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Question 1
Incorrect
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What is a true statement about poisoning or overdose?
Your Answer: Phenobarbitone causes a metabolic acidosis
Correct Answer: Methanol causes a metabolic acidosis with an increased anion gap
Explanation:Effects of Common Poisonings on Acid-Base Balance
Aspirin overdose can lead to hyperventilation, which can cause respiratory alkalosis. In severe cases, it may result in metabolic acidosis. Phenobarbitone and chlormethiazole are central nervous system depressants that can cause hypoventilation, leading to respiratory acidosis. They can also cause hypotension and hypothermia. Ethylene glycol poisoning can cause metabolic acidosis, while methanol poisoning can result in metabolic acidosis due to the production of formaldehyde and formic acid during metabolism. It is important to be aware of the potential effects of these common poisonings on acid-base balance to provide appropriate treatment and prevent further complications.
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This question is part of the following fields:
- Pharmacology
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Question 2
Correct
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A 55-year-old woman is prescribed tamoxifen for the management of an oestrogen receptor positive breast cancer. What types of cancers are linked to the use of tamoxifen?
Your Answer: Endometrial cancer
Explanation:Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Postmenopausal bleeding is the most common symptom of endometrial cancer, which is usually slight and intermittent initially before becoming more heavy. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.
When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness (< 4 mm). Hysteroscopy with endometrial biopsy is also commonly used for investigation. The management of localized disease involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may have postoperative radiotherapy. progesterone therapy is sometimes used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.
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This question is part of the following fields:
- Gynaecology
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Question 3
Incorrect
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As an investigator, you will be participating in a clinical trial of a new antihypertensive agent. The drug has already been tested on healthy volunteers, but this trial will be the first to involve patients. The aim of the trial is to determine the optimal dosage for therapy, which will be used in future studies. Are you ready to take part in this clinical trial?
Your Answer: Phase 3 study
Correct Answer: Phase 2 study
Explanation:Phases of Clinical Trials
Clinical trials are conducted in several phases to determine the safety and efficacy of a new drug. The first phase, known as phase 1, involves testing the drug on healthy volunteers to determine its safety. In phase 2, the drug is tested on patients across a range of doses to establish the most effective dose with respect to clinical efficacy and adverse events. The third phase, known as phase 3, involves expanding the number of patients to confirm the drug’s efficacy and adverse event profile. This phase is conducted prior to registration. Finally, in phase 4, the drug is tested post-marketing to support clinical endpoints for reimbursement or to support marketing messages. These phases are crucial in determining the safety and efficacy of a new drug before it is made available to the public.
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This question is part of the following fields:
- Pharmacology
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Question 4
Correct
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A 79-year-old woman presents with recent-onset confusion. She had been in her usual state of health until she was observed to be confused and agitated during dinner yesterday. This morning, she was alert and oriented, but later in the evening, she became completely confused, agitated, and hostile. She was subsequently transported to the Emergency Department by ambulance. Additional history reveals no prior instances of confusion, but she has experienced increased frequency of urination over the past few days.
What is the probable reason for her confusion?Your Answer: Urinary tract infection (UTI)
Explanation:Diagnosing Delirium in an Elderly Patient: UTI vs. Dementia vs. Pyelonephritis
When an 89-year-old woman presents with waxing and waning consciousness, punctuated by ‘sun-downing’, it is important to consider the possible causes of delirium. In this case, the patient has normal cognitive function but is experiencing acute global cerebral dysfunction. One possible cause of delirium in the elderly is a urinary tract infection (UTI), which can present with symptoms such as frequency and confusion.
However, it is important to rule out other potential causes of delirium, such as vascular dementia or Alzheimer’s dementia. In these conditions, cognitive decline is typically steady and progressive, whereas the patient in this case is experiencing waxing and waning consciousness. Additionally, neither of these conditions would account for the patient’s new urinary symptoms.
Another possible cause of delirium is pyelonephritis, which can present with similar symptoms to a UTI but may also include pyrexia, renal angle tenderness, and casts on urinalysis. However, in this case, the patient does not exhibit these additional symptoms.
Finally, pseudodementia is unlikely in this scenario as the patient does not exhibit any affective signs. Overall, it is important to consider all possible causes of delirium in an elderly patient and conduct a thorough evaluation to determine the underlying condition.
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This question is part of the following fields:
- Acute Medicine And Intensive Care
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Question 5
Incorrect
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A 24-year-old female patient complains of palpitations and admits to using cocaine for the first time. She denies any chest pain. Upon examination, her heart rate is regular at 165 beats per minute. An electrocardiogram shows sinus tachycardia with a QRS of 105ms and widespread ST segment depression. Her blood pressure is 112/82 mmHg. What is the most appropriate next step in managing this patient?
Your Answer: Atropine
Correct Answer: Diazepam
Explanation:When managing cocaine toxicity, it is important to avoid beta-blockers. The recommended first-line treatment is diazepam, a benzodiazepine. Atropine should not be used as it can increase heart rate, while brimonidine is only used for treating open-angle glaucoma. Beta-blockers are not recommended due to the potential risk of unopposed alpha-adrenergic effects. Clonidine, an alpha-2-receptor adrenergic agonist, may reduce heart rate and blood pressure, but it is not recommended for cocaine toxicity.
Understanding Cocaine Toxicity
Cocaine is a popular recreational stimulant derived from the coca plant. However, its widespread use has resulted in an increase in cocaine toxicity cases. The drug works by blocking the uptake of dopamine, noradrenaline, and serotonin, leading to a variety of adverse effects.
Cardiovascular effects of cocaine include coronary artery spasm, tachycardia, bradycardia, hypertension, QRS widening, QT prolongation, and aortic dissection. Neurological effects may include seizures, mydriasis, hypertonia, and hyperreflexia. Psychiatric effects such as agitation, psychosis, and hallucinations may also occur. Other complications include ischaemic colitis, hyperthermia, metabolic acidosis, and rhabdomyolysis.
