00
Correct
00
Incorrect
00 : 00 : 0 00
Session Time
00 : 00
Average Question Time ( Mins)
  • Question 1 - A 32-year-old woman with HIV presents to clinic with complaints of tiredness, abdominal...

    Incorrect

    • A 32-year-old woman with HIV presents to clinic with complaints of tiredness, abdominal discomfort, and urinary frequency for the past two months. Despite a course of trimethoprim prescribed by her general practitioner 10 days ago, her symptoms have not improved. She has been on antiretroviral therapy for six months and is currently taking Atripla. Her latest HIV viral load was undetectable, and her CD4+ count was 450. She has been amenorrhoeic for the past two years due to her contraceptive implant. Blood tests reveal abnormal liver function tests. What investigation would be most helpful in confirming the diagnosis?

      Your Answer: Therapeutic drug monitoring (TDM) of efavirenz levels

      Correct Answer: Serum beta-HCG

      Explanation:

      Diagnosis of Pregnancy in a Woman on Contraceptive Implant and Antiretroviral Therapy

      This woman, who is on antiretroviral therapy, has been using a contraceptive implant for birth control. However, her new medication, efavirenz, is a potent enzyme inducer that reduces the effectiveness of the implant. Although an ultrasound can detect pregnancy by examining the uterus, a urine or blood test for beta-human chorionic gonadotropin (B-HCG) is the definitive diagnostic tool. During pregnancy, alkaline phosphatase (AlkP) levels increase due to placental production, while hemoglobin (HB) levels may decrease slightly. Thrombocytopenia is a common occurrence in individuals with HIV infection. The University of Liverpool offers a helpful website that provides accurate information on HIV drug interactions.

      Hepatitis B is more prevalent in people with HIV than in the general population, but it is typically associated with elevated transaminases. A mid-stream specimen urine (MSSU) is unlikely to be useful after antibiotic treatment for a urinary tract infection (UTI), which would not explain the elevated AlkP levels. TDM (therapeutic drug monitoring) of efavirenz levels may reveal liver abnormalities, but it would not account for urinary symptoms. Although an ultrasound of the liver may incidentally detect pregnancy if the radiographer also examines the pelvis, it is not the most effective diagnostic test. Apart from AlkP, liver function tests (LFTs) are normal.

    • This question is part of the following fields:

      • Infectious Diseases
      66.2
      Seconds
  • Question 2 - A 25-year-old obese man presents with mild ankle swelling and a urinalysis that...

    Incorrect

    • A 25-year-old obese man presents with mild ankle swelling and a urinalysis that shows +++ protein but no blood. Upon further examination, he is diagnosed with nephrotic syndrome based on his cholesterol level of 6.9, albumin level of 30 g/dL, and proteinuria of 8 g/24 hours. He also has high blood pressure with a reading of 145/90 mmHg. A renal biopsy is scheduled for the following week, and a protein selectivity index of 15% is found in his urine analysis. He is started on prednisolone 60 mg daily as a precaution. Prior to the biopsy, his 24-hour urine collection is repeated and shows a decrease in urine protein output to 1.5 g/24 hours. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Minimal change nephropathy

      Explanation:

      Diagnosis of Nephrotic Syndrome in Young Adults

      In young adults without haematuria, the most probable cause of nephrotic syndrome is minimal change nephropathy. Steroid treatment is highly effective in minimal change nephropathy, with a response rate of almost 100%. However, in focal segmental glomerulosclerosis, the response rate is only about 40%. The protein selectivity index, which is the ratio of serum and urine IgG and albumin, is a highly selective indicator of minimal change disease when it is less than 10%. However, this indicator is less reliable in adults. Therefore, in young adults with nephrotic syndrome, minimal change nephropathy is the most likely diagnosis, and steroid treatment is highly effective.

    • This question is part of the following fields:

      • Renal Medicine
      0
      Seconds
  • Question 3 - A 62-year-old male presents with sudden onset back pain while gardening at home,...

    Incorrect

    • A 62-year-old male presents with sudden onset back pain while gardening at home, radiating to his right anterior chest and jaw, associated with nausea and vomiting. The pain has been constant for the past 2 hours since onset and is his first ever episode. His past medical history includes hypertension, hypercholesterolaemia and one previous transient ischaemic attack.

