequency, and foul-smelling urine...

    Incorrect

    • A 54-year-old woman with Rheumatoid arthritis complains of dysuria, frequency, and foul-smelling urine for the past 3 days. Upon urinalysis, blood, nitrites, leukocytes, and protein are detected. Upon checking her repeat prescription, it is found that she is taking methotrexate for her Rheumatoid disease. She has no allergies. Which antibiotic should not be prescribed due to the potential for severe bone marrow suppression?

      Your Answer:

      Correct Answer: Trimethoprim

      Explanation:

      The combination of methotrexate and antibiotics containing trimethoprim can lead to bone marrow suppression and potentially fatal pancytopenia. Therefore, it is important to avoid using trimethoprim and co-trimoxazole with methotrexate due to their anti-folate properties, which can cause folate depletion. Fatal cases of megaloblastic anemia and pancytopenia have been reported. Nitrofurantoin and cefalexin do not have any known interactions with methotrexate, and penicillins may reduce its excretion.

      Methotrexate is an antimetabolite that hinders the activity of dihydrofolate reductase, an enzyme that is crucial for the synthesis of purines and pyrimidines. It is a significant drug that can effectively control diseases, but its side-effects can be life-threatening. Therefore, careful prescribing and close monitoring are essential. Methotrexate is commonly used to treat inflammatory arthritis, especially rheumatoid arthritis, psoriasis, and acute lymphoblastic leukaemia. However, it can cause adverse effects such as mucositis, myelosuppression, pneumonitis, pulmonary fibrosis, and liver fibrosis.

      Women should avoid pregnancy for at least six months after stopping methotrexate treatment, and men using methotrexate should use effective contraception for at least six months after treatment. Prescribing methotrexate requires familiarity with guidelines relating to its use. It is taken weekly, and FBC, U&E, and LFTs need to be regularly monitored. Folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose. The starting dose of methotrexate is 7.5 mg weekly, and only one strength of methotrexate tablet should be prescribed.

      It is important to avoid prescribing trimethoprim or co-trimoxazole concurrently as it increases the risk of marrow aplasia. High-dose aspirin also increases the risk of methotrexate toxicity due to reduced excretion. In case of methotrexate toxicity, the treatment of choice is folinic acid. Overall, methotrexate is a potent drug that requires careful prescribing and monitoring to ensure its effectiveness and safety.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 7 - A Jewish family brings their 6-month-old son to their GP to discuss circumcision...

    Incorrect

    • A Jewish family brings their 6-month-old son to their GP to discuss circumcision and whether there are any medical reasons why it should not be performed for religious purposes. What congenital conditions would be considered a contraindication for circumcision in this case?

      Your Answer:

      Correct Answer: Hypospadias

      Explanation:

      Hypospadias is the only condition that would prevent circumcision in infancy as the foreskin is necessary for the repair process. This means that if a child with hypospadias were to undergo circumcision for religious reasons, it would complicate the repair process as grafting from another part of the body would be required. On the other hand, balanitis xerotica obliterans and phimosis are common reasons for medical circumcision in children in the UK. A horseshoe kidney and an imperforate anus would not affect circumcision for religious reasons and would not be a contraindication.

      Understanding Circumcision

      Circumcision is a practice that has been carried out in various cultures for centuries. Today, it is mainly practiced by people of the Jewish and Islamic faith for religious or cultural reasons. However, it is important to note that circumcision for these reasons is not available on the NHS.

      The medical benefits of circumcision are still a topic of debate. However, some studies have shown that it can reduce the risk of penile cancer, urinary tract infections, and sexually transmitted infections, including HIV.

      There are also medical indications for circumcision, such as phimosis, recurrent balanitis, balanitis xerotica obliterans, and paraphimosis. It is crucial to rule out hypospadias before performing circumcision as the foreskin may be needed for surgical repair.

      Circumcision can be performed under local or general anesthesia. It is a personal decision that should be made after careful consideration of the potential benefits and risks.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 8 - According to the UK immunisation schedule, at what age would you administer the...

    Incorrect

    • According to the UK immunisation schedule, at what age would you administer the pneumococcal polysaccharide (PPV) vaccine to an otherwise healthy individual?

      Your Answer:

      Correct Answer: 65 years of age

      Explanation:

      Understanding the Pneumococcal Vaccine

      The pneumococcal vaccine is an important immunization that helps protect against pneumococcal disease, which can cause serious illnesses such as pneumonia, meningitis, and blood infections. However, it’s important to note that there are two types of pneumococcal vaccines – the pneumococcal conjugate vaccine (PCV) and the pneumococcal polysaccharide vaccine (PPV).

      The PCV vaccine is given to children under the age of 2, with the first dose administered at 12 weeks old and a booster at 1 year. On the other hand, the PPV vaccine is given to individuals over the age of 2, with otherwise healthy individuals receiving it at 65 years of age. It’s important to know which vaccine to administer as the immune response to each vaccine is different.

