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  • Question 1 - Which nerve provides innervation to the interossei of the fifth finger? ...

    Incorrect

    • Which nerve provides innervation to the interossei of the fifth finger?

      Your Answer: Radial

      Correct Answer: Deep ulnar

      Explanation:

      PAD and DAB can be remembered as a mnemonic for the actions of the palmar and dorsal interossei muscles. The palmar interossei muscles ADduct the fingers towards the midline of the hand, while the dorsal interossei muscles ABduct the fingers away from the midline.

      Interossei: Muscles of the Hand

      Interossei are a group of muscles located in the hand that occupy the spaces between the metacarpal bones. There are three palmar and four dorsal interossei, each with a specific origin and insertion point. Palmar interossei originate from the metacarpal of the digit on which it acts, while dorsal interossei come from the surface of the adjacent metacarpal on which it acts. The interosseous tendons, except the first palmar, pass to one or other side of the metacarpophalangeal joint posterior to the deep transverse metacarpal ligament. They become inserted into the base of the proximal phalanx and partly into the extensor hood.

      All interossei are innervated by the ulnar nerve and have specific actions. Dorsal interossei abduct the fingers, while palmar interossei adduct the fingers. Along with the lumbricals, the interossei flex the metacarpophalangeal joints and extend the proximal and distal interphalangeal joints. They are responsible for fine-tuning these movements.

      In cases where the interossei and lumbricals are paralyzed, the digits are pulled into hyperextension by extensor digitorum, resulting in a claw hand. Understanding the function and innervation of the interossei is important in diagnosing and treating hand injuries and conditions.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 2 - A nulliparous woman visits her obstetrician at 28 weeks of pregnancy. She has...

    Incorrect

    • A nulliparous woman visits her obstetrician at 28 weeks of pregnancy. She has a history of asthma and has noticed a deterioration in her asthma symptoms over the past few days. She is concerned that her asthma may affect her unborn child, as she has read online about the presence of extra antibodies in her blood due to asthma. Which immunoglobulin can be transmitted to her baby?

      Your Answer:

      Correct Answer: IgG

      Explanation:

      The immunoglobulin that fixes complement and is able to pass to the fetal circulation is IgG. This immunoglobulin is produced by plasma cells and is present in all body fluids, being the most abundant in the body. IgG is the only immunoglobulin that can provide immunity to a fetus by crossing the placenta. It indirectly promotes phagocytosis through complement activation. To remember this, you can associate the letter G with gestation.

      On the other hand, IgA is the predominant immunoglobulin found in breast milk and in the secretions of digestive, respiratory, and urogenital tracts and systems. However, it does not transmit to the fetus during pregnancy.

      IgD does not pass into the fetal circulation and is poorly understood. It is found on naive B cells and is involved in B cell activation, which in turn activates mast cell release. Mast cells produce antimicrobial factors involved in immune defense.

      Finally, IgE is involved in asthma and allergic reactions, as well as in protecting against parasitic worms and other allergens. It acts by binding to the allergen, activating mast cells and basophils. However, it does not pass into the fetal circulation.

      Immunoglobulins, also known as antibodies, are proteins produced by the immune system to help fight off infections and diseases. There are five types of immunoglobulins found in the body, each with their own unique characteristics.

      IgG is the most abundant type of immunoglobulin in blood serum and plays a crucial role in enhancing phagocytosis of bacteria and viruses. It also fixes complement and can be passed to the fetal circulation.

      IgA is the most commonly produced immunoglobulin in the body and is found in the secretions of digestive, respiratory, and urogenital tracts and systems. It provides localized protection on mucous membranes and is transported across the interior of the cell via transcytosis.

      IgM is the first immunoglobulin to be secreted in response to an infection and fixes complement, but does not pass to the fetal circulation. It is also responsible for producing anti-A, B blood antibodies.

      IgD’s role in the immune system is largely unknown, but it is involved in the activation of B cells.

      IgE is the least abundant type of immunoglobulin in blood serum and is responsible for mediating type 1 hypersensitivity reactions. It provides immunity to parasites such as helminths and binds to Fc receptors found on the surface of mast cells and basophils.

    • This question is part of the following fields:

      • General Principles
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  • Question 3 - A 23-year-old man presents to the emergency department with recurrent fevers. He has...

    Incorrect

    • A 23-year-old man presents to the emergency department with recurrent fevers. He has a medical history of Adult-onset Still's disease.

      As the admission progresses, the patient's condition worsens, with high-grade fevers and tachycardia.

      The following blood results are obtained:

      - Hb: 112 g/L (Male: 135-180, Female: 115-160)
      - Platelets: 80 * 109/L (150-400)
      - WBC: 2.3 * 109/L (4.0-11.0)
      - CRP: 72 mg/L (<5)
      - Ferritin: 22,500 mg/mL (30-400)
      - Triglycerides: 4.9 mmol/L (<1.7)
      - Fibrinogen: 0.8 g/L (2-4)

      What cytokine is believed to play a crucial role in the pathophysiology of this likely diagnosis?

      Your Answer:

      Correct Answer: Interferon-γ

      Explanation:

      Overview of Cytokines and Their Functions

      Cytokines are signaling molecules that play a crucial role in the immune system. Interleukins are a type of cytokine that are produced by various immune cells and have specific functions. IL-1, produced by macrophages, induces acute inflammation and fever. IL-2, produced by Th1 cells, stimulates the growth and differentiation of T cell responses. IL-3, produced by activated T helper cells, stimulates the differentiation and proliferation of myeloid progenitor cells. IL-4, produced by Th2 cells, stimulates the proliferation and differentiation of B cells. IL-5, also produced by Th2 cells, stimulates the production of eosinophils. IL-6, produced by macrophages and Th2 cells, stimulates the differentiation of B cells and induces fever. IL-8, produced by macrophages, promotes neutrophil chemotaxis. IL-10, produced by Th2 cells, inhibits Th1 cytokine production and is known as an anti-inflammatory cytokine. IL-12, produced by dendritic cells, macrophages, and B cells, activates NK cells and stimulates the differentiation of naive T cells into Th1 cells.

      In addition to interleukins, there are other cytokines with specific functions. Tumor necrosis factor-alpha, produced by macrophages, induces fever and promotes neutrophil chemotaxis. Interferon-gamma, produced by Th1 cells, activates macrophages. Understanding the functions of cytokines is important in developing treatments for various immune-related diseases.

    • This question is part of the following fields:

      • General Principles
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  • Question 4 - A 57-year-old man presents to the emergency department with a severe headache that...

    Incorrect

    • A 57-year-old man presents to the emergency department with a severe headache that started 3 weeks ago and is localised to the back of the head. He rates it 8/10 on a pain scale and reports that it has gradually become worse. The patient has a medical history of Ehlers-Danlos syndrome.

      Unfortunately, the patient passes away after suffering a brainstem stroke.

      During the autopsy, a vertebral artery dissection is discovered at the point of entry into the cranial cavity.

      Where is this location?

      Your Answer:

      Correct Answer: Foramen magnum

      Explanation:

      The vertebral arteries pass through the foramen magnum to enter the cranial cavity.

      Other foramina and their corresponding arteries include the stylomastoid foramen for the posterior auricular artery (stylomastoid branch), the foramen ovale for the accessory meningeal artery, and the foramen spinosum for the middle meningeal artery.