Managing cocaine toxicity involves using benzodiazepines as a first-line treatment for most cocaine-related problems. For chest pain, benzodiazepines and glyceryl trinitrate may be used, and primary percutaneous coronary intervention may be necessary if myocardial infarction develops. Hypertension can be treated with benzodiazepines and sodium nitroprusside. The use of beta-blockers in cocaine-induced cardiovascular problems is controversial, with some experts warning against it due to the risk of unopposed alpha-mediated coronary vasospasm.
In summary, cocaine toxicity can lead to a range of adverse effects, and managing it requires careful consideration of the patient’s symptoms and medical history.
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This question is part of the following fields:
- Pharmacology
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Question 6
Incorrect
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A 14-year-old girl comes to your GP clinic seeking contraception. She has been in a relationship with her 15-year-old boyfriend for 10 months. What is the best initial step to take?
Your Answer: Explore the reasons why contraception is needed, Respect her autonomy, maintain confidentiality and give her a prescription
Correct Answer: Contact the relevant safeguarding lead as this is a child protection issue.
Explanation:Even if a child is Gillick competent, they are still unable to consent to sexual intercourse if they are under the age of 13. Therefore, any interaction with this age group should prompt child protection measures to be taken. Simply prescribing medication or ignoring the situation would not be in compliance with this protocol.
When it comes to providing contraception to young people, there are legal and ethical considerations to take into account. In the UK, the age of consent for sexual activity is 16 years, but practitioners may still offer advice and contraception to young people they deem competent. The Fraser Guidelines are often used to assess a young person’s competence. Children under the age of 13 are considered unable to consent to sexual intercourse, and consultations regarding this age group should trigger child protection measures automatically.
It’s important to advise young people to have STI tests 2 and 12 weeks after an incident of unprotected sexual intercourse. Long-acting reversible contraceptive methods (LARCs) are often the best choice for young people, as they may be less reliable in remembering to take medication. However, there are concerns about the effect of progesterone-only injections (Depo-provera) on bone mineral density, and the UKMEC category of the IUS and IUD is 2 for women under the age of 20 years, meaning they may not be the best choice. The progesterone-only implant (Nexplanon) is therefore the LARC of choice for young people.
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This question is part of the following fields:
- Gynaecology
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Question 7
Incorrect
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A 30-year-old man is brought by ambulance, having fallen off his motorbike. He was wearing a helmet at the time of the crash; the helmet cracked on impact. At presentation, he is haemodynamically stable and examination is unremarkable, aside from superficial abrasions on the arms and legs. Specifically, he is neurologically intact. He is nevertheless offered admission for head injury charting and observation. Two hours after admission, nurses find him unresponsive, with a unilateral fixed, dilated pupil. An emergency computed tomography (CT) scan is performed.
What is the likely diagnosis in this case?Your Answer: Subdural haemorrhage
Correct Answer: Extradural haemorrhage
Explanation:Extradural Haemorrhage: Causes, Symptoms, and Treatment
Extradural haemorrhage is a type of head injury that can lead to neurological compromise and coma if left untreated. It is typically caused by trauma to the middle meningeal artery, meningeal veins, or a dural venous sinus. The condition is most prevalent in young men involved in road traffic accidents and is characterized by a lucid interval followed by a decrease in consciousness.
CT scans typically show a high-density, lens-shaped collection of peripheral blood in the extradural space between the inner table of the skull bones and the dural surface. As the blood collects, patients may experience severe headache, vomiting, confusion, fits, hemiparesis, and ipsilateral pupil dilation.
Treatment for extradural haemorrhage involves urgent decompression by creating a borehole above the site of the clot. Prognosis is poor if the patient is comatose or decerebrate or has a fixed pupil, but otherwise, it is excellent.
It is important to differentiate extradural haemorrhage from other types of head injuries, such as subdural haemorrhage, subarachnoid haemorrhage, and Intraparenchymal haemorrhage. Subdural haemorrhage is not limited by cranial sutures, while subarachnoid haemorrhage is characterized by blood lining the sulci of the brain. Intraparenchymal haemorrhage, on the other hand, refers to blood within the brain parenchyma.
In conclusion, extradural haemorrhage is a serious condition that requires urgent medical attention. Early diagnosis and treatment can significantly improve the patient’s prognosis.
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This question is part of the following fields:
- Acute Medicine And Intensive Care
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Question 8
Incorrect
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A 27-year-old female is found in a confused and drowsy state. Her friend discovered her this morning after a night of drinking, but also mentions that she was upset about her recent breakup. Upon examination, she has a Glasgow coma scale rating of 10/15, a blood pressure of 138/90 mmHg, a temperature of 37.5°C, large pupils that react slowly to light, a pulse of 120 beats per minute, a respiratory rate of 32/min, and exaggerated reflexes with Downgoing plantar responses. Additionally, a palpable bladder is found during abdominal examination. What substance is she most likely to have taken?
Your Answer: Ecstasy
Correct Answer: Tricyclic antidepressants
Explanation:Anticholinergic Overdose and Treatment
Anticholinergic overdose can be identified by symptoms such as drowsiness, irritability, large pupils, pyrexia, and tachycardia. Tricyclics, commonly used as antidepressants, can be lethal in overdose. Patients with anticholinergic overdose should be closely monitored for ventricular arrhythmias and seizures, which can be treated with phenytoin and lidocaine, respectively. Additionally, metabolic acidosis should be corrected with bicarbonate.
Paracetamol overdose may not present with many symptoms or signs initially, but can later lead to fulminant hepatic failure. Opiates typically cause small pupils and depressed respirations, while benzodiazepines usually only result in marked drowsiness. Ecstasy, on the other hand, often causes excitability, tachycardia, and hypertension, except in cases of severe hyponatremia associated with excessive water consumption.
In summary, anticholinergic overdose requires close monitoring and prompt treatment to prevent potentially lethal complications. Other types of overdose may present with different symptoms and require different interventions.
