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Question 1
Correct
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A 7-year-old boy is presented for surgery due to recurring headaches. What is the primary reason for headaches in children?
Your Answer: Migraine
Explanation:In children, primary headache is most commonly caused by migraine.
Understanding Headaches in Children
Headaches are a common occurrence in children, with up to 50% of 7-year-olds and 80% of 15-year-olds experiencing at least one headache. Migraine without aura is the most common cause of primary headache in children, with a strong female preponderance after puberty. The International Headache Society has produced criteria for diagnosing pediatric migraine without aura, which includes headache attacks lasting 4-72 hours, with at least two of four specific features and accompanying symptoms such as nausea and vomiting.
When it comes to acute management, ibuprofen is considered more effective than paracetamol for pediatric migraine. Triptans may be used in children over 12 years old, but follow-up is required, and only sumatriptan nasal spray is licensed for use in young people. However, oral triptans are not currently licensed for those under 18 years old, and side effects may include tingling, heat, and pressure sensations.
Prophylaxis for pediatric migraine is limited, with no clear consensus guidelines. Pizotifen and propranolol are recommended as first-line preventatives, while valproate, topiramate, and amitriptyline are considered second-line preventatives. Tension-type headache is the second most common cause of headache in children, with diagnostic criteria including at least 10 previous headache episodes lasting from 30 minutes to 7 days, with specific pain characteristics and the absence of nausea or vomiting.
In summary, headaches in children are common, and migraine without aura is the most common primary headache. Acute management includes ibuprofen and triptans, while prophylaxis is limited. Tension-type headache is also a common cause of headache in children. It is important to seek medical advice if headaches are frequent or severe, or if there are any concerning symptoms such as neurological deficits or changes in behavior.
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This question is part of the following fields:
- Paediatrics
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Question 2
Correct
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You are a foundation doctor working in general practice. You review a sixty-five-year-old gentleman with a facial rash. On examination you note a vesicular rash extending to the tip of the nose. Observations are unremarkable.
What is your primary concern?Your Answer: Possible involvement of the cornea
Explanation:The presence of vesicles extending to the tip of the nose, known as Hutchinson’s sign, is strongly linked to shingles affecting the eyes. This is because the trigeminal nerve branch that supplies the cornea and nasal tip is affected. While pneumonia can be associated with herpes, this patient does not exhibit any respiratory symptoms. Despite the potential for post-herpetic neuralgia from the painful rash of shingles, the primary concern for this patient is the ocular involvement indicated by Hutchinson’s sign.
Herpes Zoster Ophthalmicus: Symptoms, Treatment, and Complications
Herpes zoster ophthalmicus (HZO) is a condition that occurs when the varicella-zoster virus reactivates in the area supplied by the ophthalmic division of the trigeminal nerve. It is responsible for approximately 10% of shingles cases. The main symptom of HZO is a vesicular rash around the eye, which may or may not involve the eye itself. Hutchinson’s sign, a rash on the tip or side of the nose, is a strong indicator of nasociliary involvement and increases the risk of ocular involvement.
Treatment for HZO involves oral antiviral medication for 7-10 days, ideally started within 72 hours of symptom onset. Intravenous antivirals may be necessary for severe infections or immunocompromised patients. Topical antiviral treatment is not recommended for HZO, but topical corticosteroids may be used to treat any secondary inflammation of the eye. Ocular involvement requires urgent ophthalmology review to prevent complications such as conjunctivitis, keratitis, episcleritis, anterior uveitis, ptosis, and post-herpetic neuralgia.
In summary, HZO is a condition caused by the reactivation of the varicella-zoster virus in the ophthalmic division of the trigeminal nerve. It presents with a vesicular rash around the eye and may involve the eye itself. Treatment involves oral antiviral medication and urgent ophthalmology review is necessary for ocular involvement. Complications of HZO include various eye conditions, ptosis, and post-herpetic neuralgia.
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This question is part of the following fields:
- Ophthalmology
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Question 3
Correct
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Sarah, a 5-year-old child visits the allergy clinic with her parents. She has a confirmed milk protein allergy and her parents are interested in using the milk ladder to manage it. Which food item would be suitable to gradually introduce?
Your Answer: Malted milk biscuits
Explanation:Children with cows milk protein allergy can use the milk ladder to reintroduce milk protein after they turn 6 months old.
To gradually introduce milk, the milk ladder starts with cooked or baked milk. The process begins with malted milk biscuits and then progresses in a step-by-step manner towards pasteurised milk.
Understanding Cow’s Milk Protein Intolerance/Allergy
Cow’s milk protein intolerance/allergy (CMPI/CMPA) is a condition that affects around 3-6% of children, typically presenting in the first 3 months of life in formula-fed infants. Both immediate and delayed reactions can occur, with CMPA used for immediate reactions and CMPI for mild-moderate delayed reactions. Symptoms include regurgitation, vomiting, diarrhea, urticaria, atopic eczema, colic symptoms, wheeze, chronic cough, and rarely, angioedema and anaphylaxis. Diagnosis is often clinical, with investigations including skin prick/patch testing and total IgE and specific IgE (RAST) for cow’s milk protein.
Management for formula-fed infants includes using extensive hydrolyzed formula (eHF) milk as the first-line replacement formula for mild-moderate symptoms and amino acid-based formula (AAF) for severe CMPA or if no response to eHF. Around 10% of infants are also intolerant to soya milk. For breastfed infants, mothers should eliminate cow’s milk protein from their diet and consider prescribing calcium supplements to prevent deficiency. eHF milk can be used when breastfeeding stops until at least 6 months and up to 12 months of age.
The prognosis for CMPI is usually good, with most children becoming milk tolerant by the age of 3-5 years. However, a challenge is often performed in a hospital setting as anaphylaxis can occur. It is important to refer infants with severe symptoms to a pediatrician for management. Understanding CMPI/CMPA and its management can help parents and healthcare providers provide appropriate care for affected children.
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This question is part of the following fields:
- Paediatrics
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Question 4
Correct
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A 65-year-old man comes to your clinic complaining of progressive slurred speech over the past few months. He is embarrassed because he frequently gives presentations for work and some people have joked that he sounds drunk. Upon examination, there is no droop or drooling in his head and face, but he struggles to articulate certain phrases and has difficulty swallowing. His tongue also appears to fasciculate when he sticks it out. In addition, there is mild weakness and hypotonia in his limbs, but his knees and ankles have slight hyperreflexia. What is the most likely cause of his symptoms?
