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Question 1
Incorrect
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A 40-year-old male comes to his GP complaining of experiencing dull pain in the orbital area, redness in the eye, tearing, and sensitivity to light for the past 4 days. During the examination, the doctor notices that the patient has an irregular, constricted pupil. What would be the best course of action for managing this condition?
Your Answer: Latanoprost eye drops
Correct Answer: Steroid + cycloplegic eye drops
Explanation:Anterior uveitis, also known as iritis, is a type of inflammation that affects the iris and ciliary body in the front part of the uvea. It is a common cause of red eye and is associated with HLA-B27, which may also be linked to other conditions. Symptoms of anterior uveitis include sudden onset of eye discomfort and pain, small or irregular pupils, intense sensitivity to light, blurred vision, redness, tearing, and the presence of pus and inflammatory cells in the front part of the eye. This condition may be associated with ankylosing spondylitis, reactive arthritis, ulcerative colitis, Crohn’s disease, Behcet’s disease, and sarcoidosis. Urgent review by an ophthalmologist is necessary, and treatment may involve the use of cycloplegics and steroid eye drops.
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This question is part of the following fields:
- Ophthalmology
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Question 2
Correct
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A 55-year-old man with a long history of ulcerative colitis (UC) presents to the clinic for evaluation. Although his inflammatory bowel disease is currently under control, he reports experiencing increased lethargy and itching. During the physical examination, his blood pressure is 118/72 mmHg, and his pulse is 68 bpm. The patient displays mildly jaundiced sclerae and evidence of scratch marks on his skin.
Lab Results:
Test Result Normal Range
Hemoglobin 112g/L 135–175 g/L
White blood cell count (WBC) 8.9 × 109/L 4–11 × 109/L
Platelets 189 × 109/L 150–400 × 109/L
Sodium (Na+) 140 mmol/L 135–145 mmol/L
Potassium (K+) 4.2 mmol/L 3.5–5.0 mmol/L
Creatinine 115 μmol/L 50–120 µmol/L
Alkaline phosphatase 380 U/L 30–130 IU/L
Alanine aminotransferase (ALT) 205 U/L 5–30 IU/L
Bilirubin 80 μmol/L 2–17 µmol/L
Ultrasound Evidence of bile duct dilation
What is the most probable diagnosis?Your Answer: Primary sclerosing cholangitis (PSC)
Explanation:Differentiating Primary Sclerosing Cholangitis from Other Liver Conditions
Primary sclerosing cholangitis (PSC) is a condition that affects the liver and bile ducts, causing autoimmune sclerosis and irregularities in the biliary diameter. Patients with PSC may present with deranged liver function tests, jaundice, itching, and chronic fatigue. PSC is more common in men, and up to 50% of patients with PSC also have ulcerative colitis (UC). Ultrasound, endoscopic retrograde cholangiopancreatography (ERCP), or magnetic resonance cholangiopancreatography (MRCP) can show intrahepatic biliary duct stricture and dilation, often with extrahepatic duct involvement. Cholangiocarcinoma is a long-term risk in cases of PSC.
Alcoholic-related cirrhosis is a possibility, but it is unlikely in the absence of a history of alcohol excess. Primary biliary cholangitis (PBC) is an autoimmune condition that causes destruction of the intrahepatic bile ducts, resulting in a cholestatic pattern of jaundice. PBC mostly affects middle-aged women and does not cause bile duct dilation on ultrasound. Ascending cholangitis is a medical emergency that presents with a triad of jaundice, fever, and right upper quadrant tenderness. Autoimmune hepatitis most often occurs in middle-aged women presenting with general malaise, anorexia, and weight loss of insidious onset, with abnormal liver function tests. It normally causes hepatitis, rather than cholestasis.
In summary, differentiating PSC from other liver conditions requires a thorough evaluation of the patient’s medical history, symptoms, and diagnostic tests.
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This question is part of the following fields:
- Gastroenterology
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Question 3
Incorrect
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A 65-year-old woman presented with worsening constipation. One year previously she had been discharged from hospital following an acute coronary syndrome and atrial fibrillation. She was treated with several new drugs in hospital and was adherent to all of them.
Which one of her medications is most likely to have caused her constipation?Your Answer: Nicorandil
Correct Answer: Verapamil
Explanation:Common Side-Effects of Medications for Cardiovascular Conditions
Verapamil, Ramipril, Aspirin, Nicorandil, and Simvastatin are medications commonly used in the treatment of cardiovascular conditions. However, they also come with some common side-effects that patients should be aware of.
Verapamil is a calcium channel blocker that can cause constipation, headache, hypotension, reflux symptoms, nausea, peripheral oedema, fatigue, atrioventricular block, flushing, and bradycardia.
Ramipril, an angiotensin-converting enzyme (ACE) inhibitor, can cause first-dose hypotension, dry cough, renal dysfunction, dizziness, and diarrhoea.
Aspirin, a blood thinner, can cause gastrointestinal bleeding, nosebleeds, reflux symptoms, and abdominal pain/cramping.
Nicorandil, a vasodilator, can cause mouth/skin/anal ulceration, headaches, dizziness, flushing, tachycardia, nausea, and vomiting.
Simvastatin, a cholesterol-lowering medication, can cause myopathy, deranged liver function tests/hepatitis, reflux symptoms, diarrhoea, gastrointestinal disturbance, and joint pains.
It is important for patients to be aware of these potential side-effects and to discuss any concerns with their healthcare provider.
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This question is part of the following fields:
- Pharmacology
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Question 4
Incorrect
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A 47-year-old woman presents with a 4-month history of low mood, fatigue, and weight gain. She has constantly felt cold during this time. This is her first presentation with these symptoms and she has noticed them after starting a new medication for her hypertension.
She has a past medical history of hypertension and takes amlodipine, lisinopril, and hydrochlorothiazide.
Investigations are performed:
Thyroid-stimulating hormone (TSH) 19.2 mU/L (0.5 - 5.5)
Free T4 1.8 pmol/L (9-18)
What is the most appropriate step in her management?Your Answer: Stop amiodarone and remeasure thyroid function
Correct Answer: Add levothyroxine and continue amiodarone
Explanation:Levothyroxine can be added to continue amiodarone in cases of amiodarone-induced hypothyroidism. This patient is exhibiting symptoms of hypothyroidism, which can occur in around 1 in 6 patients taking amiodarone. Amiodarone’s high iodine content can inhibit thyroxine production, leading to hypothyroidism. However, amiodarone can usually be continued alongside levothyroxine to counteract this effect. As the patient’s AF is currently being effectively controlled by amiodarone, it would be inappropriate to switch to digoxin, dronedarone, or flecainide, as these medications would require a period of re-titration and assessment that could increase the risk of stroke due to the AF. Additionally, amiodarone is preferred in patients with structural heart disease, which this patient has due to her heart failure.