      In addition to the recommended age groups, individuals with certain medical conditions such as chronic respiratory or heart disease, diabetes, and immunosuppression are also eligible for the pneumococcal vaccine. Surgeries will carry both vaccines in stock, so it’s crucial to be aware of the appropriate vaccine to administer based on age and medical history. By understanding the pneumococcal vaccine and its administration, we can help protect ourselves and others from serious illnesses.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 9 - Which one of the following statements regarding the management of elderly, non-sensitised Rhesus...

    Incorrect

    • Which one of the following statements regarding the management of elderly, non-sensitised Rhesus negative women is inaccurate?

      Your Answer:

      Correct Answer: External cephalic version doesn't require prophylaxis

      Explanation:

      Rhesus negative mothers can develop anti-D IgG antibodies if they deliver a Rh +ve child, which can cause haemolysis in future pregnancies. Prevention involves testing for D antibodies and giving anti-D prophylaxis at 28 and 34 weeks. Anti-D should also be given in various situations, such as delivery of a Rh +ve infant or amniocentesis. Tests include cord blood FBC, blood group, direct Coombs test, and Kleihauer test. Affected fetuses may experience oedema, jaundice, anaemia, hepatosplenomegaly, heart failure, and kernicterus, and may require transfusions and UV phototherapy.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
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  • Question 10 - A 5-year-old girl is brought to the clinic with a cough, conjunctivitis and...

    Incorrect

    • A 5-year-old girl is brought to the clinic with a cough, conjunctivitis and coryza. She developed a confluent maculopapular rash starting in the head and neck area and spreading elsewhere on the body within a few days. Subsequent testing has confirmed measles. Her mother has reached out to you because she seems to be more unwell and you schedule an appointment for her evaluation.

      What is the most frequent complication that occurs after a measles infection?

      Your Answer:

      Correct Answer: Acute demyelinating encephalitis

      Explanation:

      Complications of Measles

      It is crucial to understand that measles can lead to various complications. While it is essential to be aware of the rare and severe complications, it is also important to keep in mind the common ones. Pneumonia occurs in 1-6% of cases, while otitis media affects 7-9% of cases. Diarrhoea is another common complication, occurring in approximately 8% of cases, and convulsions may occur in 1 in every 200 cases. Although rare, encephalitis (1 per 1000 cases) and subacute sclerosing panencephalitis are also possible complications. It is worth noting that pancreatitis is more commonly associated with mumps infection.

      After advising parents to treat their children symptomatically with fluids, rest, and paracetamol, it is crucial to remain vigilant for any symptoms and signs of complications. While death in the UK occurs in around 1 in every 5000 cases, it is still important to take necessary precautions and seek medical attention if any complications arise.

    • This question is part of the following fields:

      • Infectious Disease And Travel Health
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  • Question 11 - You are conducting a review of your repeat prescribing system due to a...

    Incorrect

    • You are conducting a review of your repeat prescribing system due to a recent complaint following a prescribing error involving a pediatric patient.
      What are the recommended best practices for repeat prescribing in order to reduce the occurrence of prescribing or monitoring errors in pediatric patients?

      Your Answer:

      Correct Answer: Request repeat prescriptions from any staff member by telephone

      Explanation:

      Practice-wide Defences Against Prescribing Errors

      A study conducted by GMC has identified several practice-wide defences against prescribing errors. These defences include strongly discouraging verbal repeat requests, performing face to face medication reviews, having blood tests one week before scheduled reviews, and updating records within 48 hours with hospital correspondence.

      To prevent prescribing errors, it is important to discourage verbal repeat requests as they can lead to confusion and mistakes. Face to face medication reviews can also help identify any potential errors and ensure that the patient is receiving the correct medication. Having blood tests one week before scheduled reviews can help monitor the patient’s health and ensure that the medication is working effectively. Finally, updating records within 48 hours with hospital correspondence can help ensure that all healthcare providers are aware of any changes in the patient’s medication or health status.

      By implementing these practice-wide defences, healthcare providers can help prevent prescribing errors and ensure that patients receive safe and effective care.

    • This question is part of the following fields:

      • Improving Quality, Safety And Prescribing
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  • Question 12 - A 28-year-old woman in her first pregnancy visits you at 30 weeks gestation...

    Incorrect

    • A 28-year-old woman in her first pregnancy visits you at 30 weeks gestation complaining of itchiness. Upon examination, there is no rash present. After being referred to an obstetrician, she is diagnosed with intrahepatic cholestasis of pregnancy and prescribed ursodeoxycholic acid. During her visit, the patient mentions that her obstetrician mentioned something about her labor, but she is unsure.

      What plans need to be made for this patient's labor?