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This question is part of the following fields:
- Emergency Medicine
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Question 9
Correct
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A 20-year-old female underwent an appendicectomy and was administered an antiemetic for her nausea and vomiting. However, she is now experiencing an oculogyric crisis and has a protruding tongue. Which antiemetic is the most probable cause of her symptoms?
Your Answer: Metoclopramide
Explanation:Extrapyramidal Effects of Antiemetic Drugs
Anti-nausea medications such as metoclopramide, domperidone, and cyclizine can have extrapyramidal effects, which involve involuntary muscle movements. Metoclopramide is known to cause acute dystonic reactions, which can result in facial and skeletal muscle spasms and oculogyric crisis. These effects are more common in young girls and women, as well as the elderly. However, they typically subside within 24 hours of stopping treatment with metoclopramide.
On the other hand, domperidone is less likely to cause extrapyramidal effects because it does not easily cross the blood-brain barrier. Cyclizine is also less likely to cause these effects, making it a safer option for those who are susceptible to extrapyramidal reactions. It is important to discuss any concerns about potential side effects with a healthcare provider before starting any new medication.
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This question is part of the following fields:
- Neurology
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Question 10
Correct
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A 5-year-old girl is brought to the hospital with a suspected fracture of her left femur. Her parents are unsure how this happened and deny any injury. During the examination, you observe extensive dental decay, a bluish hue to the whites of her eyes, and on X-ray, multiple fractures at different stages of healing are noted.
What is the probable diagnosis in this scenario?Your Answer: Osteogenesis imperfecta
Explanation:Osteogenesis imperfecta is a collagen disorder that is identified by blue sclera, multiple fractures during childhood, dental caries, and deafness due to otosclerosis. It is often mistaken for child abuse or neglect, but the presence of blue sclera is a crucial indicator of osteogenesis imperfecta. In contrast, rickets is more likely to cause growth stunting and deformities rather than multiple fractures.
Osteogenesis imperfecta, also known as brittle bone disease, is a group of disorders that affect collagen metabolism, leading to bone fragility and fractures. The most common type of osteogenesis imperfecta is type 1, which is inherited in an autosomal dominant manner and is caused by a decrease in the synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides. This condition typically presents in childhood and is characterized by fractures that occur following minor trauma, as well as blue sclera, dental imperfections, and deafness due to otosclerosis.
When investigating osteogenesis imperfecta, it is important to note that adjusted calcium, phosphate, parathyroid hormone, and ALP results are usually normal. This condition can have a significant impact on a person’s quality of life, as it can lead to frequent fractures and other complications. However, with proper management and support, individuals with osteogenesis imperfecta can lead fulfilling lives.
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This question is part of the following fields:
- Musculoskeletal
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Question 11
Correct
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A 65-year-old woman visits her GP complaining of a persistent headache that has been bothering her for two weeks. The pain is more intense on the right side and is aggravated when she combs her hair. She also experiences discomfort in her jaw when eating. Her neurological and fundoscopy examinations reveal no abnormalities, and she is referred to the emergency department.
Upon admission, the patient is prescribed high-dose oral prednisolone and undergoes a temporal artery biopsy, which yields normal results. What is the next most appropriate course of action for her treatment?Your Answer: Continue high-dose prednisolone and repeat biopsy
Explanation:Performing an emergency computed tomography (CT) of the brain is not necessary for this patient. Emergency CT head scans are typically reserved for cases of head injury with symptoms such as reduced GCS, repeated vomiting, skull base fracture signs, post-traumatic seizures, or focal neurological deficits. Elderly patients may require a CT scan if they have experienced a fall with head injury or confusion.
Stopping high-dose prednisolone and referring the patient to a neurology clinic is not recommended. With a high suspicion of GCA, it is crucial to continue corticosteroid treatment to prevent inflammation from spreading to the eye. Any vision changes caused by GCA are typically irreversible, making it an acute problem that cannot wait for a referral to a neurology clinic.
Switching the patient to a lower dose of oral prednisolone is not advised. There is no evidence to suggest that reducing the dose of prednisolone is beneficial for GCA if the biopsy is negative. It is important to remember that a negative biopsy result may be due to skip lesions and not because the diagnosis is less likely.
Temporal arthritis, also known as giant cell arthritis, is a condition that affects medium and large-sized arteries and is of unknown cause. It typically occurs in individuals over the age of 50, with the highest incidence in those in their 70s. Early recognition and treatment are crucial to minimize the risk of complications, such as permanent loss of vision. Therefore, when temporal arthritis is suspected, urgent referral for assessment by a specialist and prompt treatment with high-dose prednisolone is necessary.
Temporal arthritis often overlaps with polymyalgia rheumatica, with around 50% of patients exhibiting features of both conditions. Symptoms of temporal arthritis include headache, jaw claudication, and tender, palpable temporal artery. Vision testing is a key investigation in all patients, as anterior ischemic optic neuropathy is the most common ocular complication. This results from occlusion of the posterior ciliary artery, leading to ischemia of the optic nerve head. Fundoscopy typically shows a swollen pale disc and blurred margins. Other symptoms may include aching, morning stiffness in proximal limb muscles, lethargy, depression, low-grade fever, anorexia, and night sweats.
Investigations for temporal arthritis include raised inflammatory markers, such as an ESR greater than 50 mm/hr and elevated CRP. A temporal artery biopsy may also be performed, and skip lesions may be present. Treatment for temporal arthritis involves urgent high-dose glucocorticoids, which should be given as soon as the diagnosis is suspected and before the temporal artery biopsy. If there is no visual loss, high-dose prednisolone is used. If there is evolving visual loss, IV methylprednisolone is usually given prior to starting high-dose prednisolone. Urgent ophthalmology review is necessary, as visual damage is often irreversible. Other treatments may include bone protection with bisphosphonates and low-dose aspirin.
