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  • Question 1 - A 30-year-old man presents to the clinic with 4 unprovoked episodes of rapid...

    Incorrect

    • A 30-year-old man presents to the clinic with 4 unprovoked episodes of rapid bilateral upper and lower limb muscle contraction and relaxation lasting approximately 15 seconds before stopping. He reports falling to the ground during these episodes but denies any loss of consciousness and is able to resume his activities afterward. Upon taking a collateral history, it is determined that there is no incontinence or tongue biting. There is no history of head injury. What is the most probable treatment for this patient's diagnosis?

      Your Answer: Levetiracetam

      Correct Answer: Sodium valproate

      Explanation:

      For males with myoclonic seizures, sodium valproate is the recommended first-line treatment. This patient is experiencing clonus, which is the contracting and relaxing of both upper and lower limbs. Myoclonic epilepsy is the likely diagnosis as there are no signs of loss of consciousness, incontinence, tongue-biting, or postictal fatigue. Sodium valproate is the correct choice as it has been proven effective for this use through high-quality evidence. However, it is contraindicated for women of childbearing potential due to its teratogenic effects. Ethosuximide is not appropriate as it is used for absence seizures, which are characterized by staring blankly and being unresponsive, and typically occur in children aged 3-10 years. Lamotrigine is a third-line treatment option for myoclonic seizures in men, and levetiracetam is the second-line option for men and the first-line option for women of childbearing potential. In this case, it is best to try the first-line option of sodium valproate as the patient has not yet received any treatment and is male. If sodium valproate is unsuccessful, then levetiracetam may be considered.

      Treatment for Epilepsy

      Epilepsy is a neurological disorder that affects millions of people worldwide. The condition is characterized by recurrent seizures, which can be debilitating and life-threatening. Treatment for epilepsy typically involves the use of antiepileptic drugs (AEDs) to control seizures and improve quality of life.

      According to NICE guidelines, AEDs should be started after the second epileptic seizure. However, if a patient has a neurological deficit, brain imaging shows a structural abnormality, the EEG shows unequivocal epileptic activity, or the patient or their family considers the risk of having a further seizure unacceptable, AEDs may be started after the first seizure. It is important to note that sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary due to the risk of neurodevelopmental delay in children.

      The choice of AEDs depends on the type of epilepsy. For generalized tonic-clonic seizures, males are typically prescribed sodium valproate, while females are prescribed lamotrigine or levetiracetam. For focal seizures, lamotrigine or levetiracetam are the first-line treatments, with carbamazepine, oxcarbazepine, or zonisamide as second-line options. Ethosuximide is the first-line treatment for absence seizures, with sodium valproate or lamotrigine/levetiracetam as second-line options. For myoclonic seizures, males are prescribed sodium valproate, while females are prescribed levetiracetam. Finally, for tonic or atonic seizures, males are prescribed sodium valproate, while females are prescribed lamotrigine.

      In summary, treatment for epilepsy involves the use of AEDs to control seizures and improve quality of life. The choice of AEDs depends on the type of epilepsy, and sodium valproate should be used with caution in women of childbearing age.

    • This question is part of the following fields:

      • Medicine
      187
      Seconds
  • Question 2 - A 26-year-old woman with type 1 diabetes becomes pregnant.
    Which of the following statements...

    Correct

    • A 26-year-old woman with type 1 diabetes becomes pregnant.
      Which of the following statements is correct?

      Your Answer: There is an increased risk of polyhydramnios

      Explanation:

      Misconceptions about Diabetes in Pregnancy

      During pregnancy, diabetic patients are at an increased risk of developing polyhydramnios, which is diagnosed when the amniotic fluid index is >25 cm or if the deepest vertical pool is >8 cm. Contrary to popular belief, fetal macrosomia is a risk of a diabetic pregnancy, rather than microsomia. All patients should be treated with insulin because this has no teratogenic effects, in contrast to oral hypoglycaemics. The mortality rate from DKA in pregnant patients approaches 50%, so very close monitoring and counselling about the importance of good diabetic control are essential. Hypertension in pregnancy may be treated with other anti-hypertensives, eg labetalol or methyldopa, as ACE inhibitors are contraindicated in pregnancy because they are associated with oligohydramnios.

      Debunking Common Myths about Diabetes in Pregnancy

    • This question is part of the following fields:

      • Obstetrics
      128.8
      Seconds
  • Question 3 - A 32-year-old woman presents with dyspnoea on exertion and palpitations. She has an...

    Incorrect

    • A 32-year-old woman presents with dyspnoea on exertion and palpitations. She has an irregularly irregular and tachycardic pulse, and a systolic murmur is heard on auscultation. An ECG reveals atrial fibrillation and right axis deviation, while an echocardiogram shows an atrial septal defect.
      What is true about the development of the atrial septum?

      Your Answer: Babies with atrial septal defects are typically cyanosed at birth

      Correct Answer: The septum secundum grows down to the right of the septum primum

      Explanation:

      During embryonic development, the septum primum grows down from the roof of the primitive atrium and fuses with the endocardial cushions. It initially has a hole called the ostium primum, which closes as the septum grows downwards. However, a second hole called the ostium secundum develops in the septum primum before fusion can occur. The septum secundum then grows downwards and to the right of the septum primum and ostium secundum. The foramen ovale is a passage through the septum secundum that allows blood to shunt from the right to the left atrium in the fetus, bypassing the pulmonary circulation. This defect closes at birth due to a drop in pressure within the pulmonary circulation after the infant takes a breath. If there is overlap between the foramen ovale and ostium secundum or if the ostium primum fails to close, an atrial septal defect results. This defect does not cause cyanosis because oxygenated blood flows from left to right through the defect.

    • This question is part of the following fields:

      • Cardiology
      186.4
      Seconds
  • Question 4 - As a core trainee on call in England, you are faced with a...

    Incorrect

    • As a core trainee on call in England, you are faced with a situation where a 35-year-old patient who is informally admitted and may be suffering from psychosis threatens to leave the hospital while being suicidal. What section of the Mental Health Act can be used to detain this patient?

      Your Answer: 4

      Correct Answer: 5

      Explanation:

      Emergency Detention under Section 5(2) of the Mental Health Act

      Section 5(2) of the Mental Health Act provides a legal provision for emergency detention of patients suspected of having a psychiatric cause for their illness. This section can be invoked by registered medical practitioners who are F2 and above. Once invoked, the patient can be detained for up to 72 hours while awaiting a Mental Health Act assessment. This provision is crucial in situations where a patient’s mental health poses a risk to themselves or others, and urgent intervention is required. The 72-hour period allows for a thorough assessment of the patient’s mental health status and the development of an appropriate care plan. It is important to note that the use of this section should be in line with the principles of the Mental Health Act, which prioritizes the least restrictive option for patients.

    • This question is part of the following fields:

      • Psychiatry
      103.5
      Seconds
  • Question 5 - A 15-year-old girl presents to your clinic with worries about delayed menarche. Upon...

    Correct

    • A 15-year-old girl presents to your clinic with worries about delayed menarche. Upon taking her medical history, you find no developmental issues. She is currently at the 65th percentile for weight and 5th percentile for height. During the physical examination, you observe a short webbed neck and broad chest. After conducting a karyotype analysis, you discover an abnormality. What is the most prevalent heart condition linked to this clinical presentation?

      Your Answer: Bicuspid aortic valve

      Explanation:

      The most frequently observed cardiac defect in individuals with Turner’s syndrome (45 XO) is a bicuspid aortic valve, which is more prevalent than coarctation of the aorta. Additionally, aortic root dilation and coarctation of the aorta are also associated with this condition.