      Your Answer:

      Correct Answer: Induction of labour at 37-38 weeks gestation

      Explanation:

      Due to the increased risk of stillbirth associated with intrahepatic cholestasis of pregnancy, induction of labour is typically recommended at 37-38 weeks gestation. Therefore, a normal labour is not appropriate for this patient. Ursodeoxycholic acid is used to treat the intense pruritus associated with this condition. While a caesarean section may be necessary on an emergency basis, it is not currently indicated at 37-38 weeks. Similarly, a caesarean section at 40 weeks is not currently necessary. Induction of labour at 40 weeks is later than the recommended timeline and may increase the risk of stillbirth.

      Understanding Intrahepatic Cholestasis of Pregnancy

      Intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis, is a condition that affects approximately 1% of pregnancies in the UK. It is characterized by intense itching, particularly on the palms, soles, and abdomen, and may also result in clinically detectable jaundice in around 20% of patients. Raised bilirubin levels are seen in over 90% of cases.

      The management of intrahepatic cholestasis of pregnancy typically involves induction of labor at 37-38 weeks, although this practice may not be evidence-based. Ursodeoxycholic acid is also widely used, although the evidence base for its effectiveness is not clear. Additionally, vitamin K supplementation may be recommended.

      It is important to note that the recurrence rate of intrahepatic cholestasis of pregnancy in subsequent pregnancies is high, ranging from 45-90%. Therefore, early diagnosis and management of this condition is crucial for the health and well-being of both the mother and the baby.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
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  • Question 13 - A 7-year-old boy is brought to the clinic by his father. He has...

    Incorrect

    • A 7-year-old boy is brought to the clinic by his father. He has a history of asthma and is prescribed salbutamol 100 mcg prn and Clenil (beclomethasone dipropionate) 100 mcg bd via a spacer. Despite the steroid inhaler, he is having to use salbutamol on a daily basis, especially in the morning or after physical activity. Today, his chest examination is normal.

      What would be the most suitable course of action for further management?

      Your Answer:

      Correct Answer: Add a leukotriene receptor antagonist

      Explanation:

      For children between the ages of 5 and 16 who have asthma that is not being controlled by a combination of a short-acting beta agonist (SABA) and a low-dose inhaled corticosteroid (ICS), it is recommended to add a leukotriene receptor antagonist to their asthma management plan.

      Managing Asthma in Children: NICE Guidelines

      The National Institute for Health and Care Excellence (NICE) released guidelines in 2017 for the management of asthma in children aged 5-16. These guidelines follow a stepwise approach, with treatment options based on the severity of the child’s symptoms. For newly-diagnosed asthma, short-acting beta agonists (SABA) are recommended. If symptoms persist or worsen, a combination of SABA and paediatric low-dose inhaled corticosteroids (ICS) may be used. Leukotriene receptor antagonists (LTRA) and long-acting beta agonists (LABA) may also be added to the treatment plan.

      For children under 5 years old, clinical judgement plays a greater role in diagnosis and treatment. The stepwise approach for this age group includes an 8-week trial of paediatric moderate-dose ICS for newly-diagnosed asthma or uncontrolled symptoms. If symptoms persist, a combination of SABA and paediatric low-dose ICS with LTRA may be used. If symptoms still persist, referral to a paediatric asthma specialist is recommended.

      It is important to note that NICE doesn’t recommend changing treatment for patients with well-controlled asthma simply to adhere to the latest guidelines. Additionally, maintenance and reliever therapy (MART) may be used for combined ICS and LABA treatment, but only for LABAs with a fast-acting component. The definitions for low, moderate, and high-dose ICS have also changed, with different definitions for children and adults.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 14 - You are discussing with your supervisor the management of patients who present with...

    Incorrect

    • You are discussing with your supervisor the management of patients who present with urological symptoms in elderly women.
      Which of the following presentations of urinary symptoms in elderly women requires urgent referral?

      Your Answer:

      Correct Answer: A 44-year-old patient with urinary incontinence symptoms and feeling of a 'lump down below'

      Explanation:

      Urgent Referral for Painless Visible Haematuria

      Painless macroscopic haematuria, or visible blood in the urine, is a concerning symptom that should be urgently referred for suspicion of bladder or renal cancer. However, it is important to note that if the patient also experiences pain or symptoms of a urinary tract infection, these should be assessed and managed separately.

      Prompt referral for painless visible haematuria is crucial in order to ensure timely diagnosis and treatment of potential cancer. Patients should be advised to seek medical attention immediately if they notice blood in their urine, even if they do not experience any pain or other symptoms. Healthcare providers should also be vigilant in identifying and referring these cases for further evaluation.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 15 - A 14-year-old male from France comes to the clinic complaining of feeling sick...

