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  • Question 1 - A 40-year-old man presents with wrist drop in his right hand. Upon examination,...

    Correct

    • A 40-year-old man presents with wrist drop in his right hand. Upon examination, a small region of sensory loss is noted on the back of his hand. Which nerve is most likely affected?

      Your Answer: Radial nerve

      Explanation:

      The radial nerve supplies muscles in the forearm and sensation to the dorsum of the thumb and fingers. Damage results in wrist drop and impaired sensation. The long thoracic nerve supplies serratus anterior and damage causes winging of the scapula. Median nerve palsy results in weakness in thumb and finger movement and sensory loss. T1 nerve root lesion results in Klumpke’s palsy. Ulnar nerve compression results in numbness and weakness in the hand, and can progress to a claw hand.

    • This question is part of the following fields:

      • Neurology
      23
      Seconds
  • Question 2 - A 75-year-old man presents to his General Practitioner with chest pain. The man...

    Correct

    • A 75-year-old man presents to his General Practitioner with chest pain. The man reports the pain as crushing in nature, exacerbated by exertion, particularly when climbing stairs in his home. The pain is typically relieved by rest, but he has experienced several episodes while watching television in the past two weeks. He has no other medical history and is generally in good health.
      What is the most suitable course of action?

      Your Answer: Refer to hospital for admission for observation and urgent elective angiogram

      Explanation:

      Appropriate Management for a Patient with Unstable Angina

      Unstable angina is a serious condition that requires urgent medical attention. In the case of a patient displaying textbook signs of unstable angina, such as crushing chest pain occurring at rest, admission to the hospital is necessary. Sending the patient home with only glyceryl trinitrate (GTN) spray is not appropriate, as the patient is at high risk of having a myocardial infarction (MI). Instead, the patient should be seen by Cardiology for consideration of an urgent elective angiogram.

      Prescribing ramipril and simvastatin is not indicated unless there is evidence of hypertension. Lifestyle advice, including exercise recommendation, is also not appropriate for a patient with unstable angina. The immediate problem should be addressed first, which is the need for an angiogram.

      It is important to differentiate between unstable and stable angina. Unstable angina presents with symptoms at rest, indicating a significant worsening of the patient’s cardiac disease. On the other hand, stable angina only presents with symptoms on exertion.

      Sending the patient for percutaneous coronary intervention (PCI) is not necessary unless there is evidence of an MI. The pain experienced due to angina will alleviate itself most commonly at rest, unless the angina is unstable. Therefore, an urgent elective angiogram is the appropriate management for a patient with unstable angina.

    • This question is part of the following fields:

      • Cardiology
      56.7
      Seconds
  • Question 3 - A 55-year-old woman is brought to the GP by her worried daughter. The...

    Correct

    • A 55-year-old woman is brought to the GP by her worried daughter. The patient has a history of mental health issues which limits her mobility, but she is still able to perform daily activities independently. Recently, the patient has been complaining of increased bone and joint pain, particularly in her legs and spine, accompanied by a general feeling of weakness. Upon examination, the patient exhibits tenderness in her long bones, weakness in her proximal muscles, and difficulty walking with a waddling gait. What is the most probable diagnosis based on the patient's symptoms?

      Your Answer: Osteomalacia

      Explanation:

      The patient is experiencing bone pain, tenderness, and proximal myopathy, which are indicative of osteomalacia. This condition is caused by a lack of vitamin D, which leads to decreased bone mineralization and softening of the bones. Unlike other bone disorders, osteomalacia can cause joint and bone pain as well as muscle weakness, particularly in the form of proximal myopathy. Osteopenia, on the other hand, is characterized by low bone density and typically precedes osteoporosis. While patients with osteopenia are at risk of bone fractures, the condition itself does not usually cause symptoms such as pain or weakness. Similarly, osteoporosis is a more severe form of reduced bone mass that increases the risk of fractures but does not typically cause symptoms. Paget disease, which results from dysregulated bone remodeling, can cause bone pain but is often asymptomatic. The most common features of Paget disease include skull frontal bossing, headaches, and hearing loss, but joint pain, proximal weakness, and a waddling gait are not typically associated with this condition.

      Understanding Osteomalacia

      Osteomalacia is a condition that occurs when the bones become soft due to low levels of vitamin D, which leads to a decrease in bone mineral content. This condition is commonly seen in adults, while in growing children, it is referred to as rickets. The causes of osteomalacia include vitamin D deficiency, malabsorption, lack of sunlight, chronic kidney disease, drug-induced factors, inherited conditions, liver disease, and coeliac disease.

      The symptoms of osteomalacia include bone pain, muscle tenderness, fractures, especially in the femoral neck, and proximal myopathy, which may lead to a waddling gait. To diagnose osteomalacia, blood tests are conducted to check for low vitamin D levels, low calcium and phosphate levels, and raised alkaline phosphatase levels. X-rays may also show translucent bands known as Looser’s zones or pseudofractures.

      The treatment for osteomalacia involves vitamin D supplementation, with a loading dose often needed initially. Calcium supplementation may also be necessary if dietary calcium intake is inadequate. Understanding the causes, symptoms, and treatment options for osteomalacia is crucial in managing this condition effectively.

    • This question is part of the following fields:

      • Musculoskeletal
      101.6
      Seconds
  • Question 4 - A 14-year-old boy comes to the GP complaining of left groin pain and...

    Correct

    • A 14-year-old boy comes to the GP complaining of left groin pain and a limp that has been gradually developing over the past 5 weeks. He has no medical or family history and his right leg is unaffected. Upon examination, there is a noticeable decrease in internal rotation of the left leg, but no swelling or warmth around the joints. The patient's vital signs are normal, and his height is in the 50th percentile while his weight is in the 95th percentile. What is the most probable diagnosis?

      Your Answer: Slipped capital femoral epiphysis

      Explanation:

      Slipped capital femoral epiphysis is more likely to occur in obese boys aged 10-15, as obesity is a risk factor for this condition. It is caused by a weakness in the proximal femoral growth plate, which can also be due to endocrine disorders or rapid growth. Loss of internal rotation of the affected leg is a common finding during examination. Perthes’ disease can also cause groin pain, but it typically affects children aged 4 to 8 years old. Being male and having a lower socioeconomic status are also risk factors for this condition. Septic arthritis is unlikely in this case as the child’s vital signs are normal, and it usually presents with a hot and swollen joint and systemic illness. Developmental dysplasia of the hip is usually detected during routine hip examinations in the first year of life, using Barlow/Ortolani tests and assessing hip abduction.

      Slipped Capital Femoral Epiphysis: A Rare Hip Condition in Children

      Slipped capital femoral epiphysis, also known as slipped upper femoral epiphysis, is a rare hip condition that primarily affects children between the ages of 10 and 15. It is more commonly seen in obese boys. This condition is characterized by the displacement of the femoral head epiphysis postero-inferiorly, which may present acutely following trauma or with chronic, persistent symptoms.