      The Circle of Willis is an anastomosis formed by the internal carotid arteries and vertebral arteries on the bottom surface of the brain. It is divided into two halves and is made up of various arteries, including the anterior communicating artery, anterior cerebral artery, internal carotid artery, posterior communicating artery, and posterior cerebral arteries. The circle and its branches supply blood to important areas of the brain, such as the corpus striatum, internal capsule, diencephalon, and midbrain.

      The vertebral arteries enter the cranial cavity through the foramen magnum and lie in the subarachnoid space. They then ascend on the anterior surface of the medulla oblongata and unite to form the basilar artery at the base of the pons. The basilar artery has several branches, including the anterior inferior cerebellar artery, labyrinthine artery, pontine arteries, superior cerebellar artery, and posterior cerebral artery.

      The internal carotid arteries also have several branches, such as the posterior communicating artery, anterior cerebral artery, middle cerebral artery, and anterior choroid artery. These arteries supply blood to different parts of the brain, including the frontal, temporal, and parietal lobes. Overall, the Circle of Willis and its branches play a crucial role in providing oxygen and nutrients to the brain.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 5 - A 20-year-old man visits the clinic with a complaint of ear pain that...

    Incorrect

    • A 20-year-old man visits the clinic with a complaint of ear pain that started two days ago. He mentions that the pain has reduced considerably, but there is a lot of discharge and he cannot hear from the affected ear. During the examination, you observe a perforated tympanic membrane and yellow discharge in the external auditory canal. Based on the symptoms, you suspect a middle ear infection that led to fluid buildup and subsequent perforation of the tympanic membrane. In this context, which nerve branch innervates the stapedius muscle located in the middle ear?

      Note: The changes made are minimal and do not affect the meaning or context of the original text.

      Your Answer:

      Correct Answer: Facial nerve

      Explanation:

      The correct answer is the facial nerve, the seventh cranial nerve. Other nerves mentioned include the vestibulocochlear nerve, maxillary nerve, glossopharyngeal nerve, and mandibular nerve. The stapedius muscle, innervated by the facial nerve, is also discussed. The patient’s ear pain could be due to a perforated eardrum caused by infection.

      The facial nerve is responsible for supplying the muscles of facial expression, the digastric muscle, and various glandular structures. It also contains a few afferent fibers that originate in the genicular ganglion and are involved in taste. Bilateral facial nerve palsy can be caused by conditions such as sarcoidosis, Guillain-Barre syndrome, Lyme disease, and bilateral acoustic neuromas. Unilateral facial nerve palsy can be caused by these conditions as well as lower motor neuron issues like Bell’s palsy and upper motor neuron issues like stroke.

      The upper motor neuron lesion typically spares the upper face, specifically the forehead, while a lower motor neuron lesion affects all facial muscles. The facial nerve’s path includes the subarachnoid path, where it originates in the pons and passes through the petrous temporal bone into the internal auditory meatus with the vestibulocochlear nerve. The facial canal path passes superior to the vestibule of the inner ear and contains the geniculate ganglion at the medial aspect of the middle ear. The stylomastoid foramen is where the nerve passes through the tympanic cavity anteriorly and the mastoid antrum posteriorly, and it also includes the posterior auricular nerve and branch to the posterior belly of the digastric and stylohyoid muscle.

    • This question is part of the following fields:

      • Neurological System
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  • Question 6 - A 49-year-old patient visits your clinic with complaints of unintentional weight loss, increased...

    Incorrect

    • A 49-year-old patient visits your clinic with complaints of unintentional weight loss, increased appetite, and diarrhea. She frequently experiences a rapid heartbeat and feels hot and sweaty in your office. During examination, you observe lid retraction in her eyes and a pulse rate of 110 beats per minute. You suspect thyrotoxicosis and plan to measure her serum levels of thyroid stimulating hormone (TSH), triiodothyronine (T3), and thyroxine (T4). Since TSH is secreted by the anterior pituitary, which other hormone is also released by this gland?

      Your Answer:

      Correct Answer: Prolactin

      Explanation:

      The hormone secreted by the anterior pituitary gland that stimulates breast development in puberty and during pregnancy, as well as milk production after delivery, is prolactin. Along with prolactin, the anterior pituitary gland also secretes growth hormone, adrenocorticotropic hormone (ACTH), luteinizing hormone (LH), follicle-stimulating hormone (FSH), and melanocyte releasing hormone.

      antidiuretic hormone (ADH), also known as vasopressin, is secreted by the posterior pituitary gland. It increases water reabsorption in the collecting ducts of the kidneys.

      Aldosterone is released by the zona glomerulosa of the adrenal cortex. It is a mineralocorticoid that increases sodium reabsorption in the distal nephron of the kidney, leading to water retention.

      Cortisol is released by the zona fasiculata of the adrenal gland. It is a glucocorticoid that has various actions, including increasing protein catabolism, glycogenolysis, and gluconeogenesis.

      The pituitary gland is a small gland located within the sella turcica in the sphenoid bone of the middle cranial fossa. It weighs approximately 0.5g and is covered by a dural fold. The gland is attached to the hypothalamus by the infundibulum and receives hormonal stimuli from the hypothalamus through the hypothalamo-pituitary portal system. The anterior pituitary, which develops from a depression in the wall of the pharynx known as Rathkes pouch, secretes hormones such as ACTH, TSH, FSH, LH, GH, and prolactin. GH and prolactin are secreted by acidophilic cells, while ACTH, TSH, FSH, and LH are secreted by basophilic cells. On the other hand, the posterior pituitary, which is derived from neuroectoderm, secretes ADH and oxytocin. Both hormones are produced in the hypothalamus before being transported by the hypothalamo-hypophyseal portal system.

    • This question is part of the following fields:

      • Neurological System
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  • Question 7 - A 35-year-old female patient complains of symptoms suggestive of endometriosis, including pelvic pain...

    Incorrect

    • A 35-year-old female patient complains of symptoms suggestive of endometriosis, including pelvic pain and pain during bowel movements. Where is the probable site of blood accumulation resulting from the presence of endometrial tissue outside the pelvic region?

      Your Answer:

      Correct Answer: Pouch of Douglas (rectouterine pouch)

      Explanation:

      The most probable cause of the woman’s pain during defecation is bleeding in either the bowel or the pouch of Douglas. Since the only given option is the latter, it is the correct answer. Bleeding into the ovaries can result in ‘chocolate cysts’ that can be observed during laparoscopy. None of the other options mentioned provide anatomical landmarks that could lead to bleeding in the spaces and pain during defecation.

      Endometriosis is a condition where endometrial tissue grows outside of the uterus, affecting around 10% of women of reproductive age. Symptoms include chronic pelvic pain, painful periods, pain during sex, and subfertility. Diagnosis is made through laparoscopy, and treatment depends on the severity of symptoms. First-line treatments include NSAIDs and hormonal treatments such as the combined oral contraceptive pill or progestogens. If these do not improve symptoms or fertility is a priority, referral to secondary care may be necessary. Treatment options in secondary care include GnRH analogues and surgery, with laparoscopic excision or ablation of endometriosis plus adhesiolysis recommended for women trying to conceive. Ovarian cystectomy may also be necessary for endometriomas.

    • This question is part of the following fields:

      • Reproductive System
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  • Question 8 - A research lab is exploring a novel therapy for beta thalassaemia that involves...

    Incorrect

    • A research lab is exploring a novel therapy for beta thalassaemia that involves manipulating the RNA splicing process within the cells of affected individuals.

      Where does this process primarily occur within the organelles?