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This question is part of the following fields:
- Musculoskeletal
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Question 12
Correct
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Which of the following combinations of age and percentage of hearing loss is incorrect for the overall population?
Your Answer: Aged 80-89: approximately 50% affected
Explanation:Age and Hearing Loss
As people age, the likelihood of experiencing hearing loss increases. In fact, the percentage of the population with a significant hearing loss rises with each passing decade. For those in the 80-89-year-old age group, it is estimated that between 70-80% of them will have a degree of hearing loss greater than 25 dB. This means that the majority of individuals in this age range will have difficulty hearing and may require hearing aids or other assistive devices to communicate effectively. It is important for individuals of all ages to take steps to protect their hearing, such as avoiding loud noises and wearing ear protection when necessary, in order to minimize the risk of hearing loss as they age.
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This question is part of the following fields:
- Neurology
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Question 13
Incorrect
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An 80-year-old man visits his doctor with a complaint of pain while swallowing and frequent nausea that has been going on for 4 weeks. Due to his age and symptoms, the doctor refers him for an oesophagogastroduodenoscopy (OGD), which reveals oesophageal ulceration. What medication is the most probable cause of this condition?
Your Answer: Ibuprofen
Correct Answer: Alendronic acid
Explanation:Alendronic acid is a bisphosphonate that can cause various oesophageal problems, including oesophagitis and ulceration. It is commonly used to treat and prevent osteoporosis. Other side effects of bisphosphonates include fever, myalgia, arthralgia, and hypocalcaemia. In this case, the patient has developed oesophageal ulceration, which is a common side effect of alendronic acid. Treatment may involve high-dose PPI and discontinuation of the medication.
Amlodipine is not the correct answer. It is a calcium channel blocker used to treat angina and hypertension. While it can cause dyspepsia, it does not typically cause gastrointestinal ulceration. Some studies have even suggested that amlodipine may have a protective effect. Common side effects of amlodipine include constipation, lower limb oedema, and headache.
Aspirin is also not the correct answer. While aspirin and other NSAIDs are associated with peptic ulcer disease, there is no evidence to suggest that they cause oesophageal ulcers.
Ibuprofen is also not the correct answer. It is a commonly used NSAID that can cause gastric irritation and peptic ulcers with prolonged use. However, oesophageal ulcers are rare and are more likely to be caused by alendronic acid.
Bisphosphonates: Uses and Adverse Effects
Bisphosphonates are drugs that mimic the action of pyrophosphate, a molecule that helps prevent bone demineralization. They work by inhibiting osteoclasts, which are cells that break down bone tissue. This reduces the risk of bone fractures and can be used to treat conditions such as osteoporosis, hypercalcemia, Paget’s disease, and pain from bone metastases.
However, bisphosphonates can have adverse effects, including oesophageal reactions such as oesophagitis and ulcers, osteonecrosis of the jaw, and an increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate. Patients may also experience an acute phase response, which can cause fever, myalgia, and arthralgia. Hypocalcemia, or low calcium levels, can also occur due to reduced calcium efflux from bone, but this is usually not clinically significant.
To minimize the risk of adverse effects, patients taking oral bisphosphonates should swallow the tablets whole with plenty of water while sitting or standing. They should take the medication on an empty stomach at least 30 minutes before breakfast or other oral medications and remain upright for at least 30 minutes after taking the tablet. Hypocalcemia and vitamin D deficiency should be corrected before starting bisphosphonate treatment, and calcium supplements should only be prescribed if dietary intake is inadequate. The duration of bisphosphonate treatment varies depending on the patient’s level of risk, and some authorities recommend stopping treatment after five years for low-risk patients with a femoral neck T-score of > -2.5.
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This question is part of the following fields:
- Musculoskeletal
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Question 14
Correct
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A 16-year-old girl weighing approximately 70 kg is brought to the Emergency department in cardiac arrest. She was found collapsed at home surrounded by empty packets of amitriptyline 25 mg. The ambulance service reports that she had a weak pulse and no respiratory effort. She has been intubated and is being ventilated by bag-valve mask. The presenting rhythm is a sinusoidal supraventricular tachycardia with wide QRS complexes. Blood pressure is barely recordable but a weak carotid and femoral pulse are palpable.
Immediate arterial bloods gases are obtained and reveal an arterial pH of 6.99 (7.35-7.45), pO2 of 11.8 kPa (11.0-14.0), pCO2 of 5.9 kPa (4.5-6.0), HCO3- of 9.6 mmol/L (16-22), base excess of −19.7 mmol/L (-2 to +2), lactate of 7.4 mmol/L (0.5-2.0), potassium of 4.9 mmol/L (3.3-5.5), and glucose of 4.8 mmol/L (5.0-7.0).
What is the most appropriate next step?Your Answer: Administer IV bicarbonate 8.4% 50 ml through a large bore cannula
Explanation:Amitriptyline is a cheap and effective tricyclic antidepressant drug that is highly toxic in overdose and often lethal. Symptoms of overdose include tachycardia, hot dry skin, dilated pupils, and cardiac failure. Rapid correction of severe acidosis with intravenous 8.4% sodium bicarbonate solution is recommended, even in the absence of significant acidosis. Glucagon is given in tricyclic overdoses when the patient develops cardiac failure or profound hypotension refractory to fluids. Resuscitation attempts should continue for at least 60 minutes in the absence of significant comorbidity. Intralipid is a second line agent used to stabilize the myocardium in instances where bicarbonate has been ineffective or cardiac arrhythmias persist despite adequate alkalinisation of the blood.
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This question is part of the following fields:
- Emergency Medicine
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Question 15
Correct
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A 39-year-old patient with a history of peripheral vascular disease presents to the emergency department with complaints of rest pain in their left leg. Despite being a smoker, their BMI is 25 kg/m² and they have no other medical issues. Upon examination, the patient has absent foot pulses and lower limb pallor. A CT angiogram is performed and reveals a long segmental obstruction, leading to suspicion of critical limb ischaemia. What is the best course of treatment?