Your Answer: Motor neurone disease
Explanation:The presence of fasciculations, along with upper and lower motor neurone signs, strongly suggests motor neuron disease as the underlying condition. The patient’s difficulty with speech and swallowing may be due to bulbar palsy, which is commonly associated with this disease. A stroke, which typically presents with sudden onset of symptoms, is unlikely to be the cause of the patient’s progressive symptoms over weeks or months. While a cerebellar tumour may cause slurred speech, it would typically be accompanied by other symptoms such as ataxia, vertigo, and difficulty with basic movements. Multiple sclerosis is an uncommon diagnosis in late-middle-aged men and is an upper motor neurone disease, whereas this patient has a combination of upper and lower motor neurone signs. There is no evidence of tremor or bradykinesia in this case.
Understanding Motor Neuron Disease: Signs and Diagnosis
Motor neuron disease is a neurological condition that affects both upper and lower motor neurons. It is a rare condition that usually presents after the age of 40 and can manifest in different patterns such as amyotrophic lateral sclerosis, progressive muscular atrophy, and bulbar palsy. The diagnosis of motor neuron disease is based on clinical features, including the presence of fasciculations, the absence of sensory signs, and the combination of upper and lower motor neuron signs. Wasting of the small hand muscles and tibialis anterior is also common.
Other features that can help diagnose motor neuron disease include the absence of external ocular muscle involvement, the absence of cerebellar signs, and preserved abdominal reflexes. Sphincter dysfunction, if present, is usually a late feature. While vague sensory symptoms may occur early in the disease, sensory signs are typically absent.
Nerve conduction studies can help exclude a neuropathy, while electromyography shows a reduced number of action potentials with increased amplitude. MRI is usually performed to exclude other conditions such as cervical cord compression and myelopathy. Understanding the signs and diagnosis of motor neuron disease is crucial for early detection and management of the condition.
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This question is part of the following fields:
- Neurology
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Question 5
Incorrect
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As a junior doctor in a community mental health team, you are attending to a 35-year-old woman who is suffering from moderate-severe depression. She often voices out intense suicidal ideations and has a history of intentional overdose. Which category of antidepressants is currently less utilized due to their high toxicity in overdose?
Your Answer: Selective serotonin reuptake inhibitors
Correct Answer: Tricyclic antidepressants
Explanation:Tricyclic antidepressants are not commonly used for depression anymore due to their high risk of causing dangerous overdose. Therefore, when selecting an antidepressant for a patient who is at high risk of overdose, it is important to choose a class of antidepressants that are less toxic if taken in excess. TCAs have a narrow therapeutic index, which means that even moderate doses can lead to severe cardiovascular and CNS toxicity. Complications of TCA overdose include prolonged hypotension, cardiac arrhythmias, and seizures, which can ultimately result in death due to cardiovascular collapse.
Diagnosis of TCA overdose is typically made based on clinical presentation, and classic ECG changes may be observed, such as sinus tachycardia progressing to wide complex tachycardia and ventricular arrhythmias as the severity of intoxication increases. Treatment involves correcting acidosis, hypoxia, and electrolyte imbalances, as well as administering hypertonic sodium bicarbonate to improve conduction abnormalities and hypotension. Anti-arrhythmic drugs should generally be avoided, and benzodiazepines are the preferred treatment for seizures.
Tricyclic Antidepressants for Neuropathic Pain
Tricyclic antidepressants (TCAs) were once commonly used for depression, but their side-effects and toxicity in overdose have led to a decrease in their use. However, they are still widely used in the treatment of neuropathic pain, where smaller doses are typically required. TCAs such as low-dose amitriptyline are commonly used for the management of neuropathic pain and the prophylaxis of headache, while lofepramine has a lower incidence of toxicity in overdose. It is important to note that some TCAs, such as amitriptyline and dosulepin, are considered more dangerous in overdose than others.
Common side-effects of TCAs include drowsiness, dry mouth, blurred vision, constipation, urinary retention, and lengthening of the QT interval. When choosing a TCA for neuropathic pain, the level of sedation may also be a consideration. Amitriptyline, clomipramine, dosulepin, and trazodone are more sedative, while imipramine, lofepramine, and nortriptyline are less sedative. It is important to work with a healthcare provider to determine the appropriate TCA and dosage for the individual’s specific needs.
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This question is part of the following fields:
- Psychiatry
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Question 6
Correct
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A 45-year-old non-smoker with hypertension and diabetes has been diagnosed with bilateral renal artery stenosis. Blood tests reveal that he has normal renal function. He has undergone percutaneous angioplasty to both renal arteries, which was unsuccessful.
Which medication should this patient be started on?
Your Answer: Start angiotensin-converting enzyme (ACE) inhibitors
Explanation:Medical Management of Renal Artery Stenosis
Renal artery stenosis is a condition that requires medical management to control hypertension. Even if the arteries are treated successfully with angioplasty, antihypertensive therapy should be initiated. The ideal agent for this purpose is one that blocks the renin-angiotensin-aldosterone system, such as angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs). Warfarin is not indicated in patients with renal artery stenosis, but may be used for prophylaxis of embolisation in other conditions. Clopidogrel is not indicated for hypertension management in renal artery stenosis. Statins may be used for primary prevention of cardiovascular disease if cholesterol levels are raised, but controlling blood pressure is the primary consideration in renal artery stenosis. Spironolactone should not be used in patients with renal compromise. Control of blood pressure should ideally be achieved using ACE inhibitors or ARBs.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 7
Incorrect
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Methimazole (MMI) has a modest therapeutic advantage over carbimazole in the treatment of thyrotoxicosis.
Which of the following properties causes this?
Select the SINGLE property from the list below.Your Answer: Is more potent
Correct Answer: Inhibits T4 to T3 conversion
Explanation:Comparison of PTU and Carbimazole in the Treatment of Hyperthyroidism
PTU and carbimazole are two commonly used medications in the treatment of hyperthyroidism. While both drugs are effective in reducing thyroid hormone levels, there are some differences in their mechanisms of action and adverse effects.
One advantage of PTU over carbimazole is its ability to inhibit the conversion of T4 to the more active form T3. This is due to its inhibition of the enzyme 5′-deiodinase. However, both drugs inhibit the organification of iodine at the thyroid gland by inhibiting the enzyme thyroperoxidase.
While both drugs are present in breast milk, the amount is likely too small to affect the infant. However, high doses may impact neonatal thyroid function, so monitoring is necessary.
Carbimazole is considered to be at least 10 times as potent as PTU. Additionally, the two drugs have different chemical structures and therefore have slightly different adverse effects profiles. Common side effects include rash, hair loss, and skin pigmentation, while rare but serious side effects include aplastic anaemia, agranulocytosis, and fulminant liver failure.
