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  • Question 1 - A 60-year-old man is discovered to have hypocalcaemia during routine blood tests for...

    Incorrect

    • A 60-year-old man is discovered to have hypocalcaemia during routine blood tests for his chronic kidney disease. He has a medical history of polycystic kidney disease, and it is anticipated that the low calcium result is a complication of this. What abnormalities would you anticipate in his other laboratory values?

      Your Answer: ↓ serum phosphate, ↑ ALP and ↑ PTH

      Correct Answer: ↑ serum phosphate, ↑ ALP and ↑ PTH

      Explanation:

      Chronic kidney disease can lead to secondary hyperparathyroidism, which is characterized by low serum calcium, high serum phosphate, high ALP, and high PTH levels. The kidneys are unable to activate vitamin D and excrete phosphate, resulting in calcium being used up in calcium phosphate. This leads to hypocalcemia, which triggers an increase in PTH levels to try and raise calcium levels. PTH stimulates osteoclast activity, causing a rise in ALP found in bone. Normal serum phosphate, normal ALP, and normal PTH levels are associated with osteoporosis or osteopetrosis, but in this case, the patient’s hypocalcemia and chronic kidney disease suggest other abnormal results. High serum phosphate, normal ALP, and low PTH levels are found in hypoparathyroidism, which is not consistent with chronic kidney disease. Low serum phosphate, normal ALP, and normal PTH levels suggest an isolated phosphate deficiency, which is also not consistent with the patient’s clinical picture.

      Lab Values for Bone Disorders

      When it comes to bone disorders, certain lab values can provide important information for diagnosis and treatment. In cases of osteoporosis, calcium, phosphate, alkaline phosphatase (ALP), and parathyroid hormone (PTH) levels are typically within normal ranges. However, in osteomalacia, there is a decrease in calcium and phosphate levels, an increase in ALP levels, and an increase in PTH levels.

      Primary hyperparathyroidism, which can lead to osteitis fibrosa cystica, is characterized by increased calcium and PTH levels, but decreased phosphate levels. Chronic kidney disease can also lead to secondary hyperparathyroidism, with decreased calcium levels and increased phosphate and PTH levels.

      Paget’s disease, which causes abnormal bone growth, typically shows normal calcium and phosphate levels, but an increase in ALP levels. Osteopetrosis, a rare genetic disorder that causes bones to become dense and brittle, typically shows normal lab values for calcium, phosphate, ALP, and PTH.

      Overall, understanding these lab values can help healthcare professionals diagnose and treat various bone disorders.

    • This question is part of the following fields:

      • Musculoskeletal
      23.7
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  • Question 2 - A 50-year-old woman visits your clinic to ask about the national screening programme...

    Incorrect

    • A 50-year-old woman visits your clinic to ask about the national screening programme for colorectal cancer. What is the correct statement regarding this?

      Your Answer: Faecal immunochemical test (FIT) test kits are sent every 2 years to all patients aged 50- 74 years, 50-64 years in Scotland

      Correct Answer: Faecal immunochemical test (FIT) test kits are sent every 2 years to all patients aged 60-74 years in England, 50-74 years in Scotland

      Explanation:

      To screen for colorectal cancer, faecal immunochemical tests (FIT) are utilized. Patients aged 60-74 years in England and 50-74 years in Scotland receive screening kits every 2 years. If the test results are abnormal, the patient is provided with the option of undergoing a colonoscopy.

      Colorectal Cancer Screening: Faecal Immunochemical Test (FIT)

      Colorectal cancer is often developed from adenomatous polyps. Screening for this type of cancer has been proven to reduce mortality by 16%. The NHS offers a home-based screening programme called Faecal Immunochemical Test (FIT) to older adults. A one-off flexible sigmoidoscopy was trialled in England for people aged 55 years, but it was abandoned in 2021 due to the inability to recruit enough clinical endoscopists, which was exacerbated by the COVID-19 pandemic. The trial, partly funded by Cancer Research UK, showed promising early results, and it remains to be seen whether flexible sigmoidoscopy will be used as part of a future bowel screening programme.