Your Answer: Open bypass graft
Explanation:Open surgical revascularization is more appropriate for low-risk patients with long-segment/multifocal lesions who have peripheral arterial disease with critical limb ischaemia.
Peripheral arterial disease (PAD) is a condition that is strongly associated with smoking. Therefore, patients who still smoke should be provided with assistance to quit smoking. It is also important to treat any comorbidities that the patient may have, such as hypertension, diabetes mellitus, and obesity. All patients with established cardiovascular disease, including PAD, should be taking a statin, with Atorvastatin 80 mg being the recommended dosage. In 2010, NICE published guidance recommending the use of clopidogrel as the first-line treatment for PAD patients instead of aspirin. Exercise training has also been shown to have significant benefits, and NICE recommends a supervised exercise program for all PAD patients before other interventions.
For severe PAD or critical limb ischaemia, there are several treatment options available. Endovascular revascularization and percutaneous transluminal angioplasty with or without stent placement are typically used for short segment stenosis, aortic iliac disease, and high-risk patients. On the other hand, surgical revascularization, surgical bypass with an autologous vein or prosthetic material, and endarterectomy are typically used for long segment lesions, multifocal lesions, lesions of the common femoral artery, and purely infrapopliteal disease. Amputation should only be considered for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty or bypass surgery.
There are also drugs licensed for use in PAD, including naftidrofuryl oxalate, a vasodilator sometimes used for patients with a poor quality of life. Cilostazol, a phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects, is not recommended by NICE.
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This question is part of the following fields:
- Surgery
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Question 16
Incorrect
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A 25-year-old patient has a history of irregular menstrual cycles over the past few years. She is well known to you and has seen you regularly with regard to her weight problem, oily skin and acne. She presents to you on this occasion with a 6-month history of amenorrhoea and weight gain.
What is the most appropriate initial investigation in the above scenario?Your Answer: Luteinising hormone (LH) : follicle-stimulating hormone (FSH) levels
Correct Answer: Urine pregnancy test
Explanation:The Most Appropriate Initial Investigation for Amenorrhoea: Urine Pregnancy Test
When a patient presents with amenorrhoea, the most appropriate initial investigation is always a pregnancy test. If pregnancy is excluded, further investigations may be necessary to determine the underlying cause. For example, a diagnosis of polycystic ovary syndrome (PCOS) may be supported by high levels of free testosterone with low levels of sex-hormone binding globulin, which can be tested after excluding pregnancy. A pelvic ultrasound is also a useful investigation for PCOS and should be done following β-HCG estimation. While a raised LH: FSH ratio may be suggestive of PCOS, it is not diagnostic and not the initial investigation of choice here. Similarly, an oral glucose tolerance test might be useful in patients diagnosed with PCOS, but it would not be an appropriate initial investigation. Therefore, a urine pregnancy test is the most important first step in investigating amenorrhoea.
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This question is part of the following fields:
- Gynaecology
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Question 17
Correct
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A 30-year-old woman visits her doctor, reporting a progressive weakness on the left side of her face for the past 48 hours. What symptom would be indicative of Bell's palsy in this case?
Your Answer: Loss of taste on the anterior two-thirds of the left-hand side of the tongue
Explanation:Understanding Bell’s Palsy: Symptoms and their Causes
Bell’s palsy is a condition that affects the facial nerve, causing weakness or paralysis on one side of the face. Here are some common symptoms of Bell’s palsy and their causes:
1. Loss of taste on the anterior two-thirds of the left-hand side of the tongue: This is due to a unilateral lower motor neurone facial nerve lesion, which carries taste sensation from the anterior two-thirds of the tongue.
2. Deviation of the tongue to the left on tongue protrusion: This is caused by a hypoglossal nerve (cranial nerve XII) lesion, which affects the movement of the tongue.
3. Sparing of function of the forehead muscles and eye closure: This occurs with an upper motor neurone lesion, which affects the muscles of facial expression on the whole of one side of the face.
4. Weakened voluntary facial movements but normal spontaneous movements: Bell’s palsy affects both voluntary and involuntary movements equally, but some stroke patients may show relative sparing of spontaneous movements.
5. Inability to close both the right and the left eye: Bell’s palsy refers to a unilateral lower motor neurone facial nerve lesion, which affects the facial muscles on the side ipsilateral to the lesion only.
Understanding these symptoms and their causes can help in the diagnosis and treatment of Bell’s palsy.
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This question is part of the following fields:
- Neurology
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Question 18
Correct
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A 35-year-old female smoker presents with acute severe asthma.
The patient's SaO2 levels are at 91% even with 15 L of oxygen, and her pO2 is at 8.2 kPa (10.5-13). There is widespread expiratory wheezing throughout her chest.
The medical team administers IV hydrocortisone, 100% oxygen, and 5 mg of nebulised salbutamol and 500 micrograms of nebulised ipratropium, but there is little response. Nebulisers are repeated 'back-to-back,' but the patient remains tachypnoeic with wheezing, although there is good air entry.
What should be the next step in the patient's management?Your Answer: IV Magnesium
Explanation:Acute Treatment of Asthma
When dealing with acute asthma, the initial approach should be SOS, which stands for Salbutamol, Oxygen, and Steroids (IV). It is also important to organize a CXR to rule out pneumothorax. If the patient is experiencing bronchoconstriction, further efforts to treat it should be considered. If the patient is tiring or has a silent chest, ITU review may be necessary. Magnesium is recommended at a dose of 2 g over 30 minutes to promote bronchodilation, as low magnesium levels in bronchial smooth muscle can favor bronchoconstriction. IV theophylline may also be considered, but magnesium is typically preferred. While IV antibiotics may be necessary, promoting bronchodilation should be the initial focus. IV potassium may also be required as beta agonists can push down potassium levels. Oral prednisolone can wait, as IV hydrocortisone is already part of the SOS approach. Non-invasive ventilation is not recommended for the acute management of asthma.
