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  • Question 1 - A 15-year-old girl is admitted to hospital following a ruptured ectopic pregnancy. She...

    Incorrect

    • A 15-year-old girl is admitted to hospital following a ruptured ectopic pregnancy. She comes from a family of Jehovah's Witnesses. Her haemoglobin on admission is 6.7 g/dl. She consents to a blood transfusion but her mother refuses. What is the most appropriate course of action?

      Your Answer: Advise the parents she will have to get a High Court injunction in order to stop the transfusion

      Correct Answer: Give the blood transfusion

      Explanation:

      People aged 16 or over are entitled to consent to their own treatment. This can only be overruled in exceptional circumstances. Children under the age of 16 can consent to their own treatment if they’re believed to have enough intelligence, competence and understanding to fully appreciate what’s involved in their treatment. This is known as being Gillick competent.

      Otherwise, someone with parental responsibility can consent for them.
      This could be:
      the child’s mother or father
      the child’s legally appointed guardian
      a person with a residence order concerning the child
      a local authority designated to care for the child
      a local authority or person with an emergency protection order for the child.
      Giving the blood transfusion is therefore both clinically and ethically the right course of action.
      Jehovah’s Witnesses frequently carry a signed and witnessed Advance Decision Document listing the blood products and autologous procedures that are, or are not, acceptable to them It is appropriate to have a frank, confidential discussion with the patient about the potential risks of their decision and the possible alternatives to transfusion, but the freely expressed wish of a competent adult must always be respected.

    • This question is part of the following fields:

      • Clinical Sciences
      50.9
      Seconds
  • Question 2 - A 80 yr. old male with hypertension presented with his second episode of...

    Incorrect

    • A 80 yr. old male with hypertension presented with his second episode of atrial fibrillation. He was warfarinised and discharged. Later he was reviewed and found to be in sinus rhythm. Which of the following is the most appropriate next step?

      Your Answer:

      Correct Answer: Continue lifelong warfarin

      Explanation:

      CHA₂DS₂-VASc score is used for atrial fibrillation stroke risk calculation.
      Congestive heart failure – 1 point
      Hypertension – 1 point
      Age ≥75 years – 2 points
      Diabetes mellitus – 1 point
      Stroke/Transient Ischemic Attack/Thromboembolic event – 2 points
      Vascular disease (prior MI, PAD, or aortic plaque) – 1 point
      Age 65 to 74 years – 1 point
      Sex category (i.e., female sex) – 1 point
      A score of 2 or more is considered as high risk and anticoagulation is indicated. This patient’s score is 3, so he needs life long warfarin to prevent stroke.

    • This question is part of the following fields:

      • Cardiology
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      Seconds
  • Question 3 - A 35-year-old female patient complains of frequent palpitations that have worsened over the...

    Incorrect

    • A 35-year-old female patient complains of frequent palpitations that have worsened over the past week. Her blood pressure is 130/80 mmHg, and her ECG shows atrial fibrillation. During the examination, a palpable, smooth thyroid goitre is detected. She gave birth three months ago and is currently breastfeeding her healthy baby. She has no medical history. Her TSH is < 0.05 mU/l, and she is positive for TSH receptor and TPO antibodies. What is the most likely diagnosis for her goitre?

      Your Answer:

      Correct Answer: Postpartum thyroiditis

      Explanation:

      Understanding Postpartum Thyroiditis

      Postpartum thyroiditis is a condition that occurs in the first few months after pregnancy and is characterized by clinical hyperthyroidism. It is the most likely diagnosis for a patient presenting with these symptoms. TSH receptor antibodies are often found in women with postpartum thyroiditis who have symptoms of thyrotoxicosis, although TPO antibodies are also associated with the condition. Following the episode of thyrotoxicosis, there is a transient period of hypothyroidism, and up to 30% of patients may eventually develop permanent hypothyroidism.

      Subacute thyroiditis, on the other hand, is not associated with pregnancy and is characterized by symptoms of a flu-like illness, pain over the thyroid gland, and thyrotoxicosis. Pregnancy may cause the development of a goitre, but thyrotoxicosis is pathological. Graves’ disease may be a potential diagnosis, but the timing of the symptoms points towards postpartum thyroiditis. Struma ovarii, caused by ectopic thyroid tissue, does not present with a goitre.

      In conclusion, understanding the symptoms and potential diagnoses of postpartum thyroiditis is crucial for proper management and treatment of the condition.

    • This question is part of the following fields:

      • Endocrinology, Diabetes And Metabolic Medicine
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  • Question 4 - A 54-year-old male presented to the dermatology clinic with a persistent rash that...

    Incorrect

    • A 54-year-old male presented to the dermatology clinic with a persistent rash that had been bothering him for four months. He complained of an extremely itchy blistering rash on his popliteal fossa and buttocks. Despite being prescribed levocetirizine 5 mg OD, Eumovate BD, and Diprobase QDS, his symptoms had worsened. The patient had a medical history of refractory eczema, gout, angina, hypertension, and type 2 diabetes for which he was taking allopurinol 100mg OD, aspirin 75mg OD, simvastatin 40 mg OD, ramipril 5mg OD, and metformin M/R 1g BD. His eczema was in remission after being treated with azathioprine six months ago. He also had a history of irritable bowel syndrome diagnosed several years ago. On examination, he had multiple bullae and papules on the extensor surface of his knees and buttocks with excoriation. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Dermatitis herpetiformis

      Explanation:

      The rash appears as a blistering and papular rash that is extremely itchy, typically found on the extensor surfaces but can occur anywhere on the body. This condition is closely linked to unmanaged coeliac disease, and the key indicator in this scenario is the presence of abdominal bloating and diarrhea (although being diagnosed with irritable bowel syndrome is a common error in clinical practice!).

      Understanding Dermatitis Herpetiformis

      Dermatitis herpetiformis is a skin disorder that is linked to coeliac disease and is caused by the deposition of IgA in the dermis. It is characterized by itchy, vesicular skin lesions that appear on the extensor surfaces such as the elbows, knees, and buttocks.

      To diagnose dermatitis herpetiformis, a skin biopsy is performed, and direct immunofluorescence is used to show the deposition of IgA in a granular pattern in the upper dermis.