    Incorrect

    • A 14-year-old male from France comes to the clinic complaining of feeling sick for the past 2 weeks. At first, he had a sore throat but now he is having occasional joint pains in his knees, hips, and ankles. During the examination, some pink, ring-shaped lesions are observed on his trunk, and he occasionally experiences jerking movements of his face and hands. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Rheumatic fever

      Explanation:

      Rheumatic fever is a condition that occurs as a result of an immune response to a recent Streptococcus pyogenes infection, typically occurring 2-4 weeks after the initial infection. The pathogenesis of rheumatic fever involves the activation of the innate immune system, leading to antigen presentation to T cells. B and T cells then produce IgG and IgM antibodies, and CD4+ T cells are activated. This immune response is thought to be cross-reactive, mediated by molecular mimicry, where antibodies against M protein cross-react with myosin and the smooth muscle of arteries. This response leads to the clinical features of rheumatic fever, including Aschoff bodies, which are granulomatous nodules found in rheumatic heart fever.

      To diagnose rheumatic fever, evidence of recent streptococcal infection must be present, along with 2 major criteria or 1 major criterion and 2 minor criteria. Major criteria include erythema marginatum, Sydenham’s chorea, polyarthritis, carditis and valvulitis, and subcutaneous nodules. Minor criteria include raised ESR or CRP, pyrexia, arthralgia, and prolonged PR interval.

      Management of rheumatic fever involves antibiotics, typically oral penicillin V, as well as anti-inflammatories such as NSAIDs as first-line treatment. Any complications that develop, such as heart failure, should also be treated. It is important to diagnose and treat rheumatic fever promptly to prevent long-term complications such as rheumatic heart disease.

    • This question is part of the following fields:

      • Infectious Disease And Travel Health
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  • Question 16 - A 30-year-old man comes to his General Practitioner complaining of a suddenly swollen...

    Incorrect

    • A 30-year-old man comes to his General Practitioner complaining of a suddenly swollen and painful right knee, along with red, gritty eyes and difficulty urinating. He has recently returned from a trip to Southeast Asia, where he experienced several days of vomiting and diarrhea. During joint aspiration, giant macrophages are found, but no organisms are visible on gram staining. What is the most probable diagnosis? Choose only ONE answer.

      Your Answer:

      Correct Answer: Reactive arthritis

      Explanation:

      Differential Diagnosis for a Patient with Arthritis, Conjunctivitis, and nonspecific Urethritis

      The patient presents with a classic triad of reactive arthritis, including arthritis, conjunctivitis, and nonspecific urethritis. This condition is often associated with human leukocyte antigen B27 and typically occurs after bacterial dysentery caused by Salmonella, Shigella, Campylobacter, or Yersinia spp. or sexually acquired infection with Chlamydia spp. Joint aspiration may reveal the presence of giant macrophages.

      Other potential diagnoses include Behçet’s disease, which typically presents with recurrent oral and genital ulcers and uveitis, but is less likely in this case as there is no ulceration described. Sjögren syndrome, which produces dry eyes, dry mouth, and parotid enlargement, is also less likely as these symptoms are not present. Gonococcal arthritis, which can occur in sexually active patients, may present with a swollen knee, but the ocular and urinary tract symptoms are more consistent with reactive arthritis. Septic arthritis, which presents as a red, hot, swollen joint, is also a possibility, but joint aspiration would likely reveal the presence of Staphylococcus aureus.

    • This question is part of the following fields:

      • Musculoskeletal Health
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  • Question 17 - Which one of the following conditions is NOT an autosomal recessive condition? ...

    Incorrect

    • Which one of the following conditions is NOT an autosomal recessive condition?

      Your Answer:

      Correct Answer: Hereditary spherocytosis

      Explanation:

      Exceptions aside, metabolic conditions are typically inherited in an autosomal recessive manner, while structural conditions are usually inherited in an autosomal dominant manner. However, it should be noted that hereditary spherocytosis is an example of a condition that is inherited in an autosomal dominant fashion.

      Autosomal recessive conditions are often referred to as metabolic conditions, while autosomal dominant conditions are considered structural. However, there are notable exceptions to this rule. For example, some metabolic conditions like Hunter’s and G6PD are X-linked recessive, while some structural conditions like ataxia telangiectasia and Friedreich’s ataxia are autosomal recessive.

      Autosomal recessive conditions occur when an individual inherits two copies of a mutated gene, one from each parent. Some examples of autosomal recessive conditions include albinism, cystic fibrosis, sickle cell anemia, and Wilson’s disease. These conditions can affect various systems in the body, including metabolism, blood, and the nervous system. It is important to note that some conditions, such as Gilbert’s syndrome, are still a matter of debate and may be listed as autosomal dominant in some textbooks.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 18 - Which one of the following entries on a birth certificate would never be...

    Incorrect

    • Which one of the following entries on a birth certificate would never be acceptable?

      Your Answer:

      Correct Answer: 1a: Cardiac arrest. 2: Non-insulin dependent diabetes mellitus

      Explanation:

      Cardiac arrest cannot be listed as the sole cause of death on a death certificate as it is a method of dying and requires further clarification.

      While the use of old age is discouraged, it may be listed on a death certificate for patients over the age of 80 if specific criteria are met (refer to the provided link).