Patients taking either medication should be aware of the signs of liver disease and seek medical attention if they experience symptoms such as anorexia, nausea, vomiting, fatigue, abdominal pain, jaundice, dark urine, or pruritus. Regular liver function monitoring is also recommended.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 8
Correct
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A 68-year-old man with hypertension has an annual review. He is medicated with amlodipine 10 mg once daily. He has never smoked and does not have diabetes. His past medical history is unremarkable. He has a blood pressure of 126/74 mmHg, total cholesterol:HDL-cholesterol ratio of 6.3, and QRISK2-2017 of 26.1%.
Target blood pressure in people aged <80 years, with treated hypertension: <140/90 mmHg.
Target blood pressure in people aged ≥80 years, with treated hypertension: <150/90 mmHg.
Total cholesterol: HDL-cholesterol ratio: high risk if >6.
You decide to initiate statin therapy for primary prevention of cerebrovascular disease (CVD).
Which of the following drugs is most appropriate for this patient?
Select the SINGLE drug from the slit below. Select ONE option only.Your Answer: Atorvastatin 20mg
Explanation:NICE Guidelines for Statin Use in Primary and Secondary Prevention of CVD
The National Institute for Health and Care Excellence (NICE) provides guidelines for the use of statins in the prevention of cardiovascular disease (CVD). For primary prevention, NICE recommends offering atorvastatin 20 mg to individuals with a 10-year risk of developing CVD ≥10%. Fluvastatin and simvastatin are not recommended as first-line agents for primary prevention.
For secondary prevention in individuals with established CVD, NICE recommends using atorvastatin 80 mg, with a lower dose used if there are potential drug interactions or high risk of adverse effects. Simvastatin 80 mg is considered a high-intensity statin, but is not recommended as a first-line agent for primary or secondary prevention.
NICE guidelines emphasize the importance of assessing CVD risk using a recognized scoring system, such as QRISK2, for primary prevention. All modifiable risk factors should be addressed for individuals with a risk score >10%, including weight loss, tight control of blood pressure, exercise, smoking cessation, and statin use to lower cholesterol.
For secondary prevention, all patients with CVD should be offered a statin. The QRISK2 risk assessment tool is recommended for assessing CVD risk in individuals up to and including age 84 years.
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This question is part of the following fields:
- Cardiovascular
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Question 9
Incorrect
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A 28-year-old woman is referred by her General Practitioner due to irregular and unpredictable menstrual cycle and headaches. Magnetic resonance imaging of the brain shows a midline lesion. Further investigations reveal that her prolactin level is 2314 ng/ml (normal range: 2–29 ng/ml). To reduce the prolactin level, which mediator is manipulated for medical treatment?
Your Answer: Gonadotropin-releasing hormone (GnRH)
Correct Answer: Dopamine
Explanation:Targeting Hormones in Prolactinoma Treatment
Prolactinoma is a pituitary lesion that results in excessive prolactin secretion. To reduce prolactin levels, dopamine agonists like bromocriptine are used to target dopamine receptors in the anterior pituitary. While increased prolactin can indirectly decrease gonadotropin-releasing hormone (GnRH) secretion, GnRH receptors are not a therapeutic target in prolactin disorders. Corticotropin-releasing hormone (CRH) increases adrenocorticotropic hormone secretion and is not a target in prolactin disorders. Somatostatin decreases thyroid-stimulating hormone (TSH) and growth hormone secretion but does not affect prolactin levels. Thyrotropin-releasing hormone (TRH) increases prolactin and TSH release, but its use is limited due to side-effects on thyroid regulation and the superiority of dopamine agonists.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 10
Correct
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A 58-year-old man complains of recurrent episodes of vertigo and dizziness. These episodes are usually triggered by a change in head position and usually last for about 30 seconds. The examination of the cranial nerves and ears shows no abnormalities. His blood pressure is 122/80 mmHg while sitting and 118/76 mmHg while standing. Assuming that the diagnosis is benign paroxysmal positional vertigo, what is the most suitable course of action to confirm the diagnosis?
Your Answer: Dix-Hallpike manoeuvre
Explanation:Understanding Benign Paroxysmal Positional Vertigo
Benign paroxysmal positional vertigo (BPPV) is a common condition that causes sudden dizziness and vertigo triggered by changes in head position. It typically affects individuals over the age of 55 and is less common in younger patients. Symptoms include vertigo triggered by movements such as rolling over in bed or looking upwards, and may be accompanied by nausea. Each episode usually lasts between 10-20 seconds and can be diagnosed through a positive Dix-Hallpike manoeuvre, which involves the patient experiencing vertigo and rotatory nystagmus.
Fortunately, BPPV has a good prognosis and often resolves on its own within a few weeks to months. Treatment options include the Epley manoeuvre, which is successful in around 80% of cases, and vestibular rehabilitation exercises such as the Brandt-Daroff exercises. While medication such as Betahistine may be prescribed, it tends to have limited value. However, it is important to note that around half of people with BPPV will experience a recurrence of symptoms 3-5 years after their initial diagnosis.
Overall, understanding BPPV and its symptoms can help individuals seek appropriate treatment and manage their condition effectively.
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This question is part of the following fields:
- ENT
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Question 11
Incorrect
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A 62-year-old woman complains of blood in her stool and unintentional weight loss. During rectal examination, you notice a suspicious lesion below the pectinate line, which raises concern for cancer. You proceed to check for any signs of lymphadenopathy.
Where would you anticipate discovering enlarged lymph nodes?Your Answer: Internal iliac
Correct Answer: Inguinal
Explanation:Lymph Node Drainage in the Pelvic Region
The lymphatic drainage in the pelvic region is an important aspect of the body’s immune system. There are several lymph nodes in this area that drain different parts of the body. Here is a breakdown of the lymph node drainage in the pelvic region:
1. Inguinal: The inguinal lymph nodes drain the anal canal inferior to the pectinate line. These nodes then drain into the lateral pelvic nodes.
2. External iliac: The external iliac nodes drain the adductor region of the upper thigh, glans, clitoris, cervix, and upper bladder.
3. Inferior mesenteric: The inferior mesenteric nodes drain the sigmoid, upper rectum, and descending colon.
4. Internal iliac: The internal iliac nodes drain the rectum and the part of the anal canal superior to the pectinate line.
5. Superior mesenteric: The superior mesenteric nodes drain parts of the upper gastrointestinal tract, specifically the duodenum and jejunum.