      Your Answer:

      Correct Answer: Nucleus

      Explanation:

      RNA splicing occurs primarily within the nucleus.

      The nucleus is where RNA splicing takes place, which involves removing non-coding introns from pre-mRNA and joining coding exons to form mRNA. Alternative splicing can also occur, resulting in different configurations of exons and the ability for a single gene to code for multiple proteins.

      Proteasomes are organelles found in eukaryotic cells that break down large proteins.

      Ribosomes are responsible for translating mRNA into peptide structures.

      Proteins are folded into their proper shape within the rough endoplasmic reticulum.

      The smooth endoplasmic reticulum is involved in the synthesis of steroids and lipids.

      Functions of Cell Organelles

      The functions of major cell organelles can be summarized in a table. The rough endoplasmic reticulum (RER) is responsible for the translation and folding of new proteins, as well as the manufacture of lysosomal enzymes. It is also the site of N-linked glycosylation. Cells such as pancreatic cells, goblet cells, and plasma cells have extensive RER. On the other hand, the smooth endoplasmic reticulum (SER) is involved in steroid and lipid synthesis. Cells of the adrenal cortex, hepatocytes, and reproductive organs have extensive SER.

      The Golgi apparatus modifies, sorts, and packages molecules that are destined for cell secretion. The addition of mannose-6-phosphate to proteins designates transport to lysosome. The mitochondrion is responsible for aerobic respiration and contains mitochondrial genome as circular DNA. The nucleus is involved in DNA maintenance, RNA transcription, and RNA splicing, which removes the non-coding sequences of genes (introns) from pre-mRNA and joins the protein-coding sequences (exons).

      The lysosome is responsible for the breakdown of large molecules such as proteins and polysaccharides. The nucleolus produces ribosomes, while the ribosome translates RNA into proteins. The peroxisome is involved in the catabolism of very long chain fatty acids and amino acids, resulting in the formation of hydrogen peroxide. Lastly, the proteasome, along with the lysosome pathway, is involved in the degradation of protein molecules that have been tagged with ubiquitin.

    • This question is part of the following fields:

      • General Principles
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  • Question 9 - A 28-year-old female is prescribed a medication by her physician. Upon reviewing the...

    Incorrect

    • A 28-year-old female is prescribed a medication by her physician. Upon reviewing the drug's properties, you observe that the rate of excretion remains constant despite an increase in its concentration.

      Which medication exhibits this unique pharmacokinetic characteristic?

      Your Answer:

      Correct Answer: Aspirin

      Explanation:

      When drugs are excreted by zero-order kinetics, the rate at which they are eliminated from the body remains constant regardless of their concentration in the body. This is different from first-order kinetics, where the elimination rate is proportional to the drug’s plasma concentration. Some examples of drugs that follow zero-order kinetics include aspirin, phenytoin, ethanol, and fluoxetine, while drugs like amitriptyline, ampicillin, apixaban, and atenolol follow first-order kinetics.

      Pharmacokinetics of Excretion

      Pharmacokinetics refers to the study of how drugs are absorbed, distributed, metabolized, and eliminated by the body. One important aspect of pharmacokinetics is excretion, which is the process by which drugs are removed from the body. The rate of drug elimination is typically proportional to drug concentration, a phenomenon known as first-order elimination kinetics. However, some drugs exhibit zero-order kinetics, where the rate of excretion remains constant regardless of changes in plasma concentration. This occurs when the metabolic process responsible for drug elimination becomes saturated. Examples of drugs that exhibit zero-order kinetics include phenytoin and salicylates. Understanding the pharmacokinetics of excretion is important for determining appropriate dosing regimens and avoiding toxicity.

    • This question is part of the following fields:

      • General Principles
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  • Question 10 - Which muscle is connected to the front of the fibrous capsule that surrounds...

    Incorrect

    • Which muscle is connected to the front of the fibrous capsule that surrounds the elbow joint?

      Your Answer:

      Correct Answer: Brachialis

      Explanation:

      When the brachialis muscle contracts, it aids in elbow flexion by inserting some of its fibers into the fibrous joint of the elbow capsule.

      Anatomy of the Elbow Joint

      The elbow joint is a large synovial hinge joint that connects the bones of the forearm to the lower end of the humerus. It consists of the humeral articular surface, which comprises the grooved trochlea, the spheroidal capitulum, and the sulcus between them, and the ulnar and radial surfaces. The joint is encased within a fibrous capsule that is relatively weak anteriorly and posteriorly but strengthened at the sides to form the radial and ulnar collateral ligaments. The synovial membrane follows the attachments of the fibrous capsule, and the joint is innervated by the musculocutaneous, median, radial, and ulnar nerves.

      Movement occurs around a transverse axis, with flexion occurring when the forearm makes anteriorly a diminishing angle with the upper arm and extension when the opposite occurs. The axis of movement passes through the humeral epicondyles and is not at right angles with either the humerus or bones of the forearm. In full extension with the forearm supinated, the arm and forearm form an angle which is more than 180 degrees, the extent to which this angle is exceeded is termed the carrying angle. The carrying angle is masked when the forearm is pronated.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 11 - A 30-year-old sailor has been diagnosed with scurvy.

    What is the underlying cause...

    Incorrect

    • A 30-year-old sailor has been diagnosed with scurvy.

      What is the underlying cause of scurvy?

      Your Answer:

      Correct Answer: Vitamin C deficiency

      Explanation:

      The Importance of Vitamins and Their Deficiencies

      Vitamins play a crucial role in maintaining the body’s overall health and well-being. Scurvy, a condition caused by a deficiency in vitamin C, is commonly observed in sailors who lack access to fresh fruits and vegetables during long sea voyages. The symptoms of scurvy include a widespread rash, bleeding mucous membranes, impaired wound healing, rough skin, fatigue, and depression. Vitamin C has several essential functions in the body, including acting as an antioxidant, reducing iron and copper, synthesizing collagen, producing energy from fats, synthesizing neurotransmitters, enhancing immune function, and acting as an antihistamine.

      Deficiencies in other vitamins can also lead to various health problems. A lack of vitamin B3 can cause diarrhea, confusion, and skin changes known as pellagra. Vitamin B12 deficiency can lead to macrocytic anemia and paresthesia. Vitamin A toxicity can cause bone pain, dizziness, and blurred vision, while vitamin D toxicity can lead to vomiting, bone pain, and increased urinary frequency. It is essential to maintain a balanced diet and ensure adequate intake of all essential vitamins to prevent deficiencies and maintain optimal health.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 12 - You are a GP and your next patient is a 5-year-old girl who...

    Incorrect

    • You are a GP and your next patient is a 5-year-old girl who has developed a maculopapular rash. The rash started behind her ears and has now spread all over her body. Her mother noticed some white spots in her mouth before the rash appeared. The child has been lethargic, irritable and had a fever during this time. Upon checking her medical records, you find out that she has not been vaccinated and has had chickenpox before. Which family of viruses is most likely responsible for causing this in the child?

      Your Answer:

      Correct Answer: Paramyxoviridae

      Explanation:

      Measles is caused by a virus in the paramyxovirus family. The child in this question is exhibiting classic symptoms of measles, including the presence of Koplik spots. Since the child has not received the MMR vaccine, they are at risk for contracting the virus.

      Measles: A Highly Infectious Disease

      Measles is a viral infection caused by an RNA paramyxovirus. It is one of the most infectious viruses known and is spread through aerosol transmission. The incubation period is 10-14 days, and the virus is infective from the prodromal phase until four days after the rash starts. Measles is now rare in developed countries due to immunization programs, but outbreaks can occur when vaccination rates drop.