Amiodarone and Thyroid Dysfunction
Amiodarone is a medication used to treat heart rhythm disorders. However, around 1 in 6 patients taking amiodarone develop thyroid dysfunction. This can manifest as either amiodarone-induced hypothyroidism (AIH) or amiodarone-induced thyrotoxicosis (AIT).
The pathophysiology of AIH is thought to be due to the high iodine content of amiodarone causing a Wolff-Chaikoff effect. This is an autoregulatory phenomenon where thyroxine formation is inhibited due to high levels of circulating iodide. Despite this, amiodarone may be continued if desirable.
On the other hand, AIT may be divided into two types: type 1 and type 2. Type 1 is caused by excess iodine-induced thyroid hormone synthesis, while type 2 is caused by amiodarone-related destructive thyroiditis. In patients with AIT, amiodarone should be stopped if possible.
It is important for healthcare professionals to monitor patients taking amiodarone for any signs of thyroid dysfunction and adjust treatment accordingly.
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This question is part of the following fields:
- Pharmacology
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Question 5
Incorrect
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An 8-year-old girl visits her GP complaining of an itchy scalp. Upon detection combing, head lice are found. What is a recognized treatment for head lice?
Your Answer: Ketoconazole shampoo
Correct Answer: Dimeticone 4% gel
Explanation:Treatment Options for Head Lice
Head lice infestations are a common problem, especially among children. There are several treatment options available, but not all of them are effective or recommended. Here are some of the commonly used treatments and their effectiveness:
Dimeticone 4% gel: This gel works by suffocating and coating the lice, making it a well-recognized treatment for head lice.
Ketoconazole shampoo: While this medicated shampoo is used to treat suspected fungal infections in the scalp, it is not a recognized treatment for head lice.
Permethrin 5% cream: Although permethrin is an insecticide used to treat scabies, it is not recommended for head lice treatment as the 10-minute contact time may not be enough for it to be effective.
Topical antibiotics: These are not recommended for head lice treatment.
Topical antifungal: Topical antifungals have no role in the management of head lice.
In conclusion, dimeticone 4% gel is a well-recognized treatment for head lice, while other treatments such as ketoconazole shampoo, permethrin 5% cream, topical antibiotics, and topical antifungal are not recommended. It is important to consult a healthcare professional for proper diagnosis and treatment of head lice.
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This question is part of the following fields:
- Dermatology
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Question 6
Correct
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A 26-year-old nursing student has visited her GP clinic for her first cervical screening. She is curious about the testing procedure and knows that the sample will be screened for high-risk strains of HPV. The student inquires with the practice nurse about the next steps if the smear test comes back positive in the lab.
What follow-up test will be conducted if the smear test shows high-risk HPV (hrHPV) positivity?Your Answer: Cytology testing
Explanation:Cytological examination of a cervical smear sample is only conducted if it tests positive for high risk HPV (hrHPV). If the sample is negative for hrHPV, there is no need for cytology testing.
The cervical cancer screening program has evolved to include HPV testing, which allows for further risk stratification. A negative hrHPV result means a return to normal recall, while a positive result requires cytological examination. Abnormal cytology results lead to colposcopy, while normal cytology results require a repeat test at 12 months. Inadequate samples require a repeat within 3 months, and two consecutive inadequate samples lead to colposcopy. Treatment for CIN typically involves LLETZ or cryotherapy. Individuals who have been treated for CIN should be invited for a test of cure repeat cervical sample 6 months after treatment.
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This question is part of the following fields:
- Gynaecology
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Question 7
Correct
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A 70-year-old woman with a long history of arthritis presents with worsening difficulty walking. Upon examination, she displays several neurological abnormalities in her lower limbs. However, her upper limbs and cranial nerves appear normal. An MRI scan reveals a ruptured intervertebral disc at the L3-4 level. The diagnosis is cauda equina syndrome.
What is a characteristic of this syndrome?Your Answer: Urinary incontinence
Explanation:Understanding Cauda Equina Syndrome: Symptoms and Signs
Cauda equina syndrome is a condition that affects the bundle of nerves at the lower end of the spinal cord. It is important to recognize the symptoms and signs of this syndrome to ensure prompt diagnosis and treatment.
One of the key features of cauda equina syndrome is bladder and bowel dysfunction due to autonomic nerve involvement. This can result in urinary incontinence, which is often one of the first symptoms to appear. However, it is important to note that a lesion at the L3-4 level would not be associated with upper motor neuron signs.
Another potential symptom of cauda equina syndrome is bradycardia, which is a slow heart rate. This is typically only seen in cases where the spinal cord injury is located in the cervical or high thoracic region.
While cauda equina syndrome can cause weakness and sensory loss in the lower limbs, it is important to note that this is due to a lower motor neuron lesion, not an upper motor neuron lesion. Similarly, a lesion in the upper limbs would have to be higher to cause neurological symptoms and signs.
Finally, it is worth noting that a positive Babinski reflex is not typically associated with cauda equina syndrome. This reflex is a sign of an upper motor neuron lesion, which is not typically seen in this condition.
Overall, recognizing the symptoms and signs of cauda equina syndrome is crucial for prompt diagnosis and treatment. If you or someone you know is experiencing bladder or bowel dysfunction, weakness or sensory loss in the lower limbs, or other potential symptoms of this condition, it is important to seek medical attention right away.
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This question is part of the following fields:
- Neurosurgery
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Question 8
Correct
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A 40-year-old woman presents to your clinic with complaints of difficulty reading, which she has noticed over the past two weeks. She has never worn glasses and is not taking any medications.
Upon examination, her pupils are of normal size but react sluggishly to light. Both optic discs appear sharp, without signs of haemorrhages or exudates. However, her visual acuity is significantly impaired and remains so even when using a pinhole card. Additionally, she exhibits five-beat nystagmus and double vision when looking to the left.
What is the most likely diagnosis for this patient?Your Answer: Multiple sclerosis
Explanation:Possible Diagnosis of Multiple Sclerosis in a Young Woman
This young woman shows signs of retrobulbar neuritis, which is characterized by inflammation of the optic nerve behind the eye. Additionally, she exhibits some cerebellar features such as nystagmus, which is an involuntary eye movement. These symptoms suggest a possible diagnosis of Multiple sclerosis (MS), a chronic autoimmune disease that affects the central nervous system.
Further diagnostic tests can support this diagnosis. Visual evoked responses can measure the electrical activity in the brain in response to visual stimuli, which can be abnormal in MS. Magnetic resonance imaging (MRI) can reveal demyelinating plaques, or areas of damage to the protective covering of nerve fibers in the brain and spinal cord. Finally, oligoclonal bands can be detected in the cerebrospinal fluid (CSF) of MS patients, indicating an immune response in the central nervous system.