      The most common symptoms of slipped capital femoral epiphysis include hip, groin, medial thigh, or knee pain and loss of internal rotation of the leg in flexion. In some cases, a bilateral slip may occur. Diagnostic imaging, such as AP and lateral (typically frog-leg) views, can confirm the diagnosis.

      The management of slipped capital femoral epiphysis typically involves internal fixation, which involves placing a single cannulated screw in the center of the epiphysis. However, if left untreated, this condition can lead to complications such as osteoarthritis, avascular necrosis of the femoral head, chondrolysis, and leg length discrepancy.

      In summary, slipped capital femoral epiphysis is a rare hip condition that primarily affects children, especially obese boys. It is characterized by the displacement of the femoral head epiphysis postero-inferiorly and can present with various symptoms. Early diagnosis and management are crucial to prevent complications.

    • This question is part of the following fields:

      • Paediatrics
      61.1
      Seconds
  • Question 5 - A 78-year-old man with known dementia is admitted to hospital for treatment of...

    Correct

    • A 78-year-old man with known dementia is admitted to hospital for treatment of a community acquired pneumonia. Unfortunately, he was not accompanied by a family member and the history provided by the patient seems confused. Upon arrival of the daughter, she confirms that her father has been confusing real events with those from his imagination. Through this process he appears to be able to maintain a superficial conversation despite significant cognitive impairment.
      Which of the following describes this phenomenon?

      Your Answer: Confabulation

      Explanation:

      Differentiating Confabulation, Delusions, and Other Psychiatric Phenomena

      Confabulation, delusions, and other psychiatric phenomena can be confusing and difficult to differentiate. Confabulation is a phenomenon where patients fabricate imaginary experiences due to memory loss, often seen in patients with cognitive impairment. Delusions, on the other hand, are beliefs held with strong conviction despite evidence to the contrary, commonly seen in conditions such as schizophrenia. Flight of ideas, pressure of speech, and hallucinations are other psychiatric phenomena that can be seen in different conditions. Understanding the differences between these phenomena is crucial in making accurate diagnoses and providing appropriate treatment.

    • This question is part of the following fields:

      • Psychiatry
      446.9
      Seconds
  • Question 6 - A 23-year-old woman slipped and fell on her left hand, resulting in injury...

    Incorrect

    • A 23-year-old woman slipped and fell on her left hand, resulting in injury to her left anatomical snuffbox. Which structures are more likely to be affected by an injury to the anatomical snuffbox?

      Your Answer: Radial nerve

      Correct Answer: Radial artery

      Explanation:

      Anatomical Snuffbox and Nerve and Artery Relations in the Wrist

      The anatomical snuffbox is a triangular depression located on the lateral side of the wrist, bounded by tendons and limited above by the styloid process of the radius. The floor of the snuffbox is formed by the scaphoid and the trapezium and is crossed by the radial artery.

      The radial nerve can be damaged by a midshaft humerus fracture, leading to wrist drop, but it does not pass over the anatomical snuffbox. The median nerve can be compressed when passing through the carpal tunnel, causing tingling and numbness in the hand, but it has no relation to the snuffbox. The ulnar nerve can be compressed in the cubital fossa, leading to numbness and tingling in the fourth and fifth fingers, but it also has no relation to the snuffbox. The ulnar artery is on the medial side of the wrist and has no relation to the snuffbox.

    • This question is part of the following fields:

      • Orthopaedics
      37.9
      Seconds
  • Question 7 - A 75-year-old woman comes in with weight loss and a serum calcium concentration...

    Incorrect

    • A 75-year-old woman comes in with weight loss and a serum calcium concentration of 3.22 mmol/l (normal range 2.1-2.8 mmol/l). Her skeletal survey shows no abnormalities. The doctors suspect non-metastatic hypercalcaemia. What is the probable substance being produced by the tumor?

      Your Answer: Calcitonin

      Correct Answer: Parathyroid hormone-related peptide (PTHrP)

      Explanation:

      Causes of Hypercalcaemia in Cancer Patients

      Hypercalcaemia is a common occurrence in cancer patients, affecting around 10-20% of cases. It is caused by increased bone resorption and release of calcium from bone. The most common cancers associated with hypercalcaemia are breast and lung cancers, as well as multiple myeloma.

      One of the most common causes of hypercalcaemia in patients with non-metastatic solid tumours is the secretion of parathyroid hormone-related peptide (PTHrP), also known as humoral hypercalcaemia of malignancy. This should be suspected in any patient with a solid tumour in the absence of bony metastases or in patients with unexplained hypercalcaemia and low serum PTH concentration. PTHrP is related in function to PTH and is most commonly secreted by breast and lung tumours.

      Osteoclast-activating cytokines can also cause osteolytic metastases and release of calcium. Calcitonin is used to lower plasma calcium concentration in patients with hypercalcaemia associated with malignancy. Calcitriol is the cause of almost all cases of hypercalcaemia in Hodgkin’s disease and approximately one-third of cases in non-Hodgkin’s lymphoma. Secretion of PTH as a cause is rare, and serum PTH concentrations are typically low.

      In conclusion, hypercalcaemia in cancer patients can have various causes, and it is important to identify the underlying cause to provide appropriate treatment.

    • This question is part of the following fields:

      • Oncology
      1033.7
      Seconds
  • Question 8 - A 65-year-old man fell off a ladder while painting a wall and dislocated...

    Correct

    • A 65-year-old man fell off a ladder while painting a wall and dislocated his right shoulder. X-rays showed an anterior dislocation but no fractures. The shoulder was easily reduced without complications, and post-reduction radiographs were satisfactory. At his 2-week follow-up with his general practitioner, he reports difficulty in abducting his right arm. There are no neurovascular defects, and he has full sensation and good radial pulses. What imaging modality would be most helpful in confirming the diagnosis for this patient?

      Your Answer: Magnetic resonance imaging (MRI) of the shoulder

      Explanation:

      Diagnostic Imaging for Shoulder Injuries: MRI, Bone Scans, CT Scans, X-rays, and EMG

      Shoulder injuries in patients over 40 years old are often associated with acute avulsion injuries and rotator cuff tears. These tears can be degenerative and not related to trauma. The incidence of rotator cuff tears after acute dislocation in patients over 40 years old is high. Ultrasound and MRI are the preferred diagnostic tools for rotator cuff disease.

      Bone scans are not useful in this scenario, and CT scans with iv contrast may reveal bony pathology but are not necessary. Repeat shoulder X-rays are also not beneficial if the post-reduction X-rays are normal.

      Axillary nerve and brachial plexus injuries can occur after acute shoulder dislocation, but EMG is not necessary if there is no sensory deficit or distal weakness. Overall, MRI is the most effective diagnostic tool for shoulder injuries in this patient population.

    • This question is part of the following fields:

      • Orthopaedics
      35.1
      Seconds
  • Question 9 - A patient presents with jaundice. The following results are available:
    HBsAg +ve, HBeAg +ve,...

    Correct

    • A patient presents with jaundice. The following results are available:
      HBsAg +ve, HBeAg +ve, HBeAb −ve, HBc IgM +ve
      Which one of the following interpretations is correct for a patient who is slightly older?