      Faecal Immunochemical Test (FIT) Screening:
      The NHS now has a national screening programme that offers screening every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent FIT tests through the post. FIT is a type of faecal occult blood (FOB) test that uses antibodies that specifically recognise human haemoglobin (Hb). It is used to detect and quantify the amount of human blood in a single stool sample. FIT has advantages over conventional FOB tests because it only detects human haemoglobin, as opposed to animal haemoglobin ingested through diet. Only one faecal sample is needed compared to the 2-3 for conventional FOB tests. While a numerical value is generated, this is not reported to the patient or GP. Instead, they will be informed if the test is normal or abnormal. Patients with abnormal results are offered a colonoscopy. At colonoscopy, approximately 5 out of 10 patients will have a normal exam, 4 out of 10 patients will be found to have polyps that may be removed due to their premalignant potential, and 1 out of 10 patients will be found to have cancer.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      75.3
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  • Question 3 - An 80-year-old man arrives at the Emergency Department after slipping on ice and...

    Correct

    • An 80-year-old man arrives at the Emergency Department after slipping on ice and falling backwards, hitting his head on the kerb and landing on his right arm. He did not lose consciousness and is currently feeling fine. The patient has a medical history of atrial fibrillation and is taking bisoprolol and warfarin. His INR was 2.2 four days ago. There are no visible injuries to his arm or scalp. What is the best course of action for his head injury?

      Your Answer: Arrange a CT head scan to be performed within 8 hours

      Explanation:

      NICE Guidelines for Investigating Head Injuries in Adults

      Head injuries can be serious and require prompt medical attention. The National Institute for Health and Care Excellence (NICE) has provided clear guidelines for healthcare professionals to determine which adult patients need further investigation with a CT head scan. Patients who require immediate CT head scans include those with a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment, suspected open or depressed skull fractures, signs of basal skull fractures, post-traumatic seizures, focal neurological deficits, and more than one episode of vomiting.

      For patients with any loss of consciousness or amnesia since the injury, a CT head scan within 8 hours is recommended for those who are 65 years or older, have a history of bleeding or clotting disorders, experienced a dangerous mechanism of injury, or have more than 30 minutes of retrograde amnesia of events immediately before the head injury. Additionally, patients on warfarin who have sustained a head injury with no other indications for a CT head scan should also receive a scan within 8 hours of the injury.

      It is important for healthcare professionals to follow these guidelines to ensure that patients receive appropriate and timely care for their head injuries. By identifying those who require further investigation, healthcare professionals can provide the necessary treatment and support to prevent further complications and improve patient outcomes.

    • This question is part of the following fields:

      • Neurology
      13.4
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  • Question 4 - A 70-year-old man presented to the clinic with proximal muscle weakness and a...

    Correct

    • A 70-year-old man presented to the clinic with proximal muscle weakness and a cough lasting eight weeks. He also reported pain in the small joints of his hands and small haemorrhages in the nailfolds. On examination, there was no lymphadenopathy or clubbing, but bibasal crackles were heard. A chest radiograph revealed diffuse reticular infiltrates, and lung function tests showed a restrictive pattern. What is the most likely underlying cause of his interstitial lung disease?

      Your Answer: Polymyositis

      Explanation:

      Differential Diagnosis of Polymyositis: A Comparison with Other Connective Tissue Diseases

      Polymyositis is a systemic connective tissue disease that causes inflammation of the striated muscle and skin in the case of dermatomyositis. Patients typically present with muscle weakness, pain in the small joints of the fingers, and dermatitis. The disease is associated with HLA-B8 and HLA-DR3, and underlying malignancy is present in at least 5-8% of cases. Here, we compare polymyositis with other connective tissue diseases to aid in differential diagnosis.

      Rheumatoid arthritis (RA) is another systemic inflammatory disease that affects mainly the joints, in particular, the proximal interphalangeal joints, in a symmetrical fashion. Pulmonary fibrosis is a known complication of RA, and muscular weakness is also a possible feature. However, in RA, joint-related symptoms are typically more prominent than muscle weakness, making polymyositis a more likely diagnosis in cases of predominant muscle weakness.

      Cryptogenic fibrosing alveolitis, also known as idiopathic pulmonary fibrosis, presents with diffuse reticular infiltrates on chest radiographs and a restrictive pattern on lung function tests. However, the history of proximal muscle weakness and pain in the small joints of the hands does not fit with this diagnosis and suggests polymyositis instead.

      Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects multiple systems in the body. While SLE would be in the differential diagnosis for polymyositis, the prominent proximal muscle weakness and the fact that the patient is a man (SLE affects women in 90% of cases) make polymyositis a more likely diagnosis.