Understanding the lymph node drainage in the pelvic region is important for diagnosing and treating certain conditions. By knowing which lymph nodes drain which parts of the body, healthcare professionals can better identify the source of an infection or cancer and provide appropriate treatment.
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This question is part of the following fields:
- Immunology/Allergy
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Question 12
Correct
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A 35-year-old woman presents for review at her local general practice surgery. She has noticed a number of patches of pale skin on her hands over the past few weeks. The patient has tried using emollients and topical clotrimazole with no result.
On examination, a number of depigmented patches on the dorsum of both hands are noted. Her past medical history includes thyrotoxicosis for which she takes carbimazole and thyroxine.
Given the likely diagnosis, which of the following is most appropriate before starting treatment?
Select the SINGLE best option from the list below.
Select ONE option only.Your Answer: No further testing required
Explanation:Understanding Vitiligo: Diagnosis and Testing
Vitiligo is an autoimmune condition that causes depigmentation of the skin due to the loss of melanocytes. It is usually diagnosed based on clinical features, such as well-demarcated patches of depigmented skin. While there are no specific diagnostic tests for vitiligo, a punch biopsy may be used to obtain a skin sample for histological analysis in cases of suspected skin cancer or inflammatory skin disease. However, skin patch testing and skin prick testing are not useful in diagnosing vitiligo.
It is important to note that vitiligo is commonly associated with other autoimmune conditions, such as type I diabetes mellitus, Addison’s disease, thyroid disorders, pernicious anemia, and alopecia areata. While it can affect individuals of any age, it often arises before the age of 20 years and is equally prevalent in men and women. Itching and other symptoms are rare, and the changes may be more noticeable in individuals with light skin during the summer months.
In contrast, a radioallergosorbent test (RAST) is unsuitable for diagnosing vitiligo as it is used to determine the amount of immunoglobulin E (IgE) that reacts with suspected or known allergens. RAST is useful for diagnosing food allergies, inhaled allergens, and venom allergies. Blood tests may be used when skin prick tests are not suitable, such as when the patient is taking antihistamines or has extensive eczema.
In summary, vitiligo is a clinical diagnosis that does not require further testing. While a punch biopsy may be used in certain cases, skin patch testing and skin prick testing are not useful in diagnosing vitiligo. It is important to be aware of the potential association with other autoimmune conditions and to monitor for any changes in skin pigmentation.
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This question is part of the following fields:
- Dermatology
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Question 13
Correct
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Which one of the following investigations is essential prior to initiating anti-tuberculosis treatment in elderly patients?
Your Answer: Liver functions tests
Explanation:The management of tuberculosis has been outlined in guidelines by the British Thoracic Society. It is recommended that liver function tests are conducted in all cases and monitored during treatment. Prior to starting ethambutol, it is important to check visual acuity and renal function.
Side-Effects and Mechanism of Action of Tuberculosis Drugs
Rifampicin is a drug that inhibits 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. Additionally, it is a liver enzyme inhibitor.
Pyrazinamide is converted by pyrazinamidase into pyrazinoic acid, which in turn inhibits fatty acid synthase (FAS) I. However, it can cause hyperuricaemia, leading to gout, as well as arthralgia, myalgia, and hepatitis.
Lastly, Ethambutol inhibits the enzyme arabinosyl transferase, which polymerizes arabinose into arabinan. It can cause optic neuritis, so it is important to check visual acuity before and during treatment. Additionally, the dose needs adjusting in patients with renal impairment.
In summary, these tuberculosis drugs have different mechanisms of action and can cause various side-effects. It is important to monitor patients closely and adjust treatment accordingly to ensure the best possible outcomes.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 14
Correct
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A 30-year-old female patient arrives at the Emergency Department with a two-day history of fever, headache, vomiting, and seizures. She has no significant medical history or allergies. Upon CT head examination, hypodensity of the left temporal lobe is identified, while a lumbar puncture reveals lymphocytes at 57 cells/µL (0-5 cells/µL), protein at 92 mg/100 mL (15-60 mg/100 mL), and glucose at 66 mg/100 mL (50-80 mg/100 mL). Serum blood glucose is normal. A brain MRI is subsequently performed, revealing prominent swelling and increased signal of the left temporal lobe and insular cortex. What is the urgent medication that must be initiated in this patient?
Your Answer: Aciclovir
Explanation:In cases of encephalitis caused by herpes simplex virus (HSV), urgent administration of IV aciclovir (which is effective against HSV) is necessary. Amantadine, which is used to manage influenza, is not appropriate. Cefotaxime, which is often used for suspected meningococcal disease, is also not appropriate. Fluconazole, an anti-fungal medication, is not appropriate as encephalitis is unlikely to be caused by a fungal infection.
Encephalitis: Symptoms, Causes, and Treatment
Encephalitis is a condition characterized by inflammation of the brain. It presents with symptoms such as fever, headache, psychiatric symptoms, seizures, and vomiting. Focal features such as aphasia may also be present. Peripheral lesions like cold sores are not related to the presence of HSV encephalitis. HSV-1 is responsible for 95% of cases in adults, and it typically affects the temporal and inferior frontal lobes.
To diagnose encephalitis, cerebrospinal fluid analysis is done, which shows lymphocytosis and elevated protein. PCR for HSV, VZV, and enteroviruses is also performed. Neuroimaging may reveal medial temporal and inferior frontal changes, such as petechial hemorrhages, but it is normal in one-third of patients. MRI is a better diagnostic tool. EEG may show lateralized periodic discharges at 2 Hz.
The treatment for encephalitis involves intravenous aciclovir, which should be started in all cases of suspected encephalitis. Early diagnosis and treatment are crucial in preventing complications and improving outcomes.
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This question is part of the following fields:
- Neurology
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Question 15
Correct
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For what has the National Institute for Health and Care Excellence (NICE) recommended the use of varenicline?
Your Answer: Smoking cessation (cigarettes)
Explanation:The Use of Varenicline in Smoking Cessation and Other Substance Withdrawals
Varenicline, marketed as Champix®, is a medication used in combination with motivational support to aid smoking cessation. The National Institute for Health and Care Excellence (NICE) recommends offering varenicline or nicotine replacement therapy (NRT) to all smokers, along with advice and encouragement to quit. The choice of therapy depends on factors such as the smoker’s compliance, availability of counseling and support, previous experience with cessation aids, contraindications, and personal preference. However, varenicline use has been associated with changes in behavior and thinking, anxiety, psychosis, mood swings, depression, and suicidal ideation, so monitoring is advised.