      The only acceptable abbreviations for HIV and AIDS should be used on a death certificate.

      Death Certification in the UK

      There are no legal definitions of death in the UK, but guidelines exist to verify it. According to the current guidance, a doctor or other qualified personnel should verify death, and nurse practitioners may verify but not certify it. After a patient has died, a doctor needs to complete a medical certificate of cause of death (MCCD). However, there is a list of circumstances in which a doctor should notify the Coroner before completing the MCCD.

      When completing the MCCD, it is important to note that old age as 1a is only acceptable if the patient was at least 80 years old. Natural causes is not acceptable, and organ failure can only be used if the disease or condition that led to the organ failure is specified. Abbreviations should be avoided, except for HIV and AIDS.

      Once the MCCD is completed, the family takes it to the local Registrar of Births, Deaths, and Marriages office to register the death. If the Registrar decides that the death doesn’t need reporting to the Coroner, he/she will issue a certificate for Burial or Cremation and a certificate of Registration of Death for Social Security purposes. Copies of the Death Register are also available upon request, which banks and insurance companies expect to see. If the family wants the burial to be outside of England, an Out of England Order is needed from the coroner.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
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  • Question 19 - You are assessing a 70-year old man with a history of heart failure....

    Incorrect

    • You are assessing a 70-year old man with a history of heart failure. He is still exhibiting signs of fluid overload, prompting you to raise his furosemide dosage from 20 mg to 40 mg. What additional monitoring should be recommended?

      Your Answer:

      Correct Answer: Renal function, serum electrolytes and blood pressure within 1-2 weeks

      Explanation:

      Monitoring Recommendations for Loop Diuretics

      To ensure the safe and effective use of loop diuretics, the National Institute for Health and Care Excellence (NICE) recommends monitoring renal function, serum electrolytes, and blood pressure within 1-2 weeks after each dose increase. It is also important to check these parameters before starting treatment and after treatment initiation.

      For patients with known chronic kidney disease (CKD), those aged 60 years or older, or those taking an ACE-I, ARB, or aldosterone antagonist, earlier monitoring (5-7 days) may be necessary. By closely monitoring these parameters, healthcare professionals can identify any potential adverse effects and adjust treatment accordingly to optimize patient outcomes.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 20 - A 50-year-old woman with a known history of depression, previously well controlled with...

    Incorrect

    • A 50-year-old woman with a known history of depression, previously well controlled with fluoxetine, has started to suffer from anxiety, loss of interest and reduced appetite. She also complains of insomnia.

      She claims that she is taking her medications regularly according to prescription. You conclude that her depression has not responded to treatment.

      What will be the most appropriate management for her?

      Your Answer:

      Correct Answer: Switch to another SSRI

      Explanation:

      Treatment for Non-Responsive Depression

      When a patient fails to respond to fluoxetine, which is a selective serotonin reuptake inhibitor (SSRI), it is recommended to switch to another SSRI first. If this doesn’t work, the NICE update on depression (2010) suggests trying a newer generation antidepressant that is better tolerated. It is important to find the right medication for each individual patient, as depression can have a significant impact on their quality of life. Therefore, healthcare professionals should closely monitor patients and adjust their treatment plan accordingly.

    • This question is part of the following fields:

      • Mental Health
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  • Question 21 - Samantha is a 58-year-old woman who comes to see you with her husband...

    Incorrect

    • Samantha is a 58-year-old woman who comes to see you with her husband John.

      John has noticed that Samantha's left hand shakes, particularly when she is relaxed. This has been gradually worsening over the past few months and he has also noticed that she appears to be less steady when she is walking. On further questioning, you find that Samantha is also having trouble with her sleep.

      On examination, Samantha has a resting tremor of her left hand and cogwheel rigidity is present. Her gait demonstrates a reduced arm swing and is slow.

      What is the next best management step?

      Your Answer:

      Correct Answer: Refer Michael urgently to a specialist with expertise in movement disorders

      Explanation:

      According to the NICE guidelines, only a specialist with expertise in movement disorders, such as a neurologist or elderly care physician, should diagnose Parkinson’s disease and initiate management. Therefore, further investigations such as an MRI or PET scan should not be carried out in primary care, as this will be decided upon by the specialist. Treatment should also not be initiated in primary care, including the use of levodopa or a dopamine agonist. However, if Parkinson’s disease is suspected but the person is taking a drug known to induce parkinsonism, it may be appropriate to reduce or stop the drug in primary care. It is important to refer all people with suspected Parkinson’s disease urgently and untreated to a specialist for confirmation of the diagnosis and exclusion of alternative diagnoses, without delaying assessment of the response.