      Understanding Turner’s Syndrome

      Turner’s syndrome is a genetic disorder that affects approximately 1 in 2,500 females. It is caused by the absence of one sex chromosome (X) or a deletion of the short arm of one of the X chromosomes. This condition is denoted as 45,XO or 45,X.

      The features of Turner’s syndrome include short stature, a shield chest with widely spaced nipples, a webbed neck, a bicuspid aortic valve (15%), coarctation of the aorta (5-10%), primary amenorrhea, cystic hygroma (often diagnosed prenatally), a high-arched palate, a short fourth metacarpal, multiple pigmented naevi, lymphoedema in neonates (especially feet), and elevated gonadotrophin levels. Hypothyroidism is much more common in Turner’s syndrome, and there is also an increased incidence of autoimmune disease (especially autoimmune thyroiditis) and Crohn’s disease.

      In summary, Turner’s syndrome is a chromosomal disorder that affects females and can cause a range of physical features and health issues. Early diagnosis and management can help individuals with Turner’s syndrome lead healthy and fulfilling lives.

    • This question is part of the following fields:

      • Paediatrics
      37.2
      Seconds
  • Question 6 - A 10 week old male infant is presented to the GP by his...

    Incorrect

    • A 10 week old male infant is presented to the GP by his mother with concerns about an undescended testis on the right side since birth. The mother was advised to seek medical attention if the issue persisted after 6 to 8 weeks of age. Upon examination, the GP confirms the presence of a unilateral undescended testis on the right side, with a normal appearing penis. What would be the next step in management?

      Your Answer: Arrange ultrasound scan

      Correct Answer: Review at 3 months of age

      Explanation:

      If the testicle remains undescended after 3 months, it is recommended to refer the child to a paediatric surgeon for review before they reach 6 months of age, as per the NICE guidelines for undescended testes.

      Undescended Testis: Causes, Complications, and Management

      Undescended testis is a condition that affects around 2-3% of male infants born at term, but it is more common in preterm babies. Bilateral undescended testes occur in about 25% of cases. This condition can lead to complications such as infertility, torsion, testicular cancer, and psychological issues.

      To manage unilateral undescended testis, NICE CKS recommends considering referral from around 3 months of age, with the baby ideally seeing a urological surgeon before 6 months of age. Orchidopexy, a surgical procedure, is typically performed at around 1 year of age, although surgical practices may vary.

      For bilateral undescended testes, it is crucial to have the child reviewed by a senior paediatrician within 24 hours as they may require urgent endocrine or genetic investigation. Proper management of undescended testis is essential to prevent complications and ensure the child’s overall health and well-being.

    • This question is part of the following fields:

      • Paediatrics
      7661
      Seconds
  • Question 7 - A 68-year-old retired electrician presents with complaints of progressive dyspnea, unintentional weight loss,...

    Correct

    • A 68-year-old retired electrician presents with complaints of progressive dyspnea, unintentional weight loss, and two episodes of hemoptysis in the past week. He has a history of smoking 40 pack years. Upon examination, there is stony dullness at the right base with absent breath sounds and decreased vocal resonance.

      Which of the following statements about mesothelioma is most accurate?

      Your Answer: It may have a lag period of up to 45 years between exposure and diagnosis

      Explanation:

      Understanding Mesothelioma: Causes, Diagnosis, and Prognosis

      Mesothelioma is a type of cancer that affects the pleura, and while it can be caused by factors other than asbestos exposure, the majority of cases are linked to this cause. Asbestos was commonly used in various industries until the late 1970s/early 1980s, and the lag period between exposure and diagnosis can be up to 45 years. This means that the predicted peak of incidence of mesothelioma in the UK is around 2015-2020.

      Contrary to popular belief, smoking does not cause mesothelioma. However, smoking and asbestos exposure can act as synergistic risk factors for bronchial carcinoma. Unfortunately, there is no known cure for mesothelioma, and the 5-year survival rate is less than 5%. Treatment is supportive and palliative, with an emphasis on managing symptoms and improving quality of life.

      Diagnosis is usually made through CT imaging, with or without thoracoscopic-guided biopsy. Open lung biopsy is only considered if other biopsy methods are not feasible. Mesothelioma typically presents with a malignant pleural effusion, which can be difficult to distinguish from a pleural tumor on a plain chest X-ray. The effusion will be an exudate.

      In conclusion, understanding the causes, diagnosis, and prognosis of mesothelioma is crucial for early detection and management of this devastating disease.

    • This question is part of the following fields:

      • Respiratory
      207.4
      Seconds
  • Question 8 - A 28-year-old male patient complains of a tender swelling in the natal cleft...

    Correct

    • A 28-year-old male patient complains of a tender swelling in the natal cleft that has been present for two days. Upon examination, three midline pits are observed, and there is a fluctuant swelling to the right of the natal cleft. What is the probable diagnosis?

      Your Answer: Pilonidal abscess

      Explanation:

      Pilonidal and Perianal Abscesses

      Pilonidal abscesses are a type of inflammatory condition that occurs when hair produces a sinus. These abscesses are typically found in or near the midline of the body, close to the natal cleft. They are more common in Caucasian males who are in their thirties, particularly those who are obese or have a lot of body hair.

      When someone presents with a pilonidal abscess, they will typically undergo an incision and drainage procedure. However, if the disease becomes non-healing or recurrent, a more definitive procedure such as excision may be required.

      Perianal and ischiorectal abscesses, on the other hand, are caused by an infection of the anal glands found in the intersphincteric space. These abscesses can also be treated with incision and drainage procedures, but may require more extensive treatment if they become chronic or recurrent.

      Overall, the causes and treatments of pilonidal and perianal abscesses is important for anyone who may be at risk for these conditions. By seeking prompt medical attention and following a proper treatment plan, individuals can manage these conditions and prevent them from becoming more serious.

    • This question is part of the following fields:

      • Surgery
      27.5
      Seconds
  • Question 9 - A teenager attends the GP with his mother who is concerned about his...

    Correct

    • A teenager attends the GP with his mother who is concerned about his height. The GP charts the teenager's height on a growth chart and finds him to be in the 5th percentile. At birth, he was in the 50th percentile. However, the teenager's developmental milestones are normal, and he appears to be content with himself. What is the most appropriate next step in managing this teenager?

      Your Answer: Make a referral to the the paediatric outpatients clinic

      Explanation:

      A paediatrician should review children who fall below the 0.4th centile for height. Referral is the appropriate course of action as it is not an urgent matter. While waiting for the review, it is advisable to conduct thyroid function tests and insulin-like growth factor tests on the child.

      Understanding Growth and Factors Affecting It

      Growth is a significant aspect that distinguishes children from adults. It occurs in three stages: infancy, childhood, and puberty. Several factors affect fetal growth, including environmental, placental, hormonal, and genetic factors. Maternal nutrition and uterine capacity are the most crucial environmental factors that affect fetal growth.

      During infancy, nutrition and insulin are the primary drivers of growth. Insulin plays a significant role in fetal growth, as high levels of insulin in a mother with poorly controlled diabetes can result in hypoglycemia and macrosomia in the baby. In childhood, growth hormone and thyroxine drive growth, while in puberty, growth hormone and sex steroids are the primary drivers. Genetic factors are the most important determinant of final adult height.