      The management of dermatitis herpetiformis involves a gluten-free diet and the use of dapsone. By adhering to a gluten-free diet, patients can reduce the severity of their symptoms and prevent further damage to their skin. Dapsone is a medication that can help to alleviate the symptoms of dermatitis herpetiformis by reducing inflammation and suppressing the immune system.

      In summary, dermatitis herpetiformis is a skin disorder that is associated with coeliac disease and is caused by the deposition of IgA in the dermis. It is characterized by itchy, vesicular skin lesions and can be managed through a gluten-free diet and the use of dapsone.

    • This question is part of the following fields:

      • Dermatology
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  • Question 5 - A 65-year-old man has recently undergone successful mitral valve replacement for rheumatic valvular...

    Incorrect

    • A 65-year-old man has recently undergone successful mitral valve replacement for rheumatic valvular heart disease. He has been started on warfarin and his INR has been stabilised with a plan to maintain it within the range of 2.5-3.5. However, he now presents to his general practitioner with complaints of recurrent episodes of dysuria and frequency, for which he has been prescribed co-trimoxazole. What steps should be taken to ensure that his INR remains within the target range?

      Your Answer:

      Correct Answer: Reduce dose of warfarin

      Explanation:

      Interaction between Co-trimoxazole and Warfarin

      When Co-trimoxazole and Warfarin are taken together, it can lead to an increased anticoagulant effect. This means that the blood-thinning effect of Warfarin is enhanced, which can increase the risk of bleeding. Therefore, it is important to reduce the dose of Warfarin when taking Co-trimoxazole to avoid any potential complications. It is recommended to consult with a healthcare provider before taking these medications together to ensure proper dosing and monitoring. Proper management of this drug interaction can help prevent adverse effects and ensure safe and effective treatment.

    • This question is part of the following fields:

      • Haematology
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  • Question 6 - A 65-year-old man receiving treatment for acute leukaemia presents at the haematology clinic...

    Incorrect

    • A 65-year-old man receiving treatment for acute leukaemia presents at the haematology clinic with symptoms of cough, wheezing, occasional haemoptysis, and fever. A chest x-ray reveals the air crescent sign, and a galactomannan test confirms the diagnosis. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Aspergillosis

      Explanation:

      Aspergillosis

      Aspergillosis is a type of fungal infection that typically affects individuals with weakened immune systems. This condition is particularly dangerous for those with acute leukaemia and haemopoietic stem cell transplantation, as it can lead to death. Symptoms of aspergillosis include coughing, chest pain, fever, and shock. Medical professionals often use chest x-rays and CT scans to diagnose the condition, as well as microscopy and the galactomannan test.

      While other conditions like pneumocystis pneumonia and tuberculosis can also affect immunocompromised individuals, the symptoms described are more indicative of aspergillosis.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 7 - A 58-year-old female patient is being investigated for breathlessness, cough, and severe weight...

    Incorrect

    • A 58-year-old female patient is being investigated for breathlessness, cough, and severe weight loss. On the medical ward round, her CXR is reviewed showing hilar lymphadenopathy and multiple peripheral lung metastases. Which of the following tumours is least likely to be the underlying cause of this lung appearance?

      Your Answer:

      Correct Answer: Brain

      Explanation:

      All of the aforementioned listed tumours, except brain tumours, can metastasise to lungs and produce the typical CXR picture consisting of hilar lymphadenopathy with either diffuse multinodular shadows resembling miliary disease or multiple large well-defined masses (canon balls). Occasionally, cavitation or calcification may also be seen.

      Most brain tumours, however, do not metastasise. Some, derived form neural elements, do so but in these cases, intraparenchymal metastases generally precede distant haematogenous spread.

    • This question is part of the following fields:

      • Haematology & Oncology
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  • Question 8 - A 56-year-old woman comes to the clinic complaining of an itchy rash. She...

    Incorrect

    • A 56-year-old woman comes to the clinic complaining of an itchy rash. She reports observing a bluish-purple patchy rash mainly on areas exposed to the sun. During the examination, she displays purple eyelids and rough raised purple patches on her knuckles. Her nails exhibit ragged cuticles, and blood vessels are visible on the nail fold. A poorly defined purple rash is present on both her arms extending up to her shoulders. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Dermatomyositis

      Explanation:

      The diagnosis is dermatomyositis. The patient exhibits a rash that is sensitive to sunlight, as well as a rash around the eyelids known as heliotrope rash, and Gottron’s papules. The rash distribution is consistent with dermatomyositis. Lupus typically presents with a butterfly-shaped rash that is erythematous and sensitive to sunlight, and there may be a history of joint and neurological symptoms. Lichen planus is a purple and itchy rash that appears in patches, with a distribution similar to psoriasis.

      Understanding Dermatomyositis

      Dermatomyositis is a condition that causes inflammation and weakness in the muscles, as well as distinct skin lesions. It can occur on its own or be associated with other connective tissue disorders or underlying malignancies. Patients with dermatomyositis may experience symmetrical, proximal muscle weakness, and photosensitive skin rashes. The skin lesions may include a macular rash over the back and shoulders, a heliotrope rash in the periorbital region, Gottron’s papules, and mechanic’s hands. Other symptoms may include Raynaud’s, respiratory muscle weakness, interstitial lung disease, dysphagia, and dysphonia.

      To diagnose dermatomyositis, doctors may perform various tests, including screening for underlying malignancies. The majority of patients with dermatomyositis are ANA positive, and around 30% have antibodies to aminoacyl-tRNA synthetases, such as anti-synthetase antibodies, antibodies against histidine-tRNA ligase (Jo-1), antibodies to signal recognition particle (SRP), and anti-Mi-2 antibodies.

      In summary, dermatomyositis is a condition that affects both the muscles and skin. It can be associated with other disorders or malignancies, and patients may experience a range of symptoms. Proper diagnosis and management are essential for improving outcomes and quality of life for those with dermatomyositis.

    • This question is part of the following fields:

      • Rheumatology
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  • Question 9 - A 20-year-old woman presents to her clinic appointment in distress. She has been...