      Your Answer: Chronic hepatitis B with high infectivity

      Explanation:

      Understanding Hepatitis B Test Results

      Hepatitis B is a viral infection that affects the liver. Testing for hepatitis B involves several blood tests that can provide information about the patient’s current infection status, susceptibility to the virus, and immunity. Here are some key points to understand about hepatitis B test results:

      Chronic Hepatitis B with High Infectivity
      If a patient tests positive for HBsAg and HBeAg, it indicates a current infection with high infectivity. This means that the virus is highly active and can easily spread to others.

      Susceptible to Hepatitis B
      If a patient tests negative for HBsAg, anti-HBc, IgM anti-HBc, and anti-HBs, it indicates that they are susceptible to hepatitis B and have not been infected or vaccinated against it.

      Chronic Hepatitis B with Low Infectivity
      If a patient tests positive for HBeAg but negative for HBeAb, it indicates a chronic carrier state with low infectivity. This means that the virus is less active and less likely to spread to others.

      Previous Immunisation Against Hepatitis B
      If a patient tests positive for HBV surface antibody, it indicates immunity to hepatitis B either through vaccination or natural infection. However, if they also test positive for HBsAg and HBeAg, it indicates an active infection rather than immunisation.

      Natural Immunity Against Hepatitis B
      If a patient tests positive for HBV surface antibody, it indicates immunity to hepatitis B either through vaccination or natural infection. This means that they have been exposed to the virus in the past and have developed immunity to it.

    • This question is part of the following fields:

      • Gastroenterology
      114.6
      Seconds
  • Question 10 - A 57-year-old male with diabetes comes to the clinic complaining of weakness in...

    Correct

    • A 57-year-old male with diabetes comes to the clinic complaining of weakness in his left foot. He has noticed a dragging sensation when walking for the past two days. The patient has been diabetic for two years and has had no previous abnormalities during annual check-ups.

      During the examination, the patient is unable to dorsiflex his left foot and evert it. However, his right foot is unaffected, and plantar flexion and inversion are normal. What sensory abnormality would you anticipate finding in conjunction with this motor defect?

      Your Answer: Sensory loss over the lateral part of the leg and dorsum of the foot

      Explanation:

      Common Peroneal Nerve Neuropathy in a Diabetic Patient

      A male patient with diabetes has developed a mononeuropathy that is consistent with a common peroneal nerve neuropathy. This condition results in a loss of sensation in the lateral part of the leg and dorsum of the foot, while the fifth toe remains unaffected. Although peripheral neuropathy may be expected in diabetic patients, the sudden onset of this condition and previously normal findings suggest otherwise.

      In summary, this patient’s symptoms are indicative of a common peroneal nerve neuropathy, which is a type of mononeuropathy that affects the peroneal nerve. This condition is commonly seen in diabetic patients and can result in a loss of sensation in specific areas of the leg and foot.

    • This question is part of the following fields:

      • Neurology
      75
      Seconds
  • Question 11 - A 17-year-old pupil comes in with rapid breathing, lack of fluids and high...

    Incorrect

    • A 17-year-old pupil comes in with rapid breathing, lack of fluids and high blood sugar levels. What evidence would most strongly suggest a diagnosis of type 1 diabetes?

      Your Answer: Pancreatic alpha cell failure

      Correct Answer: Positive anti-glutamic acid decarboxylase antibodies

      Explanation:

      Type 1 Diabetes

      Type 1 diabetes is a condition where the body’s immune system attacks the pancreas, specifically the islet cells and glutamic acid decarboxylase (GAD). This autoimmune process leads to a loss of insulin production, which is necessary for regulating blood sugar levels. However, it is important to note that the exocrine function of the pancreas, which is responsible for producing digestive enzymes, remains intact.

      Interestingly, the alpha and delta cells in the pancreas, which produce glucagon and somatostatin respectively, are initially unaffected by the autoimmune process. This means that early on in the development of type 1 diabetes, these cells continue to function normally.

      Overall, the mechanisms behind type 1 diabetes can help individuals with the condition better manage their symptoms and improve their quality of life. It is important to work closely with healthcare professionals to develop a personalized treatment plan.

    • This question is part of the following fields:

      • Clinical Sciences
      89.9
      Seconds
  • Question 12 - A 57-year-old man who has been physically active throughout his life experiences a...

    Correct

    • A 57-year-old man who has been physically active throughout his life experiences a sudden onset of severe chest pain that spreads to his back, causing him to lose consciousness within minutes. He has a medical history of hypertension, but a recent treadmill test showed no signs of cardiac disease. What is the most probable diagnosis?

      Your Answer: Tear in the aortic intima

      Explanation:

      Aortic Dissection: A Probable Cause of Sudden Collapse with Acute Chest Pain

      The given history suggests that aortic dissection is the most probable cause of sudden collapse with acute chest pain radiating to the back. Although other conditions may also lead to sudden collapse, they do not typically present with acute chest pain radiating to the back in the presence of a recent normal exercise test. While acute myocardial infarction (MI) is a possible cause, it is not the most likely in this scenario.

      References such as BMJ Best Practice, BMJ Clinical Review, and eMedicine support the diagnosis and management of aortic dissection. Therefore, it is crucial to consider this condition as a potential cause of sudden collapse with acute chest pain and seek immediate medical attention. Early diagnosis and prompt treatment can significantly improve the patient’s prognosis and prevent life-threatening complications.

    • This question is part of the following fields:

      • Emergency Medicine
      88
      Seconds
  • Question 13 - You are requested to evaluate a 15-year-old Caucasian girl who has been feeling...

    Incorrect

    • You are requested to evaluate a 15-year-old Caucasian girl who has been feeling unwell for a few days. She has been experiencing intermittent fevers and chills and complains of extreme fatigue. Suddenly, half an hour before her admission to the hospital, she lost all vision in her left eye.

      During the examination, the patient appears pale and unwell. Her vital signs are as follows: temperature 38.5°C, pulse 120/minute, regular, blood pressure 100/55 mmHg, and respiratory rate 22/minute. A pansystolic murmur is audible at the apex and lower left sternal border. Both lungs are clear.

      The right pupil reacts normally to light, but there is no reaction from the left pupil, which remains fixed and dilated. The patient has complete loss of vision in the left eye, and the left fundus appears paler than the right, without papilloedema. The only additional finding on examination was a paronychia on her right thumb, and light pressure on the nail bed was very uncomfortable.

      Investigations reveal the following results: Hb 109 g/L (115-165), WBC 14.1 ×109/L (4-11), Neutrophils 9.0 ×109/L (1.5-7), Lymphocytes 4.8 ×109/L (1.5-4), Monocytes 0.29 ×109/L (0-0.8), Eosinophils 0.01 ×109/L (0.04-0.4), and Platelets 550 ×109/L (150-400).

      What is the most crucial investigation to determine the cause of her illness?