      It is essential to monitor growth regularly to ensure that children are growing at a healthy rate. Infants aged 0-1 years should have at least five weight recordings, while children aged 1-2 years should have at least three weight recordings. Children older than two years should have annual weight recordings. Children below the 2nd centile for height should be reviewed by their GP, while those below the 0.4th centile for height should be reviewed by a paediatrician. Understanding growth and the factors that affect it is crucial for ensuring healthy development in children.

    • This question is part of the following fields:

      • Paediatrics
      20.2
      Seconds
  • Question 10 - A 46-year-old primiparous woman, who is 37 weeks pregnant, presents to the emergency...

    Incorrect

    • A 46-year-old primiparous woman, who is 37 weeks pregnant, presents to the emergency department with a sudden onset of painful vaginal bleeding. She had been feeling unwell for a few days, experiencing lightheadedness upon standing. Despite being pregnant, she has not sought antenatal care, except for her initial booking visit. Upon examination, her heart rate is 130 beats per minute, respiratory rate is 21 breaths per minute, and blood pressure is 96/65 mmHg. Her abdomen is tense, with a firm and fixed uterus. What is the most likely risk factor for this complication in this pregnant woman?

      Your Answer: Macrosomia

      Correct Answer: Older age

      Explanation:

      Placental abruption is a condition that occurs when the placenta separates from the uterine wall, leading to maternal bleeding into the space between them. Although the exact cause of this condition is unknown, certain factors have been associated with it, including proteinuric hypertension, cocaine use, multiparity, maternal trauma, and increasing maternal age. Placental abruption is not a common occurrence, affecting approximately 1 in 200 pregnancies.

      The clinical features of placental abruption include shock that is disproportionate to the visible blood loss, constant pain, a tender and tense uterus, and a normal lie and presentation of the fetus. The fetal heart may be absent or distressed, and there may be coagulation problems. It is important to be aware of other conditions that may present with similar symptoms, such as pre-eclampsia, disseminated intravascular coagulation (DIC), and anuria.

      In summary, placental abruption is a serious condition that can have significant consequences for both the mother and the fetus. Understanding the risk factors and symptoms of this condition is important for early detection and appropriate management.

    • This question is part of the following fields:

      • Obstetrics
      30.7
      Seconds
  • Question 11 - A 46-year-old man comes in for a follow-up visit after beginning rate control...

    Incorrect

    • A 46-year-old man comes in for a follow-up visit after beginning rate control therapy for his atrial fibrillation. He reports no instances of palpitations, dizziness, or fainting. During the examination, his pulse is irregularly irregular with a heart rate of 82 beats per minute. He feels that his atrial fibrillation is well-managed, but he has noticed a change in his bowel movements since starting the treatment and has experienced difficulty passing stools. What is the most probable rate control medication he is taking?

      Your Answer: Digoxin

      Correct Answer: Verapamil

      Explanation:

      Verapamil is known to induce constipation as a side effect.

      Constipation is a common side effect of calcium channel blockers. Verapamil, one of the two calcium channel blockers used for controlling heart rate in atrial fibrillation, is more likely to cause constipation. NICE guidelines suggest that individuals who start taking verapamil should consume more fiber and increase their water intake to counteract this side effect. Calcium channel blockers cause constipation by relaxing smooth muscles, which inadvertently relaxes the muscles of the gut, leading to reduced motility. Although diltiazem may also cause constipation, it is less common than with verapamil.

      Understanding Calcium Channel Blockers

      Calcium channel blockers are medications primarily used to manage cardiovascular diseases. These blockers target voltage-gated calcium channels present in myocardial cells, cells of the conduction system, and vascular smooth muscle cells. The different types of calcium channel blockers have varying effects on these three areas, making it crucial to differentiate their uses and actions.

      Verapamil is an example of a calcium channel blocker used to manage angina, hypertension, and arrhythmias. However, it is highly negatively inotropic and should not be given with beta-blockers as it may cause heart block. Verapamil may also cause side effects such as heart failure, constipation, hypotension, bradycardia, and flushing.

      Diltiazem is another calcium channel blocker used to manage angina and hypertension. It is less negatively inotropic than verapamil, but caution should still be exercised when patients have heart failure or are taking beta-blockers. Diltiazem may cause side effects such as hypotension, bradycardia, heart failure, and ankle swelling.

      On the other hand, dihydropyridines such as nifedipine, amlodipine, and felodipine are calcium channel blockers used to manage hypertension, angina, and Raynaud’s. These blockers affect the peripheral vascular smooth muscle more than the myocardium, resulting in no worsening of heart failure but may cause ankle swelling. Shorter-acting dihydropyridines such as nifedipine may cause peripheral vasodilation, resulting in reflex tachycardia and side effects such as flushing, headache, and ankle swelling.

      In summary, understanding the different types of calcium channel blockers and their effects on the body is crucial in managing cardiovascular diseases. It is also important to note the potential side effects and cautions when prescribing these medications.

    • This question is part of the following fields:

      • Pharmacology
      121.2
      Seconds
  • Question 12 - A 66-year-old man visits his primary care physician for his annual check-up, reporting...

    Correct

    • A 66-year-old man visits his primary care physician for his annual check-up, reporting constant fatigue and thirst. He has a medical history of hypertension, hyperlipidemia, and obesity. The doctor orders a screening for type II diabetes and the results are as follows:
      Test Result Normal Range
      HbA1C 48 mmol/mol < 53 mmol/mol (<7.0%)
      Fasting plasma glucose 7.2 mmol/l < 7 mmol/l
      Glomerular filtration rate (GFR) 90 ml/min > 90 ml/min
      Which of the following is included in the diagnostic criteria for type II diabetes?

      Your Answer: Fasting plasma glucose ≥7.0 mmol/l

      Explanation:

      To diagnose diabetes, several criteria must be met. One way is to measure fasting plasma glucose levels, which should be at least 7.0 mmol/l after an eight-hour fast. Another method is to test for HbA1C levels, which should be at least 48 mmol/mol (6.5%) using a certified and standardized method. A 2-hour plasma glucose test after a 75 g glucose load should result in levels of at least 11.1 mmol/l. If a patient exhibits classic symptoms of diabetes or hyperglycemic crisis, a random plasma glucose test should show levels of at least 11.1 mmol/l. All results should be confirmed by repeat testing. It’s important to note that 1-hour plasma glucose levels are not used in the diagnostic criteria for type II diabetes, but are part of screening tests for gestational diabetes.

    • This question is part of the following fields:

      • Endocrinology
      179.9
      Seconds
  • Question 13 - A 65-year-old man comes to the Emergency Department with confusion and difficulty breathing,...

    Incorrect

    • A 65-year-old man comes to the Emergency Department with confusion and difficulty breathing, with an AMTS score of 9. During the examination, his respiratory rate is 32 breaths/minute, and his blood pressure is 100/70 mmHg. His blood test shows a urea level of 6 mmol/l. What is a predictive factor for increased mortality in this pneumonia patient?

      Your Answer: New-onset confusion with AMTS of 9

      Correct Answer: Respiratory rate >30 breaths/minute

      Explanation:

      Prognostic Indicators in Pneumonia: Understanding the CURB 65 Score

      The CURB 65 score is a widely used prognostic tool for patients with pneumonia. It consists of five indicators, including confusion, urea levels, respiratory rate, blood pressure, and age. A respiratory rate of >30 breaths/minute and new-onset confusion with an AMTS score of <8 are two of the indicators that make up the CURB 65 score. However, in the case of a patient with a respiratory rate of 32 breaths/minute and an AMTS score of 9, these indicators still suggest a poor prognosis. A urea level of >7 mmol/l and a blood pressure of <90 mmHg systolic and/or 60 mmHg diastolic are also indicators of a poor prognosis. Finally, age >65 is another indicator that contributes to the CURB 65 score. Understanding these indicators can help healthcare professionals assess the severity of pneumonia and determine appropriate treatment plans.