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This question is part of the following fields:
- Emergency Medicine
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Question 19
Correct
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A 65-year-old man arrives at the Emergency Department complaining of central crushing chest pain that spreads to his arm and jaw. Upon examination, his ECG reveals ST elevation in leads II, III, and aVF, with reciprocal changes in I and aVL. Based on this information, which of the following vessels is most likely obstructed?
Your Answer: Right coronary artery
Explanation:Differentiating Myocardial Infarctions Based on ECG Changes
Myocardial infarction (MI) is a serious condition that requires prompt diagnosis and treatment. Electrocardiogram (ECG) changes can help differentiate the location of the MI and guide appropriate management. Here are the ECG changes expected in different types of MI:
Right Coronary Artery (RCA) Infarction: An inferior MI affects the RCA in 80% of cases, with ST elevation in leads II, III, and aVF, and reciprocal changes in leads I and aVL.
Left Circumflex Artery (LCX) Infarction: LCX infarction presents with ST elevation in leads I, aVL, V5, and V6 (lateral leads), and reciprocal changes in the inferior leads II, III, and aVF.
Left Coronary Artery (LCA) Infarction: If the clot is in the LCA before bifurcation, ST changes are expected in leads I, aVL, and V1–V6 (anterolateral leads).
Posterior Descending Artery (PDA) Infarction: PDA infarction gives ECG changes in keeping with a posterior MI, such as ST depression in the anterior leads.
Left Anterior Descending Artery (LAD) Infarction: LAD runs in the anterior of the heart, almost parallel to the septum, and then lateralizes. Therefore, in an LAD infarction, ST changes are expected in leads V1–V6 (anteroseptal leads).
In conclusion, recognizing the ECG changes in different types of MI can help clinicians make an accurate diagnosis and provide appropriate treatment.
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This question is part of the following fields:
- Cardiology
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Question 20
Correct
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A 42-year-old black woman comes in with depigmented patches of skin on her hands and face. What is the probable diagnosis?
Your Answer: Vitiligo
Explanation:Common Skin Pigmentation Disorders
Vitiligo, Pityriasis alba, Albinism, Melasma, and Melanoma are all skin pigmentation disorders that affect people of different ages and ethnicities. Vitiligo is a rare autoimmune condition that destroys melanocytes, causing white patches on the skin. Pityriasis alba is a scaly, white patch that usually affects children’s facial skin. Albinism is a genetic disorder that reduces tyrosinase activity in melanocytes, resulting in a lack of pigment in the skin, hair, and irises. Melasma is a condition of increased pigmentation, usually occurring underneath the eyes, and is common in pregnant women and oral contraceptive users. Melanoma is a malignant skin cancer that develops from melanocytes and is characterized by irregular, highly pigmented moles. Understanding these disorders can help individuals identify and manage their skin conditions.
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This question is part of the following fields:
- Dermatology
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Question 21
Correct
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A 4-year-old child presents with a 4-month history of recurrent episodes of cough and wheeze. The cough is worse at night. Chest examination is normal between episodes of wheeze, but there is prolonged expiratory wheeze during an episode.
What is the most appropriate course of action?Your Answer: Trial of bronchodilators
Explanation:Diagnosis and Treatment of Childhood Asthma: A Guide for Healthcare Professionals
Asthma is a condition characterized by reversible airways obstruction, and its diagnosis is primarily based on the patient’s history and response to bronchodilators. Objective measurements such as spirometry and peak flow measurements may not be reliable in children under five years old due to poor technique. Therefore, a trial of bronchodilators and a thorough history are sufficient to make a diagnosis in this age group.
A full blood count is unlikely to be useful in diagnosing asthma, as it is usually normal. Similarly, a chest X-ray is not necessary for routine diagnosis, although it may be helpful in identifying other pathologies. Antibiotics should only be prescribed if there is evidence of a bacterial infection, as the vast majority of asthma exacerbations are non-infective.
While some cases of asthma may be allergic in nature, antihistamines are not routinely used in the management of childhood asthma. Skin-prick testing and specific immunoglobulin E (IgE) to aeroallergens are not part of routine care.
The starting step for asthma treatment is based on the patient’s symptoms around the time of presentation. As required bronchodilators may be effective in mild cases, but a stepwise approach should be followed for more severe cases. Regular follow-up and monitoring of symptoms are essential for effective management of childhood asthma.
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This question is part of the following fields:
- Paediatrics
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Question 22
Correct
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A 43-year-old man presents with intermittent claudication. He has a body mass index of 32 kg/m2 and smokes 40 cigarettes a day. He admits that he has an extremely unhealthy diet. There is no family history of cardiovascular disease but his father died of complications of diabetes. His blood pressure is 160/110 mmHg.
What is the most likely cause of the claudication?Your Answer: Atherosclerosis
Explanation:Atherosclerosis, a disease commonly associated with the elderly, is now being observed in younger patients. This patient exhibits all the risk factors for atherosclerosis, which is the leading cause of intermittent claudication. While diabetes is not a direct cause of limb ischaemia, it is a risk factor for atherosclerosis, which this patient may have. Buerger’s disease, an arthritis that affects young male smokers, is rare and unlikely in this patient who is obese, hypertensive, and has a family history of diabetes. Coarctation of the aorta, which is characterized by hypertension and radiofemoral delay, should be considered in young patients with intermittent claudication, but there are no other signs in this patient. Takayasu’s disease, a rare arthritis that causes claudication and neurological signs, is more common in women and often presents with pulseless upper limbs due to arterial occlusion caused by intimal fibrosis.