While varenicline is not currently indicated for cannabis cessation, some studies suggest that it may reduce the enjoyment reported from using cannabis, which could lead to further investigation in this area. However, varenicline has no role in the treatment of alcohol withdrawal, and the FDA has warned that people taking varenicline should reduce their alcohol intake due to the potential for unusual behavior, including aggression. The use of varenicline for opioid withdrawal in patients with chronic pain is also under investigation but is not currently recommended. Finally, varenicline is not indicated for cocaine cessation.
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This question is part of the following fields:
- Psychiatry
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Question 16
Correct
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A social worker in their 40s has been diagnosed with hepatitis C infection.
Which test will conclusively establish the presence of this infection?Your Answer: HCV RNA
Explanation:Hepatitis C Testing Methods
Hepatitis C is a viral infection that affects the liver. There are several testing methods available to diagnose and monitor hepatitis C infection.
Quantitative HCV RNA tests measure the amount of hepatitis C virus in the blood, which is also known as the viral load. This test is the most sensitive and accurate way to confirm a hepatitis C diagnosis, especially when viral loads are low.
Screening tests for co-infection with other viruses, such as hepatitis B or HIV, may be done but do not assist in the diagnosis of hepatitis C infection itself.
Anti-hepatitis C virus (HCV) serologic screening involves an enzyme immunoassay (EIA) that can detect antibodies to the virus. However, this test cannot distinguish between acute and chronic infection and may yield false-positive results.
HCV genotyping is a helpful tool for predicting the likelihood of response and duration of treatment. It is used in adult, non-immunocompromised patients with known chronic HCV infection.
Immunoglobulin M (IgM) anti-HAV screening tests for co-infection with hepatitis A virus may be done but do not assist in the diagnosis of hepatitis C infection itself.
Hepatitis C Testing Methods
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This question is part of the following fields:
- Immunology/Allergy
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Question 17
Correct
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An infant develops bile-stained vomiting; an abdominal X-ray shows a ‘double bubble’ appearance. The infant is also hypotonic with brachycephaly.
Which of the following is the most likely diagnosis?
Your Answer: Trisomy 21
Explanation:Genetic Disorders and Associated Phenotypic Features
Trisomy 21: Down Syndrome and Duodenal Atresia
Neonates with Down syndrome have an increased risk of duodenal atresia, accounting for around a third of cases. Prenatal imaging can detect this condition, which presents with bilious vomiting within hours of birth. Down syndrome is also characterized by distinct physical features such as brachiocephaly, upward slanting palpebral fissures, and joint hyperflexibility.45,XO: Turner Syndrome and Cardiac Defects
Turner syndrome affects females with a genetic complement of 45XO. It is characterized by short stature, webbed neck, and lymphoedema. Cardiac defects, including coarctation of the aorta, may also be present.Fragile X: Learning Disability and Autism
Fragile X is a common X-linked form of learning disability and autism. Physical features are difficult to detect in infancy, but delayed motor milestones and speech and language delay may be present. Macro-orchidism is almost universal post-puberty, and cardiac defects, including mitral valve prolapse, may occur.Trisomy 18: Edwards’ Syndrome and Neonatal Hypotonia
Trisomy 18, or Edwards’ syndrome, is characterized by neonatal hypotonia, apnoea, and seizures. There is severe psychomotor and growth retardation, microcephaly, and microphthalmia. Over 90% have cardiac defects, commonly VSD, as well as anomalies in most organ systems.47,XXY: Klinefelter’s Syndrome and Infertility
Klinefelter’s syndrome affects males with a genetic complement of either 47,XXY or 48,XXXY. It is a random mutation, not inherited, and is characterized by tall stature, poorly developed testes or cryptorchidism, and gynaecomastia. Infertility is common. Physical features are not obvious in infancy. -
This question is part of the following fields:
- Paediatrics
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Question 18
Incorrect
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A 55-year-old woman with a history of diabetes, obesity, and smoking developed sudden pain in her left foot with a dusky colour change. On examination, in the Emergency Department, she had a cold, blue, painful foot with an absent dorsalis pedis and posterior tibial pulse.
Which of the following will be the most appropriate investigation for this patient?Your Answer: Ankle–brachial pressure index (ABPI)
Correct Answer: Lower limb angiography
Explanation:Diagnostic Tests for Lower Limb Ischaemia
Lower limb ischaemia is a medical emergency that requires prompt diagnosis and treatment. Several diagnostic tests can be used to determine the cause and severity of the condition. Here are some of the most common tests:
1. Lower limb angiography: This test can identify the site of arterial occlusion and help plan the appropriate treatment, such as embolectomy or fasciotomy.
2. Focused assessment with sonography for trauma (FAST) scan of the abdomen: This test is useful in cases of trauma or suspected abdominal aortic aneurysm rupture.
3. Ankle-brachial pressure index (ABPI): This quick and easy test can provide an early indication of the severity of ischaemia. A value of 0.9-1.2 is considered normal, while values below 0.3 indicate critical ischaemia.
4. Echocardiogram: This test can rule out a cardiac source of embolisation, but lower limb angiography is the priority in cases of acute ischaemia.
5. Lower limb Doppler: This test can be used to assess arterial or venous flow, depending on the suspected cause of ischaemia.In summary, a combination of these diagnostic tests can help diagnose and treat lower limb ischaemia effectively.
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This question is part of the following fields:
- Cardiovascular
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Question 19
Incorrect
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You are conducting a medication review for a 67-year-old man who has a history of cerebrovascular disease (having suffered a stroke 3 years ago), depression, and knee osteoarthritis. He is currently taking the following medications:
- Clopidogrel 75 mg once daily
- Simvastatin 20 mg once daily
- Amlodipine 5mg once daily
- Ramipril 10mg once daily
- Diclofenac 50mg as needed
- Sertraline 50mg once daily
What changes would you recommend to his medication regimen?Your Answer:
Correct Answer: Switch diclofenac for an alternative NSAID
Explanation:The use of diclofenac is now prohibited for individuals with any type of cardiovascular ailment.
MHRA Guidance on Diclofenac and Cardiovascular Safety
The MHRA has updated its guidance on diclofenac, a nonsteroidal anti-inflammatory drug (NSAID), after a Europe-wide review of cardiovascular safety. While it has been known for some time that NSAIDs may increase the risk of cardiovascular events, the evidence base has become clearer. Diclofenac is associated with a significantly higher risk of cardiovascular events compared to other NSAIDs. Therefore, it is contraindicated in patients with ischaemic heart disease, peripheral arterial disease, cerebrovascular disease, and congestive heart failure (New York Heart Association classification II-IV). Patients should switch from diclofenac to other NSAIDs such as naproxen or ibuprofen, except for topical diclofenac. Studies have shown that naproxen and low-dose ibuprofen have the best cardiovascular risk profiles of the NSAIDs.