    • This question is part of the following fields:

      • Respiratory
      17.4
      Seconds
  • Question 14 - A 76-year-old man presents to Accident and Emergency confused, dehydrated and constipated. He...

    Correct

    • A 76-year-old man presents to Accident and Emergency confused, dehydrated and constipated. He is complaining of significant pain down his left flank. He was diagnosed with multiple myeloma 6 months ago and is currently undergoing treatment. He is treated with aggressive fluid resuscitation and recovers promptly.
      Elevated levels of which biochemical parameter would has caused this presentation?

      Your Answer: Calcium

      Explanation:

      Electrolyte Imbalances and their Symptoms

      Calcium: Hypercalcaemia of malignancy is a common cause of lytic bone lesions in multiple myeloma patients. Symptoms include dehydration, which can be prevented with aggressive fluid resuscitation. Treatment involves intravenous bisphosphonate or denosumab and calcitonin to inhibit osteoclastic bone resorption.

      Vitamin D: Over-medication with vitamin D can lead to hypervitaminosis D, which presents similar symptoms to hypercalcaemia. However, hypercalcaemia of malignancy is more likely in patients with lytic bone lesions.

      Phosphate: Hyperphosphataemia can be caused by impaired renal excretion or massive extracellular phosphate loadings. Symptoms are similar to hypercalcaemia, but hypercalcaemia of malignancy is more likely in patients with multiple myeloma.

      Sodium: Hypernatraemia presents with symptoms of thirst, lethargy, weakness, and irritability.

      Potassium: Hyperkalaemia can present with symptoms of chest pain, palpitations, and weakness.

    • This question is part of the following fields:

      • Oncology
      438.1
      Seconds
  • Question 15 - A 91-year-old woman with known vascular dementia presents to the Emergency Department after...

    Correct

    • A 91-year-old woman with known vascular dementia presents to the Emergency Department after a routine blood test uncovered that the patient had a sodium level of 149 mmol/l. Her carer comments that the patient’s fluid intake has been minimal over the past week. The patient’s past medical history includes a previous lacunar stroke and peripheral vascular disease. Her regular medications are atorvastatin, ramipril, amlodipine and clopidogrel. She currently is fully dependent on the assistance provided by carers. The patient’s National Early Warning (NEWS) score is 0, and her Glasgow Coma Scale (GCS) score is 15.
      A physical examination does not reveal any source of infection. A bedside capillary glucose is recorded as 5.8 mmol/mmol. A full set of blood tests are repeated, reported as follows:
      Full blood count and urea and electrolytes (U&Es):
      Investigations Results Normal Values
      Haemoglobin (Hb) 131 g/l 115–155 g/l
      Mean corpuscular volume (MCV) 91 fl 76–98 fl
      White cell count (WCC) 5 × 109/l 4–11 × 109/l
      Platelets (Plt) 215 × 109/l 150–400 × 109/l
      Sodium (Na+) 148 mmol/l 135–145 mmol/l
      Potassium (K+) 4.8 mmol/l 3.5–5.0 mmol/l
      Urea 3.3 mmol/l 2.5–6.5 mmol/l
      Creatinine 66 mmol/l 50–120 mmol/l
      A routine chest X-ray and urinalysis are performed and show no abnormalities.
      Which of the following is the most suitable to correct the patient’s hypernatraemia?

      Your Answer: Oral water

      Explanation:

      Treatment Options for Hypernatraemia: A Case Study

      Hypernatraemia is a condition characterized by an elevated sodium concentration in the blood. In this case study, the patient’s hypernatraemia is mild and caused by insufficient free water intake. It is important to rule out infection as a cause of hypernatraemia, which can increase free water loss. Mild calcification of the aortic arch is a common finding in the elderly and unrelated to the patient’s current complaint.

      Hypertonic saline infusion is not recommended as it would further increase the sodium concentration. Standard dialysis is not necessary in this case as the hypernatraemia is not profound enough. 500 ml of 10% dextrose is not appropriate as it is not equivalent to giving free water and is used to reverse hypoglycaemia. 500 ml of 0.9% saline is not the correct option for this patient, but it may be appropriate for hypovolaemic and hypotensive patients to restore circulating volume.

      The most appropriate treatment option for this patient is to provide free water, which can be achieved by administering 5% dextrose. It is important to monitor the patient’s sodium levels and fluid intake to prevent further complications. The decision to start hypertonic saline infusion or dialysis should be made by a consultant in severe cases of hypernatraemia.

    • This question is part of the following fields:

      • Haematology
      926.9
      Seconds
  • Question 16 - A 20-year-old individual presents with obsessive thoughts about causing harm to others since...

    Correct

    • A 20-year-old individual presents with obsessive thoughts about causing harm to others since moving away from home to attend college. They are particularly anxious about using the shared kitchen in their dormitory and tend to prepare and eat meals during the night to avoid contact with their roommates. After completing a Yale-Brown Obsessive Compulsive Scale (Y-BOCS), they are diagnosed with mild OCD. What treatment option would be most suitable for this individual?

      Your Answer: Cognitive behavioural therapy

      Explanation:

      For patients with mild symptoms of obsessive-compulsive disorder (OCD) and mild impairment, the recommended first-line treatment is cognitive behavioural therapy (CBT) with exposure and response prevention (ERP). While clomipramine, a tricyclic antidepressant, may be used in some cases, it is not typically the first choice. Dialectical behaviour therapy is not commonly used in the treatment of OCD, as CBT and ERP are more effective. Fluoxetine, an SSRI antidepressant, may also be used in the treatment of OCD, but is not typically the first-line treatment for mild cases.

      Obsessive-compulsive disorder (OCD) is characterized by the presence of obsessions and/or compulsions that can cause significant functional impairment and distress. Risk factors include family history, age, pregnancy/postnatal period, and history of abuse, bullying, or neglect. Treatment options include low-intensity psychological treatments, SSRIs, and more intensive CBT (including ERP). Severe cases should be referred to the secondary care mental health team for assessment and may require combined treatment with an SSRI and CBT or clomipramine as an alternative. ERP involves exposing the patient to an anxiety-provoking situation and stopping them from engaging in their usual safety behavior. Treatment with SSRIs should continue for at least 12 months to prevent relapse and allow time for improvement.

    • This question is part of the following fields:

      • Psychiatry
      23.9
      Seconds
  • Question 17 - What is the causative agent of roseola in toddlers? ...

    Correct

    • What is the causative agent of roseola in toddlers?

      Your Answer: Human herpes virus 6

      Explanation:

      Understanding Roseola Infantum

      Roseola infantum, also known as exanthem subitum or sixth disease, is a common illness that affects infants and is caused by the human herpes virus 6 (HHV6). This disease has an incubation period of 5-15 days and is typically seen in children aged 6 months to 2 years. The most common symptoms of roseola infantum include a high fever that lasts for a few days, followed by a maculopapular rash. Other symptoms may include Nagayama spots, which are papular enanthems on the uvula and soft palate, as well as cough and diarrhea.

      In some cases, febrile convulsions may occur in around 10-15% of children with roseola infantum. While this can be concerning for parents, it is important to note that this is a common occurrence and typically resolves on its own. Additionally, HHV6 infection can lead to other possible consequences such as aseptic meningitis and hepatitis.