In summary, this young woman’s symptoms and diagnostic tests suggest a possible diagnosis of MS. Further evaluation and treatment by a healthcare professional are necessary to confirm this diagnosis and manage her symptoms.
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This question is part of the following fields:
- Neurology
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Question 9
Incorrect
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A 40-year-old woman presents to the Neurology Clinic with a complaint of droopy eyelids that have been present for the past 6 months. She reports experiencing intermittent double vision that varies in severity. She has also noticed difficulty swallowing her food at times. Upon examination, she displays mild weakness in eyelid closure bilaterally and mild lower facial weakness. Additionally, there is mild weakness in neck flexion and bilateral shoulder abduction. Reflexes are normal throughout, and the remainder of the examination is unremarkable. Electromyography is performed, revealing a 30% decrease in the compound motor action potential (CMAP) upon repetitive nerve stimulation (right abductor pollicis brevis muscle). Single-fibre electromyography shows normal fibre density and jitter. What is the most likely diagnosis?
Your Answer: Lambert–Eaton myasthenic syndrome
Correct Answer: Autoimmune myasthenia gravis
Explanation:Differentiating Myasthenia Gravis from Other Neuromuscular Disorders
Myasthenia gravis (MG) is an autoimmune disorder that causes muscle weakness and fatigue. It occurs when antibodies block the acetylcholine receptors at the neuromuscular junction, leading to impaired muscle function. This can be detected through electromyographic testing, which measures fatigability. However, other neuromuscular disorders can present with similar symptoms, making diagnosis challenging.
Congenital myasthenia gravis is a rare form that occurs in infants born to myasthenic mothers. Guillain-Barré syndrome, although typically presenting with ophthalmoplegia, can also cause muscle weakness and reflex abnormalities. Lambert-Eaton myasthenic syndrome is caused by autoantibodies to voltage-gated calcium channels and is characterized by absent reflexes. Polymyalgia rheumatica, an inflammatory disorder of the soft tissues, can cause pain and weakness in the shoulder girdle but does not affect nerve conduction or facial muscles.
Therefore, a thorough evaluation and diagnostic testing are necessary to differentiate MG from other neuromuscular disorders.
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This question is part of the following fields:
- Neurology
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Question 10
Incorrect
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A 55-year-old man with a recent diagnosis of prostate cancer is found to be positive for a BRCA2 mutation on genetic screening. He has a strong family history of prostate cancer, with both his father and uncle receiving treatment for the condition at a young age.
He is worried that he may have passed the gene onto his son and daughter. He is also concerned that his brother may have the gene, given their family history.
During counselling, what is the most appropriate statement to make regarding the risk of his family inheriting the BRCA2 gene?Your Answer: Both children have 25% chance of inheriting the gene while her sister has a 50% chance
Correct Answer: Both children and her sister have a 50% chance of inheriting the gene
Explanation:Breast Cancer Risk Factors: Understanding the Predisposing Factors
Breast cancer is a complex disease that can be influenced by various factors. Some of these factors are considered predisposing factors, which means they increase the likelihood of developing breast cancer. One of the most well-known predisposing factors is the presence of BRCA1 and BRCA2 genes, which can increase a person’s lifetime risk of breast and ovarian cancer by 40%. Other predisposing factors include having a first-degree relative with premenopausal breast cancer, nulliparity, having a first pregnancy after the age of 30, early menarche, late menopause, combined hormone replacement therapy, combined oral contraceptive use, past breast cancer, not breastfeeding, ionizing radiation, p53 gene mutations, obesity, and previous surgery for benign disease.
To reduce the risk of developing breast cancer, it is important to understand these predisposing factors and take steps to minimize their impact. For example, women with a family history of breast cancer may choose to undergo genetic testing to determine if they carry the BRCA1 or BRCA2 genes. Women who have not yet had children may consider having their first child before the age of 30, while those who have already had children may choose to breastfeed. Additionally, women who are considering hormone replacement therapy or oral contraceptives should discuss the potential risks and benefits with their healthcare provider. By understanding these predisposing factors and taking proactive steps to reduce their impact, women can help protect themselves against breast cancer.
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This question is part of the following fields:
- Surgery
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Question 11
Incorrect
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A 60-year-old patient who has not undergone a hysterectomy visits her GP clinic for a follow-up on her hormone replacement therapy (HRT). She is currently using an estradiol patch that she changes once a week and taking norethisterone orally on a daily basis.
What is the primary advice that the patient should be mindful of when taking progestogens?Your Answer: Increased risk of endometrial cancer
Correct Answer: Increased risk of breast cancer
Explanation:The addition of progesterone to hormone replacement therapy (HRT) has been linked to an increased risk of breast cancer, as well as venous thromboembolism and cardiovascular disease. HRT may be recommended for menopausal patients experiencing vasomotor symptoms such as hot flashes, night sweats, and palpitations. However, if a patient only presents with urogenital symptoms, topical oestrogens such as oestradiol creams or pessaries may be more appropriate. These act locally to alleviate vaginal dryness, reduce UTI recurrence, and ease dyspareunia. For patients with vasomotor symptoms, HRT preparations with systemic effects (such as oral medications, topical patches, and implants) may be considered. If the patient has not undergone a hysterectomy, their HRT regime must include both oestrogen and progesterone to prevent hypertrophy of the uterus and a 5-10x increased risk of endometrial carcinoma associated with unopposed oestrogen therapy.
Adverse Effects of Hormone Replacement Therapy
Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progesterone in women with a uterus, to alleviate menopausal symptoms. While it can be effective in reducing symptoms such as hot flashes and vaginal dryness, HRT can also have adverse effects and potential complications.
Some common side-effects of HRT include nausea, breast tenderness, fluid retention, and weight gain. However, there are also more serious potential complications associated with HRT. For example, the use of HRT has been linked to an increased risk of breast cancer, particularly when a progesterone is added. The Women’s Health Initiative study found a relative risk of 1.26 at 5 years of developing breast cancer with HRT use. The risk of breast cancer is also related to the duration of use, and it begins to decline when HRT is stopped.
Another potential complication of HRT is an increased risk of endometrial cancer. Oestrogen by itself should not be given as HRT to women with a womb, as this can increase the risk of endometrial cancer. The addition of a progesterone can reduce this risk, but it is not eliminated completely. The British National Formulary states that the additional risk is eliminated if a progesterone is given continuously.
HRT has also been associated with an increased risk of venous thromboembolism (VTE), particularly when a progesterone is added. However, transdermal HRT does not appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any treatment, even transdermal, according to the National Institute for Health and Care Excellence (NICE).