    Incorrect

    • A 20-year-old woman presents to her clinic appointment in distress. She has been experiencing severe headaches for the past year, causing her to drop out of her university studies. The headaches are debilitating and often prevent her from doing anything else. She experiences vomiting most days of the week when the pain is at its worst, and her vision feels blurry. Despite trying sumatriptan, NSAIDs, paracetamol, and relaxation techniques, her GP has been unable to provide much relief. She is currently taking sertraline for depression and does not smoke.

      The patient's headaches are a constant, severe frontal headache with radiation around the eyes. She can vomit at times, often before breakfast. She has rarely found relief from her symptoms, but notes that they are better in the evenings.

      On examination, the patient has normal visual fields, equal limb strength, and normal tone. There is no sensory loss. Her fundi show no bleeds or exudate, but the disc is blurred. She has a raised body mass index of 26kg/m² and is afebrile. There is no sinus tenderness, and no inflammation of the upper respiratory tract mucosa can be seen.

      Her blood work shows:
      - Na+ 138 mmol/l
      - K+ 4.3 mmol/l
      - Urea 5.1 mmol/l
      - Creatinine 87 µmol/l

      A CT scan of her head shows no intracranial haemorrhage, mass effect, or lesions seen. However, an MRI scan shows flattening of the sclera of the eye, partially empty sella turcica, and an enlarged subarachnoid space around the oculomotor and optic nerves.

      What is the likely diagnosis?

      Your Answer:

      Correct Answer: Idiopathic intracranial hypertension

      Explanation:

      The cause of the chronic postural headache in this case is likely idiopathic intracranial hypertension, as imaging ruled out other potential causes such as myopia, chronic sinusitis, ependymoma, and venous sinus thrombosis. The headache improves throughout the day, further supporting this diagnosis.

      Understanding Idiopathic Intracranial Hypertension

      Idiopathic intracranial hypertension, also known as pseudotumour cerebri, is a medical condition that is commonly observed in young, overweight females. The condition is characterized by a range of symptoms, including headache, blurred vision, and papilloedema, which is usually present. Other symptoms may include an enlarged blind spot and sixth nerve palsy.

      There are several risk factors associated with idiopathic intracranial hypertension, including obesity, female sex, pregnancy, and certain drugs such as the combined oral contraceptive pill, steroids, tetracyclines, vitamin A, and lithium.

      Management of idiopathic intracranial hypertension may involve weight loss, diuretics such as acetazolamide, and topiramate, which can also cause weight loss in most patients. Repeated lumbar puncture may also be necessary, and surgery may be required to prevent damage to the optic nerve. This may involve optic nerve sheath decompression and fenestration, or a lumboperitoneal or ventriculoperitoneal shunt to reduce intracranial pressure.

      It is important to note that if intracranial hypertension is thought to occur secondary to a known cause, such as medication, it is not considered idiopathic. Understanding the risk factors and symptoms associated with idiopathic intracranial hypertension can help individuals seek appropriate medical attention and management.

    • This question is part of the following fields:

      • Neurology
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  • Question 10 - A 30-year-old female presented in the ophthalmology ward complaining of blurry vision for...

    Incorrect

    • A 30-year-old female presented in the ophthalmology ward complaining of blurry vision for 4 days. Fundoscopy of both eyes revealed cotton wool spots in both the retinas. What is the most likely cause of this condition?

      Your Answer:

      Correct Answer: CMV infection

      Explanation:

      Fundoscopy findings of cotton wool spots and retinal tears, accompanied by a history of blurred vision, are characteristic of retinitis. Cytomegalovirus is known to cause retinitis.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 11 - A 60–year-old woman comes to the hospital for chemotherapy for breast cancer. On...

    Incorrect

    • A 60–year-old woman comes to the hospital for chemotherapy for breast cancer. On examination, her pulse is 120 bpm and regular and BP is 90/60. Her JVP is not seen, her heart sounds are normal, and her chest is clear. There is evidence of a right mastectomy. Abdominal and neurological examination is normal. Short synacthen test was ordered and the results came as follows: Time (min): 0, 30, 60. Cortisol (nmol/l): 90, 130, 145. Which two of the following would be your immediate management?

      Your Answer:

      Correct Answer: Intravenous normal saline 1l in first hour

      Explanation:

      Synacthen test interpretation:
      – Basal Cortisol level should be greater than 180nmol/L
      – 30min or 60min Cortisol should be greater than 420nmol/L (whatever the basal level)
      – The increment should be at least 170nmol/L, apart from in severely ill patients where adrenal output is already maximal.
      The patient’s results show that she has Acute Adrenal Insufficiency
      The guidelines include the following recommendations for emergency treatment:
      Administer hydrocortisone: Immediate bolus injection of 100 mg hydrocortisone intravenously or intramuscularly followed by continuous intravenous infusion of 200 mg hydrocortisone per 24 hours (alternatively, 50 mg hydrocortisone per intravenous or intramuscular injection every 6 h)
      Rehydrate with rapid intravenous infusion of 1000 mL of isotonic saline infusion within the first hour, followed by further intravenous rehydration as required (usually 4-6 L in 24 h; monitor for fluid overload in case of renal impairment and elderly patients)
      Contact an endocrinologist for urgent review of the patient, advice on further tapering of hydrocortisone, and investigation of the underlying cause of the disease, including the diagnosis of primary versus secondary adrenal insufficiency
      Tapering of hydrocortisone can be started after clinical recovery guided by an endocrinologist; in patients with primary adrenal insufficiency, mineralocorticoid replacement must be initiated (starting dose 100 μg fludrocortisone once daily) as soon as the daily glucocorticoid dose is below 50 mg of hydrocortisone every 24 hours

    • This question is part of the following fields:

      • Endocrinology
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  • Question 12 - A 55-year-old woman diagnosed with type 2 diabetes presents with vomiting and diarrhoea...

    Incorrect

    • A 55-year-old woman diagnosed with type 2 diabetes presents with vomiting and diarrhoea after eating a meal of chicken and chips. She said her stool had small amounts of blood in. Campylobacter Jejuni was found on her stool culture exam. Which of the following is the most appropriate therapy?

      Your Answer:

      Correct Answer: IV fluids

      Explanation:

      Campylobacter is the most likely cause of diarrheal illness often due to undercooked meat being ingested. It is also a major cause of traveller’s diarrhoea. Sufficient fluid replacement and anti-emetics are indicated first followed by the antibiotic, Erythromycin although antibiotic treatment in adults is still in question. Ciprofloxacin and Tetracycline may also be effective.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 13 - A 30-year-old man has been unwell for the last 3 weeks and now...