      It is important to note that school exclusion is not necessary for children with roseola infantum. While this illness can be uncomfortable for infants, it is typically not serious and resolves on its own within a few days.

    • This question is part of the following fields:

      • Paediatrics
      8.5
      Seconds
  • Question 18 - A 67-year-old Indian woman presents to the Emergency Department with vomiting and central...

    Correct

    • A 67-year-old Indian woman presents to the Emergency Department with vomiting and central abdominal pain. She has vomited eight times over the last 24 hours. The vomit is non-bilious and non-bloody. She also reports that she has not moved her bowels for the last four days and is not passing flatus. She reports that she had some form of radiation therapy to her abdomen ten years ago in India for ‘stomach cancer’. There is no urinary urgency or burning on urination. She migrated from India to England two months ago. She reports no other past medical or surgical history.
      Her observations and blood tests results are shown below:
      Investigation Result Normal value
      Temperature 36.9 °C
      Blood pressure 155/59 mmHg
      Heart rate 85 beats per minute
      Respiratory rate 19 breaths per minute
      Sp(O2) 96% (room air)
      White cell count 8.9 × 109/l 4–11 × 109/l
      C-reactive protein 36 mg/l 0–10 mg/l
      The patient’s urine dipstick is negative for leukocytes and nitrites. Physical examination reveals a soft but distended abdomen. No abdominal scars are visible. There is mild tenderness throughout the abdomen. Bowel sounds are hyperactive. Rectal examination reveals no stool in the rectal vault, and no blood or melaena.
      Which of the following is the most likely diagnosis?

      Your Answer: Small bowel obstruction

      Explanation:

      Differential Diagnosis for Abdominal Pain: Small Bowel Obstruction, Acute Mesenteric Ischaemia, Diverticulitis, Pyelonephritis, and Viral Gastroenteritis

      Abdominal pain can have various causes, and it is important to consider different possibilities to provide appropriate management. Here are some differential diagnoses for abdominal pain:

      Small bowel obstruction (SBO) is characterized by vomiting, lack of bowel movements, and hyperactive bowel sounds. Patients who have had radiation therapy to their abdomen are at risk for SBO. Urgent management includes abdominal plain film, intravenous fluids, nasogastric tube placement, analgesia, and surgical review.

      Acute mesenteric ischaemia is caused by reduced arterial blood flow to the small intestine. Patients with vascular risk factors such as hypertension, smoking, and diabetes mellitus are at risk. Acute-onset abdominal pain that is out of proportion to examination findings is a common symptom.

      Diverticulitis presents with left iliac fossa pain, pyrexia, and leukocytosis. Vital signs are usually stable.

      Pyelonephritis is characterized by fevers or chills, flank pain, and lower urinary tract symptoms.

      Viral gastroenteritis typically presents with fast-onset diarrhea and vomiting after ingestion of contaminated food. However, the patient in this case has not had bowel movements for four days.

      In summary, abdominal pain can have various causes, and it is important to consider the patient’s history, physical examination, and laboratory findings to arrive at an accurate diagnosis and provide appropriate management.

    • This question is part of the following fields:

      • Gastroenterology
      197.2
      Seconds
  • Question 19 - A 72-year-old man visits the Emergency Department with severe sharp pain in the...

    Correct

    • A 72-year-old man visits the Emergency Department with severe sharp pain in the left groin and chronic lower back pain after falling in his garden. He is unable to walk. He has a body mass index (BMI) of 28 kg/m2. His pulse is 80 bpm and regular, blood pressure (BP) 140/80 mm Hg. Fracture of the left neck of the femur is identified on X-ray and treated.
      Routine laboratory results are below:
      Investigation Result Normal value
      Serum calcium concentration 2.1 mmol/l 2.15 – 2.6 mmol/l
      Serum phosphate concentration 0.8 mmol/l 0.8 – 1.4 mmol/l
      Parathyroid hormone level 60 pg/ml 11 – 54 pg/ml
      Urea 5 mmol/l 2.5 – 7.1 mmol/l
      Creatinine 80 μmol/l 60 – 110 μmol/l
      What is the next most appropriate investigation?

      Your Answer: Serum 25-hydroxy vitamin D (25(OH)D) levels

      Explanation:

      Diagnostic Tests for Vitamin D Deficiency, Hyperparathyroidism, and Multiple Myeloma

      Vitamin D deficiency, hyperparathyroidism, and multiple myeloma are conditions that can affect calcium and phosphate levels in the body. To diagnose these conditions, various tests are used.

      Serum 25-hydroxy vitamin D (25(OH)D) levels are the best test to determine vitamin D status. Levels lower than 25 nmol/l indicate positive vitamin D deficiency. Treatment should commence if serum 25(OH)D levels are in the range of 25–50 nmol/l.

      Serum protein electrophoresis is used in the diagnosis of multiple myeloma. In multiple myeloma, there are osteolytic bone lesions leading to hypercalcemia.

      Ultrasonogram (USG) neck is used to assess parathyroid adenoma, which is associated with hyperparathyroidism. In hyperparathyroidism, serum PTH levels are very high with increased calcium and decreased phosphate levels.

      Urine Bence Jones Protein is positive in multiple myeloma. In multiple myeloma, there are osteolytic bone lesions leading to hypercalcemia, with impaired renal function.

      24-hour urinary calcium is elevated in hyperparathyroidism, type I renal tubular acidosis, vitamin D intoxication, and Bartter syndrome. However, it has no role in the diagnosis of vitamin D deficiency.

      Overall, these diagnostic tests can help healthcare professionals identify and treat these conditions, leading to improved patient outcomes.

    • This question is part of the following fields:

      • Clinical Biochemistry
      182.7
      Seconds
  • Question 20 - You are asked to review a middle-aged man, following an admission for lower...

    Incorrect

    • You are asked to review a middle-aged man, following an admission for lower abdominal pain. The patient has a distended abdomen and has not passed urine for eight hours. He is very uncomfortable and has a large palpable bladder extending above the pubic symphysis. A digital rectal examination is performed, which reveals an enlarged, smooth prostate. Urinalysis is unremarkable, and he remains systemically well. He describes increasing difficulty with voiding and poor stream over the past six months, but no other symptoms.
      What is the most likely underlying cause for his urinary retention?

      Your Answer: Prostate carcinoma

      Correct Answer: Benign prostatic hypertrophy (BPH)

      Explanation:

      Causes of Urinary Retention in Men

      Urinary retention, the inability to empty the bladder completely, can have various underlying causes. In men, some common conditions that can lead to urinary retention are benign prostatic hypertrophy (BPH), renal calculi, prostate carcinoma, urinary tract infection, and bladder cancer.

      BPH is a non-cancerous enlargement of the prostate gland that often occurs with aging. It can compress the urethra and obstruct the flow of urine, causing symptoms such as difficulty starting urination, weak stream, dribbling, and frequent urination. Immediate treatment for acute urinary retention due to BPH may involve inserting a urinary catheter to relieve the pressure and drain the bladder.

      Renal calculi, or kidney stones, can cause urinary retention if they get stuck in the ureter or bladder neck. The pain from passing a stone can be severe and radiate from the back to the groin. Blood in the urine may also be present.

      Prostate carcinoma, or prostate cancer, can also cause urinary retention if the tumour grows large enough to block the urethra. However, this is not a common presentation of prostate cancer, which usually manifests with other symptoms such as urinary frequency, urgency, nocturia, pain, or blood in the semen.