      The prodromal phase of measles is characterized by irritability, conjunctivitis, fever, and Koplik spots. These white spots on the buccal mucosa typically develop before the rash. The rash starts behind the ears and then spreads to the whole body, becoming a discrete maculopapular rash that may become blotchy and confluent. Desquamation may occur after a week, typically sparing the palms and soles. Diarrhea occurs in around 10% of patients.

      Measles is mainly managed through supportive care, and admission may be considered for immunosuppressed or pregnant patients. It is a notifiable disease, and public health should be informed. Complications of measles include otitis media, pneumonia, encephalitis, subacute sclerosing panencephalitis, febrile convulsions, keratoconjunctivitis, corneal ulceration, diarrhea, increased incidence of appendicitis, and myocarditis.

      If an unvaccinated child comes into contact with measles, MMR should be offered within 72 hours. Vaccine-induced measles antibody develops more rapidly than that following natural infection.

    • This question is part of the following fields:

      • General Principles
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  • Question 13 - A 75-year-old man with a long-standing history of type 2 diabetes mellitus presents...

    Incorrect

    • A 75-year-old man with a long-standing history of type 2 diabetes mellitus presents to his physician with an inability to walk. The patient has a history of chronic kidney disease, diabetic retinopathy and a prior myocardial infarction treated via a stent. The patient admits to a recent loss of sensation in the lower limbs and is found to also have associated motor neuropathy. Complications of his chronic disease are found to be the cause of his gait problems.

      What findings would be expected during examination of the lower limbs?

      Your Answer:

      Correct Answer: Decreased reflexes, fasciculations, decreased tone

      Explanation:

      When there is a lower motor neuron lesion, there is a reduction in everything, including reflexes, tone, and power. Fasciculations are also a common feature. Motor neuropathy caused by diabetes is a form of peripheral neuropathy, which typically presents with lower motor neuron symptoms. On the other hand, an upper motor neuron lesion is characterized by increased tone, reflexes, and weakness. A mixed picture may occur when there are both upper and lower motor neuron signs present. For example, Babinski positive, increased reflexes, and decreased tone indicate a combination of upper and lower motor neuron lesions. Similarly, decreased tone, decreased reflexes, and clonus suggest a mixed picture, with the clonus being an upper motor neuron sign. Conversely, increased tone, decreased reflexes, and clonus also indicate a mixed picture, with the increased tone and clonus being upper motor neuron signs and the decreased reflexes being a lower motor neuron sign.

      The spinal cord is a central structure located within the vertebral column that provides it with structural support. It extends rostrally to the medulla oblongata of the brain and tapers caudally at the L1-2 level, where it is anchored to the first coccygeal vertebrae by the filum terminale. The cord is characterised by cervico-lumbar enlargements that correspond to the brachial and lumbar plexuses. It is incompletely divided into two symmetrical halves by a dorsal median sulcus and ventral median fissure, with grey matter surrounding a central canal that is continuous with the ventricular system of the CNS. Afferent fibres entering through the dorsal roots usually terminate near their point of entry but may travel for varying distances in Lissauer’s tract. The key point to remember is that the anatomy of the cord will dictate the clinical presentation in cases of injury, which can be caused by trauma, neoplasia, inflammatory diseases, vascular issues, or infection.

      One important condition to remember is Brown-Sequard syndrome, which is caused by hemisection of the cord and produces ipsilateral loss of proprioception and upper motor neuron signs, as well as contralateral loss of pain and temperature sensation. Lesions below L1 tend to present with lower motor neuron signs. It is important to keep a clinical perspective in mind when revising CNS anatomy and to understand the ways in which the spinal cord can become injured, as this will help in diagnosing and treating patients with spinal cord injuries.

    • This question is part of the following fields:

      • Neurological System
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  • Question 14 - Which of the following anatomical planes separates the prostate from the rectum? ...

    Incorrect

    • Which of the following anatomical planes separates the prostate from the rectum?

      Your Answer:

      Correct Answer: Denonvilliers fascia

      Explanation:

      The rectum is separated from the prostate by the Denonvilliers fascia, while the sacrum is separated from the rectum by Waldeyer’s fascia.

      Anatomy of the Prostate Gland

      The prostate gland is a small, walnut-shaped gland located below the bladder and separated from the rectum by Denonvilliers fascia. It receives its blood supply from the internal iliac vessels, specifically the inferior vesical artery. The gland has an internal sphincter at its apex, which can be damaged during surgery and result in retrograde ejaculation.

      The prostate gland has four lobes: the posterior lobe, median lobe, and two lateral lobes. It also has an isthmus and three zones: the peripheral zone, central zone, and transition zone. The peripheral zone, which is the subcapsular portion of the posterior prostate, is where most prostate cancers occur.

      The gland is surrounded by various structures, including the pubic symphysis, prostatic venous plexus, Denonvilliers fascia, rectum, ejaculatory ducts, lateral venous plexus, and levator ani. Its lymphatic drainage is to the internal iliac nodes, and its innervation comes from the inferior hypogastric plexus.

      In summary, the prostate gland is a small but important gland in the male reproductive system. Its anatomy includes lobes, zones, and various surrounding structures, and it plays a crucial role in ejaculation and prostate health.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 15 - A 14-year-old boy comes to his doctor complaining of swollen testicles. He mentions...

    Incorrect

    • A 14-year-old boy comes to his doctor complaining of swollen testicles. He mentions being hit by a baseball during a game. The boy feels fine and has not experienced any vomiting.

      During the examination, the physician notices a slight swelling in his testicles. The boy also has decreased sensation in the skin of his scrotum's front.

      Which nerve provides sensory innervation to the skin in the front of the scrotum?

      Your Answer:

      Correct Answer: Genital branch of the genitofemoral nerve

      Explanation:

      The anterior scrotal skin receives sensory sensation from the genital branch of the genitofemoral nerve. The ilioinguinal and genitofemoral nerves (genital branch) innervate the front of the scrotum, while the perineal branches of the pudendal nerves innervate the back. The dorsal branch of the pudendal nerve provides sensory innervation to the erectile tissue of the penis/clitoris and the skin over the foreskin, glans, and penis/foreskin’s dorsolateral aspect. The posterior scrotal nerves supply sensory innervation to the skin on the back of the scrotum. The cavernous nerves are responsible for facilitating penile erection and are postganglionic parasympathetic nerves.

      The Genitofemoral Nerve: Anatomy and Function

      The genitofemoral nerve is responsible for supplying a small area of the upper medial thigh. It arises from the first and second lumbar nerves and passes through the psoas major muscle before emerging from its medial border. The nerve then descends on the surface of the psoas major, under the cover of the peritoneum, and divides into genital and femoral branches.

      The genital branch of the genitofemoral nerve passes through the inguinal canal within the spermatic cord to supply the skin overlying the scrotum’s skin and fascia. On the other hand, the femoral branch enters the thigh posterior to the inguinal ligament, lateral to the femoral artery. It supplies an area of skin and fascia over the femoral triangle.

      Injuries to the genitofemoral nerve may occur during abdominal or pelvic surgery or inguinal hernia repairs. Understanding the anatomy and function of this nerve is crucial in preventing such injuries and ensuring proper treatment.

    • This question is part of the following fields:

      • Neurological System
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  • Question 16 - An 80-year-old man who frequently drinks alcohol presents to his doctor with symptoms...