      Understanding the Mechanism of Action of Parkinson’s Drugs

      Parkinson’s disease is a complex condition that requires specialized management. The first-line treatment for motor symptoms that affect a patient’s quality of life is levodopa, while dopamine agonists, levodopa, or monoamine oxidase B (MAO-B) inhibitors are recommended for those whose motor symptoms do not affect their quality of life. However, all drugs used to treat Parkinson’s can cause a wide variety of side effects, and it is important to be aware of these when making treatment decisions.

      Levodopa is nearly always combined with a decarboxylase inhibitor to prevent the peripheral metabolism of levodopa to dopamine outside of the brain and reduce side effects. Dopamine receptor agonists, such as bromocriptine, ropinirole, cabergoline, and apomorphine, are more likely than levodopa to cause hallucinations in older patients. MAO-B inhibitors, such as selegiline, inhibit the breakdown of dopamine secreted by the dopaminergic neurons. Amantadine’s mechanism is not fully understood, but it probably increases dopamine release and inhibits its uptake at dopaminergic synapses. COMT inhibitors, such as entacapone and tolcapone, are used in conjunction with levodopa in patients with established PD. Antimuscarinics, such as procyclidine, benzotropine, and trihexyphenidyl (benzhexol), block cholinergic receptors and are now used more to treat drug-induced parkinsonism rather than idiopathic Parkinson’s disease.

      It is important to note that all drugs used to treat Parkinson’s can cause adverse effects, and clinicians must be aware of these when making treatment decisions. Patients should also be warned about the potential for dopamine receptor agonists to cause impulse control disorders and excessive daytime somnolence. Understanding the mechanism of action of Parkinson’s drugs is crucial in managing the condition effectively.

    • This question is part of the following fields:

      • Neurology
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  • Question 22 - A 35-year-old man presents with a three month history of wheezing and dyspnoea...

    Incorrect

    • A 35-year-old man presents with a three month history of wheezing and dyspnoea whilst at work. His symptoms improve significantly when at home and at weekends.

      What is the probable cause of his symptoms?

      Your Answer:

      Correct Answer: Simple coal worker's lung

      Explanation:

      Occupational Asthma and Common Causative Substances

      Occupational asthma is a common respiratory condition that affects individuals who are exposed to certain substances in their workplace. The most likely causative substance is isocyanate, which is commonly used in the manufacture of foams and plastics. Other substances that are commonly implicated in occupational asthma include flour/grain, adhesives, metals, resins, colophony, fluxes, latex, animals, aldehydes, and wood dust. Although cotton dust can also be associated with occupational asthma, it is less recognized than isocyanates.

      Each year, there are an estimated 1500 to 3000 cases of occupational asthma reported. Symptoms of occupational asthma typically include coughing, wheezing, chest tightness, and shortness of breath. It is important for individuals who work in industries where these substances are present to be aware of the potential risks and to take appropriate precautions to protect their respiratory health.

      It is important to note that asbestos exposure is associated with a range of respiratory conditions, including pleural plaques, pleural thickening, pleural effusions, interstitial lung disease, mesothelioma, and lung carcinoma, but not occupational asthma. Silica exposure, which is found in coal dust, can result in pulmonary fibrosis. Simple coal worker’s disease is a nodular interstitial lung disease that is also associated with coal dust exposure.

    • This question is part of the following fields:

      • Respiratory Health
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  • Question 23 - A 68-year-old man has inoperable small-cell lung cancer but has been reasonably well....

    Incorrect

    • A 68-year-old man has inoperable small-cell lung cancer but has been reasonably well. He has a forthcoming hospital appointment. He reports no significant symptoms other than his long-standing persistent cough. His General Practitioner (GP) requests some blood tests as per his consultant’s last letter.
      Which of the following results would raise the most concern in this patient?

      Your Answer:

      Correct Answer: Calcium 3.14 mmol/l (normal range 2.20–2.60 mmol/l)

      Explanation:

      Interpreting Blood Test Results in Palliative Care Patients

      When interpreting blood test results in palliative care patients, it is important to consider the context and urgency of each abnormal result. In this case, the serum calcium level is the most concerning, as it is significantly elevated and could indicate symptomatic hypercalcaemia. Immediate admission to a hospital or hospice is recommended, along with intravenous fluid replacement and bisphosphonate treatment. The alkaline phosphatase level is also elevated, but further investigation is needed to determine the source. The slightly low potassium level can be monitored with routine testing, while the slight hyponatraemia may be normal for the patient or repeated non-urgently. A slightly elevated urea level may indicate mild dehydration or renal impairment, but is not significant enough to require emergency treatment. Overall, careful consideration of each abnormal result is necessary in order to provide appropriate care for palliative care patients.

    • This question is part of the following fields:

      • End Of Life
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  • Question 24 - A 25-year-old man presents with an obvious broken nose and an inability to...

    Incorrect

    • A 25-year-old man presents with an obvious broken nose and an inability to breathe through either nostril. Examination reveals a cherry-red swelling in both nasal airways.
      What is the best course of action for management?