      Your Answer: Cerebral angiogram

      Correct Answer: Blood cultures

      Explanation:

      Complications of Chronic Paronychia

      Chronic paronychia can lead to serious complications such as osteomyelitis and endocarditis. The most common causative organism for these complications is Staphylococcus aureus. Endocarditis can cause emboli, which are fragments of vegetation that can block or damage blood vessels in any part of the body. This can result in severe consequences such as blindness, stroke, or paralysis.

      To properly assess and manage a patient with chronic paronychia and its complications, several investigations may be necessary. However, the most crucial immediate investigations are blood cultures and echocardiography. These tests can help identify the causative organism and determine the extent of damage to the heart valves. Early diagnosis and treatment are essential to prevent further complications and improve the patient’s prognosis.

    • This question is part of the following fields:

      • Neurology
      89.3
      Seconds
  • Question 14 - As an Emergency department doctor, a 50-year-old man presents with intense left flank...

    Incorrect

    • As an Emergency department doctor, a 50-year-old man presents with intense left flank pain that extends to his groin. He reports that the pain began yesterday. Upon conducting a urinalysis, the following results were obtained:
      - Haemoglobin +++
      - Urobilinogen Negative
      - Bilirubin Negative
      - Protein Negative
      - Glucose Negative
      - Nitrites Negative
      - Leucocytes Negative
      - Ketones +

      What could be the possible cause of these findings?

      Your Answer: Nephritic syndrome

      Correct Answer: Renal calculus

      Explanation:

      Renal Calculi: Causes and Symptoms

      Renal calculi, commonly known as kidney stones, can be caused by various factors such as reduced urine output, changes in medication, and diet. These factors can lead to the formation of stones in the urinary tract, which can cause inflammation and damage to the lining of the urinary tract. Patients with renal calculi may experience symptoms such as blood in their urine due to the damage caused by the stones. Additionally, ketones may be present in the urine, indicating reduced oral intake due to severe pain.

      In summary, renal calculi can be caused by various factors and can lead to symptoms such as blood in the urine and reduced oral intake. It is important for patients to seek medical attention if they suspect they may have renal calculi to receive proper diagnosis and treatment.

    • This question is part of the following fields:

      • Nephrology
      129.7
      Seconds
  • Question 15 - A 35-year-old woman delivers a male infant who presents with low muscle tone...

    Incorrect

    • A 35-year-old woman delivers a male infant who presents with low muscle tone and is later diagnosed with Down's syndrome. Which of the following features is the least probable in this case?

      Your Answer: Brushfield spots

      Correct Answer: Rocker-bottom feet

      Explanation:

      Understanding the features of Down’s syndrome is crucial for clinical practice and final examinations. The correct answer to this question is option 4. While rocker-bottom feet are a characteristic of trisomy 18 or Edward’s syndrome, they are not typically observed in individuals with Down’s syndrome.

      Down’s syndrome is a genetic disorder that is characterized by various clinical features. These features include an upslanting of the palpebral fissures, epicanthic folds, Brushfield spots in the iris, a protruding tongue, small low-set ears, and a round or flat face. Additionally, individuals with Down’s syndrome may have a flat occiput, a single palmar crease, and a pronounced sandal gap between their big and first toe. Hypotonia, congenital heart defects, duodenal atresia, and Hirschsprung’s disease are also common in individuals with Down’s syndrome.

      Cardiac complications are also prevalent in individuals with Down’s syndrome, with multiple cardiac problems potentially present. The most common cardiac defect is the endocardial cushion defect, also known as atrioventricular septal canal defects, which affects 40% of individuals with Down’s syndrome. Other cardiac defects include ventricular septal defect, secundum atrial septal defect, tetralogy of Fallot, and isolated patent ductus arteriosus.

      Later complications of Down’s syndrome include subfertility, learning difficulties, short stature, repeated respiratory infections, hearing impairment from glue ear, acute lymphoblastic leukaemia, hypothyroidism, Alzheimer’s disease, and atlantoaxial instability. Males with Down’s syndrome are almost always infertile due to impaired spermatogenesis, while females are usually subfertile and have an increased incidence of problems with pregnancy and labour.

    • This question is part of the following fields:

      • Paediatrics
      29.2
      Seconds
  • Question 16 - Each of the following drugs are known to induce cytochrome p450 enzyme, except...

    Correct

    • Each of the following drugs are known to induce cytochrome p450 enzyme, except which one?
      Rifampicin
      12%
      Isoniazid
      47%
      Phenobarbitone
      8%
      Griseofulvin
      23%
      Carbamazepine
      10%

      Is it true that isoniazid inhibits the P450 system? This information is important for me to know.

      Your Answer: Isoniazid

      Explanation:

      The P450 system is inhibited by isoniazid.

      P450 Enzyme System and its Inducers and Inhibitors

      The P450 enzyme system is responsible for metabolizing drugs in the body. Induction of this system usually requires prolonged exposure to the inducing drug, unlike P450 inhibitors, which have rapid effects. Some drugs that induce the P450 system include antiepileptics like phenytoin and carbamazepine, barbiturates such as phenobarbitone, rifampicin, St John’s Wort, chronic alcohol intake, griseofulvin, and smoking, which affects CYP1A2 and is the reason why smokers require more aminophylline.

      On the other hand, some drugs inhibit the P450 system, including antibiotics like ciprofloxacin and erythromycin, isoniazid, cimetidine, omeprazole, amiodarone, allopurinol, imidazoles such as ketoconazole and fluconazole, SSRIs like fluoxetine and sertraline, ritonavir, sodium valproate, and acute alcohol intake. It is important to be aware of these inducers and inhibitors as they can affect the metabolism and efficacy of drugs in the body. Proper dosing and monitoring can help ensure safe and effective treatment.

    • This question is part of the following fields:

      • Pharmacology
      76.3
      Seconds
  • Question 17 - A 30-year-old woman presents with sudden onset of abdominal pain and swelling. She...

    Correct

    • A 30-year-old woman presents with sudden onset of abdominal pain and swelling. She works as a teacher and is in a committed relationship. Upon examination, her abdomen is tender, particularly in the right upper quadrant, and there is mild jaundice. She is currently taking the combined oral contraceptive pill (COCP) and has no significant medical history or regular medication use. After three days of hospitalization, her abdomen became distended and fluid thrill was detected. Laboratory tests show:
      Parameter Result
      Investigation Result Normal value
      Haemoglobin 150 g/l 115–155 g/l
      Bilirubin 51 μmol/ 2–17 μmol/
      Aspartate aminotransferase (AST) 1050 IU/l 10–40 IU/l
      Alanine aminotransferase (ALT) 998 IU/l 5−30 IU/l
      Alkaline phosphatase (ALP) 210 IU/l 36–76 IU/l
      Gamma-Glutamyl transferase (γGT) 108 IU/l 8–35 IU/l
      Albumin 30 g/l 35–55 g/l
      An ultrasound revealed a slightly enlarged liver with a prominent caudate lobe.
      What is the most appropriate definitive treatment for this patient?