    Incorrect

    • An 80-year-old man who frequently drinks alcohol presents to his doctor with symptoms of productive cough, fever, and chills. Upon examination, a chest x-ray reveals a distinct cavity in the right lower lobe with an air-fluid level. The patient's sputum is sent for culture and sensitivity, and he is prescribed clindamycin.

      After ten days, the patient reports experiencing watery diarrhea 3-4 times a day and abdominal pain. He has not experienced any fever or weight loss, and his vital signs are normal. What is the initial medication recommended for his condition?

      Your Answer:

      Correct Answer: Vancomycin

      Explanation:

      The preferred antibiotic for treating C. difficile infection is oral vancomycin. However, in the case of a patient with clinical features and radiological findings indicative of a lung abscess, who also has a history of alcohol consumption that increases the risk of aspiration and lung abscesses, clindamycin was used as a treatment. Unfortunately, this led to the development of a C. difficile infection, which can be confusing when considering the antibiotics involved in causing and treating the infection.

      Clostridium difficile is a type of bacteria that is commonly found in hospitals. It produces a toxin that can damage the intestines and cause a condition called pseudomembranous colitis. This bacteria usually develops when the normal gut flora is disrupted by broad-spectrum antibiotics, with second and third generation cephalosporins being the leading cause. Other risk factors include the use of proton pump inhibitors. Symptoms of C. difficile infection include diarrhea, abdominal pain, and a raised white blood cell count. The severity of the infection can be determined using the Public Health England severity scale.

      To diagnose C. difficile infection, a stool sample is tested for the presence of the C. difficile toxin. Treatment involves reviewing current antibiotic therapy and stopping antibiotics if possible. For a first episode of infection, oral vancomycin is the first-line therapy for 10 days, followed by oral fidaxomicin as second-line therapy and oral vancomycin with or without IV metronidazole as third-line therapy. Recurrent infections may require different treatment options, such as oral fidaxomicin within 12 weeks of symptom resolution or oral vancomycin or fidaxomicin after 12 weeks of symptom resolution. In life-threatening cases, oral vancomycin and IV metronidazole may be used, and surgery may be considered with specialist advice. Other therapies, such as bezlotoxumab and fecal microbiota transplant, may also be considered for preventing recurrences in certain cases.

    • This question is part of the following fields:

      • Gastrointestinal System
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  • Question 17 - A 75-year-old-male comes to your neurology clinic accompanied by his wife. She reports...

    Incorrect

    • A 75-year-old-male comes to your neurology clinic accompanied by his wife. She reports that she has observed alterations in his speech over the last six months, with frequent pauses between syllables of words. During the clinical examination, you observe that his speech is jerky and loud, and he has decreased tone in his upper and lower limbs. Considering the most probable diagnosis, what other symptom is he likely to exhibit?

      Your Answer:

      Correct Answer: Horizontal nystagmus

      Explanation:

      When a person has a cerebellar lesion, they may experience horizontal nystagmus, which is characterized by involuntary eye movements in a horizontal direction. This can be accompanied by other symptoms of cerebellar syndrome, such as scanning dysarthria and hypotonia, as well as ataxia, intention tremor, and dysdiadochokinesia.

      In contrast, vertical diplopia is a symptom of fourth nerve palsy, where a person sees one object as two images, one above the other. This condition may also cause a head tilt and the affected eye to deviate up and out. Torsional diplopia, on the other hand, is another symptom of fourth nerve palsy, where a person sees one object as two images that are slightly tilted away from each other. This condition may also cause vertical diplopia and the affected eye to deviate up and rotate outward.

      Cerebellar syndrome is a condition that affects the cerebellum, a part of the brain responsible for coordinating movement and balance. When there is damage or injury to one side of the cerebellum, it can cause symptoms on the same side of the body. These symptoms can be remembered using the mnemonic DANISH, which stands for Dysdiadochokinesia, Dysmetria, Ataxia, Nystagmus, Intention tremour, Slurred staccato speech, and Hypotonia.

      There are several possible causes of cerebellar syndrome, including genetic conditions like Friedreich’s ataxia and ataxic telangiectasia, neoplastic growths like cerebellar haemangioma, strokes, alcohol use, multiple sclerosis, hypothyroidism, and certain medications or toxins like phenytoin or lead poisoning. In some cases, cerebellar syndrome may be a paraneoplastic condition, meaning it is a secondary effect of an underlying cancer like lung cancer. It is important to identify the underlying cause of cerebellar syndrome in order to provide appropriate treatment and management.

    • This question is part of the following fields:

      • Neurological System
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  • Question 18 - A 67-year-old female presents to her primary healthcare provider with painful blisters on...

    Incorrect

    • A 67-year-old female presents to her primary healthcare provider with painful blisters on her gingival and buccal mucosa and skin that easily rupture and cause ulcers. The oral blisters began three months ago and the cutaneous lesions just a week ago. She has a medical history of hypertension, vitiligo, and type 2 diabetes mellitus. Upon examination of the oral cavity and skin, scattered shallow ulcerations ranging from 8 mm to 1 cm in diameter were observed. A biopsy of the lesions revealed acantholysis. The patient has been prescribed corticosteroids.

      What is the most likely cause of this condition in the patient?

      Your Answer:

      Correct Answer: Antibodies against desmoglein 3

      Explanation:

      Pemphigus vulgaris is an autoimmune condition that occurs when the body’s immune system attacks desmoglein 3, a type of cell adhesion molecule found in epithelial cells. This disease is more prevalent in the Ashkenazi Jewish population. The most common symptom is mucosal ulceration, which can be the first sign of the disease. Oral involvement is seen in 50-70% of patients. Skin blistering is also a common symptom, with easily ruptured vesicles and bullae. These lesions are typically painful but not itchy and may appear months after the initial mucosal symptoms. Nikolsky’s sign is a characteristic feature of pemphigus vulgaris, where bullae spread following the application of horizontal, tangential pressure to the skin. Biopsy results often show acantholysis.

      The first-line treatment for pemphigus vulgaris is steroids, which help to reduce inflammation and suppress the immune system. Immunosuppressants may also be used to manage the disease.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 19 - A 28-year-old pregnant woman discusses her varicose veins with her midwife. She has...

    Incorrect

    • A 28-year-old pregnant woman discusses her varicose veins with her midwife. She has noticed these veins for a couple of weeks now, and they appeared during her pregnancy. Lately, she has observed red-brown discoloration around the veins on the back of her calf. What could be the probable root cause of this?

      Your Answer:

      Correct Answer: Haemosiderin deposition

      Explanation:

      The hyperpigmentation observed in patients with varicose eczema/venous ulcers is likely caused by haemosiderin deposition. This occurs when red blood cells burst due to venous stasis, leading to the release of haemoglobin which is stored as haemosiderin. The excess haemosiderin causes a local red-brown discolouration around areas of varicose veins.

      Acanthosis nigricans is an unlikely cause as it is associated with metabolic disorders and not varicose veins. Atrophie blanche describes hypopigmentation seen in venous ulcers, while lipodermatosclerosis causes thickening of the skin in varicose veins without changing the skin color. Melanoma, a skin cancer that causes dark discolouration, is unlikely to be associated with varicose veins and is an unlikely explanation for the observed discolouration on the back of the calf.