      Ankylosing spondylitis (AS) is an inflammatory rheumatic disease that primarily affects the axial joints and entheses. AS can be associated with pulmonary fibrosis and produces a restrictive pattern on spirometry. However, the more prominent complaint of proximal muscle weakness and the involvement of the small joints of the hands make AS a less likely diagnosis in cases of predominant muscle weakness.

    • This question is part of the following fields:

      • Respiratory Medicine
      31.1
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  • Question 5 - A 65-year-old man visits his GP for a medication review. He has been...

    Incorrect

    • A 65-year-old man visits his GP for a medication review. He has been diagnosed with stable congestive heart failure. As you review his repeat prescriptions, you consider his new diagnosis. The patient has type 2 diabetes mellitus, osteoarthritis, and erectile dysfunction. What is the most crucial medication to avoid in patients with chronic heart failure among his current medications?

      Your Answer: Sildenafil

      Correct Answer: Diclofenac

      Explanation:

      Patients with heart failure should exercise caution when using NSAIDs as they have the potential to worsen the condition by causing fluid retention, particularly diclofenac.

      Medications to Avoid in Patients with Heart Failure

      Heart failure is a serious condition that requires careful management of medications. Some medications can exacerbate heart failure and should be avoided. Thiazolidinediones, such as pioglitazone, are contraindicated as they cause fluid retention. Verapamil has a negative inotropic effect and should be used with caution. NSAIDs and glucocorticoids can also cause fluid retention and should be used with caution. However, low-dose aspirin is an exception as many patients with heart failure also have coexistent cardiovascular disease and the benefits of taking aspirin easily outweigh the risks. Class I antiarrhythmics, such as flecainide, have a negative inotropic and proarrhythmic effect and should be avoided. It is important for healthcare providers to be aware of these medications and to carefully consider their use in patients with heart failure.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      11
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  • Question 6 - A 25-year-old patient visits their doctor with suspected tonsillitis recurrence. They report having...

    Incorrect

    • A 25-year-old patient visits their doctor with suspected tonsillitis recurrence. They report having had tonsillitis three times in the past year and currently have a fever and cough. During the examination, the doctor notes tender cervical lymphadenopathy and exudative tonsils. The patient is prescribed phenoxymethylpenicillin. On day 5 of treatment, blood tests are taken and reveal the following results:

      Hb 150 g/L Male: (135-180) Female: (115 - 160)
      Platelets 390 * 109/L (150 - 400)
      WBC 10.2 * 109/L (4.0 - 11.0)
      Neuts 0.8 * 109/L (2.0 - 7.0)
      Lymphs 9.2 * 109/L (1.0 - 3.5)
      Mono 0.2 * 109/L (0.2 - 0.8)
      Eosin 0.0 * 109/L (0.0 - 0.4)

      What could be the possible reasons for the abnormalities in these blood results?

      Your Answer: Peritonsillar abscess

      Correct Answer: Underlying diagnosis of glandular fever

      Explanation:

      The presence of lymphocytosis and neutropenia in a person who has been treated for recurrent tonsillitis may indicate an underlying condition. Glandular fever, caused by the Epstein-Barr virus, is a common cause of recurrent tonsillitis in young people and can result in an increase in activated T and B lymphocytes, leading to lymphocytosis. The virus may also cause neutropenia, although the exact cause is not fully understood. A peritonsillar abscess, tonsillitis unresponsive to treatment, and treatment with phenoxymethylpenicillin are unlikely to cause significant abnormalities in the full blood count. While lymphoma may explain the lymphocytosis, it would not account for the neutropenia and is less likely than an underlying glandular fever infection.

      Understanding Neutropaenia: Causes and Severity

      Neutropaenia is a medical condition characterized by low neutrophil counts, which is below 1.5 * 109. A normal neutrophil count ranges from 2.0 to 7.5 * 109. It is crucial to recognize this condition as it increases the risk of severe infections. Neutropaenia can be classified into three categories based on its severity: mild (1.0 – 1.5 * 109), moderate (0.5 – 1.0 * 109), and severe (< 0.5 * 109). There are several causes of neutropaenia, including viral infections such as HIV, Epstein-Barr virus, and hepatitis. Certain drugs like cytotoxics, carbimazole, and clozapine can also cause neutropaenia. Benign ethnic neutropaenia is common in people of black African and Afro-Caribbean ethnicity, but it requires no treatment. Haematological malignancies like myelodysplastic malignancies and aplastic anemia, as well as rheumatological conditions like systemic lupus erythematosus and rheumatoid arthritis, can also cause neutropaenia. Severe sepsis and haemodialysis are other potential causes of neutropaenia. In summary, neutropaenia is a medical condition that can increase the risk of severe infections. It is important to recognize its severity and underlying causes to provide appropriate treatment and management.