      Your Answer:

      Correct Answer: Review immediately for examination under anaesthetic

      Explanation:

      This patient has a condition called septal hematoma, which can lead to a hole in the septum if not treated promptly. This happens because the hematoma restricts blood flow to the cartilage and can become infected. To diagnose this condition, a doctor will use a nasal speculum or otoscope to look for asymmetry and swelling in the septum. They may also need to feel the septum with a gloved finger. Septal hematoma is usually caused by significant facial trauma in adults, but even minor nasal trauma can cause it in children. If a child has this condition, it may be a sign of abuse. Immediate drainage under anesthesia is necessary to prevent long-term damage.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 25 - A 72-year-old man had cataract surgery seven months ago. Initially, this seemed very...

    Incorrect

    • A 72-year-old man had cataract surgery seven months ago. Initially, this seemed very successful but he has recently become aware of blurring of his vision and glare when driving at night. He wonders if his cataracts have grown back. Examination of his eye reveals no abnormality of the pupils or fundus.
      What is the single most likely diagnosis?

      Your Answer:

      Correct Answer: Posterior capsular opacification

      Explanation:

      Visual Disturbances: Possible Causes and Treatments

      Visual disturbances can be caused by various conditions, and it is important to identify the underlying cause to provide appropriate treatment. One possible cause is posterior capsular opacification, which can occur after cataract surgery. This condition is characterized by visual disturbance and is caused by the thickening of the lens capsule where the artificial lens is placed. It can be treated with outpatient laser treatment using a YAG laser to create a clear area for light to enter the eye.

      Migraine can also cause visual disturbances, which are characterized by an area that is not well seen, surrounded by shimmering zig-zag lines that gradually enlarge and then break up over a period of 15-30 minutes.

      Acute angle-closure glaucoma causes rapid onset loss of vision and eye pain, which is not present in this patient. Chronic glaucoma, on the other hand, causes gradual loss of vision usually spreading from the periphery, which is also unlikely in this patient.

      Lastly, recurrence of cataract is not possible after cataract surgery since the natural lens, which causes the opacification, is removed and replaced with an artificial lens that doesn’t form cataracts.

    • This question is part of the following fields:

      • Eyes And Vision
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  • Question 26 - A 32-year-old man presents to his General Practitioner with concerns about his fertility....

    Incorrect

    • A 32-year-old man presents to his General Practitioner with concerns about his fertility. He and his partner have been trying to conceive for the past two years without success. He also reports that he has noticed his testicles appear to be shrinking. He is typically healthy, doesn't smoke or drink alcohol, exercises regularly, and is not taking any medications.
      During the examination, the patient is noted to have a muscular build, a BMI of 31 kg/m2 (normal range: 18–25 kg/m2), facial acne, and gynaecomastia.
      What is the most probable cause of his symptoms? Choose ONE answer.

      Your Answer:

      Correct Answer: Anabolic steroid use

      Explanation:

      Differential diagnosis of male infertility and related symptoms

      Anabolic steroid use, unexplained infertility, Cushing’s disease, Klinefelter syndrome, and obesity are among the possible causes of male infertility and related symptoms. Anabolic steroid use can lead to a range of unwanted effects, including acne, gynaecomastia, testicular shrinkage, and altered mood, as well as physical and psychological dependence. Unexplained infertility affects a significant proportion of infertile men and couples, but additional symptoms such as gynaecomastia and acne may suggest anabolic steroid use. Cushing’s disease, caused by a pituitary adenoma, can produce a distinct pattern of symptoms, including truncal obesity, muscle weakness, gonadal dysfunction, and impaired immune function, but in a young and muscular gym-goer, anabolic steroid use is more likely. Klinefelter syndrome, a genetic disorder affecting 1 in 660 men, can cause small testes, hypogonadism, infertility, gynaecomastia, and learning disability, but not testicular shrinkage or acne. Obesity, especially with a BMI over 30 kg/m2, can also impair fertility, but is not associated with testicular shrinkage or acne. A careful history, physical examination, and appropriate investigations can help to establish the underlying cause of male infertility and related symptoms.

    • This question is part of the following fields:

      • Smoking, Alcohol And Substance Misuse
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  • Question 27 - A woman wants advice about air travel while pregnant. She wants to visit...

    Incorrect

    • A woman wants advice about air travel while pregnant. She wants to visit her mother who is unwell. The flight will be 6 hours in duration. She will be 28 weeks pregnant at the time of the flight. There have been no complications during this pregnancy. She wants to know how late into the pregnancy she is allowed to fly.

      What would you advise her about air travel for an uncomplicated single pregnancy?

      Your Answer:

      Correct Answer: Most airlines will not let a person fly after week 24 of pregnancy

      Explanation:

      Airline Restrictions for Pregnant Passengers

      Most airlines have restrictions on pregnant passengers flying beyond a certain gestation period. For single, uncomplicated pregnancies, the limit is usually week 37, while for those carrying twins or more, it is week 32. This is due to the increased risks of medical conditions and the possibility of going into labor while in the air.