Finally, HRT has been linked to an increased risk of stroke and ischaemic heart disease if taken more than 10 years after menopause. It is important for women considering HRT to discuss the potential risks and benefits with their healthcare provider and make an informed decision based on their individual circumstances.
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This question is part of the following fields:
- Gynaecology
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Question 12
Incorrect
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A 56-year-old woman presents to the clinic with a complaint of feeling like there is a lump in her throat. She reports an itching sensation, but no pain. The symptoms are intermittent and not related to swallowing solids or liquids, and there is no persistent hoarseness. She also reports feeling anxious and tired. There is no significant family history. She was a heavy smoker between the ages of 22-32 but has since quit smoking and drinking. Her blood profile and thyroid function tests show the following results:
- Haemoglobin: 98 g/l (normal range: 115-165 g/l)
- Mean corpuscular value: 75 fl (normal range: 80-100 fl)
- Thyroid stimulating hormone: 2.2 mU/L (normal range: 0.45-4.1 mU/L)
What is the most appropriate initial investigation for this patient?Your Answer: Ultrasound neck
Correct Answer: Naso-endoscopy
Explanation:The patient is experiencing globus sensation, but before being discharged, it is important to rule out any serious conditions. Given the patient’s history of smoking and anemia, a naso-endoscopy should be performed as an initial investigation. If the results are clear, the patient can be reassured and discharged. A CT neck is not necessary at this time unless the endoscopy results are inconclusive. A barium swallow would only be appropriate if a tumor was suspected, making it a second-line investigation. An ultrasound of the neck would only be necessary if a specific mass or thyroid issue was suspected, which is not the case here. Globus sensation can typically be diagnosed through a clinical examination and a ridged endoscopy. Overall, the initial investigation should focus on ruling out any serious conditions before considering further tests.
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This question is part of the following fields:
- ENT
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Question 13
Incorrect
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A 35-year-old woman arrives at the emergency department five days after giving birth without any complications. Her husband brings her in after noticing a sudden change in her behavior. He reports that she appears confused and agitated. During the mental state examination, she describes having racing thoughts, feeling depressed, and having suicidal thoughts. Additionally, she exhibits pressured speech. What is the probable diagnosis?
Your Answer:
Correct Answer: Puerperal psychosis
Explanation:Puerperal psychosis is a condition that manifests as a sudden onset of manic or psychotic symptoms shortly after giving birth. Any sudden change in mental state should be considered a warning sign for puerperal psychosis. On the other hand, the baby blues is a milder form of depression that typically lasts only a few days after childbirth. While postpartum depression can also involve psychosis, it usually appears within the first month after delivery. Furthermore, manic symptoms such as restlessness, racing thoughts, and pressured speech are unlikely to occur in a depressive episode.
Understanding Postpartum Mental Health Problems
Postpartum mental health problems can range from mild ‘baby-blues’ to severe puerperal psychosis. To screen for depression, healthcare professionals may use the Edinburgh Postnatal Depression Scale, which is a 10-item questionnaire that indicates how the mother has felt over the previous week. A score of more than 13 indicates a ‘depressive illness of varying severity’, with sensitivity and specificity of more than 90%. The questionnaire also includes a question about self-harm.
‘Baby-blues’ is seen in around 60-70% of women and typically occurs 3-7 days following birth. It is more common in primips, and mothers are characteristically anxious, tearful, and irritable. Reassurance and support from healthcare professionals, particularly health visitors, play a key role in managing this condition. Most women with the baby blues will not require specific treatment other than reassurance.
Postnatal depression affects around 10% of women, with most cases starting within a month and typically peaking at 3 months. The features are similar to depression seen in other circumstances, and cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe. Although these medications are secreted in breast milk, they are not thought to be harmful to the infant.
Puerperal psychosis affects approximately 0.2% of women and requires admission to hospital, ideally in a Mother & Baby Unit. Onset usually occurs within the first 2-3 weeks following birth, and features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations). There is around a 25-50% risk of recurrence following future pregnancies. Paroxetine is recommended by SIGN because of the low milk/plasma ratio, while fluoxetine is best avoided due to a long half-life.
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This question is part of the following fields:
- Obstetrics
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Question 14
Incorrect
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A 35-year-old woman with bipolar disorder has been consistently taking her medication during pregnancy. During her recent ultrasound, her baby was found to have characteristics linked to spina bifida. Which medication is the most probable cause of this?
Your Answer:
Correct Answer: Sodium valproate
Explanation:The Teratogenic Effects of Certain Medications During Pregnancy
During pregnancy, certain medications can have teratogenic effects on the developing fetus. One such medication is sodium valproate, which is an anticonvulsant and bipolar disorder treatment. Its use during pregnancy is contraindicated due to its association with congenital malformations and neurodevelopmental disorders, such as spina bifida, congenital heart defects, cleft lip, and neonatal bleeding disorders. If sodium valproate must be used during pregnancy, the lowest effective dose should be administered and additional monitoring is required.
Lithium therapy during pregnancy has also been linked to an increased risk of congenital heart disease, stillbirth, and early infant deaths, as well as increased risk of toxicity for both the mother and fetus. Olanzapine, on the other hand, has been found to have the same risk of congenital defects as the general population.
Bupropion has been associated with an increased risk of congenital heart defects if used during pregnancy. However, studies suggest that carbamazepine has one of the lowest rates of teratogenicity when used during pregnancy. It is important for healthcare providers to carefully consider the risks and benefits of medication use during pregnancy and to explore alternative options whenever possible.
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This question is part of the following fields:
- Pharmacology
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Question 15
Incorrect
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A 28-year-old woman comes to the clinic after two positive pregnancy tests and seeks guidance on how to have a healthy pregnancy. She is in good health, takes folic acid, and smokes 20 cigarettes per day.
You recognize the importance of quitting smoking for the well-being of the pregnancy and employ motivational interviewing techniques to address her smoking.
What is the initial step in this process?Your Answer:
Correct Answer: Establish rapport and find out whether she wants to change
Explanation:Best Practices for Motivational Interviewing in Smoking Cessation during Pregnancy
Motivational interviewing is a patient-centered approach that aims to elicit and strengthen the patient’s own motivation and commitment to change. When it comes to smoking cessation during pregnancy, there are several best practices to follow.
Firstly, it is important to establish rapport and assess the patient’s readiness to discuss behavior change. This involves determining which stage of change the patient is at and working accordingly from there.
Next, it is important to assess the patient’s perceived difficulties and barriers to change, often using a numerical scale. However, this should not be done as the first step.
Explaining and advising why smoking is harmful in pregnancy should also not be the first step. Instead, it is best to find out what the patient understands about the risks of smoking in pregnancy and then evoke the patient’s own motivations for change, if present.