      Your Answer: Liver transplantation

      Explanation:

      Management of Budd-Chiari Syndrome: Liver Transplantation and Other Treatment Options

      Budd-Chiari syndrome (BCS) is a condition characterized by hepatic venous outflow obstruction, resulting in hepatic dysfunction, portal hypertension, and ascites. Diagnosis is typically made through ultrasound Doppler, and risk factors include the use of the combined oral contraceptive pill and genetic mutations such as factor V Leiden. Treatment options depend on the severity of the disease, with liver transplantation being necessary in cases of fulminant BCS. For less severe cases, the European Association for the Study of the Liver (EASL) recommends a stepwise approach, starting with anticoagulation and progressing to angioplasty, thrombolysis, and transjugular intrahepatic portosystemic shunt (TIPSS) procedure if needed. Oral lactulose is used to treat hepatic encephalopathy, and anticoagulation is necessary both urgently and long-term. Therapeutic drainage of ascitic fluid and diuretic therapy with furosemide or spironolactone may also be used to manage ascites, but these treatments do not address the underlying cause of BCS.

    • This question is part of the following fields:

      • Gastroenterology
      102.5
      Seconds
  • Question 18 - An 80-year-old woman complains of deep pain in her leg bones that has...

    Incorrect

    • An 80-year-old woman complains of deep pain in her leg bones that has been gradually worsening over the past 4 months. She has no significant medical history. Upon conducting blood tests, the following results were obtained:
      - Calcium: 1.6 mmol/L (normal range: 2.1-2.6)
      - Phosphate: 0.5 mmol/L (normal range: 0.8-1.4)
      - ALP: 160 u/L (normal range: 30-100)
      - Parathyroid hormone (PTH): 100 pg/mL (normal range: 14-65)
      What is the most likely diagnosis?

      Your Answer: Osteitis fibrosa cystica

      Correct Answer: Osteomalacia

      Explanation:

      Osteomalacia is the likely diagnosis for an older woman experiencing bone pain, as indicated by low serum calcium, low serum phosphate, raised ALP, and raised PTH. This condition is caused by severe vitamin D deficiency, which impairs calcium and phosphate absorption from the gastrointestinal tract and kidneys. As a result, PTH secretion increases to compensate for low calcium, leading to increased bone resorption and elevated ALP levels. Osteitis fibrosis cystica, osteopetrosis, and osteoporosis are less likely diagnoses, as they present with different metabolic blood results.

      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
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  • Question 19 - A 79-year-old woman presents to her GP with complaints of worsening pain in...

    Correct

    • A 79-year-old woman presents to her GP with complaints of worsening pain in her left knee for the past 6 months. The pain is more pronounced during the day and subsides at night or when she is at rest. She experiences increased stiffness in the morning, which takes around 15 minutes to resolve. She denies any joint problems in the past and is currently taking amlodipine for hypertension, which is well controlled. She has no known drug allergies. What is the most suitable initial management for this patient?

      Your Answer: Paracetamol and topical NSAIDS

      Explanation:

      It is likely that this woman is suffering from osteoarthritis in her right knee. Patients with osteoarthritis typically experience morning symptoms lasting less than 30 minutes. The recommended first-line pharmacological treatments for knee or hip arthritis are paracetamol and topical NSAIDs. Methotrexate is typically used for rheumatoid arthritis, while oral bisphosphonates are more appropriate for osteoporosis and not recommended as a first-line treatment for osteoarthritis. Following the analgesia ladder, patients should start with simple analgesia and increase dosage as needed. For those with hip or knee osteoarthritis, topical NSAIDs are preferred over oral NSAIDs.

      The Role of Glucosamine in Osteoarthritis Management

      Osteoarthritis (OA) is a common condition that affects the joints, causing pain and stiffness. The National Institute for Health and Care Excellence (NICE) published guidelines in 2014 on the management of OA, which includes non-pharmacological and pharmacological treatments. Glucosamine, a normal constituent of glycosaminoglycans in cartilage and synovial fluid, has been studied for its potential benefits in OA management.

      Several double-blind randomized controlled trials (RCTs) have reported significant short-term symptomatic benefits of glucosamine in knee OA, including reduced joint space narrowing and improved pain scores. However, more recent studies have produced mixed results. The 2008 NICE guidelines do not recommend the use of glucosamine, and a 2008 Drug and Therapeutics Bulletin review advised against prescribing it on the NHS due to limited evidence of cost-effectiveness.

      Despite the conflicting evidence, some patients may still choose to use glucosamine as a complementary therapy for OA management. It is important for healthcare professionals to discuss the potential benefits and risks of glucosamine with their patients and to consider individual patient preferences and circumstances.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 20 - An 88-year-old man presents to the Emergency Department with severe pain in his...

    Incorrect

    • An 88-year-old man presents to the Emergency Department with severe pain in his left leg, below the knee. This pain came on suddenly an hour ago, after walking to his bathroom. He knows that he gets claudication on walking over 250 metres, and is unsure if this pain is the same. His medical history includes hypertension, controlled with amlodipine 5 mg od. On examination, his left leg below the knee is pale, cold and numb, with absent dorsalis pedis and posterior tibial pulses, but present pulses on his right leg.
      Given the likely diagnosis, what is the most appropriate management?

      Your Answer: Angiography and stenting

      Correct Answer: Embolectomy

      Explanation:

      Treatment Options for Acute Limb Ischaemia: Embolectomy and Thrombolysis

      Acute limb ischaemia can be caused by either an embolus or a thrombosis. The diagnosis is clinical and can be remembered using the 6Ps: Pale, Pulseless, Paraesthesia, Pain, Paralysis, and Perishingly cold. In the case of an embolic cause, urgent embolectomy using a Fogarty catheter to retrieve the clot is the appropriate treatment. Post-embolectomy, patients should be anticoagulated with IV heparin and then switched over to warfarin.

      Thrombolysis is the appropriate treatment if the ischaemia is caused by a thrombosis. However, based on the clinical history, if the patient has an embolic cause, thrombolysis is not recommended. Thrombosis tends to present over hours to days, with a history of claudication and is less severe as collateral blood supply develops. Contralateral pulses tend to be absent.

      Amputation below the right knee is an effective treatment but should only be considered by experienced consultants as it will have serious long-term implications for patients. Because the man has presented relatively quickly, it is unlikely that amputation will be required.

      High dose warfarin is not a treatment for acute limb ischaemia. The clot needs to be removed.

      Angiography is not performed when complete occlusion is suggested by the clinical picture, as it introduces a delay in revascularisation. In an incomplete occlusion, angiography is used to place stents to open the vessels.

      In summary, the appropriate treatment for acute limb ischaemia caused by an embolus is embolectomy, while thrombolysis is the appropriate treatment for ischaemia caused by a thrombosis. Amputation should only be considered as a last resort, and high dose warfarin is not a treatment option. Angiography and stenting are only used in cases of incomplete occlusion.

    • This question is part of the following fields:

      • Vascular
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  • Question 21 - A 40-year-old HIV-positive man presents with weight loss and weakness and is diagnosed...