      Understanding Varicose Veins

      Varicose veins are enlarged and twisted veins that occur when the valves in the veins become weak or damaged, causing blood to flow backward and pool in the veins. They are most commonly found in the legs and can be caused by various factors such as age, gender, pregnancy, obesity, and genetics. While many people seek treatment for cosmetic reasons, others may experience symptoms such as aching, throbbing, and itching. In severe cases, varicose veins can lead to skin changes, bleeding, superficial thrombophlebitis, and venous ulceration.

      To diagnose varicose veins, a venous duplex ultrasound is typically performed to detect retrograde venous flow. Treatment options vary depending on the severity of the condition. Conservative treatments such as leg elevation, weight loss, regular exercise, and compression stockings may be recommended for mild cases. However, patients with significant or troublesome symptoms, skin changes, or a history of bleeding or ulcers may require referral to a specialist for further evaluation and treatment. Possible treatments include endothermal ablation, foam sclerotherapy, or surgery.

      In summary, varicose veins are a common condition that can cause discomfort and cosmetic concerns. While many cases do not require intervention, it is important to seek medical attention if symptoms or complications arise. With proper diagnosis and treatment, patients can manage their condition and improve their quality of life.

    • This question is part of the following fields:

      • Cardiovascular System
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  • Question 20 - A 35-year-old patient has been experiencing breathing difficulties for the past year. He...

    Incorrect

    • A 35-year-old patient has been experiencing breathing difficulties for the past year. He finds it challenging to climb small hills, has developed a persistent cough, and has had two chest infections that were treated effectively by his doctor. He has never smoked, and his mother had comparable symptoms when she was his age. Based on his spirometry results, which indicate an FEV1/FVC ratio of 60%, his doctor suspects that his symptoms are caused by a genetic disorder. What is the molecular mechanism that underlies his probable condition?

      Your Answer:

      Correct Answer: Failure to break down neutrophil elastase

      Explanation:

      The patient’s medical history suggests that they may be suffering from alpha-1 antitrypsin deficiency.

      When there is a shortage of alpha-1 antitrypsin, neutrophil elastase is not inhibited and can break down proteins in the lung interstitium. Although neutrophil elastase is a crucial part of the innate immune system, its unregulated activity can lead to excessive breakdown of extracellular proteins like elastin, collagen, fibronectin, and fibrin. This results in reduced pulmonary elasticity, which can cause emphysema and COPD.

      Alpha-1 antitrypsin (A1AT) deficiency is a genetic condition that occurs when the liver does not produce enough of a protein called protease inhibitor (Pi). This protein is responsible for protecting cells from enzymes like neutrophil elastase. A1AT deficiency is inherited in an autosomal recessive or co-dominant manner and is located on chromosome 14. The alleles are classified by their electrophoretic mobility, with M being normal, S being slow, and Z being very slow. The normal genotype is PiMM, while heterozygous individuals have PiMZ. Homozygous PiSS individuals have 50% normal A1AT levels, while homozygous PiZZ individuals have only 10% normal A1AT levels.

      A1AT deficiency is most commonly associated with panacinar emphysema, which is a type of chronic obstructive pulmonary disease (COPD). This is especially true for patients with the PiZZ genotype. Emphysema is more likely to occur in non-smokers with A1AT deficiency, but they may still pass on the gene to their children. In addition to lung problems, A1AT deficiency can also cause liver issues such as cirrhosis and hepatocellular carcinoma in adults, and cholestasis in children.

      Diagnosis of A1AT deficiency involves measuring A1AT concentrations and performing spirometry to assess lung function. Management of the condition includes avoiding smoking and receiving supportive care such as bronchodilators and physiotherapy. Intravenous alpha1-antitrypsin protein concentrates may also be used. In severe cases, lung volume reduction surgery or lung transplantation may be necessary.

    • This question is part of the following fields:

      • Respiratory System
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  • Question 21 - A 28-year-old woman presents with recurrent slurring of speech that worsens when she...

    Incorrect

    • A 28-year-old woman presents with recurrent slurring of speech that worsens when she continues to talk. She also reports feeling tired constantly, is occasionally short of breath and has experienced some double vision that gets worse when reading or watching TV. Her symptoms have progressively deteriorated over the past 4 months and she has intermittent weakness in her legs and arms, she feels as though her legs will give way when she gets up from her chair and has difficulty combing her hair.

      On examination the patient appears well, there appears to be mild ptosis bilaterally and also a midline neck lump. The patient was referred to the neurology team and is due for further investigation.

      What is the initial test that should be done?

      Your Answer:

      Correct Answer: Serum acetylcholine receptor (AChR) antibody analysis

      Explanation:

      Myasthenia gravis is an autoimmune disorder that results in muscle weakness and fatigue, particularly in the eyes, face, neck, and limbs. It is more common in women and is associated with thymomas and other autoimmune disorders. Diagnosis is made through electromyography and testing for antibodies to acetylcholine receptors. Treatment includes acetylcholinesterase inhibitors and immunosuppression, and in severe cases, plasmapheresis or intravenous immunoglobulins may be necessary.

    • This question is part of the following fields:

      • Neurological System
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  • Question 22 - A 24-year-old man visits his GP complaining of haematuria and flank pain that...

    Incorrect

    • A 24-year-old man visits his GP complaining of haematuria and flank pain that has persisted for 2 weeks despite taking nitrofurantoin. He developed these symptoms after a mild upper respiratory tract infection. He has no fever and feels generally well.

      The urine dip test reveals:
      Protein ++
      Red blood cells +++

      The patient is referred to a nephrologist who suggests a renal biopsy. The biopsy results show mesangiocapillary deposition of IgA on immunofluorescent staining.

      What is the mechanism by which this immunoglobulin is transported across the interior of cells?

      Your Answer:

      Correct Answer: Transcytosis

      Explanation:

      Immunoglobulins, also known as antibodies, are proteins produced by the immune system to help fight off infections and diseases. There are five types of immunoglobulins found in the body, each with their own unique characteristics.

      IgG is the most abundant type of immunoglobulin in blood serum and plays a crucial role in enhancing phagocytosis of bacteria and viruses. It also fixes complement and can be passed to the fetal circulation.

      IgA is the most commonly produced immunoglobulin in the body and is found in the secretions of digestive, respiratory, and urogenital tracts and systems. It provides localized protection on mucous membranes and is transported across the interior of the cell via transcytosis.

      IgM is the first immunoglobulin to be secreted in response to an infection and fixes complement, but does not pass to the fetal circulation. It is also responsible for producing anti-A, B blood antibodies.

      IgD’s role in the immune system is largely unknown, but it is involved in the activation of B cells.

      IgE is the least abundant type of immunoglobulin in blood serum and is responsible for mediating type 1 hypersensitivity reactions. It provides immunity to parasites such as helminths and binds to Fc receptors found on the surface of mast cells and basophils.

    • This question is part of the following fields:

      • General Principles
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  • Question 23 - A 4-year-old girl is rushed to the emergency department by her father due...

    Incorrect

    • A 4-year-old girl is rushed to the emergency department by her father due to breathing difficulties. He suspects that she may have ingested a small toy while he was not looking.

      Which of the following statements accurately describes the lower respiratory tract?

      Your Answer:

      Correct Answer: The right main bronchus is more vertical than the left

      Explanation:

      Anatomy of the Bronchial Tree

      The trachea divides into two bronchi at the sternal angle, with the right bronchus being wider, shorter, and more vertical than the left. This anatomical difference makes it more likely for foreign objects to become lodged in the right bronchus. However, this difference only occurs after the age of one, so younger children are at equal risk for foreign body aspiration in either bronchus.