It is important to avoid trying to break down any resistance shown by the patient. Instead, a therapeutic relationship resembling a partnership or team should be used as the cornerstone from which changes can be explored or pursued.
Finally, using a numerical scale to assess the patient’s confidence and willingness to quit smoking is an important step, but should not be done in the first instance. By following these best practices, healthcare providers can effectively use motivational interviewing to support smoking cessation during pregnancy.
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This question is part of the following fields:
- Obstetrics
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Question 16
Incorrect
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A 28-year-old man and his 26-year-old wife visit their GP for a follow-up appointment regarding their difficulty in conceiving. The couple has been trying to conceive for the past year without success. The wife has a regular menstrual cycle and no previous gynaecological issues. An ovulation test measuring her progesterone level showed normal ovulation. The GP advises the couple that the husband needs to undergo tests to determine if there is any cause on his side contributing to the infertility. Both the man and the woman have no history of sexually transmitted infections. The man has been smoking one to two cigarettes a day since he was 16 years old. What is the best next investigation for this patient?
Your Answer:
Correct Answer: Semen analysis
Explanation:Investigations for Male Infertility: Semen Analysis, Testicular Biopsy, Hormone and Genetic Testing
When a couple experiences fertility problems, a semen analysis is typically the first investigation for the man. This test measures semen volume, pH, sperm concentration, total sperm number, total motility, vitality, and sperm morphology, using World Health Organization reference values for interpretation. If the semen analysis reveals azoospermia (no sperm present), a testicular biopsy may be performed to collect spermatozoa for in-vitro fertilization treatment.
If the semen analysis does not explain the infertility, follicle-stimulating hormone and testosterone levels may be measured, but these are not first-line investigations. Genetic testing may also be considered to identify genetic abnormalities, such as Klinefelter syndrome, which can cause male infertility. Overall, a combination of these investigations can help diagnose and treat male infertility.
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This question is part of the following fields:
- Urology
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Question 17
Incorrect
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You review a 47-year-old man who is postoperative following a laparotomy. He complains of a lump in the middle of his abdomen. On examination, you note a mass arising from the site of surgical incision, which is reducible and reproducible when the patient coughs.
Which of the following is a risk factor for the development of an incisional hernia?Your Answer:
Correct Answer: Wound infection
Explanation:Understanding Risk Factors for Incisional Hernia Development
An infected wound can increase the risk of developing an incisional hernia due to poor wound healing and susceptibility to abdominal content herniation. Increasing age is also a risk factor, likely due to delayed wound healing and reduced collagen synthesis. However, being tall and thin does not increase the risk, while obesity can increase abdominal pressure and lead to herniation. A sedentary lifestyle does not appear to be associated with incisional hernias, but smoking and nutritional deficiencies can increase the risk. Post-operative vomiting, not nausea alone, can cause episodic increases in abdominal pressure and increase the risk of herniation. Understanding these risk factors can help prevent the development of incisional hernias.
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This question is part of the following fields:
- Surgery
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Question 18
Incorrect
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A 42-year-old man is admitted with a 30-min history of severe central ‘crushing’ chest pain radiating down the left arm. He is profusely sweating and looks ‘grey’. The electrocardiogram (ECG) shows sinus tachycardia and 3-mm ST elevation in V3–V6.
Which of the following is the most appropriate treatment?Your Answer:
Correct Answer: Give the patient aspirin, ticagrelor and low-molecular-weight heparin, followed by a primary percutaneous coronary intervention (PCI)
Explanation:Treatment Options for ST Elevation Myocardial Infarction (STEMI)
When a patient presents with a ST elevation myocardial infarction (STEMI), prompt and appropriate treatment is crucial. The gold standard treatment for a STEMI is a primary percutaneous coronary intervention (PCI), which should be performed as soon as possible. In the absence of contraindications, all patients should receive aspirin, ticagrelor, and low-molecular-weight heparin before undergoing PCI.
Delaying PCI by treating the pain with sublingual glyceryl trinitrate (GTN), aspirin, and oxygen, and reviewing the patient in 15 minutes is not recommended. Similarly, giving the patient aspirin, ticagrelor, and low molecular weight heparin without performing PCI is incomplete management.
Thrombolysis therapy can be performed on patients without access to primary PCI. However, if primary PCI is available, it is the preferred treatment option.
It is important to note that waiting for cardiac enzymes is not recommended as it would only result in a delay in definitive management. Early and appropriate treatment is crucial in improving outcomes for patients with STEMI.
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This question is part of the following fields:
- Cardiology
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Question 19
Incorrect
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A 50-year-old woman presents with a few months history of abdominal pain and diarrhoea. Further questioning reveals increasing episodes of facial flushing and occasional wheeze. Clinical examination reveals irregular, craggy hepatomegaly. Abdominal CT is performed which revealed nonspecific thickening of a terminal small bowel loop, a large calcified lesion in the small bowel mesentery and innumerable lesions in the liver.
What is the most likely diagnosis?Your Answer:
Correct Answer: Carcinoid syndrome
Explanation:Understanding Carcinoid Syndrome and Differential Diagnosis
Carcinoid syndrome is a rare neuroendocrine tumor that secretes serotonin and is commonly found in the terminal ileum. While the primary tumor is often asymptomatic, metastasis can lead to symptoms such as diarrhea, facial flushing, and bronchospasm. Abdominal pain may also be present due to liver and mesenteric metastases. Diagnosis is made through biopsy or finding elevated levels of 5-HIAA in urine. Treatment options include surgery, chemotherapy, and somatostatin analogues like octreotide.
Whipple’s disease presents with diarrhea, weight loss, and migratory arthritis, typically affecting the duodenum. Yersinia ileitis and tuberculosis both affect the terminal ileum and cause diarrhea and thickening of small bowel loops on CT, but do not match the symptoms and imaging findings described in the case of carcinoid syndrome. Normal menopause is also not a likely diagnosis based on the patient’s history and imaging results. A thorough differential diagnosis is important in accurately identifying and treating carcinoid syndrome.
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This question is part of the following fields:
- Gastroenterology
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Question 20
Incorrect
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A 42-year-old teacher from Manchester presents to her GP with a 3 month history of nonspecific upper right quadrant pain and nausea. The pain is constant, not radiating, and not affected by food. She denies any changes in bowel habits, weight loss, or fever. She drinks approximately 8 units of alcohol per week, is a non-smoker, and has no significant medical history. The GP orders blood tests and a liver ultrasound, with the following results:
Full blood count, electrolytes, liver function tests, and clotting profile are all within normal limits.
HBs antigen is negative.
Anti-HBs is positive.
Anti-HBc is negative.
IgM anti-HBc is negative.
Ultrasound reveals a single 11cm x 8 cm hyperechoic lesion in the right lobe of the liver, without other abnormalities detected and no biliary tree abnormalities noted.