    Incorrect

    • A 30-year-old man has been unwell for the last 3 weeks and now developed a rash. Chickenpox is diagnosed. What is the appropriate treatment?

      Your Answer:

      Correct Answer: Acyclovir

      Explanation:

      You may treat chickenpox with acyclovir if it is commenced within the first 24 hours of the rash’s appearance. Erythromycin, doxycycline, and ampicillin would not help because it’s a viral infection (Varicella) not a bacterial infection.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 14 - A 42-year-old woman presents to the emergency department with confusion and fevers. She...

    Incorrect

    • A 42-year-old woman presents to the emergency department with confusion and fevers. She has no medical history and is not taking any regular medications.

      Upon examination, her Glasgow coma scale is 13/15 (E3V4M5) and there are no localizing neurological signs. Cardiovascular, respiratory, and abdominal assessments are unremarkable. Her temperature is 38.8ºC.

      An urgent MRI brain is scheduled, which reveals oedema of both temporal lobes.

      A lumbar puncture is ordered.

      What is the most likely set of results that will be found?

      Your Answer:

      Correct Answer: Raised lymphocytes / elevated protein

      Explanation:

      In cases of herpes simplex encephalitis, the cerebrospinal fluid (CSF) typically shows a lymphocytosis and elevated protein levels. This is important to note when a patient presents with symptoms such as fever and confusion, and is found to be pyrexial with a low Glasgow Coma Scale (GCS) on examination. The presence of bilateral temporal lobe oedema on MRI is highly suggestive of this condition. A lumbar puncture would confirm the diagnosis by demonstrating lymphocytosis and elevated protein levels.

      It is important to note that a normal white cell count with elevated protein levels is unlikely to be indicative of HSV encephalitis, as a normal white cell count points away from infection. On the other hand, raised lymphocytes with normal protein levels may be compatible with a viral infection, but it is less likely to be seen in cases of HSV encephalitis where protein levels are more likely to be elevated.

      Herpes Simplex Encephalitis: Symptoms, Diagnosis, and Treatment

      Herpes simplex encephalitis is a common topic in medical exams. This viral infection affects the temporal lobes of the brain, causing symptoms such as fever, headache, seizures, and vomiting. Focal features like aphasia may also be present. It is important to note that peripheral lesions, such as cold sores, are not related to the presence of HSV encephalitis.

      HSV-1 is responsible for 95% of cases in adults and typically affects the temporal and inferior frontal lobes. Diagnosis is made through CSF analysis, PCR for HSV, and imaging studies like CT or MRI. EEG patterns may also show lateralized periodic discharges at 2 Hz.

      Early treatment with intravenous aciclovir is crucial for a good prognosis. Mortality rates can range from 10-20% with prompt treatment, but can approach 80% if left untreated. MRI is a better imaging modality for detecting changes in the medial temporal and inferior frontal lobes.

      In summary, herpes simplex encephalitis is a serious viral infection that affects the brain. It is important to recognize the symptoms and seek prompt medical attention for early diagnosis and treatment.

    • This question is part of the following fields:

      • Neurology
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  • Question 15 - A 27-year-old consultant who has a family history of retinitis pigmentosa is reviewed...

    Incorrect

    • A 27-year-old consultant who has a family history of retinitis pigmentosa is reviewed in the ophthalmology clinic. He reports worsening vision over the past few months. During fundoscopy, which of the following findings would most support a diagnosis of retinitis pigmentosa?

      Your Answer:

      Correct Answer: Black bone spicule-shaped pigmentation in the peripheral retina

      Explanation:

      Retinitis pigmentosa is a genetic disorder primarily affecting the peripheral retina resulting in tunnel vision. Night blindness is often the initial sign. Fundoscopy exam reveals black bone spicule-shaped pigmentation in the peripheral retina, and mottling of the retinal pigment epithelium.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 16 - An 82-year-old man is reviewed in the haematology clinic. He has been referred...

    Incorrect

    • An 82-year-old man is reviewed in the haematology clinic. He has been referred due to weight loss, lethargy, and a significantly elevated IgM level. His recent blood results show: Hb: 13.8 g/dL, Plts: 127 x 10^9/L, ESR: 45 mm/hr, IgM: 2150 mg/dL (50-330 mg/dL). Given the probable diagnosis, which one of the following complications is he most likely to develop?

      Your Answer:

      Correct Answer: Hyperviscosity syndrome

      Explanation:

      The patient is most likely suffering from Waldenström’s macroglobulinemia in which IgM paraproteinemia is found. Hyperviscosity syndrome can occur in the patients accounting for 10–15% of the cases.

      Waldenström’s macroglobulinemia (also called lymphoplasmacytic lymphoma) is an uncommon type of non-Hodgkin lymphoma seen in older people. It is a lymphoplasmacytoid malignancy characterised by the secretion of a monoclonal IgM paraprotein. Its features include monoclonal IgM paraproteinemia; hyperviscosity syndrome leading to bilateral central retinal vein occlusion (CRVO) and hence, visual disturbances; weight loss and lethargy; hepatosplenomegaly and lymphadenopathy; and cryoglobulinemia. It is not, however, associated with bone pain.

    • This question is part of the following fields:

      • Haematology & Oncology
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  • Question 17 - A 30-year-old woman presents to the Emergency Department with a suspected overdose of...

    Incorrect

    • A 30-year-old woman presents to the Emergency Department with a suspected overdose of aspirin. She has been experiencing vomiting and tinnitus. Upon examination, she appears dehydrated, restless, and is sweating profusely. Her vital signs are as follows: temperature 38.5°C, pulse 120 regular, blood pressure 140/85 mmHg, respiratory rate 25 breaths per minute, Glasgow coma score of 12, and oxygen saturation 95% on air. It is believed that the aspirin was ingested eight hours ago and that the plasma levels have already peaked. The biochemistry results show a pH of 7.25 (7.35-7.45), PaCO2 of 20 mmHg (38-42), PaO2 of 102 mmHg (75-100), BE of +8 (-3 to +3), Bicarbonate of 22 mEq/L (22-28), SpO2 of 96%, glucose of 13 mmol/L (3.5-5.5), and salicylate levels of 601 mg/L. What is the most appropriate initial clinical intervention in this case?