      Urinary tract infection (UTI) can result from incomplete voiding due to BPH or other causes. UTI can cause symptoms such as burning, urgency, frequency, cloudy or foul-smelling urine, and fever. However, not all cases of urinary retention are associated with UTI.

      Bladder cancer is a rare cause of urinary retention, but it can occur if the tumour obstructs the bladder outlet. Bladder cancer may also cause painless hematuria, urinary urgency, or pelvic discomfort.

      In summary, urinary retention in men can have multiple etiologies, and the diagnosis depends on the patient’s history, physical examination, and additional tests such as imaging, urinalysis, or prostate-specific antigen (PSA) testing. Prompt evaluation and management of urinary retention are essential to prevent complications such as urinary tract infection, bladder damage, or renal impairment.

    • This question is part of the following fields:

      • Urology
      437.2
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  • Question 21 - A 50-year-old truck driver is admitted with a left-sided facial droop, dysphasia and...

    Incorrect

    • A 50-year-old truck driver is admitted with a left-sided facial droop, dysphasia and dysarthria. His symptoms slowly improve and he is very eager to return to work as he is self-employed. After 3 weeks, he has made a complete clinical recovery and neurological examination is normal. As per the guidelines of the Driver and Vehicle Licensing Agency (DVLA), when can he recommence driving his truck?

      Your Answer: 6 months after onset of symptoms

      Correct Answer: 12 months after onset of symptoms

      Explanation:

      Driving Restrictions Following Stroke or TIA

      After experiencing a stroke or transient ischaemic attack (TIA), there are various restrictions on driving depending on the time elapsed since onset of symptoms and the type of vehicle being driven.

      For car drivers, it is recommended that they do not drive for at least 4 weeks after a TIA or stroke. After 1 month, they may resume driving if there has been satisfactory recovery.

      However, for lorry or bus drivers, licences will be revoked for 1 year following a stroke or TIA. After 12 months, relicensing may be offered subject to satisfactory clinical recovery. Functional cardiac testing and medical reports may be required.

      For car drivers who have had a single TIA or stroke, they may resume driving 1 month after the event following satisfactory clinical recovery.

      Overall, it is important to follow these restrictions to ensure the safety of both the driver and others on the road.

    • This question is part of the following fields:

      • Neurology
      143.8
      Seconds
  • Question 22 - A 48-year-old man is brought to the emergency department by ambulance with multiple...

    Incorrect

    • A 48-year-old man is brought to the emergency department by ambulance with multiple stab wounds. During clinical examination, eight stab wounds are identified on his abdomen and one on the front of his chest. His airway has been secured, and he is receiving oxygen at a rate of 15 L/min while IV fluid resuscitation has been initiated.

      Following CT scans of his abdomen, the patient has been transferred to the operating room for an emergency laparotomy. The surgeons are assessing the condition of his spleen based on the CT and laparotomy findings to determine the next steps in his treatment.

      What is one reason that may indicate the need for a splenectomy in this patient?

      Your Answer: Haemodynamic stability and complete devascularisation of the spleen

      Correct Answer: Haemodynamic instability and complete devascularisation of the spleen

      Explanation:

      When trauma patients experience uncontrollable bleeding in the spleen, a splenectomy may be necessary. CT imaging can be used to grade the severity of the splenic injury, with grades 1-3 typically managed conservatively if the patient is stable, and grades 4-5 often requiring surgical intervention. During emergency laparotomy, if certain findings such as uncontrollable bleeding, hilar vascular injuries, or a devascularized spleen are present, a splenectomy may be indicated.

      Managing Splenic Trauma

      The spleen is a commonly injured intra-abdominal organ, but in most cases, it can be conserved. The management of splenic trauma depends on several factors, including associated injuries, haemodynamic status, and the extent of direct splenic injury.

      Conservative management is appropriate for small subcapsular haematomas, minimal intra-abdominal blood, and no hilar disruption. However, if there are increased amounts of intra-abdominal blood, moderate haemodynamic compromise, or tears or lacerations affecting less than 50%, laparotomy with conservation may be necessary.

      In cases of hilar injuries, major haemorrhage, or major associated injuries, resection is the preferred management option. It is important to note that the management approach should be tailored to the individual patient’s needs and circumstances. Proper management of splenic trauma can help prevent further complications and improve patient outcomes.

    • This question is part of the following fields:

      • Surgery
      112.3
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  • Question 23 - A 25-year-old man presents to the Emergency Department with severe vomiting and diarrhoea...

    Correct

    • A 25-year-old man presents to the Emergency Department with severe vomiting and diarrhoea that has lasted for four days. He has been unable to keep down any fluids and is dehydrated, so he is started on an intravenous infusion. Upon investigation, his potassium level is found to be 2.6 mmol/L (3.5-4.9). What ECG abnormality would you anticipate?

      Your Answer: S-T segment depression

      Explanation:

      Hypokalaemia and Hyperkalaemia

      Hypokalaemia is a condition characterized by low levels of potassium in the blood. This can be caused by excess loss of potassium from the gastrointestinal or renal tract, decreased oral intake of potassium, alkalosis, or insulin excess. Additionally, hypokalaemia can be seen if blood is taken from an arm in which IV fluid is being run. The characteristic ECG changes associated with hypokalaemia include S-T segment depression, U-waves, inverted T waves, and prolonged P-R interval.

      On the other hand, hyperkalaemia is a condition characterized by high levels of potassium in the blood. This can be caused by kidney failure, medications, or other medical conditions. The changes that may be seen with hyperkalaemia include tall, tented T-waves, wide QRS complexes, and small P waves.

      It is important to understand the causes and symptoms of both hypokalaemia and hyperkalaemia in order to properly diagnose and treat these conditions. Regular monitoring of potassium levels and ECG changes can help in the management of these conditions.

    • This question is part of the following fields:

      • Cardiology
      19.7
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  • Question 24 - A 2-month-old infant is scheduled for a hearing screening test. She was born...

    Correct

    • A 2-month-old infant is scheduled for a hearing screening test. She was born at 38 weeks without any pregnancy complications and delivered vaginally. Which hearing test would be most suitable for this child?

      Your Answer: Automated otoacoustic emissions

      Explanation:

      The otoacoustic emission test is specifically designed to screen newborns for hearing issues. Different hearing tests are available for different age groups, but in the UK, newborns are typically screened using the automated otoacoustic emissions test or the evoked otoacoustic emissions test. If any abnormalities are detected, the automated auditory brainstem response test is used as a follow-up. The other hearing tests mentioned are more appropriate for older children. This information is provided by the NHS in the UK.

      Hearing Tests for Children

      Hearing tests are important for children to ensure that they are developing normally. There are several tests that may be performed on children of different ages. For newborns, an otoacoustic emission test is typically done as part of the Newborn Hearing Screening Programme. This test involves playing a computer-generated click through a small earpiece and checking for the presence of a soft echo, which indicates a healthy cochlea. If the results of this test are abnormal, an Auditory Brainstem Response test may be done.

      For infants between 6-9 months, a Distraction test may be performed by a health visitor with the help of two trained staff members. For children between 18 months to 2.5 years, a Recognition of familiar objects test may be used, which involves using familiar objects like a teddy or cup and asking the child simple questions like where is the teddy? For children over 2.5 years, Performance testing and Speech discrimination tests may be used, such as the Kendall Toy test or McCormick Toy Test. Pure tone audiometry is typically done at school entry in most areas of the UK for children over 3 years old.