What is the most likely cause of this patient's symptoms?Your Answer:
Correct Answer: Hepatic haemangioma
Explanation:Haemangiomas are benign liver growths that are usually small and do not increase in size over time. However, larger growths can cause symptoms by pressing on nearby structures, such as the stomach or biliary tree. Symptoms may include early satiety, nausea, obstructive jaundice, and right upper quadrant pain. Hepatic haemangiomas are more common than hepatocellular carcinomas in Western populations without risk factors. The presence of anti-HBs indicates previous hepatitis immunisation or immunity, which is likely for a UK phlebotomist. Symptoms of biliary colic and peptic ulcer disease typically vary with food intake, and ultrasound can detect biliary pathology such as gallbladder thickening or the presence of stones.
Benign liver lesions are non-cancerous growths that can occur in the liver. One of the most common types of benign liver tumors is a haemangioma, which is a reddish-purple hypervascular lesion that is typically separated from normal liver tissue by a ring of fibrous tissue. Liver cell adenomas are another type of benign liver lesion that are usually solitary and can be linked to the use of oral contraceptive pills. Mesenchymal hamartomas are congenital and benign, and usually present in infants. Liver abscesses can also occur, and are often caused by biliary sepsis or infections in structures drained by the portal venous system. Amoebic abscesses are a type of liver abscess that are caused by amoebiasis, and are typically seen in the right lobe of the liver. Hydatid cysts are another type of benign liver lesion that are caused by Echinococcus infection, and can grow up to 20 cm in size. Polycystic liver disease is a condition that is usually associated with polycystic kidney disease, and can cause symptoms as a result of capsular stretch. Cystadenomas are rare benign liver lesions that have malignant potential and are usually solitary multiloculated lesions. Surgical resection is often indicated for the treatment of these lesions.
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This question is part of the following fields:
- Surgery
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Question 21
Incorrect
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A 7-year-old girl was brought to the Emergency Department by her parents. Her lips were swollen; she had stridor and was short of breath, and she was sweaty and clammy. She has a known allergy to shellfish and had eaten some seafood at a family gathering.
What is the appropriate course of action?Your Answer:
Correct Answer: 300 mcg of 1 : 1000 adrenaline im
Explanation:Correct Doses and Administration of Adrenaline for Anaphylaxis
Adrenaline is a crucial medication for treating anaphylaxis, and it is always administered intramuscularly (im) at a concentration of 1:1000. However, it is essential to know the correct doses and volumes for different age groups, as vials can vary.
For adults and children over 12 years old, the appropriate dose is 500 mcg or 0.5 ml. For children aged 6-12 years, the correct dose is 300 mcg or 0.3 ml. For children under 6 years old, the recommended dose is 150 mcg or 0.15 ml.
It is crucial to administer the correct dose for the patient’s age and weight to avoid adverse effects. Additionally, it is essential to administer adrenaline im and not intravenously (iv) to prevent complications. By following these guidelines, healthcare providers can ensure safe and effective treatment of anaphylaxis with adrenaline.
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This question is part of the following fields:
- Acute Medicine And Intensive Care
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Question 22
Incorrect
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An 8-year-old boy arrives at the Emergency Department after falling on his outstretched hand. He is experiencing severe pain and cannot move his arm. An X-ray shows a fracture of the distal radius, along with dislocation of the distal radioulnar joint. The ulna appears to be intact. What is the most probable type of injury that this patient has suffered?
Your Answer:
Correct Answer: Galeazzi fracture-dislocation
Explanation:Common Fracture-Dislocations: Types and Characteristics
Fracture-dislocations are common injuries that occur due to falls or direct blows. Here are some of the most common types and their characteristics:
Galeazzi Fracture-Dislocation: This type of injury is most common in children and occurs when falling onto an outstretched hand with the elbow in flexion. It involves a radial shaft fracture with dorsal angulation, dislocation of the distal radioulnar joint, and radial shortening. Surgical fixation is required due to its instability.
Colles Fracture: This type of fracture occurs following a fall onto an outstretched hand and involves a fracture of the distal radius with dorsal angulation and impaction. There is no associated dislocation of the distal radioulnar joint.
Bankart Fracture: This type of fracture occurs as a complication of an anterior shoulder dislocation where the labrum and glenohumeral capsule/ligament are injured due to compression of the humeral head against the labrum. It is often seen with a Hill-Sachs lesion.
Monteggia Fracture-Dislocation: This type of injury involves a fracture of the ulnar shaft and dislocation of the radial head. It typically occurs following a fall onto an outstretched hand.
Smith’s Fracture: This type of fracture occurs due to a fall onto a flexed wrist or a direct blow to the back of the wrist. It involves a fracture of the distal radius with volar, not dorsal, angulation of the distal fragments.
In summary, fracture-dislocations are common injuries that require prompt medical attention and appropriate treatment to ensure proper healing and prevent long-term complications.
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This question is part of the following fields:
- Trauma
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Question 23
Incorrect
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A 65-year-old man has been diagnosed as being vitamin B12-deficient with a B12 level of < 50 pmol/l (160–900 pmol/l) and a haemoglobin (Hb) level of 85 (115–155 g/l). It is not diet-related.
What is the most suitable course of action?Your Answer:
Correct Answer: Hydroxocobalamin 1 mg im three times a week for two weeks and then 1 mg im 3-monthly
Explanation:Treatment Options for Pernicious Anemia with Hydroxocobalamin
Pernicious anemia is a type of anemia caused by a deficiency in vitamin B12, often due to the presence of anti-intrinsic factor antibodies. Hydroxocobalamin is a form of vitamin B12 that can be used for supplementation in patients with pernicious anemia. Here are some treatment options with hydroxocobalamin:
1. Hydroxocobalamin 1 mg IM three times a week for two weeks, then 1 mg IM every three months: This is the standard dose for patients with pernicious anemia without neurological deficits.
2. Hydroxocobalamin 1 mg IM on alternate days indefinitely: This is used for patients with pernicious anemia and neurological involvement until symptom improvement reaches a plateau, then maintenance involves 1 mg IM every two months.
3. Hydroxocobalamin 1 mg IV three times a week for two weeks, then monthly: This is used for the treatment of cyanide poisoning, not for pernicious anemia.
4. Hydroxocobalamin 1 mg IM three times a week for two weeks, then oral 1 mg hydroxocobalamin: Oral supplementation is not appropriate for patients with pernicious anemia due to absorption issues.
5. Hydroxocobalamin 1 mg subcutaneously three times a week for two weeks, monthly for three months, then 3-monthly: Hydroxocobalamin is administered IM, not subcutaneously.
In conclusion, hydroxocobalamin is an effective treatment option for pernicious anemia, but the dosage and administration route should be carefully considered based on the patient’s individual needs.