    Incorrect

    • A 40-year-old HIV-positive man presents with weight loss and weakness and is diagnosed with disseminated tuberculosis. During examination, he exhibits hypotension and hyperpigmentation of the mucosa, elbows, and skin creases. Further testing reveals a diagnosis of Addison's disease. What is the most common biochemical abnormality associated with this condition?

      Your Answer: Increased sodium

      Correct Answer: Increased potassium

      Explanation:

      Biochemical Findings in Addison’s Disease

      Addison’s disease is a condition characterized by primary adrenocortical insufficiency, which is caused by the destruction or dysfunction of the entire adrenal cortex. The most prominent biochemical findings in patients with Addison’s disease are hyponatremia, hyperkalemia, and mild non-anion gap metabolic acidosis. This article discusses the various biochemical changes that occur in Addison’s disease, including increased potassium, increased glucose, increased bicarbonate, increased sodium, and reduced urea. These changes are a result of the loss of gland function, which leads to reduced glucocorticoid and mineralocorticoid function. The sodium-retaining and potassium and hydrogen ion-secreting action of aldosterone is particularly affected, resulting in the biochemical changes noted above. The article also highlights the most common causes of Addison’s disease, including tuberculosis, autoimmune disease, and removal of exogenous steroid therapy.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 22 - A 27-year-old man with a history of eczema presents with itchy, red patches...

    Correct

    • A 27-year-old man with a history of eczema presents with itchy, red patches of skin on his antecubital fossae, lateral thighs, and popliteal fossae. The skin on his right thigh is weeping and inflamed. He reports feeling fatigued and wonders if he has had a fever. His vital signs are within normal limits. Based on your examination, you diagnose him with moderately severe eczema.
      What is the best course of action for managing his condition?

      Your Answer: Regular Diprobase® ointment and once-daily betamethasone valerate 0.025% cream plus 10 days of oral flucloxacillin

      Explanation:

      Treatment Regime for Moderately Severe Eczema with Superimposed Infection

      Moderately severe eczema with evidence of superimposed infection requires a specific treatment regime. The severity of eczema is categorized into four categories: clear, mild, moderate, and severe. In this case, the patient has small areas of dry skin mainly in the flexures, and there is evidence of infected eczema/cellulitis with an erythematosus, weeping patch of skin in the lateral thigh.

      The treatment regime should include a regular emollient ointment, such as Diprobase®, applied generously to the skin multiple times a day. Additionally, a moderately potent topical corticosteroid, such as betamethasone valerate 0.025% or clobetasone butyrate 0.05%, should be used sparingly on the inflamed areas once a day. The patient must be advised to apply the steroid first and allow 15-20 minutes for it to be absorbed before applying the emollient. Treatment should last 7-14 days and continue until 48 hours after the eczematous patches have cleared.

      Furthermore, oral antibiotics are necessary for the treatment of infected eczema. Oral flucloxacillin is considered first-line, and treatment usually lasts for a 10-day period.

      Treatment Regime for Moderately Severe Eczema with Superimposed Infection

    • This question is part of the following fields:

      • Dermatology
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  • Question 23 - A 24-year-old student is brought into the emergency department by paramedics. He is...

    Correct

    • A 24-year-old student is brought into the emergency department by paramedics. He is unconscious.
      Interpret the liver function tests and choose the most appropriate investigation to confirm the likely diagnosis:
      Bilirubin 164 µmol/l
      ALP 213 u/l
      ALT 11641 u/l
      AST 9465 u/l
      Albumin 27 g/l

      Your Answer: Paracetamol level

      Explanation:

      Paracetamol overdose is the most common cause of a transaminitis with elevated ALT and AST levels in the 10,000s. It is important to note that hepatitis A and B typically cause elevations in AST and ALT, but not as high as the levels seen in this patient during the acute phase. Alcoholism usually results in a greater elevation in AST than ALT and is often associated with reduced albumin and protein levels due to decreased hepatic synthetic function. An abdominal ultrasound is particularly useful for detecting gallstones, signs of obstruction, and cholecystitis in the biliary tract. However, given the severity of the transaminitis, paracetamol overdose is a more likely diagnosis than these conditions.

      Paracetamol overdose management guidelines were reviewed by the Commission on Human Medicines in 2012. The new guidelines removed the ‘high-risk’ treatment line on the normogram, meaning that all patients are treated the same regardless of their risk factors for hepatotoxicity. However, for situations outside of the normal parameters, it is recommended to consult the National Poisons Information Service/TOXBASE. Patients who present within an hour of overdose may benefit from activated charcoal to reduce drug absorption. Acetylcysteine should be given if the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity. Acetylcysteine is now infused over 1 hour to reduce adverse effects. Anaphylactoid reactions to IV acetylcysteine are generally treated by stopping the infusion, then restarting at a slower rate. The King’s College Hospital criteria for liver transplantation in paracetamol liver failure include arterial pH < 7.3, prothrombin time > 100 seconds, creatinine > 300 µmol/l, and grade III or IV encephalopathy.

    • This question is part of the following fields:

      • Pharmacology
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  • Question 24 - A 35-year-old man arrives at the Emergency Department after smoking excessive amounts of...

    Correct

    • A 35-year-old man arrives at the Emergency Department after smoking excessive amounts of heroin. He is unresponsive and exhibits pinpoint pupils and symptoms of respiratory depression.
      What is the most suitable antidote for this patient?

      Your Answer: Naloxone

      Explanation:

      Antidotes for Overdose: Understanding the Correct Treatment for Different Types of Overdose

      Overdose can be a life-threatening situation that requires immediate medical attention. Different types of overdose require different antidotes for effective treatment. Here is a breakdown of some common antidotes and their uses:

      Naloxone: This is the first-line treatment for opioid overdose. It works by binding to opioid receptors in the brain and reversing the effects of opioids. Naloxone can be given intravenously, intramuscularly, subcutaneously, or intranasally.

      Vitamin K: This antidote is used for patients with severe bleeding on anticoagulation therapy or those who are vitamin K-deficient. Vitamin K takes time to take effect, with the maximum effect occurring 6-24 hours after administration.

      Lithium: This medication is not used as an antidote for overdose. It is commonly used for mania and bipolar disorder.

      Flumazenil: This is the first-line treatment for benzodiazepine overdose. It works by competing with benzodiazepines for receptor binding sites. Flumazenil should only be given in cases of known benzodiazepine overdose.

      N-acetylcysteine (NAC): This is the first-line antidote for paracetamol overdose. It works by replenishing depleted glutathione reserves in the liver and enhancing non-toxic metabolism of acetaminophen.

      In conclusion, understanding the correct antidote for different types of overdose is crucial for effective treatment. Naloxone for opioid overdose, vitamin K for severe bleeding, flumazenil for benzodiazepine overdose, and NAC for paracetamol overdose are some common examples of antidotes used in clinical practice.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
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  • Question 25 - John, a 35-year-old Caucasian man visited his doctor with a range of symptoms....