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This question is part of the following fields:
- Vascular
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Question 23
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A 50-year-old man presents with a chronic cough and shortness of breath. He has recently developed a red/purple nodular rash on both shins. He has a history of mild asthma and continues to smoke ten cigarettes per day. On examination, he has mild wheezing and red/purple nodules on both shins. His blood pressure is 135/72 mmHg, and his pulse is 75/min and regular. The following investigations were performed: haemoglobin, white cell count, platelets, erythrocyte sedimentation rate, sodium, potassium, creatinine, and corrected calcium. His chest X-ray shows bilateral hilar lymphadenopathy. What is the most likely underlying diagnosis?
Your Answer: Sarcoidosis
Explanation:Differential Diagnosis for a Patient with Chest Symptoms, Erythema Nodosum, and Hypercalcaemia: Sarcoidosis vs. Other Conditions
When a patient presents with chest symptoms, erythema nodosum, hypercalcaemia, and signs of systemic inflammation, sarcoidosis is a likely diagnosis. To confirm the diagnosis, a transbronchial biopsy is usually performed to demonstrate the presence of non-caseating granulomata. Alternatively, skin lesions or lymph nodes may provide a source of tissue for biopsy. Corticosteroids are the main treatment for sarcoidosis.
Other conditions that may be considered in the differential diagnosis include asthma, bronchial carcinoma, chronic obstructive pulmonary disease (COPD), and primary hyperparathyroidism. However, the presence of erythema nodosum and bilateral hilar lymphadenopathy are more suggestive of sarcoidosis than these other conditions. While hypercalcaemia may be a symptom of primary hyperparathyroidism, the additional symptoms and findings in this patient suggest a more complex diagnosis.
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This question is part of the following fields:
- Respiratory
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Question 24
Incorrect
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A 7-year-old girl presents with haematuria, hearing loss, and poor eyesight caused by lens dislocation. After conducting additional tests, the diagnosis of Alport syndrome is made. What type of collagen is typically affected by a molecular defect in this disease?
Your Answer: Type II
Correct Answer: Type IV
Explanation:Types and Effects of Collagen Defects on Human Health
Collagen is an essential protein that provides structural support to various tissues in the human body. Defects in different types of collagen can lead to various health conditions. Type IV collagen is crucial for the integrity of the basement membrane, and mutations in its genes can cause Alport syndrome, resulting in haematuria, hearing loss, and visual disturbances. Type III collagen defects cause Ehlers–Danlos syndrome, characterized by joint hypermobility, severe bruising, and blood vessel defects. Type I collagen defects lead to osteogenesis imperfecta, characterized by brittle bones, abnormal teeth, and weak tendons. Kniest dysplasia is caused by defects in type II collagen, leading to short stature, poor joint mobility, and eventual blindness. Kindler syndrome is characterized by the absence of epidermal anchoring fibrils due to defects in type VII collagen, resulting in skin fragility. Understanding the effects of collagen defects on human health is crucial for diagnosis and treatment of these conditions.
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This question is part of the following fields:
- Renal
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Question 25
Incorrect
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A 72-year-old man is admitted to the hospital by his wife who reports that he has been experiencing distressing visual hallucinations of animals in their home. You suspect that he may be suffering from Charles-Bonnet syndrome. What are some potential risk factors that could make him more susceptible to this condition?
Your Answer: Male gender
Correct Answer: Peripheral visual impairment
Explanation:Peripheral visual impairment is a risk factor for Charles-Bonnet syndrome, which is a condition characterized by visual hallucinations in individuals with eye disease. The most frequent hallucinations include faces, children, and wild animals. This syndrome is more common in older individuals, without significant difference in occurrence between males and females, and no known increased risk associated with family history.
Understanding Charles-Bonnet Syndrome
Charles-Bonnet syndrome (CBS) is a condition characterized by complex hallucinations, usually visual or auditory, that occur in clear consciousness. These hallucinations persist or recur and are often experienced by individuals with visual impairment, although this is not a mandatory requirement for diagnosis. People with CBS maintain their insight and do not exhibit any other significant neuropsychiatric disturbance. The risk factors for CBS include advanced age, peripheral visual impairment, social isolation, sensory deprivation, and early cognitive impairment. The syndrome is equally distributed between sexes and does not show any familial predisposition. The most common ophthalmological conditions associated with CBS are age-related macular degeneration, glaucoma, and cataract.
Well-formed complex visual hallucinations are experienced by 10-30% of individuals with severe visual impairment. The prevalence of CBS in visually impaired people is estimated to be between 11 and 15%. However, around a third of people with CBS find the hallucinations unpleasant or disturbing. A large study published in the British Journal of Ophthalmology found that 88% of people had CBS for two years or more, and only 25% experienced resolution at nine years. Therefore, CBS is not generally a transient experience.
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This question is part of the following fields:
- Psychiatry
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Question 26
Correct
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A woman at 28 weeks gestation presents to the maternity assessment unit with complaints of reduced fetal movements (RFM). She reports that she has not felt her baby move for the past 10 hours. There is no history of vaginal bleeding or pain. The midwife is unable to detect a fetal heartbeat using the handheld Doppler. What further investigations would be carried out to assess the reduced fetal movements?
Your Answer: Ultrasound
Explanation:Understanding Reduced Fetal Movements
Introduction:
Reduced fetal movements can indicate fetal distress and are a response to chronic hypoxia in utero. This can lead to stillbirth and fetal growth restriction. It is believed that placental insufficiency may also be linked to reduced fetal movements.Physiology:
Quickening is the first onset of fetal movements, which usually occurs between 18-20 weeks gestation and increases until 32 weeks gestation. Multiparous women may experience fetal movements sooner. Fetal movements should not reduce towards the end of pregnancy. There is no established definition for what constitutes reduced fetal movements, but less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) is an indication for further assessment.Epidemiology:
Reduced fetal movements affect up to 15% of pregnancies, with 3-5% of pregnant women having recurrent presentations with RFM. Fetal movements should be established by 24 weeks gestation.Risk factors for reduced fetal movements:
Posture, distraction, placental position, medication, fetal position, body habitus, amniotic fluid volume, and fetal size can all affect fetal movement awareness.Investigations:
Fetal movements are usually based on maternal perception, but can also be objectively assessed using handheld Doppler or ultrasonography. Investigations are dependent on gestation at onset of RFM. If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used.Prognosis:
Reduced fetal movements can represent fetal distress, but in 70% of pregnancies with a single episode of reduced fetal movement, there is no onward complication. However, between 40-55% of women who suffer from stillbirth experience reduced fetal movements prior to diagnosis. Recurrent RFM requires further investigations to consider structural or genetic fetal abnormalities. -
This question is part of the following fields:
- Obstetrics
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Question 27
Incorrect
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A 4-year-old girl is brought into resus in cardiac arrest. The patient was brought in by ambulance with her father. He is too distraught to give any history other than the child had been okay when he had left the room. She was found unconscious on his return so an ambulance was called.