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This question is part of the following fields:
- Haematology
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Question 24
Incorrect
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An 80-year-old man is brought to the Emergency Department from a nursing home with fever and a non-healing infected ulcer in his leg. He has a history of obesity and type 2 diabetes. He reports that his leg was extremely painful but now is no longer painful. On clinical examination, his temperature is 38.6 °C, heart rate 110 bpm and blood pressure 104/69 mmHg. Peripheral pulses are palpable on examining his legs. There is tense oedema, dusky blue/purple plaques and haemorrhagic bullae on his right leg, with an underlying venous ulcer. Palpation reveals crepitus. After taking blood cultures, treatment is commenced with intravenous (IV) antibiotics and fluids.
What is the next and most important step in management?Your Answer:
Correct Answer: Surgical debridement in theatre
Explanation:Treatment Options for Necrotising Fasciitis
Necrotising fasciitis (NF) is a serious medical emergency that requires immediate surgical intervention. Antimicrobial therapy and support alone have shown to have a mortality rate of almost 100%. The primary goal of surgical intervention is to remove all necrotic tissue until healthy, viable tissue is reached. This can be done through surgical debridement in theatre or bedside wound debridement by a plastic surgeon in an aseptic environment.
Hyperbaric oxygen (HBO) treatment is believed to increase the bactericidal effects of neutrophils and can be useful in treating synergistic infections. However, access to HBO units with appropriate staffing and chambers large enough for intensive care patients is limited.
IV immunoglobulin (IVIG) has shown potential benefits in group A streptococcal (GAS) infections, but further studies are needed to determine its exact benefits in NF.
While X-ray, MRI, and CT scans can aid in the diagnosis of NF, surgical treatment should never be delayed for these tests. Immediate surgical intervention is crucial in treating this life-threatening condition.
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This question is part of the following fields:
- Acute Medicine And Intensive Care
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Question 25
Incorrect
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What are the typical vaccines administered to adolescents aged 12-19 years?
Your Answer:
Correct Answer: Tetanus/diphtheria/polio + Men ACWY
Explanation:The UK immunisation schedule recommends certain vaccines at different ages. At birth, the BCG vaccine is given if the baby is at risk of tuberculosis. At 2, 3, and 4 months, the ‘6-1 vaccine’ (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) and oral rotavirus vaccine are given, along with Men B and PCV at certain intervals. At 12-13 months, the Hib/Men C, MMR, and PCV vaccines are given, along with Men B. At 3-4 years, the ‘4-in-1 preschool booster’ (diphtheria, tetanus, whooping cough and polio) and MMR vaccines are given. At 12-13 years, the HPV vaccination is given, and at 13-18 years, the ‘3-in-1 teenage booster’ (tetanus, diphtheria and polio) and Men ACWY vaccines are given. Additionally, the flu vaccine is recommended annually for children aged 2-8 years.
It is important to note that the meningitis ACWY vaccine has replaced meningitis C for 13-18 year-olds due to an increased incidence of meningitis W disease in recent years. The ACWY vaccine will also be offered to new students (up to the age of 25 years) at university. GP practices will automatically send letters inviting 17-and 18-year-olds in school year 13 to have the Men ACWY vaccine. Students going to university or college for the first time as freshers, including overseas and mature students up to the age of 25, should contact their GP to have the Men ACWY vaccine, ideally before the start of the academic year.
It is worth noting that the Men C vaccine used to be given at 3 months but has now been discontinued. This is because the success of the Men C vaccination programme means there are almost no cases of Men C disease in babies or young children in the UK any longer. All children will continue to be offered the Hib/Men C vaccine at one year of age, and the Men ACWY vaccine at 14 years of age to provide protection across all age groups.
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This question is part of the following fields:
- Paediatrics
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Question 26
Incorrect
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A 25-year-old patient is worried about her amenorrhea for the past 3 months. She has a body mass index of 33 kg/m² and severe acne. A pregnancy test came back negative. Upon testing, her results are as follows:
Investigation Result Normal value
Testosterone 3.5 nmol/l 0.21-2.98 nmol/l
Luteinizing hormone (LH) 31 u/l 3-16 u/l
Follicle-stimulating hormone (FSH) 5 u/l 2-8 u/l
What is the most probable diagnosis?Your Answer:
Correct Answer: Polycystic ovary syndrome
Explanation:Differential Diagnosis for Secondary Amenorrhoea: Polycystic Ovary Syndrome, Cushing’s Syndrome, Primary Ovarian Failure, Hypothalamic Disease, and Adrenal Tumour
Secondary amenorrhoea, the cessation of menstruation after previously menstruating, can have various causes. In a patient who is overweight, has acne, and slightly elevated testosterone and LH levels, polycystic ovary syndrome (PCOS) is a likely diagnosis. PCOS is characterized by small cysts in the ovaries and is linked to insulin resistance, hypertension, lipid abnormalities, and increased risk for cardiovascular disease. Hirsutism is also common in PCOS.
Cushing’s syndrome is a potential differential diagnosis for this patient, but blood results would show suppression of LH and FSH, not elevation. Primary ovarian failure is much rarer than PCOS and would show elevated serum FSH levels. Hypothalamic disease is less likely in this patient with multiple risk factors for PCOS, as it would result in decreased production of gonadotropin-releasing hormone and lower than normal detectable serum levels of LH and FSH. An adrenal tumour, particularly an adenoma, could rarely lead to amenorrhoea, but would also present with other symptoms such as palpitations and weight loss. Other adrenal tumours that secrete sex hormones are even rarer and would also be associated with weight loss.
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This question is part of the following fields:
- Gynaecology
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Question 27
Incorrect
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A 2-year-old girl presents to the emergency department with a 1-day history of rectal bleeding. Her parents report seeing fresh blood in her nappies mixed with her stool. Upon examination, she appears alert, active, afebrile, and hemodynamically stable. She has non-specific abdominal tenderness without guarding, and there is no active bleeding. An abdominal ultrasound is performed, which shows no abnormalities. Meckel's diverticulum is suspected. What is the most appropriate next step in investigating this patient?
Your Answer:
Correct Answer: Technetium scan
Explanation:When investigating stable children with suspected Meckel’s diverticulum, a technetium scan is the preferred method.
Meckel’s diverticulum is a small pouch in the small intestine that is present from birth. It is a leftover part of the omphalomesenteric duct, which is also known as the vitellointestinal duct. The diverticulum can contain tissue from the ileum, stomach, or pancreas. This condition is relatively rare, occurring in only 2% of the population. Meckel’s diverticulum is typically located about 2 feet from the ileocaecal valve and is around 2 inches long.