    Correct

    • John, a 35-year-old Caucasian man visited his doctor with a range of symptoms. He reported feeling feverish on and off for the past few months, experiencing fatigue, unintentional weight loss of around 3kg, and general muscle aches and pains. He was not taking any medication. Upon examination, his doctor found no abnormalities in his observations or physical examination. The doctor ordered a full blood count, which showed the following results:

      - Hb 112g/L Male: (130 - 180)
      - Platelets 200 * 109/L (150 - 400)
      - WBC 3.8 * 109/L (4.0 - 11.0)
      - Lymphocytes 2.8 * 109/L (1.0 - 4.5)
      - Mean corpuscular volume 92 fL (76 - 98)
      - Mean corpuscular haemoglobin 31 pg (27 - 32)
      - Ferritin 40 ng/mL (20 - 230)

      Based on these results, the doctor suspects that John may have systemic lupus erythematosus (SLE) and orders further blood tests. Which test, if positive, would best indicate that John is likely to have this condition?

      Your Answer: Anti-dsDNA

      Explanation:

      The sensitivity of ANA is high, making it a valuable test for ruling out SLE, but its specificity is low. Anti-histone antibodies are typically utilized as an indicator for drug-induced SLE. ESR is not a serum antibody and is not employed for diagnosing or ruling out SLE.

      Systemic lupus erythematosus (SLE) can be investigated through various tests, including antibody tests. ANA testing is highly sensitive, making it useful for ruling out SLE, but it has low specificity. About 99% of SLE patients are ANA positive. Rheumatoid factor testing is positive in 20% of SLE patients. Anti-dsDNA testing is highly specific (>99%), but less sensitive (70%). Anti-Smith testing is also highly specific (>99%), but only 30% of SLE patients test positive. Other antibody tests include anti-U1 RNP, SS-A (anti-Ro), and SS-B (anti-La).

      Monitoring of SLE can be done through various markers, including inflammatory markers such as ESR. During active disease, CRP levels may be normal, but a raised CRP may indicate an underlying infection. Complement levels (C3, C4) are low during active disease due to the formation of complexes that lead to the consumption of complement. Anti-dsDNA titres can also be used for disease monitoring, but it is important to note that they are not present in all SLE patients. Proper monitoring of SLE is crucial for effective management of the disease.

    • This question is part of the following fields:

      • Musculoskeletal
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  • Question 26 - A three-year-old child is admitted to the hospital with a high fever of...

    Correct

    • A three-year-old child is admitted to the hospital with a high fever of 39ºC that has persisted for the past five days. The parents are worried as they have noticed redness in the child's eyes, swelling in the neck, and a new rash.

      During the examination, the child is found to have a widespread maculopapular rash and bilateral conjunctivitis. Additionally, there is unilateral cervical lymphadenopathy, cracked and erythematosus lips, and a strawberry tongue.

      What is the initial treatment that should be given to this three-year-old child?

      Your Answer: Aspirin

      Explanation:

      Kawasaki disease is a systemic vasculitis that typically affects children under the age of 5. Symptoms include a fever lasting over 5 days, bilateral non-purulent conjunctivitis, a rash, mucosal erythema with a strawberry tongue, and unilateral cervical lymphadenopathy. In some cases, swelling of the hands and feet can occur, followed by desquamation in the second week. If left untreated, up to one-quarter of patients can develop coronary aneurysms. The main goal of treatment is to reduce the risk of cardiac complications. In the UK, the standard treatment is intravenous immunoglobulin and high dose aspirin, despite the fact that aspirin is usually contraindicated in children. Benzylpenicillin is not indicated in the treatment of Kawasaki disease. Conservative management is also not appropriate, as specific treatment is required to reduce inflammation and prevent the risk of coronary complications. Corticosteroids may be used as a second-line treatment if the patient does not respond to intravenous immunoglobulins.

      Understanding Kawasaki Disease

      Kawasaki disease is a rare type of vasculitis that primarily affects children. It is important to identify this disease early on as it can lead to serious complications, such as coronary artery aneurysms. The disease is characterized by a high-grade fever that lasts for more than five days and is resistant to antipyretics. Other symptoms include conjunctival injection, bright red, cracked lips, strawberry tongue, cervical lymphadenopathy, and red palms and soles that later peel.

      Diagnosis of Kawasaki disease is based on clinical presentation as there is no specific diagnostic test available. Management of the disease involves high-dose aspirin, which is one of the few indications for aspirin use in children. Intravenous immunoglobulin is also used as a treatment option. Echocardiogram is the initial screening test for coronary artery aneurysms, rather than angiography.

      Complications of Kawasaki disease can be serious, with coronary artery aneurysm being the most common. It is important to recognize the symptoms of Kawasaki disease early on and seek medical attention promptly to prevent potential complications.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 27 - A 50-year-old woman presents with acute right upper quadrant abdominal pain and vomiting,...

    Incorrect

    • A 50-year-old woman presents with acute right upper quadrant abdominal pain and vomiting, which started earlier today.
      On examination, the patient is not jaundiced and there is mild tenderness in the right upper quadrant and epigastrium. The blood results are as follows:
      Investigation Result Normal value
      Haemoglobin 130 g/l 115–155 g/l
      White cell count (WCC) 14 × 109/l 4–11 × 109/l
      Sodium (Na+) 138 mmol/l 135–145 mmol/l
      Potassium (K+) 4.0 mmol/l 3.5–5.0 mmol/l
      Urea 6.0 mmol/l 2.5–6.5 mmol/l
      Creatinine 70 μmmol/l 50–120 μmol/l
      Bilirubin 25 mmol/l 2–17 mmol/l
      Alkaline phosphatase 120 IU/l 30–130 IU/l
      Alanine aminotransferase (ALT) 40 IU/l 5–30 IU/l
      Amylase 200 U/l < 200 U/l
      Which of the following is the most appropriate management plan?

      Your Answer: Analgesia, iv fluids, iv antibiotics, endoscopic retrograde cholangiopancreatography (ERCP)

      Correct Answer: Analgesia, intravenous (iv) fluids, iv antibiotics, ultrasound (US) abdomen

      Explanation:

      The patient is suspected to have acute cholecystitis, and a confirmation of the diagnosis will rely on an ultrasound scan of the abdomen. To manage the patient’s symptoms and prevent sepsis, it is essential to administer intravenous antibiotics and fluids. Antiemetics may also be necessary to prevent dehydration from vomiting. It is recommended to keep the patient ‘nil by mouth’ until the scan is performed and consider prescribing analgesia for pain relief. An NG tube is not necessary at this stage, and an OGD or ERCP may be appropriate depending on the scan results. The NICE guidelines recommend cholecystectomy within a week of diagnosis.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 28 - The patient in the picture has a slow-growing facial lump and has been...

    Correct

    • The patient in the picture has a slow-growing facial lump and has been referred to the Ear, Nose and Throat (ENT) Outpatient Clinic. He denies any other symptoms and is in good health. Radiology confirms a parotid swelling. What is the most likely pathology he has?