The MHRA’s updated guidance on diclofenac and cardiovascular safety highlights the increased risk of cardiovascular events associated with this NSAID compared to other NSAIDs. Patients with certain conditions are advised to avoid diclofenac and switch to other NSAIDs. This guidance is important for healthcare professionals to consider when prescribing NSAIDs to patients with cardiovascular risk factors.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 20
Incorrect
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A 65-year-old man presents to the ophthalmology clinic with a complaint of gradual vision loss. During tonometry, his intraocular pressure is found to be 26mmHg and optic disc cupping is observed on fundoscopy. Visual field examination reveals peripheral visual loss. The physician prescribes timolol eye drops to be used twice daily. What is the mechanism of action of this medication?
Your Answer:
Correct Answer: Decrease production of aqueous fluid
Explanation:Timolol, a beta blocker, is effective in treating primary open-angle glaucoma by reducing the production of aqueous fluid. This condition is characterized by increased intraocular pressure due to inefficient drainage of fluid in the eye’s trabecular meshwork. Symptoms include gradual loss of vision, particularly in the peripheral fields. Brimonidine, an alpha-adrenergic agonist, also reduces aqueous fluid production and increases uveoscleral outflow. However, drugs that decrease uveoscleral outflow or increase aqueous fluid production would worsen the patient’s condition. Glucocorticoids can cause reduced drainage of aqueous humour and are implicated in causing open-angle glaucoma. Latanoprost, a prostaglandin analogue, increases uveoscleral outflow.
Glaucoma is a condition where the optic nerve is damaged due to increased pressure in the eye. Primary open-angle glaucoma is a type where the iris is clear of the trabecular meshwork, which is responsible for draining aqueous humour from the eye. This results in increased resistance to outflow and raised intraocular pressure. The condition affects 0.5% of people over 40 years old and increases with age. Genetics also play a role, with first-degree relatives having a 16% chance of developing the disease. Symptoms are usually absent, and diagnosis is made through routine eye examinations. Investigations include visual field tests, tonometry, and slit lamp examinations. Treatment involves eye drops to lower intraocular pressure, with prostaglandin analogues being the first line of treatment. Surgery may be considered in refractory cases. Regular reassessment is necessary to monitor progression and prevent visual field loss.
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This question is part of the following fields:
- Ophthalmology
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Question 21
Incorrect
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A 42-year-old woman is found to have breast cancer. She has no significant medical history, is premenopausal, and has no family history of breast or ovarian cancer. The cancer is in its early stages and she undergoes a wide-local excision followed by whole-breast radiotherapy. The pathology report reveals that the tumour is positive for oestrogen receptors but negative for HER2. What is the most probable adjuvant treatment that she will be recommended?
Your Answer:
Correct Answer: Tamoxifen
Explanation:The use of Tamoxifen is limited to pre-menopausal women, and there is a continuing discussion regarding the duration of therapy, whether it should be for 5 years or more.
Breast cancer management varies depending on the stage of the cancer, type of tumor, and patient’s medical history. Treatment options may include surgery, radiotherapy, hormone therapy, biological therapy, and chemotherapy. Surgery is typically the first option for most patients, except for elderly patients with metastatic disease who may benefit more from hormonal therapy. Prior to surgery, an axillary ultrasound is recommended for patients without palpable axillary lymphadenopathy, while those with clinically palpable lymphadenopathy require axillary node clearance. The type of surgery offered depends on various factors, such as tumor size, location, and type. Breast reconstruction is also an option for patients who have undergone a mastectomy.
Radiotherapy is recommended after a wide-local excision to reduce the risk of recurrence, while mastectomy patients may receive radiotherapy for T3-T4 tumors or those with four or more positive axillary nodes. Hormonal therapy is offered if tumors are positive for hormone receptors, with tamoxifen being used in pre- and peri-menopausal women and aromatase inhibitors like anastrozole in post-menopausal women. Tamoxifen may increase the risk of endometrial cancer, venous thromboembolism, and menopausal symptoms. Biological therapy, such as trastuzumab, is used for HER2-positive tumors but cannot be used in patients with a history of heart disorders. Chemotherapy may be used before or after surgery, depending on the stage of the tumor and the presence of axillary node disease. FEC-D is commonly used in the latter case.
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This question is part of the following fields:
- Haematology/Oncology
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Question 22
Incorrect
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An anxious, 30-year-old saleswoman presents with mild shortness of breath on exertion, which had come on gradually over several months. The symptom was intermittent and seemed to get worse in the evening. She has also been on treatment for depression over the last two months. On examination, she has minimal weakness of shoulder abductors and slight weakness of eye closure bilaterally. Deep tendon reflexes are present and symmetrical throughout and plantar responses are flexor. You now have the results of the investigations: FBC, U&E, LFT, TFT - normal; chest radiograph and lung function tests - normal; ECG - normal.
Which of the following is the most likely diagnosis?
Select the SINGLE most likely diagnosis.Your Answer:
Correct Answer: Myasthenia gravis
Explanation:Understanding Myasthenia Gravis: Symptoms, Diagnosis, and Treatment
Myasthenia gravis (MG) is a neuromuscular disorder that occurs when the body produces autoantibodies against the nicotinic acetylcholine receptor at the neuromuscular junction. This results in muscular weakness that is characterized by fatigability, meaning that the muscles become increasingly weaker during their use. MG primarily affects the muscles of the face, the extrinsic ocular muscles (causing diplopia), and the muscles involved in deglutition. Respiratory and proximal lower limb muscles may also be involved early in the disease, which can cause breathlessness and even sudden death.
Diagnosing MG can be challenging, as weakness may not be apparent on a single examination. However, electrodiagnostic tests and detecting the autoantibodies can confirm the diagnosis. The Tensilon test, which involves injecting edrophonium chloride to reverse the symptoms of MG, is now used only when other tests are negative and clinical suspicion of MG is still high.
Treatment of MG involves anticholinesterase medications, but many patients also benefit from thymectomy. It is important to note that a thymoma may be present in up to 15% of patients with MG.
Other conditions, such as transient ischaemic attacks, angina, multiple sclerosis, and somatisation disorder, may cause weakness, but they do not typically present with the same symptoms as MG. Therefore, it is crucial to consider MG as a potential diagnosis when a patient presents with fatigable muscular weakness.