      In addition to these restrictions, pregnant passengers should also be advised on how to prevent deep vein thrombosis (DVT) during flights longer than four hours. This includes walking when possible, doing in-seat exercises, staying hydrated, and wearing compression stockings. The Royal College of Obstetricians and Gynaecologists (RCOG) provides a helpful patient leaflet on this topic.

    • This question is part of the following fields:

      • Infectious Disease And Travel Health
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  • Question 28 - A 62-year-old lady comes to see you after a routine assessment by her...

    Incorrect

    • A 62-year-old lady comes to see you after a routine assessment by her optician. She has had no visual problems prior to the assessment. The assessment revealed early nuclear sclerotic cataracts bilaterally. Her corrected visual acuity today is 6/5 in the right eye and 6/5 in the left eye.

      What is the most appropriate action to take?

      Your Answer:

      Correct Answer: No action is required

      Explanation:

      Understanding Cataracts and Driving Requirements

      It is common for individuals to develop nuclear sclerotic cataracts as they age. However, there is no need for referral unless there is a visual impairment that affects the patient’s lifestyle. If a person has a visual acuity of 6/5, it means they can read at a distance of six meters what a person with normal vision can read at five meters. Therefore, if a patient has excellent vision, they are unlikely to benefit from new glasses.

      There is no indication for a person to stop driving if they meet the minimum eyesight standard for driving, which is a visual acuity of at least 6/12 measured on the Snellen scale. To drive legally, a person must also be able to read a car number plate made after 1 September 2001 from a distance of 20 meters, with glasses or contact lenses if necessary.

      It is important to note that YAG laser capsulotomy is a procedure carried out for posterior capsular opacification, which can develop after cataract extraction. This procedure is not necessary for a patient with nuclear sclerotic cataracts and would not benefit them.

    • This question is part of the following fields:

      • Eyes And Vision
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  • Question 29 - A small study examines the age of patients diagnosed with hypertension. A total...

    Incorrect

    • A small study examines the age of patients diagnosed with hypertension. A total of 64 patients were analyzed. The average age was 55 years, with a standard deviation of 8 years. What is the standard error of the mean?

      Your Answer:

      Correct Answer: 1.5

      Explanation:

      The formula to calculate the standard error of the mean is to divide the standard deviation by the square root of the number of patients. For example, if the standard deviation is 12 and there are 64 patients, the standard error of the mean would be 12 divided by the square root of 64, which equals 1.5.

      Understanding Confidence Interval and Standard Error of the Mean

      The confidence interval is a widely used concept in medical statistics, but it can be confusing to understand. In simple terms, it is a range of values that is likely to contain the true effect of an intervention. The likelihood of the true effect lying within the confidence interval is determined by the confidence level, which is the specified probability of including the true value of the variable. For instance, a 95% confidence interval means that the range of values should contain the true effect of intervention 95% of the time.

      To calculate the confidence interval, we use the standard error of the mean (SEM), which measures the spread expected for the mean of the observations. The SEM is calculated by dividing the standard deviation (SD) by the square root of the sample size (n). As the sample size increases, the SEM gets smaller, indicating a more accurate sample mean from the true population mean.

      A 95% confidence interval is calculated by subtracting and adding 1.96 times the SEM from the mean value. However, if the sample size is small (n < 100), a 'Student's T critical value' look-up table should be used instead of 1.96. Similarly, if a different confidence level is required, such as 90%, the value used in the formula should be adjusted accordingly. In summary, the confidence interval is a range of values that is likely to contain the true effect of an intervention, and its calculation involves using the standard error of the mean. Understanding these concepts is crucial in interpreting statistical results in medical research.

    • This question is part of the following fields:

      • Evidence Based Practice, Research And Sharing Knowledge
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  • Question 30 - A 14-year-old boy is approaching his GCSE exams and is struggling with his...

    Incorrect

    • A 14-year-old boy is approaching his GCSE exams and is struggling with his hay fever. He has tried oral antihistamines, nasal steroids and homeopathic treatments. These help his nasal symptoms but do nothing for his itchy eyes.
      What is the most suitable treatment for his symptoms at this point?

      Your Answer:

      Correct Answer: Azelastine eye drops

      Explanation:

      Treatment Options for Allergic Conjunctivitis

      Allergic conjunctivitis can be treated with depot intramuscular steroids and oral steroids, but these options come with potential side effects. Steroid eye drops should be avoided due to the risk of infection, cataract, and glaucoma. Instead, a topical antihistamine is the preferred treatment option. Additionally, Grazax® is a form of immunotherapy that can stimulate blocking antibodies against grass pollen, but it must be started in the autumn before hay fever season begins. It’s important to discuss all treatment options with a healthcare provider to determine the best course of action.

    • This question is part of the following fields:

      • Eyes And Vision
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