      Your Answer: Pleomorphic adenoma

      Explanation:

      Possible Parotid Gland Conditions and Their Characteristics

      The parotid gland is a salivary gland located in front of the ear. It can be affected by various conditions, including pleomorphic adenoma, lymphoma, parotid adenitis, parotid abscess, and adenocarcinoma.

      Pleomorphic adenoma is the most common tumour of the parotid gland. It is a slow-growing, mixed benign tumour that can potentially become malignant and has a high chance of recurrence. Surgical removal through a parotidectomy is the current treatment approach.

      Lymphoma is a possibility in the parotid gland, but it is less common than pleomorphic adenoma. Patients with lymphoma may have constitutional symptoms, such as night sweats, weight loss, and fever.

      Parotid adenitis is inflammation of the parotid gland, which can occur for various reasons. It may be unilateral or bilateral, as seen in mumps. Inflammatory conditions typically cause more tenderness than swelling.

      Parotid abscess is a collection of pus in the parotid gland. However, the unusual shape of the gland in combination with normal overlying skin is not typical of abscesses or inflammation.

      Adenocarcinoma of the parotid gland is a malignant tumour that can involve the facial nerve. However, the lack of facial nerve involvement and the relative size of the tumour make adenocarcinoma unlikely in this case.

      In summary, the characteristics of each condition can help differentiate between them, and a proper diagnosis is crucial for appropriate treatment.

    • This question is part of the following fields:

      • ENT
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  • Question 29 - A 47-year-old woman is recuperating after a live donor related kidney transplant. She...

    Correct

    • A 47-year-old woman is recuperating after a live donor related kidney transplant. She is experiencing considerable abdominal discomfort. What pain-relieving medication should she steer clear of?

      Your Answer: Diclofenac

      Explanation:

      Patients who have received renal transplants are typically advised to avoid non-steroidal anti-inflammatory drugs due to their potential nephrotoxicity. The liver is primarily responsible for metabolizing paracetamol and morphine, although there is some renal involvement in the metabolism and excretion of morphine. If the transplanted kidney ceases to function, morphine should be administered in lower doses or avoided altogether.

      Organ Transplant: Matching and Rejection

      Organ and tissue transplants have become increasingly available, with allografts being the most common type of transplant where an organ is transplanted from one individual to another. However, allografts can elicit an immune response, leading to organ rejection. This is mainly due to allelic differences at genes that code immunohistocompatability complex genes, such as ABO blood group, human leucocyte antigens (HLA), and minor histocompatibility antigens. ABO incompatibility can result in early organ rejection, while HLA mismatching can lead to acute or chronic rejection. An ideal organ match would be one in which all eight alleles are matched.

      There are three types of organ rejection: hyperacute, acute, and chronic. Hyperacute rejection occurs immediately due to pre-formed antigens, such as ABO incompatibility. Acute rejection occurs during the first six months and is usually T cell mediated, while chronic rejection occurs after the first six months and is characterized by vascular changes. All types of transplanted organs are susceptible to acute and chronic rejection, with renal transplants being at the greatest risk for hyperacute rejection and liver transplants being at the least risk.

      In renal transplantation, patients with end-stage renal failure who are dialysis dependent or likely to become so in the immediate future are considered for transplant. Donor kidneys may be taken from live related donors or brain dead or dying patients. Laparoscopic donor nephrectomy minimizes operative morbidity for the donor, while minimizing warm ischaemic time in the donor phase is crucial. The kidney is prepared on the bench in theatre by the transplant surgeon immediately prior to implantation. The operation is performed under general anaesthesia, with the external iliac artery and vein being anastomosed to the iliacs and the ureter being implanted into the bladder. Acute tubular necrosis is a common problem encountered in cadaveric kidneys, but it tends to resolve. Graft survival times from cadaveric donors are typically of the order of 9 years, while monozygotic twin transplants may survive as long as 25 years.

    • This question is part of the following fields:

      • Surgery
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  • Question 30 - A 4-year-old girl is brought to the GP by her father who is...

    Correct

    • A 4-year-old girl is brought to the GP by her father who is concerned about her growth. He reports that she is not keeping up with her peers in terms of height and weight. The girl has been experiencing smelly diarrhoea around 4-5 times per week and complains of stomach pain.
      During the examination, the GP notes that the girl's abdomen is distended and her buttocks appear wasted. Her growth chart shows a drop of 2 centile lines, now placing her on the 10th centile.
      Which investigation is most likely to lead to a diagnosis?

      Your Answer: IgA TTG antibodies

      Explanation:

      The most probable diagnosis in this case is coeliac disease, which can be confirmed by testing for IgA TTG antibodies. To determine the appropriate antibiotic, a stool sample would be necessary to diagnose gastroenteritis. The hydrogen breath test is typically used to diagnose irritable bowel syndrome or certain food intolerances. Endoscopy is more frequently used in adults who are suspected of having cancer. An abdominal X-ray may be beneficial in cases where obstruction is suspected. Coeliac disease is a digestive disorder that is becoming more prevalent and is characterized by an adverse reaction to gluten, a protein found in wheat, barley, and rye.

      Coeliac Disease in Children: Causes, Symptoms, and Diagnosis

      Coeliac disease is a condition that affects children and is caused by sensitivity to gluten, a protein found in cereals. This sensitivity leads to villous atrophy, which causes malabsorption. Children usually present with symptoms before the age of 3, coinciding with the introduction of cereals into their diet. The incidence of coeliac disease is around 1 in 100 and is strongly associated with HLA-DQ2 and HLA-DQ8. Symptoms of coeliac disease include failure to thrive, diarrhoea, abdominal distension, and anaemia in older children. However, many cases are not diagnosed until adulthood.

      Diagnosis of coeliac disease involves a jejunal biopsy showing subtotal villous atrophy. Screening tests such as anti-endomysial and anti-gliadin antibodies are also useful. Duodenal biopsies can show complete atrophy of the villi with flat mucosa and marked crypt hyperplasia, as well as dense mixed inflammatory infiltrate in the lamina propria. Increased number of intraepithelial lymphocytes and vacuolated superficial epithelial cells can also be observed.

      In summary, coeliac disease is a condition that affects children and is caused by sensitivity to gluten. It is important to be aware of the symptoms and to seek medical attention if necessary. Diagnosis involves a biopsy and screening tests, and treatment involves a gluten-free diet.

    • This question is part of the following fields:

      • Paediatrics
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SESSION STATS - PERFORMANCE PER SPECIALTY

Neurology (2/3) 67%
Cardiology (1/1) 100%
Musculoskeletal (3/4) 75%
Paediatrics (3/4) 75%
Psychiatry (1/1) 100%
Orthopaedics (1/2) 50%
Oncology (0/1) 0%
Gastroenterology (2/3) 67%
Clinical Sciences (0/1) 0%
Emergency Medicine (1/1) 100%
Nephrology (0/1) 0%
Pharmacology (2/2) 100%
Vascular (0/1) 0%
Endocrinology (0/1) 0%
Dermatology (1/1) 100%
Acute Medicine And Intensive Care (1/1) 100%
ENT (1/1) 100%
Surgery (1/1) 100%
Passmed