      Your Answer:

      Correct Answer: Alkalinise the urine

      Explanation:

      Management of Salicylate Poisoning

      The clinical presentation of a patient with salicylate poisoning is indicative of a moderate overdose of aspirin. Unfortunately, there is no specific antidote for salicylate ingestion. Therefore, the management of this type of poisoning is supportive, with measures aimed at preventing further absorption from the gastrointestinal tract and enhancing excretion.

      The initial treatment for salicylate poisoning should involve the administration of activated charcoal, which should be repeated as necessary to prevent delayed absorption of salicylate. Gastric lavage may be useful if the ingestion occurred within one hour, but airway protection is essential during the procedure. Afterward, the patient should be rehydrated, and their urine should be alkalinized to promote urinary excretion. This can be achieved by administering an infusion of sodium bicarbonate. The goal is to increase the ionization of salicylic acid, a weak acid, in an alkaline environment, which will increase its excretion tenfold.

      Forced diuresis alone is not recommended as it can lead to severe electrolyte imbalances and pulmonary or cerebral edema. In severe cases of salicylate poisoning, such as those with high plasma levels of salicylate (>800 mg/L), severe metabolic acidosis, acute kidney injury, or neurological impairment (coma, hallucinations, or seizures), early hemodialysis may be necessary. Overall, the management of salicylate poisoning requires a comprehensive approach that includes supportive care, prevention of further absorption, and enhanced excretion.

    • This question is part of the following fields:

      • Clinical Pharmacology And Therapeutics
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  • Question 18 - A patient shows reduced central vision upon visual acuity test. He is advised...

    Incorrect

    • A patient shows reduced central vision upon visual acuity test. He is advised to undergo a fundoscopy, which turns out to be normal. Which drug could be responsible for his symptoms?

      Your Answer:

      Correct Answer: Corticosteroids

      Explanation:

      Corticosteroids are well known for their ocular complications such as glaucoma and cataracts.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 19 - An 83-year-old man visits the dermatology clinic with scalp changes. He is bald...

    Incorrect

    • An 83-year-old man visits the dermatology clinic with scalp changes. He is bald and has noticed thickened and abnormal skin. He has a history of sun exposure from living in Spain for five years but has now returned to the UK permanently. He also has a history of smoking, but quit 15 years ago, and has quit drinking. He has been diagnosed with COPD, fractured NOF, gout, and hypertension. He regularly uses ipratropium, seretide, allopurinol, ramipril, amlodipine, and alendronic acid.

      During the examination, the scalp appears erythematous with thickened plaques. It is mildly tender and slightly irritated. What is the most suitable treatment?

      Your Answer:

      Correct Answer: Topical 5-FU

      Explanation:

      Actinic keratosis can be effectively treated with topical 5-FU, imiquimod or diclofenac as a first line of defense. This patient’s symptoms are consistent with actinic keratosis, which is a type of sun-damaged skin that can develop into squamous cell carcinoma. Other treatment options include cryotherapy. However, hydrocortisone and emollients are used for eczema, while miconazole shampoo is used for treating tinea and other infections.

      Actinic keratoses, also known as solar keratoses, are skin lesions that develop due to prolonged exposure to the sun. These lesions are typically small, crusty, and scaly, and can appear in various colors such as pink, red, brown, or the same color as the skin. They are commonly found on sun-exposed areas like the temples of the head, and multiple lesions may be present.

      To manage actinic keratoses, prevention of further risk is crucial, such as avoiding sun exposure and using sun cream. Treatment options include a 2 to 3 week course of fluorouracil cream, which may cause redness and inflammation. Topical hydrocortisone may be given to help settle the inflammation. Topical diclofenac is another option for mild AKs, with moderate efficacy and fewer side-effects. Topical imiquimod has shown good efficacy in trials. Cryotherapy and curettage and cautery are also available as treatment options.

    • This question is part of the following fields:

      • Dermatology
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  • Question 20 - A 29-year-old female patient visits the genitourinary medicine clinic complaining of dysuria and...

    Incorrect

    • A 29-year-old female patient visits the genitourinary medicine clinic complaining of dysuria and vaginal discharge that has been present for four days. She has no medical history and is not taking any regular medications. The patient had unprotected sexual intercourse with a casual partner two weeks ago.

      During the speculum examination, the healthcare provider observed cervicitis and clear vaginal discharge. The genitalia examination was otherwise unremarkable. The nucleic acid amplification test confirmed the causative organism.

      What is the likely organism responsible for the patient's symptoms, and what treatment is prescribed?

      Your Answer:

      Correct Answer: Chlamydia trachomatis

      Explanation:

      Chlamydia trachomatis is the correct answer for the sexually transmitted infection that is treated with doxycycline. Symptoms may include dysuria, cervicitis, and a clear vaginal discharge, but it can also be asymptomatic. Diagnosis is done through a nucleic acid amplification test. Trichomonas vaginalis is not the correct answer, as it presents with a greenish discharge and is treated with metronidazole. Candida albicans is also incorrect, as it is a fungal infection that causes a creamy, itchy discharge and is treated with anti-fungal agents. Gardnerella vaginalis is not the correct answer either, as it is a cause of bacterial vaginosis that presents with a fishy odor and is treated with metronidazole.

      Chlamydia is the most common sexually transmitted infection in the UK caused by Chlamydia trachomatis. It is often asymptomatic but can cause cervicitis and dysuria in women and urethral discharge and dysuria in men. Complications include epididymitis, pelvic inflammatory disease, and infertility. Testing is done through nuclear acid amplification tests (NAATs) on urine or swab samples. Screening is recommended for sexually active individuals aged 15-24 years. Doxycycline is the first-line treatment, but azithromycin may be used if contraindicated. Partners should be notified and treated.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 21 - A 48-year-old male with a history of bipolar disorder presents with acute confusion....