      In addition to these tests, there is also a questionnaire for parents in the Personal Child Health Records called Can your baby hear you? It is important for parents to be aware of these tests and to have their child’s hearing checked regularly to ensure proper development.

    • This question is part of the following fields:

      • Paediatrics
      12.2
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  • Question 25 - A 30-year-old G1P0 woman in her 12th week of pregnancy presents to the...

    Correct

    • A 30-year-old G1P0 woman in her 12th week of pregnancy presents to the emergency department with severe nausea and vomiting that has been worsening over the past week. She reports difficulty keeping any food down over the past 24 hours and noticed a small amount of fresh blood in her vomit. She denies any abdominal pain or change in bowel habits. Despite using cyclizine tablets, her symptoms have not improved. The patient has no significant medical history.

      The following blood tests were taken and revealed abnormal results: Na+ 140 mmol/l (reference range 135-145 mmol/l), K+ 3.3 mmol/l (reference range 3.5-5.0 mmol/l), Cl- 100 mmol/l (reference range 95-105 mmol/l), HCO3- 23 mmol/l (reference range 22-28 mmol/l), urea 13 mmol/l (reference range 2.0-7.0 mmol/l), creatinine 80 mmol/l (reference range 55-120 umol/l), and blood glucose 6.0 mmol/l (reference range 4.0-7.8 mmol/l). A urine dipstick revealed 4+ ketonuria but no white or red cells.

      What is the most appropriate course of action for this patient?

      Your Answer: Admit for IV fluid and electrolyte replacement, anti-emetics and trial of bland diet

      Explanation:

      In cases where pregnant women experience severe nausea and vomiting leading to ketonuria and dehydration, admission to the hospital should be considered. This is especially true if they have already tried oral anti-emetics without success. Such symptoms are indicative of hyperemesis gravidarum, which can be confirmed by urine dipstick and increased blood urea levels. While pyridoxine is not recommended by the Royal College of Obstetricians and Gynaecologists (RCOG), ondansetron is effective as a second-line option. However, inpatient treatment is necessary. Gastroscopy is unlikely to be helpful at this stage, even if there is a small amount of blood in the vomit, which is likely due to a Mallory-Weiss tear caused by constant retching. Low K+ levels due to vomiting need to be replaced, and anti-emetics are necessary. Therefore, admission to the hospital for IV fluids, anti-emetics, and a trial of a bland diet is the appropriate course of action.

      Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.

    • This question is part of the following fields:

      • Obstetrics
      212.7
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  • Question 26 - A 28-year-old gravida 4, para 3 undergoes an assisted delivery with mid-cavity forceps...

    Correct

    • A 28-year-old gravida 4, para 3 undergoes an assisted delivery with mid-cavity forceps following a prolonged second stage. After a couple of weeks, the patient visits her GP complaining of difficulty walking. Upon examination, she displays a limp in her left leg, a numb thigh, weak knee extension, and the absence of patellar reflex. Her right leg appears normal. What nerve has been affected by the forceps delivery?

      Your Answer: Femoral nerve

      Explanation:

      The observed symptoms indicate that the femoral nerve has been affected. Although nerve damage during instrumental delivery is uncommon, it can occur during challenging deliveries and mid-cavity forceps use. The table below outlines the nerves that may be impacted by forceps and the corresponding clinical manifestations.
      Nerve Clinical features
      Femoral nerve Weakness in extending the knee, absence of the patellar reflex, and numbness in the thigh
      Lumbosacral trunk Weakness in dorsiflexing the ankle and numbness in the calf and foot.

      Selected Facts about Lower Limb Anatomy

      The lower limb anatomy is a complex system that is often tested in medical examinations. One of the important aspects of this system is the nerves that control the motor and sensory functions of the lower limb. The femoral nerve, for example, controls knee extension and thigh flexion, and is responsible for the sensation in the anterior and medial aspect of the thigh and lower leg. This nerve is commonly injured in cases of hip and pelvic fractures, as well as stab or gunshot wounds.

      Another important nerve is the obturator nerve, which controls thigh adduction and provides sensation to the medial thigh. Injuries to this nerve can occur in cases of anterior hip dislocation. The lateral cutaneous nerve of the thigh, on the other hand, does not control any motor function but is responsible for the sensation in the lateral and posterior surfaces of the thigh. Compression of this nerve near the ASIS can lead to meralgia paraesthetica, a condition characterized by pain, tingling, and numbness in the distribution of the lateral cutaneous nerve.

      The tibial nerve controls foot plantarflexion and inversion and provides sensation to the sole of the foot. This nerve is not commonly injured as it is deep and well-protected. The common peroneal nerve, which controls foot dorsiflexion and eversion, is often injured at the neck of the fibula, resulting in foot drop. The superior gluteal nerve controls hip abduction and is commonly injured in cases of misplaced intramuscular injection, hip surgery, pelvic fracture, or posterior hip dislocation. Injury to this nerve results in a positive Trendelenburg sign. Finally, the inferior gluteal nerve controls hip extension and lateral rotation and is generally injured in association with the sciatic nerve. Injury to this nerve results in difficulty rising from a seated position, as well as an inability to jump or climb stairs.

    • This question is part of the following fields:

      • Musculoskeletal
      112
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  • Question 27 - A 7-year-old girl has been brought to the GP with a 2-day history...

    Incorrect

    • A 7-year-old girl has been brought to the GP with a 2-day history of fever, malaise, and sore throat. She also has some facial redness that started yesterday evening. On examination, there is flushing of the cheeks and a fine, blanching, erythematosus rash that feels like sandpaper on the anterior aspect of the neck. There is erythema of the tonsils and tongue, without exudate. The GP also notices some erythematosus, non-tender lines in the creases of the elbows. The GP decides to prescribe a 10-day course of antibiotics.

      What advice should the mother be given regarding her child's return to school?

      Your Answer: The GP must examine them in two weeks to clear them for return to school

      Correct Answer: They can return to school 24 hours after taking the first dose of antibiotics

      Explanation:

      If a child has scarlet fever, they can go back to school after 24 hours of taking antibiotics. The symptoms of tonsillopharyngitis (red tonsils and a tongue that looks like a strawberry) and maculopapular exanthem (a rash that feels like sandpaper and lines on the elbows) suggest that the child has scarlet fever. The GP does not need to see the child again because antibiotics should help them recover. However, the child should not go back to school right away because they may still be contagious. The antibiotics will last for 10 days, but the child only needs to wait for 1 day before returning to school. Alternatively, after 7 days, the child will no longer be contagious and can go back to school as usual.

      Scarlet fever is a condition caused by erythrogenic toxins produced by Group A haemolytic streptococci, usually Streptococcus pyogenes. It is more prevalent in children aged 2-6 years, with the highest incidence at 4 years. The disease spreads through respiratory droplets or direct contact with nose and throat discharges, especially during sneezing and coughing. The incubation period is 2-4 days, and symptoms include fever, malaise, headache, nausea/vomiting, sore throat, ‘strawberry’ tongue, and a rash that appears first on the torso and spares the palms and soles. The rash has a rough ‘sandpaper’ texture and desquamination occurs later in the course of the illness, particularly around the fingers and toes.

      To diagnose scarlet fever, a throat swab is usually taken, but antibiotic treatment should be initiated immediately, rather than waiting for the results. Management involves administering oral penicillin V for ten days, while patients with a penicillin allergy should be given azithromycin. Children can return to school 24 hours after commencing antibiotics, and scarlet fever is a notifiable disease. Although usually a mild illness, scarlet fever may be complicated by otitis media, rheumatic fever, acute glomerulonephritis, or rare invasive complications such as bacteraemia, meningitis, or necrotizing fasciitis, which may present acutely with life-threatening illness.