    • This question is part of the following fields:

      • Infectious Diseases
      32.9
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  • Question 7 - A 58-year-old individual is rushed to the Emergency Department via ambulance, experiencing intense...

    Incorrect

    • A 58-year-old individual is rushed to the Emergency Department via ambulance, experiencing intense chest pain, difficulty breathing, and excessive sweating. The paramedics conducted an ECG on the scene, revealing ST depression in V1-V3 with tall, wide R waves and upward T waves. What should be the next appropriate step to take?

      Your Answer: Give calcium gluconate IV

      Correct Answer: Record a posterior ECG

      Explanation:

      To confirm posterior infarction, a posterior ECG should be recorded when ST elevation and Q waves are present in posterior leads (V7-9). In this case, the patient presented with symptoms suggestive of myocardial infarction and the ECG showed changes that indicated the need for a posterior ECG. This involves placing leads V4-V6 on the patient’s back to make leads V7-V9. ST-elevation and Q waves in these leads confirm posterior infarction, and the patient should be transferred for primary percutaneous coronary intervention as soon as possible. It is important to have a high index of suspicion for posterior MIs and a low threshold for getting a posterior ECG.

      Giving IV potassium replacement or calcium gluconate IV would be incorrect in this case. These treatments are used for hypokalaemia and severe hyperkalaemia, respectively, and are not the most likely diagnoses. Ibuprofen and colchicine would be appropriate for pericarditis, which presents with chest pain that is worse on lying flat and has characteristic ECG changes. However, the clinical picture and ECG changes in this case are more consistent with ACS.

      A CT aortogram is used to investigate for aortic dissection, which can present with severe chest pain, breathlessness, and sweating. However, it would be best to record a posterior ECG to investigate for posterior MI prior to investigating for an aortic dissection due to the classic features of ACS in the history.

      Anteroseptal changes in V1-V4 indicate involvement of the left anterior descending artery. Inferior changes in II, III, and aVF suggest the right coronary artery is affected. Anterolateral changes in V1-6, I, and aVL indicate the proximal left anterior descending artery is involved. Lateral changes in I, aVL, and possibly V5-6 suggest the left circumflex artery is affected. Posterior changes in V1-3 may indicate a posterior infarction, which is confirmed by ST elevation and Q waves in posterior leads (V7-9). This type of infarction is usually caused by the left circumflex artery, but can also be caused by the right coronary artery. Reciprocal changes of STEMI are typically seen as horizontal ST depression, tall and broad R waves, upright T waves, and a dominant R wave in V2. It is important to note that a new left bundle branch block (LBBB) may indicate acute coronary syndrome.

      Overall, understanding the correlation between ECG changes and coronary artery territories is crucial in diagnosing acute coronary syndrome. By identifying the specific changes in the ECG, medical professionals can determine which artery is affected and provide appropriate treatment. Additionally, recognizing the reciprocal changes of STEMI and the significance of a new LBBB can aid in making an accurate diagnosis.

    • This question is part of the following fields:

      • Cardiovascular
      24.3
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  • Question 8 - A 25-year-old student taking the oral contraceptive pill develops pain and soreness around...

    Correct

    • A 25-year-old student taking the oral contraceptive pill develops pain and soreness around the genitals. She has just completed an elective year in the United States (USA). On examination, there are multiple, shallow and tender ulcers at the skin and mucous membrane of the vagina.
      Which of the following is the most probable diagnosis?

      Your Answer: Genital herpes

      Explanation:

      Sexually Transmitted Diseases: Causes and Symptoms

      Sexually transmitted diseases (STDs) are infections that are spread through sexual contact. There are various types of STDs, each with its own set of symptoms and causes. Genital herpes is caused by herpes simplex viruses, with type 2 being responsible for the majority of cases. It can present as vesicular lesions around the genitals, rectum or mouth, but most individuals are asymptomatic. Granuloma inguinale is a chronic bacterial infection that results in nodular lesions that evolve into ulcers. Chancroid is a bacterial STD caused by Haemophilus ducreyi, characterised by painful necrotising genital ulcers. Primary syphilis is caused by the spirochaete Treponema pallidum, with lesions beginning as solitary, raised, firm, red papules that can be several centimetres in diameter. Lymphogranuloma venereum is an uncommon STD caused by Chlamydia trachomatis, characterised by self-limited genital papules or ulcers, followed by painful inguinal and/or femoral lymphadenopathy. Non-infectious causes include fixed drug reactions, Behçet’s disease, neoplasms and trauma. It is important to consider these alternative causes if evaluations for the infectious aetiologies do not lead to a diagnosis. HIV infection should always be considered and tested for.