Which of the reversible causes of cardiac arrest are most likely in this situation?Your Answer: Hypovolaemia
Correct Answer: Hypoxia
Explanation:Respiratory arrest is the most frequent reason for children’s arrest, with hypoxia being the probable cause in this case. Choking incidents are a common cause of collapse and arrest in young children who are able to walk, particularly toddlers, due to their age and the absence of a clear history for another cause. Hypovolaemia and tension pneumothorax are less likely since there is no indication of trauma in the history, and hypothermia is not a factor.
Paediatric Basic Life Support Guidelines
Paediatric basic life support guidelines were updated in 2015 by the Resuscitation Council. Lay rescuers should use a compression:ventilation ratio of 30:2 for children under 1 year and between 1 year and puberty, a child is defined. If there are two or more rescuers, a ratio of 15:2 should be used.
The algorithm for paediatric basic life support starts with checking if the child is unresponsive and shouting for help. The airway should be opened, and breathing should be checked by looking, listening, and feeling for breaths. If the child is not breathing, five rescue breaths should be given, and signs of circulation should be checked.
For infants, the brachial or femoral pulse should be used, while children should use the femoral pulse. Chest compressions should be performed at a ratio of 15:2, with a rate of 100-120 compressions per minute for both infants and children. The depth of compressions should be at least one-third of the anterior-posterior dimension of the chest, which is approximately 4 cm for an infant and 5 cm for a child.
In children, the lower half of the sternum should be compressed, while in infants, a two-thumb encircling technique should be used for chest compressions. These guidelines are crucial for anyone who may need to perform basic life support on a child, and it is essential to follow them carefully to ensure the best possible outcome.
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This question is part of the following fields:
- Paediatrics
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Question 28
Correct
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A 52-year-old man is shot in the abdomen and suffers a significant intra-abdominal injury. He undergoes a laparotomy, bowel resection, and end colostomy, and requires a 6-unit blood transfusion due to an associated vascular injury. After a prolonged recovery, he is paralyzed and ventilated for 2 weeks in the intensive care unit. He is given total parenteral nutrition and eventually weaned off the ventilator and transferred to the ward. During a routine blood test, the following results are observed:
Full blood count
Hb 11.3 g/dl
Platelets 267 x 109/l
WBC 10.1 x109/l
Urea and electrolytes
Na+ 131 mmol/l
K+ 4.6 mmol/l
Urea 2.3 mmol/l
Creatinine 78 µmol/l
Liver function tests
Bilirubin 25 µmol/l
ALP 445 u/l
ALT 89 u/l
γGT 103 u/l
What is the most probable underlying cause for the noted abnormalities?Your Answer: Total parenteral nutrition
Explanation:Liver function tests are often affected by TPN, which can cause cholestasis but it is unlikely to lead to the formation of gallstones as seen in the image. While blood transfusion reactions may cause hepatitis, they usually present earlier and with changes in haemoglobin, which is rare in modern times.
Understanding Total Parenteral Nutrition
Total parenteral nutrition is a commonly used method of providing nutrition to surgical patients who are nutritionally compromised. The bags used in this method contain a combination of glucose, lipids, and essential electrolytes, with the exact composition being determined by the patient’s nutritional requirements. While it is possible to infuse this nutrition peripherally, doing so may result in thrombophlebitis. As such, longer-term infusions should be administered into a central vein, preferably via a PICC line.
Complications associated with total parenteral nutrition are related to sepsis, refeeding syndromes, and hepatic dysfunction. It is important to monitor patients closely for any signs of these complications and adjust the nutrition accordingly. By understanding the basics of total parenteral nutrition, healthcare professionals can provide optimal care to their patients and ensure their nutritional needs are being met.
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This question is part of the following fields:
- Surgery
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Question 29
Incorrect
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A 67-year-old male comes to the clinic with a complaint of sudden flailing of his left arm. During examination, it is observed that his left arm occasionally makes rapid, sudden, and uncontrollable thrusts. What is the diagnosis for this condition?
Your Answer: Chorea
Correct Answer: Hemiballismus
Explanation:Hemiballismus: A Sudden Thrusting Movement of the Right Arm
Hemiballismus is a medical condition characterized by a sudden, forceful movement of the right arm. This condition is caused by a lesion in the subthalamic nucleus on the opposite side of the brain. The lesion can be a result of a stroke or trauma.
The subthalamic nucleus is a small structure located deep within the brain that plays a crucial role in controlling movement. When it is damaged, it can cause involuntary movements, such as hemiballismus. This condition can be distressing for the patient and can interfere with their daily activities.
Treatment for hemiballismus typically involves addressing the underlying cause of the lesion, such as managing stroke risk factors or providing rehabilitation for trauma. Medications may also be prescribed to help control the involuntary movements. In severe cases, surgery may be necessary to remove the damaged tissue.
In conclusion, hemiballismus is a medical condition that causes sudden, forceful movements of the right arm due to a lesion in the subthalamic nucleus. It can be caused by stroke or trauma and can be treated with medication, rehabilitation, or surgery.
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This question is part of the following fields:
- Neurology
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Question 30
Correct
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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: 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.
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This question is part of the following fields:
- Nephrology
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