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This question is part of the following fields:
- Respiratory Medicine
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Question 23
Incorrect
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A 30-year-old woman visits her GP after a staging CT revealed the presence of gallstones in her gallbladder, following her recent diagnosis of renal cell carcinoma (RCC). She is interested in discussing the available management options. The patient reports no history of abdominal pain and is in good health otherwise. She is scheduled to undergo a left-sided nephrectomy for her RCC in three weeks. During the examination, the GP notes tenderness over the left flank, but no palpable masses. What is the appropriate course of action for this patient?
Your Answer:
Correct Answer: Reassurance
Explanation:If you have been diagnosed with asymptomatic gallbladder stones, there is no need to worry. These stones are often found incidentally during imaging tests that are unrelated to gallstone disease. As long as you have not experienced any symptoms for at least a year before the diagnosis and the stones are located in a normal gallbladder and biliary tree, no intervention is necessary.
However, if you are experiencing symptoms or if the stones are located in the common bile duct, intervention is required. This can be done through surgical removal during laparoscopic cholecystectomy or through endoscopic retrograde cholangiopancreatography (ERCP) before or during the surgery. Rest assured that with proper intervention, you can effectively manage your gallbladder stones and prevent any complications.
Gallstones: Symptoms, Diagnosis, and Treatment
Gallstones are a common condition, with up to 24% of women and 12% of men affected. Local infection and cholecystitis may develop in up to 30% of cases, and 12% of patients undergoing surgery will have stones in the common bile duct. The majority of gallstones are of mixed composition, with pure cholesterol stones accounting for 20% of cases. Symptoms typically include colicky right upper quadrant pain that worsens after fatty meals. Diagnosis involves abdominal ultrasound and liver function tests, with magnetic resonance cholangiography or intraoperative imaging used to confirm the presence of stones in the bile duct. Treatment options include expectant management for asymptomatic gallstones, laparoscopic cholecystectomy for symptomatic gallstones, and early ERCP or surgical exploration for stones in the bile duct. Intraoperative cholangiography or laparoscopic ultrasound may be used to confirm anatomy or exclude CBD stones during surgery. ERCP carries risks such as bleeding, duodenal perforation, cholangitis, and pancreatitis.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 24
Incorrect
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A feature of a severe acute asthma exacerbation in an adult is:
Your Answer:
Correct Answer: Cannot complete full sentences
Explanation:Understanding the Indicators of Acute Asthma Exacerbations
Acute asthma exacerbations can range from mild to life-threatening, and it is important to recognize the indicators of each level of severity. In a severe exacerbation, the individual may not be able to complete full sentences, have a peak expiratory flow rate of 33-50% best or predicted, a respiratory rate of ≥25 breaths/min, a heart rate of ≥110 beats/min, use of accessory muscles, and oxygen saturation of ≥92%. A life-threatening exacerbation is characterized by a peak expiratory flow rate of <33% best or predicted, oxygen saturation of <92%, silent chest, cyanosis, cardiac arrhythmia or hypotension, confusion, coma, or altered consciousness. A moderate exacerbation may include talking in full sentences, a peak expiratory flow rate of >50-75% best or predicted, a respiratory rate of <25 breaths per minute, and a heart rate of <110 beats/min. Finally, a life-threatening exacerbation may also include a peak expiratory flow rate of <33% best or predicted, oxygen saturation of <92%, silent chest, cyanosis, cardiac arrhythmia or hypotension, confusion, coma, or altered consciousness, as well as exhaustion and poor respiratory effort. It is important to understand these indicators in order to properly assess and treat acute asthma exacerbations.
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This question is part of the following fields:
- Respiratory Medicine
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Question 25
Incorrect
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A 25-year-old man presents to the emergency department with symptoms of nausea and vomiting. An F1 administers metoclopramide, but 20 minutes later the patient reports feeling as though his eyes are stuck in an abnormal position and he cannot move them. What is the likely cause of this man's symptoms?
Your Answer:
Correct Answer: Acute dystonia
Explanation:The administration of metoclopramide can result in extrapyramidal side effects, with acute dystonia being the earliest and most common. This can lead to oculogyric crises, particularly in young individuals. Long-term side effects may include akathisia, parkinsonism, and tardive dyskinesia. The patient’s history does not suggest an allergic reaction, as there were no symptoms such as facial or lip swelling, breathing or circulatory issues, or the presence of a rash.
Metoclopramide is a medication that is commonly used to manage nausea. It works by blocking D2 receptors in the chemoreceptor trigger zone, which helps to alleviate feelings of sickness. In addition to its antiemetic properties, metoclopramide also has other uses, such as treating gastro-oesophageal reflux disease and gastroparesis caused by diabetic neuropathy. It is often combined with analgesics to treat migraines, which can cause gastroparesis and slow the absorption of pain medication.
However, metoclopramide can have some adverse effects, such as extrapyramidal effects, acute dystonia, diarrhoea, hyperprolactinaemia, tardive dyskinesia, and parkinsonism. These side effects are particularly problematic in children and young adults. It is important to note that metoclopramide should not be used in cases of bowel obstruction, but it may be helpful in cases of paralytic ileus.
Although metoclopramide primarily works as a D2 receptor antagonist, its mechanism of action is quite complex. It also acts as a mixed 5-HT3 receptor antagonist and 5-HT4 receptor agonist. The antiemetic effects of metoclopramide are due to its D2 receptor antagonist activity in the chemoreceptor trigger zone, while its gastroprokinetic effects are mediated by both D2 receptor antagonist and 5-HT4 receptor agonist activity. At higher doses, the 5-HT3 receptor antagonist activity also comes into play.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 26
Incorrect
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A 28-year-old woman is referred to the Neurology Clinic with suspected Guillain–Barré syndrome (GBS). A lumbar puncture (LP) is performed on the patient to rule out any other causes. The results of the LP show normal white blood cells (WBCs) and elevated proteins.
What immediate management should be started for this patient?
Select the SINGLE most appropriate management from the list below.
Your Answer:
Correct Answer: Intravenous immunoglobulins
Explanation:Guillain-Barré syndrome (GBS) can be treated with either plasma exchange or intravenous immunoglobulin (IVIG), both of which are equally effective. The decision on which treatment to use depends on the institution. Plasma exchange is recommended for ambulatory patients within two weeks of symptom onset and for non-ambulatory patients within four weeks. It is most effective when started within seven days of symptom onset, but improvement can still be seen up to 30 days after onset. Patients receiving plasma exchange should be closely monitored for electrolyte abnormalities and coagulopathies, as well as complications such as infection, blood pressure instability, cardiac arrhythmias, and pulmonary embolus. Compared to IVIG, plasma exchange has a higher risk of pneumonia, atelectasis, thrombosis, and hemodynamic difficulties. Urgent referral to oncology is appropriate if the patient has signs of metastatic spinal cord compression. High-dose dexamethasone is not indicated in this case as there is no history of cancer. Intravenous ceftriaxone is used to treat meningitis, which was ruled out by the LP findings. Intravenous itraconazole would be appropriate if fungal meningitis were suspected based on the patient’s history and LP results.