    • This question is part of the following fields:

      • Paediatrics
      40.5
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  • Question 28 - A 25-year-old man has been referred for investigation of Peutz-Jegher syndrome due to...

    Incorrect

    • A 25-year-old man has been referred for investigation of Peutz-Jegher syndrome due to his family history. His grandmother passed away at the age of 30 from colonic carcinoma associated with the syndrome. What is the most probable mode of inheritance for Peutz-Jegher syndrome?

      Your Answer: Autosomal recessive

      Correct Answer: Autosomal dominant

      Explanation:

      Peutz-Jegher Syndrome: A Genetic Disorder with Pigmentation and Bowel Abnormalities

      Peutz-Jegher syndrome is a genetic disorder that is characterized by the presence of perioral pigmentation and multiple hamartomas in the bowel. Initially, it was believed that these hamartomas did not increase the risk of developing cancer. However, recent studies have shown that individuals with Peutz-Jegher syndrome are at an increased risk of developing various types of cancer, including breast, colon, and pancreatic cancer. This condition is inherited in an autosomal dominant pattern, which means that a person only needs to inherit one copy of the mutated gene from one parent to develop the disorder. Regular screening and surveillance are recommended for individuals with Peutz-Jegher syndrome to detect any potential cancerous growths early on.

    • This question is part of the following fields:

      • Clinical Sciences
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  • Question 29 - An 8-year old boy is referred for squint correction surgery on his left...

    Incorrect

    • An 8-year old boy is referred for squint correction surgery on his left eye.
      Regarding the extraocular muscles, which of the following statements is accurate?

      Your Answer: The superior oblique muscle is innervated by the oculomotor nerve

      Correct Answer: The lateral rectus is supplied by the abducens nerve

      Explanation:

      Cranial Nerves and Extraocular Muscles: Understanding Innervation

      The movement of the eye is controlled by six extraocular muscles, each innervated by a specific cranial nerve. Understanding the innervation of these muscles is crucial in diagnosing and treating various eye conditions.

      The abducens nerve (cranial nerve VI) supplies only one muscle, the lateral rectus, responsible for the abduction of the eye. The oculomotor nerve (cranial nerve III) supplies all extraocular muscles except the superior oblique and lateral rectus. The trochlear nerve (cranial nerve IV) supplies the superior oblique muscle.

      The levator palpebrae superioris, responsible for lifting the eyelid, is innervated by both the oculomotor nerve and sympathetic nerve fibers. A third cranial nerve palsy or sympathetic interruption can result in ptosis (droopy eyelid), which can be distinguished by inspecting the pupil for mydriasis (enlarged pupil) or miosis (constricted pupil).

      The superior and inferior oblique muscles are more complex in their actions. The superior oblique muscle abducts, depresses, and internally rotates the eye, while the inferior oblique muscle causes extorsion, abduction, and elevation. This is due to their attachment behind the axis of movement.

      In summary, understanding the innervation of the extraocular muscles is essential in diagnosing and treating eye conditions. Remembering the cranial nerves and their corresponding muscles can be aided by the mnemonics SO4 (superior oblique, cranial nerve IV) and LR6 (lateral rectus, cranial nerve VI).

    • This question is part of the following fields:

      • Ophthalmology
      116.6
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  • Question 30 - A paediatrician is asked to assess a 2-day-old neonate delivered spontaneously at 38...

    Correct

    • A paediatrician is asked to assess a 2-day-old neonate delivered spontaneously at 38 weeks. The neonate's birth weight is normal and the mother is recovering well. The neonate has vomited several times in the past 24 hours, with the mother describing it as 'projectile vomiting'. On examination, the abdomen is moderately distended, and there is no jaundice. The neonate appears dehydrated and lethargic, and the vomit bowl contains bright green liquid. What is the most probable diagnosis?

      Your Answer: Jejunal atresia

      Explanation:

      Jejunal atresia is the likely cause of bilious vomiting within 24 hours of birth. Intestinal atresia, which includes duodenal atresia, jejunal atresia, or ileal atresia, is the most common cause of bilious vomiting in neonates. Bilious vomiting is typically caused by an obstruction beyond the sphincter of Oddi, where the common bile duct enters the duodenum. Given the neonate’s age, term-birth, and bilious vomiting, intestinal atresia is the most probable diagnosis.
      Necrotising enterocolitis is an incorrect answer, as it is less likely to cause bilious vomiting in a term-born baby than intestinal atresia. This neonate has no risk factors for necrotising enterocolitis.
      Oesophageal atresia is also incorrect, as it would not result in bilious vomiting. The obstruction is proximal to the sphincter of Oddi, so bile could not be present in the vomitus of neonates with oesophageal atresia.
      Pyloric stenosis is another incorrect answer, as it usually starts between 3-5 weeks of life and is not associated with bilious vomiting. As the obstruction in pyloric stenosis is proximal to the sphincter of Oddi, bile cannot enter the stomach and is not present in the vomitus of patients with pyloric stenosis.

      Causes and Treatments for Bilious Vomiting in Neonates

      Bilious vomiting in neonates can be caused by various disorders, including duodenal atresia, malrotation with volvulus, jejunal/ileal atresia, meconium ileus, and necrotising enterocolitis. Duodenal atresia occurs in 1 in 5000 births and is more common in babies with Down syndrome. It typically presents a few hours after birth and can be diagnosed through an abdominal X-ray that shows a double bubble sign. Treatment involves duodenoduodenostomy. Malrotation with volvulus is usually caused by incomplete rotation during embryogenesis and presents between 3-7 days after birth. An upper GI contrast study or ultrasound can confirm the diagnosis, and treatment involves Ladd’s procedure. Jejunal/ileal atresia is caused by vascular insufficiency in utero and occurs in 1 in 3000 births. It presents within 24 hours of birth and can be diagnosed through an abdominal X-ray that shows air-fluid levels. Treatment involves laparotomy with primary resection and anastomosis. Meconium ileus occurs in 15-20% of babies with cystic fibrosis and presents in the first 24-48 hours of life with abdominal distension and bilious vomiting. Diagnosis involves an abdominal X-ray that shows air-fluid levels, and a sweat test can confirm cystic fibrosis. Treatment involves surgical decompression, and segmental resection may be necessary for serosal damage. Necrotising enterocolitis occurs in up to 2.4 per 1000 births, with increased risks in prematurity and inter-current illness. It typically presents in the second week of life and can be diagnosed through an abdominal X-ray that shows dilated bowel loops, pneumatosis, and portal venous air. Treatment involves conservative and supportive measures for non-perforated cases, while laparotomy and resection are necessary for perforated cases or ongoing clinical deterioration.

    • This question is part of the following fields:

      • Surgery
      75.2
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Medicine (0/1) 0%
Obstetrics (2/3) 67%
Cardiology (1/2) 50%
Psychiatry (1/2) 50%
Paediatrics (4/6) 67%
Respiratory (1/2) 50%
Surgery (2/3) 67%
Pharmacology (0/1) 0%
Endocrinology (1/1) 100%
Oncology (1/1) 100%
Haematology (1/1) 100%
Gastroenterology (1/1) 100%
Clinical Biochemistry (1/1) 100%
Urology (0/1) 0%
Neurology (0/1) 0%
Musculoskeletal (1/1) 100%
Clinical Sciences (0/1) 0%
Ophthalmology (0/1) 0%
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