    Incorrect

    • A 48-year-old male with a history of bipolar disorder presents with acute confusion. In-transit to hospital he had a generalized seizure which terminated spontaneously after around 30 seconds. On arrival to the emergency department, his GCS is 14/15 and he is noted to have a coarse tremor. Suspecting a diagnosis of lithium toxicity, intravenous access is obtained, a blood sample was drawn for investigations and a saline infusion is started. The blood investigations revealed: Lithium level: 4.2 mmol/L, Na+: 136 mmol/L, K+: 4.6 mmol/L, Urea: 8.1 mmol/L, Creatinine: 99 µmol/L, Bicarbonate: 18 mmol/L, What is the most appropriate management for the patient?

      Your Answer:

      Correct Answer: Arrange haemodialysis

      Explanation:

      The presentation of the patient is typical of chronic lithium toxicity (due to the presence of mainly neurological manifestations). Additional to the blood investigations mentioned, urine analysis, electrolyte levels, and renal function should also be performed. A low urine Anion gap and a low urine specific gravity are highly suggestive of lithium toxicity.
      ECG obtained in this patient is likely to show: nonspecific, diffuse ST segment depression with T wave inversion.
      Acute lithium toxicity presents with more GI manifestations while, the clinical features of chronic lithium toxicity are mainly neurological and can include:
      Coarse tremors (fine tremors are seen in therapeutic levels), hyperreflexia, acute confusion, seizures, and coma.
      The management of lithium toxicity is as follows:
      Immediate GI decontamination with gastric lavage (in case of acute intoxication)
      Saline Administrations: the goal of saline administration is to restore GFR, normalize urine output and enhance lithium clearance.
      Haemodialysis remains the mainstay treatment for lithium toxicity as lithium is readily dialyzed because of water solubility, low volume of distribution, and lack of protein binding.
      The Extracorporeal Treatments in Poisoning Workgroup (EXTRIP Workgroup) recommendations for dialysis (extracorporeal treatment) in lithium toxicity include:
      • Impaired kidney function and lithium levels > 4.0 mEq/L
      • Decreased consciousness, seizures, or life-threatening dysrhythmias, regardless of lithium levels
      • Levels are > 5.0 mEq/L, significant confusion is noted, or the expected time to reduce levels to < 1.0 mEq/L is more than 36 hours
      As post-dialysis rebound elevations in lithium levels have been documented, continuous veno-venous hemofiltration (CVVH) has been advocated.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 22 - A 66 year old man visits the clinic because he has been experiencing...

    Incorrect

    • A 66 year old man visits the clinic because he has been experiencing increasing breathlessness for the past five months while doing daily tasks. His exercise tolerance is now limited to 75 metres while on a flat surface and walking up the stairs makes him breathless. He sleeps on four pillows and has swollen ankles in the morning. He occasionally coughs up phlegm. Past Medical history of importance: 36 pack year smoking history Hypertension Ischaemic heart disease Coronary artery stenting done 10 months ago Pulmonary function testing revealed: FEV1 0.90 L (1.80 – 3.02 predicted) FVC 1.87 L (2.16 – 3.58 predicted) Diffusion capacity 3.0 mmol/min/kPa (5.91 – 9.65 predicted) Total lung capacity 4.50 L (4.25 – 6.22 predicted) Residual volume 2.70 L (1.46 – 2.48 predicted)   Which condition does he have?

      Your Answer:

      Correct Answer: Chronic obstructive pulmonary disease

      Explanation:

      Whilst asthma and COPD are different diseases they cause similar symptoms, which can present a challenge in identifying which of the two diseases a patient is suffering from. COPD causes chronic symptoms and narrowed airways which do not respond to treatment to open them up. In the case of asthma the constriction of the airways through inflammation tends to come and go and treatment to reduce inflammation and to open up the airways usually works well.

      COPD is more likely than asthma to cause a chronic cough with phlegm and is rare before the age of 35 whilst asthma is common in under-35s. Disturbed sleep caused by breathlessness and wheeze is more likely in cases of asthma, as is a history of allergies, eczema and hay fever. Differentiating between COPD and asthma requires a history of both symptoms and spirometry. The spirometry history should include post bronchodilator measurements, the degree of reversibility and, ideally, home monitoring which gives a history of diurnal variation.

      Airflow Obstruction: Both asthma and COPD are characterised by airflow obstruction. Airflow obstruction is defined as a reduced FEV1 and a reduced FEV1/FVC ratio, such that FEV1 is less than 80% of that predicted, and FEV1/FVC is less than 0.7.

      These episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment.

      COPD: COPD is a chronic, slowly progressive disorder characterised by airflow obstruction (reduced FEV1 and FEV1/VC ratio) that does not change markedly over several months. The airflow obstruction is not fully reversible.

      Spirometry COPD Asthma
      VC Reduced Nearly normal
      FEV1 Reduced Reduced in attack
      FVC (or FEV6) Reduced Nearly normal
      FEV1 Ratio
      (of VC/FVC/FEV6) Reduced in attack

      This man has a low FEV1 and FVC. His diffusions capacity is also low despite having a normal total lung capacity. These values confirm a diagnosis of COPD.

    • This question is part of the following fields:

      • Respiratory
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  • Question 23 - A 68 yr. old male with history of poorly controlled hypertension was admitted...

    Incorrect

    • A 68 yr. old male with history of poorly controlled hypertension was admitted with shortness of breath on exertion, orthopnoea for three months. He was diagnosed with congestive cardiac failure and was started on digoxin 62.5 μg daily, furosemide 80mg daily and amiloride 10mg daily. On admission his lab results showed that his serum urea was 6 mmol/L and serum creatinine was 115 μmol/L. One month later he came for a follow up consultation. On examination he had bilateral ankle oedema. His blood pressure was 138/90 mmHg and pulse rate was 92 bpm. His JVP was not elevated. His apex beat was displaced laterally and he had a few bibasal crepitations on auscultation. There were no cardiac murmurs. His investigation results revealed the following: Serum sodium 143 mmol/L (137-144), Serum potassium 3.5 mmol/L (3.5-4.9), Serum urea 8 mmol/L (2.5-7.5), Serum creatinine 140 μmol/L (60-110), Serum digoxin 0.7 ng/mL (1.0-2.0). CXR showed cardiomegaly and a calcified aorta. ECG showed left ventricular hypertrophy. Which of the following is the most appropriate next step in the management of this patient?