    • This question is part of the following fields:

      • Infectious Diseases
      10.6
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  • Question 9 - You assess a 65-year-old man with chronic obstructive pulmonary disease (COPD) who receives...

    Incorrect

    • You assess a 65-year-old man with chronic obstructive pulmonary disease (COPD) who receives approximately 7-8 rounds of oral prednisolone annually to manage infectious exacerbations of his condition. What is one of the potential negative consequences associated with prolonged steroid use?

      Your Answer: Osteomalacia

      Correct Answer: Avascular necrosis

      Explanation:

      Osteopaenia and osteoporosis are associated with prolonged use of corticosteroids, not osteomalacia.

      Understanding Corticosteroids and Their Side-Effects

      Corticosteroids are commonly prescribed therapies used to replace or augment the natural activity of endogenous steroids. They can be administered systemically or locally, depending on the condition being treated. However, the usage of corticosteroids is limited due to their numerous side-effects, which are more common with prolonged and systemic therapy.

      Glucocorticoid side-effects include impaired glucose regulation, increased appetite and weight gain, hirsutism, hyperlipidaemia, Cushing’s syndrome, moon face, buffalo hump, striae, osteoporosis, proximal myopathy, avascular necrosis of the femoral head, immunosuppression, increased susceptibility to severe infection, reactivation of tuberculosis, insomnia, mania, depression, psychosis, peptic ulceration, acute pancreatitis, glaucoma, cataracts, suppression of growth in children, intracranial hypertension, and neutrophilia.

      On the other hand, mineralocorticoid side-effects include fluid retention and hypertension. It is important to note that patients on long-term steroids should have their doses doubled during intercurrent illness. Longer-term systemic corticosteroids suppress the natural production of endogenous steroids, so they should not be withdrawn abruptly as this may precipitate an Addisonian crisis. The British National Formulary suggests gradual withdrawal of systemic corticosteroids if patients have received more than 40mg prednisolone daily for more than one week, received more than three weeks of treatment, or recently received repeated courses.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      50.1
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  • Question 10 - A 40-year-old woman presents to her General Practitioner for investigation as she and...

    Correct

    • A 40-year-old woman presents to her General Practitioner for investigation as she and her male partner have not become pregnant after 24 months of trying to conceive. Her female partner has also had normal investigations and on examination, she has a small uncomplicated left-sided inguinal hernia. She takes fluoxetine for depression and occasionally uses acetaminophen for back pain but is not on any other medications. Her male partner's sperm count is normal.
      What would be the next most appropriate step in managing this couple’s inability to conceive?

      Your Answer: Refer to secondary care fertility services

      Explanation:

      Recommendations for a Couple Struggling with Infertility

      When a couple is struggling to conceive, there are several recommendations that healthcare providers may suggest. Firstly, if the couple has been trying to conceive for a year without success, they should be referred to fertility services. However, if there is an underlying reason for conception difficulties, earlier investigation may be necessary. In cases where the male partner is taking non-steroidal anti-inflammatory drugs, there is no impact on his ability to conceive. A hernia repair is not indicated to improve the couple’s chances of conception. Watching and waiting is not appropriate, and referral to fertility services is recommended. Finally, while sertraline and other SSRIs are not teratogenic, they can cause sexual dysfunction, which should be explored with the patient.

    • This question is part of the following fields:

      • Reproductive Medicine
      20.7
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SESSION STATS - PERFORMANCE PER SPECIALTY

Musculoskeletal (0/1) 0%
Gastroenterology/Nutrition (0/1) 0%
Neurology (1/1) 100%
Respiratory Medicine (1/1) 100%
Pharmacology/Therapeutics (0/1) 0%
Infectious Diseases (1/2) 50%
Cardiovascular (0/1) 0%
Endocrinology/Metabolic Disease (0/1) 0%
Reproductive Medicine (1/1) 100%
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