      Each main bronchus further divides into lobar bronchi, with the left having two and the right having three. These lobar bronchi then give rise to tertiary or segmental bronchi, which supply a specific bronchopulmonary segment. These segments are anatomically and functionally separate from each other and can be removed without affecting the surrounding lung tissue.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 24 - A 45-year-old patient is hospitalized for suspected typhoid fever and started on an...

    Incorrect

    • A 45-year-old patient is hospitalized for suspected typhoid fever and started on an antibiotic. After a week, she experiences extreme fatigue and blood tests show anaemia, neutropenia, and thrombocytopenia. Which antibiotic is the most probable cause of these symptoms?

      Your Answer:

      Correct Answer: Chloramphenicol

      Explanation:

      Aplastic anaemia is a severe side effect of chloramphenicol, which is often used to treat typhoid fever. Ciprofloxacin can increase the risk of tendon rupture and lower the seizure threshold. Clindamycin is known to cause C. difficile diarrhoea, while doxycycline can lead to discolouration of teeth and photosensitivity.

      Antibiotics that inhibit protein synthesis work by targeting specific components of the bacterial ribosome, which is responsible for translating genetic information into proteins. Aminoglycosides bind to the 30S subunit of the ribosome, causing errors in the reading of mRNA. Tetracyclines also bind to the 30S subunit, but block the binding of aminoacyl-tRNA. Chloramphenicol and clindamycin both bind to the 50S subunit, inhibiting different steps in the process of protein synthesis. Macrolides also bind to the 50S subunit, but specifically inhibit the movement of tRNA from the acceptor site to the peptidyl site.

      While these antibiotics can be effective in treating bacterial infections, they can also have adverse effects. Aminoglycosides are known to cause nephrotoxicity and ototoxicity, while tetracyclines can cause discolouration of teeth and photosensitivity. Chloramphenicol is associated with a rare but serious side effect called aplastic anaemia, and clindamycin is a common cause of C. difficile diarrhoea. Macrolides can cause nausea, especially erythromycin, and can also inhibit the activity of certain liver enzymes (P450) and prolong the QT interval. Despite these potential side effects, these antibiotics are still commonly used in clinical practice, particularly in patients who are allergic to penicillin.

    • This question is part of the following fields:

      • General Principles
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  • Question 25 - A 38-year-old man visits his GP complaining of fevers, night sweats, and haemoptysis...

    Incorrect

    • A 38-year-old man visits his GP complaining of fevers, night sweats, and haemoptysis that have persisted for three weeks. He recently moved to the country from Bangladesh and did not receive any childhood vaccinations. The patient's medical history is otherwise unremarkable. During the examination, the doctor notices tender bruise-like lesions on the man's anterior shins. Sputum microscopy reveals acid-fast bacilli, and the doctor prescribes isoniazid. What is the mechanism of action of this drug?

      Your Answer:

      Correct Answer: Inhibition of mycolic acid synthesis

      Explanation:

      The mechanism of isoniazid is the inhibition of mycolic acid synthesis. This is relevant to the patient’s presentation of tuberculosis, as Mycobacterium tuberculosis has mycolic acids in its cell wall. Isoniazid affects cell wall integrity by inhibiting the synthesis of mycolic acids, which are responsible for the acid-fast staining of the bacteria.

      It is important to note that the mechanisms of other antibiotics, such as fluoroquinolones and glycopeptides, are different and not relevant to this case. Rifampicin, another antibiotic used to treat tuberculosis, works by inhibiting DNA-dependent RNA polymerase.

      Tuberculosis is a bacterial infection that can be treated with a combination of drugs. Each drug has a specific mechanism of action and can also cause side-effects. Rifampicin works by inhibiting bacterial DNA dependent RNA polymerase, which prevents the transcription of DNA into mRNA. However, it is a potent liver enzyme inducer and can cause hepatitis, orange secretions, and flu-like symptoms.

      Isoniazid, on the other hand, inhibits mycolic acid synthesis. It can cause peripheral neuropathy, which can be prevented with pyridoxine (Vitamin B6). It can also cause hepatitis and agranulocytosis, but it is a liver enzyme inhibitor.

      Pyrazinamide is converted by pyrazinamidase into pyrazinoic acid, which inhibits fatty acid synthase (FAS) I. However, it can cause hyperuricaemia, leading to gout, as well as arthralgia and myalgia. It can also cause hepatitis.

      Finally, Ethambutol inhibits the enzyme arabinosyl transferase, which polymerizes arabinose into arabinan. However, it can cause optic neuritis, so it is important to check visual acuity before and during treatment. The dose also needs adjusting in patients with renal impairment.

    • This question is part of the following fields:

      • General Principles
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  • Question 26 - A 35-year-old woman comes to the clinic complaining of worsening tingling sensation in...

    Incorrect

    • A 35-year-old woman comes to the clinic complaining of worsening tingling sensation in her legs and difficulty maintaining balance. She has no significant medical history.

      During the examination, it is observed that her lower limbs have significantly reduced proprioception and vibration sense. She also experiences distal paraesthesia. Additionally, her knee reflexes are brisk.

      A blood film is taken, which shows macrocytic anaemia and hypersegmented neutrophils.

      Based on the symptoms, what parts of the spinal cord are likely to be affected?

      Your Answer:

      Correct Answer: Dorsal column and lateral corticospinal tract

      Explanation:

      Subacute combined degeneration of the spinal cord affects the dorsal columns and lateral corticospinal tracts, as seen in this case with B12 deficiency. The loss of proprioception and vibration sense on examination, as well as brisk knee reflexes, are consistent with an upper motor neuron lesion finding. The anterior corticospinal tract, spinocerebellar tract, and spinothalamic tract are not typically affected in this condition. Therefore, the correct answer is the dorsal columns and lateral corticospinal tracts.

      Subacute Combined Degeneration of Spinal Cord

      Subacute combined degeneration of spinal cord is a condition that occurs due to a deficiency of vitamin B12. The dorsal columns and lateral corticospinal tracts are affected, leading to the loss of joint position and vibration sense. The first symptoms are usually distal paraesthesia, followed by the development of upper motor neuron signs in the legs, such as extensor plantars, brisk knee reflexes, and absent ankle jerks. If left untreated, stiffness and weakness may persist.

      This condition is a serious concern and requires prompt medical attention. It is important to maintain a healthy diet that includes sufficient amounts of vitamin B12 to prevent the development of subacute combined degeneration of spinal cord.

    • This question is part of the following fields:

      • Neurological System
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  • Question 27 - A 50-year-old woman comes to you complaining of persistent constipation. She reports that...

    Incorrect

    • A 50-year-old woman comes to you complaining of persistent constipation. She reports that this began approximately 2 weeks ago after she was prescribed a new medication by her cardiologist. She is visibly upset and holds him responsible. Her medical history includes hypertension, atrial fibrillation, and psoriasis.

      Which medication could potentially be causing her symptoms?

      Your Answer:

      Correct Answer: Verapamil

      Explanation:

      Verapamil may lead to constipation as an adverse effect. Similarly, beta-blockers can cause sleep disturbances, cold peripheries, and bronchospasm (which is not recommended for individuals with asthma). Calcium channel blockers may result in ankle oedema, dyspepsia, and relaxation of the lower oesophageal sphincter.

      Calcium channel blockers are a class of drugs commonly used to treat cardiovascular disease. These drugs target voltage-gated calcium channels found in myocardial cells, cells of the conduction system, and vascular smooth muscle. The different types of calcium channel blockers have varying effects on these areas, making it important to differentiate their uses and actions.