      Your Answer:

      Correct Answer: Add an ACE inhibitor to the current regimen

      Explanation:

      From the given history the patient has NYHA grade III heart failure. He can be safely started on an ACE inhibitor as his serum potassium was towards the lower limit. As there an impairment of renal function, his urea, creatinine and serum electrolytes should be closely monitored after commencing an ACE inhibitor. Adding atenolol will not have any clinical benefit. Increasing the digoxin dose is not needed as the patient is in sinus rhythm. Increasing furosemide will only have symptomatic relief.

    • This question is part of the following fields:

      • Cardiology
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  • Question 24 - A 30-year-old woman presents with amenorrhoea and galactorrhoea. She has normal visual fields....

    Incorrect

    • A 30-year-old woman presents with amenorrhoea and galactorrhoea. She has normal visual fields. You are concerned that she may have a prolactinoma. Investigations were done and the results are as shown below: Hb 12.5 g/dL, WCC 4.9 x109/L, PLT 199 x109/L, Na+ 140 mmol/L, K+ 4.9 mmol/L, Creatinine 90 ىmol/L, Prolactin 1150 mU/l. MRI shows a 7 mm pituitary microadenoma. Which of the following hormones would you expect to be lower than normal?

      Your Answer:

      Correct Answer: LH

      Explanation:

      Prolactinomas, benign lesions that produce the hormone prolactin, are the most common hormone-secreting pituitary tumours.
      Based on its size, a prolactinoma can be classified as a microprolactinoma (< 10 mm diameter) or a macroprolactinoma (>10 mm diameter). If the prolactinoma is large enough to compress the surrounding normal hormone-secreting pituitary cells, it may result in deficiencies of one or more hormones (e.g., thyroid-stimulating hormone [TSH], growth hormone [GH], adrenocorticotropic hormone). However, the patient has microadenoma so it is unlikely to cause compression manifestations.
      Hyperprolactinemia inhibits GnRH secretion from the medial basal hypothalamus and LH release from the pituitary.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 25 - John is an 80-year-old man with a history of chronic kidney disease. He...

    Incorrect

    • John is an 80-year-old man with a history of chronic kidney disease. He comes to the clinic for a routine follow-up of his blood tests. He reports feeling well and denies any significant bone pain or urinary issues. No recent bone fractures were noted.

      The blood test results from 1 week ago are as follows:

      - Na+ 138 mmol/L (135 - 145)
      - K+ 4.8 mmol/L (3.5 - 5.0)
      - Urea 8.0 mmol/L (2.0 - 7.0)
      - Creatinine 260 µmol/L (55 - 120)
      - Calcium 1.8 mmol/L (2.1-2.6)
      - Phosphate 2.0 mmol/L (0.8-1.4)
      - Magnesium 0.8 mmol/L (0.7-1.0)
      - PTH 75 pg/ml (10-55)

      Based on these results, what is the most appropriate course of action for managing John's abnormal blood tests?

      Your Answer:

      Correct Answer: Advice regarding reduction in foods like chocolate, nuts, shellfish and cola

      Explanation:

      The initial management of CKD-mineral bone disease involves correcting hyperphosphatemia before starting phosphate binders. This condition is often asymptomatic and detected through routine blood tests. Hyperphosphatemia and hypocalcemia lead to hyperparathyroidism, which can be managed through calcium and vitamin D supplementation to restore normal calcium homeostasis. Dietary changes to limit phosphate intake are recommended, although it can be challenging for patients to adhere to. Phosphate binders like sevelamer and lanthanum are used if dietary changes are ineffective. Cinacalcet is reserved for cases of unresponsive secondary hyperparathyroidism, while parathyroidectomy is a last resort for cases not responding to medical management and dialysis.

      Managing Mineral Bone Disease in Chronic Kidney Disease

      Chronic kidney disease (CKD) leads to low vitamin D and high phosphate levels due to the kidneys’ inability to perform their normal functions. This results in osteomalacia, secondary hyperparathyroidism, and low calcium levels. To manage mineral bone disease in CKD, the aim is to reduce phosphate and parathyroid hormone levels.

      Reduced dietary intake of phosphate is the first-line management, followed by the use of phosphate binders. Aluminium-based binders are less commonly used now, and calcium-based binders may cause hypercalcemia and vascular calcification. Sevelamer, a non-calcium based binder, is increasingly used as it binds to dietary phosphate and prevents its absorption. It also has other beneficial effects, such as reducing uric acid levels and improving lipid profiles in patients with CKD.

      In some cases, vitamin D supplementation with alfacalcidol or calcitriol may be necessary. Parathyroidectomy may also be needed to manage secondary hyperparathyroidism. Proper management of mineral bone disease in CKD is crucial to prevent complications and improve patient outcomes.

    • This question is part of the following fields:

      • Renal Medicine
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  • Question 26 - A 65-year-old man presents with a six month history of progressive unsteadiness. He...

    Incorrect

    • A 65-year-old man presents with a six month history of progressive unsteadiness. He reports an irregular swaying gait with a tendency to veer to the left when walking. His wife notes that he stands with his feet apart. He also complains of urinary urgency and frequency, despite multiple negative urine tests. He attributes occasional muscle stiffness to aging.
      On examination, his pulse is 70 beats/min, BP 135/80 mmHg supine, 105/55 mmHg standing. There is increased tone in opposing muscle groups when joints are passively moved, but no muscle wasting or weakness. Gait is broad-based with a leftward lean. Reflexes are brisk and plantar responses are downgoing bilaterally. Finger to nose testing is impaired in the upper limbs. Sensory exam is normal.
      What is the likely diagnosis?

      Your Answer:

      Correct Answer: Multiple system atrophy

      Explanation:

      Neurological Disorders: Multiple System Atrophy, Chronic Inflammatory Demyelinating Polyneuropathy, Friedreich’s Ataxia, and Polymyositis

      Multiple system atrophy is a degenerative disorder that affects the autonomic nervous system, leading to symptoms such as postural hypotension, anhidrosis, and impotence. It also presents with parkinsonian features and signs of a cerebellar deficit.

      Chronic inflammatory demyelinating polyneuropathy is a disorder that is similar to Guillain-Barre syndrome, but it follows a chronic progressive course. It presents with symptoms such as hyporeflexia or areflexia, paraesthesia, and mild sensory deficits in the upper and lower extremities, as well as weakness.