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This question is part of the following fields:
- Neurology
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Question 27
Incorrect
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A geriatric patient presents with chronic heart failure.
Which of the following drugs should be used as a first-line treatment for heart failure?
Your Answer:
Correct Answer: Enalapril
Explanation:Heart Failure Medications: Uses and Recommendations
Heart failure is a serious condition that requires proper management and treatment. There are several medications available for heart failure, each with its own specific uses and recommendations.
Enalapril is an ACE inhibitor that works by reducing levels of angiotensin II, a potent vasoconstrictor, resulting in reduced vasoconstriction and a reduction in left ventricular afterload. It is recommended as a first-line treatment for all patients with heart failure due to left ventricular systolic dysfunction.
Digoxin is recommended for worsening or severe heart failure due to left ventricular systolic dysfunction despite first- and second-line treatment for heart failure.
Aspirin should be prescribed for patients with heart failure and atherosclerotic arterial disease, including coronary heart disease. It is not useful in monotherapy for the treatment of heart failure.
Furosemide is a diuretic that is routinely used for the relief of congestive symptoms and fluid retention in patients with heart failure. It should be titrated according to need after the initiation of subsequent heart failure therapies.
Spironolactone is an aldosterone antagonist that forms the second-line treatment in patients with heart failure. It is important to closely monitor potassium and creatinine levels and the estimated glomerular filtration rate (eGFR). Specialist advice should be sought if the patient develops hyperkalaemia or renal function deteriorates.
In summary, the appropriate medication for heart failure depends on the individual patient’s condition and needs. It is important to consult with a healthcare professional for proper diagnosis and treatment.
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This question is part of the following fields:
- Cardiovascular
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Question 28
Incorrect
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A 32-year-old construction worker visits his doctor complaining of hay fever symptoms. He is experiencing frequent sneezing and a runny nose and is seeking medication to alleviate his discomfort. Considering his job, which antihistamine would be safe for him to use?
Your Answer:
Correct Answer: Loratadine
Explanation:Loratadine is an antihistamine that does not cause drowsiness. It works by targeting histamine H1 receptors to relieve allergy symptoms like sneezing and runny nose. As the patient is a heavy goods vehicle driver, it is advisable to recommend a non-sedating antihistamine like loratadine. Chlorphenamine, on the other hand, is a sedating antihistamine used in anaphylaxis treatment and is not suitable for the patient’s occupation. Cimetidine inhibits stomach acid production and does not help with allergy symptoms. Cinnarizine is a sedating antihistamine used for nausea and vomiting and may not be effective for the patient’s condition. Diphenhydramine is also a sedating antihistamine and not recommended for the patient.
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This question is part of the following fields:
- ENT
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Question 29
Incorrect
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A 28-year-old nulliparous woman presents to the labour suite at 40+6 weeks gestation. She has expressed her desire for a vaginal delivery throughout her pregnancy. On cervical examination, the cervix is found to be in an intermediate position with a firm consistency. Cervical effacement is estimated to be around 30%, and the cervical dilatation is less than 1cm. The fetal head is palpable at the level of the ischial spines, and her bishop score is 3/10. The midwife has already performed a membrane sweep. What is the next step in management?
Your Answer:
Correct Answer: Vaginal prostaglandin E2
Explanation:Vaginal PGE2 is the preferred method of induction of labour, with other options such as emergency caesarean section, maternal oxytocin infusion, amniotomy, and cervical ripening balloon being considered only in certain situations. Women undergoing vaginal PGE2 should be aware of the risk of uterine hyperstimulation and may require additional analgesia. The cervix should be reassessed before considering oxytocin infusion. Amniotomy may be used in combination with oxytocin infusion in patients with a ripe cervix. Cervical ripening balloon should not be used as the primary method for induction of labour due to its potential pain, bleeding, and infection risks.
Induction of Labour: Reasons, Methods, and Complications
Induction of labour is a medical process that involves starting labour artificially. It is necessary in about 20% of pregnancies due to various reasons such as prolonged pregnancy, prelabour premature rupture of the membranes, diabetes, pre-eclampsia, and rhesus incompatibility. The Bishop score is used to assess whether induction of labour is required, which takes into account cervical position, consistency, effacement, dilation, and fetal station. A score of less than 5 indicates that labour is unlikely to start without induction, while a score of 8 or more indicates that the cervix is ripe and there is a high chance of spontaneous labour or response to interventions made to induce labour.
There are several methods of induction of labour, including membrane sweep, vaginal prostaglandin E2, maternal oxytocin infusion, amniotomy, and cervical ripening balloon. Membrane sweeping involves separating the chorionic membrane from the decidua by rotating the examining finger against the wall of the uterus. Vaginal prostaglandin E2 is the preferred method of induction of labour, unless there are specific clinical reasons for not using it. Uterine hyperstimulation is the main complication of induction of labour, which refers to prolonged and frequent uterine contractions that can cause fetal hypoxemia and acidemia. In rare cases, uterine rupture may occur, which requires removing the vaginal prostaglandins and stopping the oxytocin infusion if one has been started, and tocolysis with terbutaline.
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This question is part of the following fields:
- Reproductive Medicine
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Question 30
Incorrect
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What is the frequency of the cervical cancer screening program in England for women over 50 years old?
Your Answer:
Correct Answer: 25-49 years - 3-yearly screening; 50-64 years - 5-yearly screening
Explanation:In England, cervical cancer screening is recommended every 3 years for women aged 25-49 and every 5 years for women aged 50-64.
Cervical Cancer Screening in the UK
Cervical cancer screening is a well-established program in the UK that aims to detect pre-malignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that around 15% of cervical adenocarcinomas are frequently undetected by screening.
The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification, and the NHS has now moved to an HPV first system. This means that a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.
All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. However, cervical screening cannot be offered to women over 64. In Scotland, screening is offered from 25-64 every five years.
In special situations, cervical screening in pregnancy is usually delayed until three months post-partum, unless there are missed screenings or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.
It is recommended to take a cervical smear around mid-cycle, although there is limited evidence to support this advice. Overall, the UK’s cervical cancer screening program is an essential tool in preventing cervical cancer and promoting women’s health.
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This question is part of the following fields:
- Haematology/Oncology
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