      Verapamil is used to treat angina, hypertension, and arrhythmias. It is highly negatively inotropic and should not be given with beta-blockers as it may cause heart block. Side effects include heart failure, constipation, hypotension, bradycardia, and flushing.

      Diltiazem is used to treat angina and hypertension. It is less negatively inotropic than verapamil, but caution should still be exercised when patients have heart failure or are taking beta-blockers. Side effects include hypotension, bradycardia, heart failure, and ankle swelling.

      Nifedipine, amlodipine, and felodipine are dihydropyridines used to treat hypertension, angina, and Raynaud’s. They affect peripheral vascular smooth muscle more than the myocardium, which means they do not worsen heart failure but may cause ankle swelling. Shorter acting dihydropyridines like nifedipine may cause peripheral vasodilation, resulting in reflex tachycardia. Side effects include flushing, headache, and ankle swelling.

      According to current NICE guidelines, the management of hypertension involves a flow chart that takes into account various factors such as age, ethnicity, and comorbidities. Calcium channel blockers may be used as part of the treatment plan depending on the individual patient’s needs.

    • This question is part of the following fields:

      • General Principles
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  • Question 28 - Which of the following hinders the production of insulin secretion? ...

    Incorrect

    • Which of the following hinders the production of insulin secretion?

      Your Answer:

      Correct Answer: Adrenaline

      Explanation:

      The release of insulin can be inhibited by alpha adrenergic drugs, beta blockers, and sympathetic nerves.

      Insulin is a hormone produced by the pancreas that plays a crucial role in regulating the metabolism of carbohydrates and fats in the body. It works by causing cells in the liver, muscles, and fat tissue to absorb glucose from the bloodstream, which is then stored as glycogen in the liver and muscles or as triglycerides in fat cells. The human insulin protein is made up of 51 amino acids and is a dimer of an A-chain and a B-chain linked together by disulfide bonds. Pro-insulin is first formed in the rough endoplasmic reticulum of pancreatic beta cells and then cleaved to form insulin and C-peptide. Insulin is stored in secretory granules and released in response to high levels of glucose in the blood. In addition to its role in glucose metabolism, insulin also inhibits lipolysis, reduces muscle protein loss, and increases cellular uptake of potassium through stimulation of the Na+/K+ ATPase pump.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 29 - A 65-year-old male is recovering from a community acquired pneumonia in hospital. He...

    Incorrect

    • A 65-year-old male is recovering from a community acquired pneumonia in hospital. He has undergone some blood tests that morning which indicate that he is experiencing AKI stage 2. The results are as follows:

      - Na+ 133 mmol/L (135 - 145)
      - K+ 3.6 mmol/L (3.5 - 5.0)
      - Bicarbonate 23 mmol/L (22 - 29)
      - Urea 6.0 mmol/L (2.0 - 7.0)
      - Creatinine 150 µmol/L (55 - 120)

      Over the past 12 hours, he has only produced 360ml of urine. In light of this, what is the most crucial medication to discontinue from his drug chart?

      Your Answer:

      Correct Answer: Diclofenac

      Explanation:

      In cases of acute kidney injury (AKI), it is crucial to discontinue the use of nonsteroidal anti-inflammatory drugs (NSAIDs) as they can potentially worsen renal function. Ibuprofen, being an NSAID, falls under this category.

      NSAIDs work by reducing the production of prostaglandins, which are responsible for vasodilation. Inhibiting their production can lead to vasoconstriction of the afferent arteriole, resulting in decreased renal perfusion and a decline in estimated glomerular filtration rate (eGFR).

      To prevent further damage to the kidneys, all nephrotoxic medications, including NSAIDs, ACE inhibitors, gentamicin, vancomycin, and metformin (which should be discussed with the diabetic team), should be discontinued in cases of AKI.

      Acute kidney injury (AKI) is a condition where there is a reduction in renal function following an insult to the kidneys. It was previously known as acute renal failure and can result in long-term impaired kidney function or even death. AKI can be caused by prerenal, intrinsic, or postrenal factors. Patients with chronic kidney disease, other organ failure/chronic disease, a history of AKI, or who have used drugs with nephrotoxic potential are at an increased risk of developing AKI. To prevent AKI, patients at risk may be given IV fluids or have certain medications temporarily stopped.

      The kidneys are responsible for maintaining fluid balance and homeostasis, so a reduced urine output or fluid overload may indicate AKI. Symptoms may not be present in early stages, but as renal failure progresses, patients may experience arrhythmias, pulmonary and peripheral edema, or features of uraemia. Blood tests such as urea and electrolytes can be used to detect AKI, and urinalysis and imaging may also be necessary.

      Management of AKI is largely supportive, with careful fluid balance and medication review. Loop diuretics and low-dose dopamine are not recommended, but hyperkalaemia needs prompt treatment to avoid life-threatening arrhythmias. Renal replacement therapy may be necessary in severe cases. Patients with suspected AKI secondary to urinary obstruction require prompt review by a urologist, and specialist input from a nephrologist is required for cases where the cause is unknown or the AKI is severe.

    • This question is part of the following fields:

      • Renal System
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  • Question 30 - A 65-year-old patient has presented to your neurology clinic for a routine follow-up...

    Incorrect

    • A 65-year-old patient has presented to your neurology clinic for a routine follow-up a couple of months after being diagnosed with progressive muscular atrophy, a variant of motor neuron disease (MND) that results in a lower motor neuron lesion pattern.

      What signs would you anticipate observing during the examination?

      Your Answer:

      Correct Answer: Hypotonia and hyporeflexia

      Explanation:

      Lower motor neuron lesions result in a reduction of muscle tone and reflexes, which is characterized by hypotonia and hyporeflexia. Additionally, atrophy, wasting, and fasciculations may be observed in the affected muscle groups. It is important to note that hypertonia and hyperreflexia are indicative of an upper motor neuron lesion, and a combination of hypertonia and hyporeflexia or hypotonia and hyperreflexia are not typical patterns of a lower motor neuron lesion. Therefore, normal muscle tone and reflexes would not be expected in a patient with a lower motor neuron lesion.

      The spinal cord is a central structure located within the vertebral column that provides it with structural support. It extends rostrally to the medulla oblongata of the brain and tapers caudally at the L1-2 level, where it is anchored to the first coccygeal vertebrae by the filum terminale. The cord is characterised by cervico-lumbar enlargements that correspond to the brachial and lumbar plexuses. It is incompletely divided into two symmetrical halves by a dorsal median sulcus and ventral median fissure, with grey matter surrounding a central canal that is continuous with the ventricular system of the CNS. Afferent fibres entering through the dorsal roots usually terminate near their point of entry but may travel for varying distances in Lissauer’s tract. The key point to remember is that the anatomy of the cord will dictate the clinical presentation in cases of injury, which can be caused by trauma, neoplasia, inflammatory diseases, vascular issues, or infection.

      One important condition to remember is Brown-Sequard syndrome, which is caused by hemisection of the cord and produces ipsilateral loss of proprioception and upper motor neuron signs, as well as contralateral loss of pain and temperature sensation. Lesions below L1 tend to present with lower motor neuron signs. It is important to keep a clinical perspective in mind when revising CNS anatomy and to understand the ways in which the spinal cord can become injured, as this will help in diagnosing and treating patients with spinal cord injuries.

    • This question is part of the following fields:

      • Neurological System
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