      Friedreich’s ataxia is a disorder that is characterised by progressive gait ataxia, depressed knee and ankle reflexes, cerebellar signs, and impairment of joint position and vibration sense. Clinical manifestations almost always begin to appear before puberty.

      Polymyositis is a disorder that often presents with muscle weakness and wasting, especially of the proximal and girdle muscles, muscle pain and tenderness, weight loss, and a low-grade fever.

    • This question is part of the following fields:

      • Neurology
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  • Question 27 - A 63-year-old man presents to your clinic with complaints of weight loss and...

    Incorrect

    • A 63-year-old man presents to your clinic with complaints of weight loss and weakness. He has a hoarse voice and no significant medical history. Upon examination, he has pedal edema up to the tibial tuberosity, an enlarged tongue, and a liver edge palpable up to three finger breadths below the right costal margin. The following laboratory results were obtained: sodium (Na+) 140 mmol/l, potassium (K+) 4.2 mmol/l, urea 7.2 mmol/l, creatinine (Cr) 80 µmol/l, haemoglobin (Hb) 120 g/l, white cell count (WCC) 5.1 × 109/l, and 3+++ protein on urine dipstick. What is the most appropriate test to determine the correct diagnosis?

      Your Answer:

      Correct Answer: Subcutaneous fat biopsy

      Explanation:

      Investigations for Amyloidosis: Subcutaneous Fat Biopsy and Other Tests

      Amyloidosis is a condition characterized by the deposition of fibrous protein in various tissues and organs. It can be primary or associated with other chronic diseases. Diagnosis is made by typical findings and demonstration of amyloid fibrils by Congo red staining under polarized light. To reach a final diagnosis, abdominal subcutaneous fat pad aspirate or rectal submucosal biopsy are often performed.

      Liver spleen scan is not specific for amyloidosis as lymphoproliferative diseases may also cause hepatosplenomegaly. Quantification of protein through 24-hour urinary protein test would not give the definitive diagnosis as proteinuria may be found in other glomerular diseases. Similarly, urine protein electrophoresis and urine protein immunophoresis would be abnormal in myeloma.

    • This question is part of the following fields:

      • Renal Medicine
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  • Question 28 - A 55 yr. old man presented with retrosternal chest pain associated with excessive...

    Incorrect

    • A 55 yr. old man presented with retrosternal chest pain associated with excessive sweating and vomiting. On examination his BP was 100/60 mmHg and pulse rate was 72 bpm. Bibasal crepitations were auscultated. His ECG showed ST elevation in V1 to V4 and ST depression in leads II, III and aVF. Which of the following would be the finding during angioplasty?

      Your Answer:

      Correct Answer: Complete occlusion of the left anterior descending artery

      Explanation:

      The ECG findings are suggestive of anterior myocardial infarction and the most likely artery affected is the left anterior descending artery. Occlusion of the right coronary artery will be shown by ST elevation in lead II, III, aVF and occlusion of the circumflex artery will show changes in leads I, aVL, V5 and V6. To have ST elevation, there should be complete occlusion of the artery.

    • This question is part of the following fields:

      • Cardiology
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  • Question 29 - A 30-year-old male diagnosed with schizophrenia was admitted to the hospital after overdosing...

    Incorrect

    • A 30-year-old male diagnosed with schizophrenia was admitted to the hospital after overdosing on his medications. He developed confusion, ataxia, and fever. During the examination, the patient exhibited lead-pipe rigidity and increased tone in his limbs. An ECG showed sinus tachycardia, and further tests including a head CT, lumbar puncture, and septic screen were negative. What medication could potentially improve this patient's condition?

      Your Answer:

      Correct Answer: Dantrolene

      Explanation:

      Neuroleptic Malignant Syndrome and its Treatment Options

      Neuroleptic malignant syndrome (NMS) is a rare but potentially life-threatening condition that can occur as a side effect of antipsychotic medication. Symptoms include fever, muscle rigidity, altered mental status, and autonomic instability. Treatment options for NMS include dantrolene or bromocriptine, which can help alleviate symptoms and improve outcomes.

      It is important to note that beta blockers like atenolol are not typically used in the treatment of NMS, as they do not address the underlying cause of the condition. Similarly, typical antipsychotics like fluphenazine can actually cause NMS, and should be avoided in patients who are at risk.

      N-acetylcysteine is a medication that is used in the treatment of paracetamol overdose, and is not indicated for the treatment of NMS. Sinemet, which contains co-careldopa, is used in the treatment of Parkinson’s disease and is not relevant to the management of NMS.

      Overall, the signs and symptoms of NMS, as well as the appropriate treatment options, is crucial for healthcare providers who may encounter this condition in their practice. By promptly identifying and treating NMS, providers can help improve outcomes and prevent potentially serious complications.

    • This question is part of the following fields:

      • Neurology
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  • Question 30 - An 80 year old woman is brought to the ER with altered sensorium....

    Incorrect

    • An 80 year old woman is brought to the ER with altered sensorium. She is accompanied by her daughter who noticed the acute change. The patient has had a nagging cough with purulent sputum and haemoptysis for the last few days. Previous history includes a visit to her GP two weeks back because of influenza. On examination, the patient appears markedly agitated with a respiratory rate of 35/min. Blood gases reveal that she is hypoxic. White blood cell count is 20 x 109/l, and creatinine is 250mmol/l. Chest X-ray is notable for patchy areas of consolidation, necrosis and empyema formation. Which of the following lead to the patient's condition?

      Your Answer:

      Correct Answer: Staphylococcus aureus pneumonia

      Explanation:

      Though a common community pathogen, Staphylococcus Aureas is found twice as frequently in pneumonias in hospitalized patients. It often attacks the elderly and patients with CF and arises as a co-infection with influenza viral pneumonia. The clinical course is characterized by high fevers, chills, a cough with purulent bloody sputum, and rapidly progressing dyspnoea. The gross pathology commonly reveals an acute bronchopneumonia pattern that may evolve into a necrotizing cavity with congested lungs and airways that contain a bloody fluid and thick mucoid secretions.

    • This question is part of the following fields:

      • Respiratory
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