In most cases, Meckel’s diverticulum does not cause any symptoms and is only discovered incidentally during medical tests. However, it can cause abdominal pain that is similar to appendicitis, rectal bleeding, and intestinal obstruction. In fact, it is the most common cause of painless massive gastrointestinal bleeding in children between the ages of 1 and 2 years.
To diagnose Meckel’s diverticulum, doctors may perform a Meckel’s scan using a radioactive substance that has an affinity for gastric mucosa. In more severe cases, mesenteric arteriography may be necessary. Treatment typically involves surgical removal of the diverticulum if it has a narrow neck or is causing symptoms. The options for surgery include wedge excision or formal small bowel resection and anastomosis.
Meckel’s diverticulum is caused by a failure of the attachment between the vitellointestinal duct and the yolk sac to disappear during fetal development. The diverticulum is typically lined with ileal mucosa, but it can also contain ectopic gastric, pancreatic, or jejunal mucosa. This can increase the risk of peptic ulceration and other complications. Meckel’s diverticulum is often associated with other conditions such as enterocystomas, umbilical sinuses, and omphalocele fistulas.
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This question is part of the following fields:
- Paediatrics
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Question 28
Incorrect
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A 50-year-old man with a history of ulcerative colitis attends the Gastroenterology Clinic for review. Over the past few months, his bowel symptoms have been generally quiescent, but he has suffered from tiredness and itching.
On examination, you notice that he has jaundiced sclerae and there are some scratch marks on his abdomen consistent with the itching.
Investigations:
Investigation Result Normal value
Sodium (Na+) 139 mmol/l 135–145 mmol/l
Potassium (K+) 4.0 mmol/l 3.5–5.0 mmol/l
Urea 5.6 mmol/l 2.5–6.5 mmol/l
Creatinine 90 μmol/l 50–120 µmol/l
Haemoglobin 110 g/l 135–175 g/l
White cell count (WCC) 6.1 × 109/l 4–11 × 109/l
Platelets 290 × 109/l 150–400 × 109/l
Erythrocyte sedimentation rate (ESR) 45 mm/hour 0–10mm in the 1st hour
Autoantibody screen ANCA +, anti-cardiolipin +, ANA +
Alanine aminotransferase (ALT) 75 IU/l 5–30 IU/l
Alkaline phosphatase 290 IU/l 30–130 IU/l
Bilirubin 85 μmol/l 2–17 µmol/l
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Primary sclerosing cholangitis (PSC)
Explanation:Differentiating Primary Sclerosing Cholangitis from Other Liver Conditions
Primary sclerosing cholangitis (PSC) is a condition that affects around 4% of patients with a history of inflammatory bowel disease. It is characterized by an obstructive liver function test (LFT) picture and autoantibody results consistent with PSC. While endoscopic retrograde cholangiopancreatography (ERCP) has been considered the gold standard for diagnosis, magnetic resonance cholangiopancreatography (MRCP) is now equally useful. Imaging typically shows a beaded appearance of biliary ducts, and liver biopsy may be useful in determining prognosis. Median survival from diagnosis to death or liver transplantation is around 10-15 years, with a disease recurrence rate of at least 30% in transplanted patients.
Cholelithiasis, on the other hand, typically presents with colicky abdominal pain and does not usually cause jaundice unless there is obstruction of the biliary system. Hepatocellular carcinoma risk is increased in patients with inflammatory bowel disease, but the clinical picture above is more in keeping with PSC. Primary biliary cholangitis would show positive anti-mitochondrial antibodies and mainly affect intrahepatic ducts, while ascending cholangitis would usually present with features of Charcot’s triad (jaundice, abdominal pain, and fever).
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This question is part of the following fields:
- Gastroenterology
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Question 29
Incorrect
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A 32-year-old Welsh Guard returning from operational duty overseas has been suffering from nightmares and intrusive memories of his military experiences for the past 6 months. He avoids anything that reminds him of his tour of duty and is emotionally detached. He has trouble sleeping, concentrating, and is easily startled by loud noises. Additionally, he has been abusing alcohol. What is the probable diagnosis?
Your Answer:
Correct Answer: Post-traumatic stress disorder (PTSD)
Explanation:Understanding Different Types of Anxiety Disorders
Post-traumatic stress disorder (PTSD) is characterized by a mix of anxiety and dissociative symptoms that persist for several months. Patients with PTSD often experience unintentional recollection, flashbacks, and nightmares of the traumatic event. They may also exhibit symptoms of chronic hyperarousal, such as sleep disruptions, irritability, and hypervigilance.
Panic disorder with agoraphobia is diagnosed in patients who avoid situations that they believe may trigger a panic attack or where it would be dangerous or embarrassing to have one.
Acute stress disorder is a condition that typically subsides within a month and is most common in patients who use dissociation to separate the events from the associated painful emotions.
Generalized anxiety disorder is characterized by a mental state of dread or fear and somatic manifestations, such as palpitations, churning stomach, and muscle tension. Patients with this disorder often have fears concerning many aspects of their personal security.
Somatization disorder is a condition where patients seek medical attention for cryptic physical symptoms that are difficult to explain. Patients with this disorder complain of problems in at least four different organ systems, usually without clear physical cause. They often deny anxiety or psychic distress, except for distress about their physical condition.
Overall, understanding the different types of anxiety disorders and their symptoms can help with proper diagnosis and treatment.
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This question is part of the following fields:
- Psychiatry
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Question 30
Incorrect
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A 25-year-old woman visits her GP complaining of sweating, tremors, and palpitations that have been ongoing for 6 weeks. The patient is currently 7 months pregnant and has no significant medical history. Upon examination, the patient has bulging eyes, a heart rate of 110 bpm, and a small goitre. The following laboratory results were obtained:
- Free T4: 42 pmol/l (normal range: 11-22 pmol/l)
- Free T3: 16 pmol/l (normal range: 3.5-5 pmol/l)
- Thyroid stimulating hormone (TSH): <0.01 µU/l (normal range: 0.17-3.2 µU/l)
- TSH receptor antibody (TRAb): 20 U/l (normal range: <0.9 U/l)
What treatment should be recommended for this patient?Your Answer:
Correct Answer: Carbimazole
Explanation:The patient is showing signs of an overactive thyroid, likely due to Graves’ disease. Propranolol can provide temporary relief, but long-term treatment involves blocking the thyroid gland with carbimazole or replacing thyroid hormones with thyroxine. Ibuprofen is not indicated for this condition. Tri-iodothyronine is more potent than thyroxine but less stable, making thyroxine the preferred hormone replacement medication. Propylthiouracil can also be used to block thyroid hormone formation, but its use in the first trimester of pregnancy is avoided due to potential teratogenic effects. PTU can be used in pregnancy, but only at the lowest effective dose.
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This question is part of the following fields:
- Endocrinology
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