      His ECG demonstrates left ventricular hypertrophy by voltage criteria and T-wave inversion in I, aVF and V5 and V6. On examination, his heart sounds are both present with a soft systolic murmur. The chest is clear and abdomen is soft and non-tender without a pulsatile mass. Both radial pulses are intact with no delay. There is a mild radio-femoral delay. His blood pressure is stable at 136/82 mmHg, heart rate 120/min and sinus rhythm. His bloods are as follows:

      Hb 120 g/l
      MCV 80 fl
      Platelets 200 * 109/l
      WBC 9.5 * 109/l
      Troponin T 250 (normal range < 32)

      His pain settles transiently with 2mg of subcutaneous morphine. What is the most appropriate immediate action?

      Your Answer:

      Correct Answer: CT aorta

      Explanation:

      The patient’s symptoms and test results suggest a possible diagnosis of acute aortic syndrome, which includes various aortic pathologies such as dissections, ulcers, and aneurysms. The lack of radial-radial delay and mild radial-femoral delay indicate a possible descending artery lesion. Further testing is needed to confirm the diagnosis.

      Aortic dissection is a serious condition that can cause chest pain. It occurs when there is a tear in the inner layer of the aorta wall. Hypertension is the most significant risk factor, but it can also be associated with trauma, bicuspid aortic valve, and certain genetic disorders. Symptoms of aortic dissection include severe and sharp chest or back pain, weak or absent pulses, hypertension, and aortic regurgitation. Specific arteries’ involvement can cause other symptoms such as angina, paraplegia, or limb ischemia. The Stanford classification divides aortic dissection into type A, which affects the ascending aorta, and type B, which affects the descending aorta. The DeBakey classification further divides type A into type I, which extends to the aortic arch and beyond, and type II, which is confined to the ascending aorta. Type III originates in the descending aorta and rarely extends proximally.

    • This question is part of the following fields:

      • Cardiology
      0
      Seconds
  • Question 4 - A 64-year-old woman comes to the haematology clinic with progressive lower back pain...

    Incorrect

    • A 64-year-old woman comes to the haematology clinic with progressive lower back pain and unexplained anaemia. Her initial protein electrophoresis and serum-free light chain assays suggest multiple myeloma. She has a medical history of hypertension and transient ischaemic attacks and takes clopidogrel, amlodipine, and ramipril. What imaging studies should be recommended for further evaluation?

      Your Answer:

      Correct Answer: Whole body MRI

      Explanation:

      Whole body MRI is recommended as the first-line imaging for patients suspected to have myeloma, according to NICE guidelines. Whole body CT should only be considered if MRI is not possible, and skeletal survey is a last resort. FDG PET CT can be used once a diagnosis is confirmed.

      Understanding Multiple Myeloma: Features and Investigations

      Multiple myeloma is a type of cancer that affects the plasma cells in the bone marrow. It is most commonly found in patients aged 60-70 years. The disease is characterized by a range of symptoms, which can be remembered using the mnemonic CRABBI. These include hypercalcemia, renal damage, anemia, bleeding, bone lesions, and increased susceptibility to infection. Other features of multiple myeloma include amyloidosis, carpal tunnel syndrome, neuropathy, and hyperviscosity.

      To diagnose multiple myeloma, a range of investigations are required. Blood tests can reveal anemia, renal failure, and hypercalcemia. Protein electrophoresis can detect raised levels of monoclonal IgA/IgG proteins in the serum, while bone marrow aspiration can confirm the diagnosis if the number of plasma cells is significantly raised. Imaging studies, such as whole-body MRI or X-rays, can be used to detect osteolytic lesions.

      The diagnostic criteria for multiple myeloma require one major and one minor criteria or three minor criteria in an individual who has signs or symptoms of the disease. Major criteria include the presence of plasmacytoma, 30% plasma cells in a bone marrow sample, or elevated levels of M protein in the blood or urine. Minor criteria include 10% to 30% plasma cells in a bone marrow sample, minor elevations in the level of M protein in the blood or urine, osteolytic lesions, or low levels of antibodies in the blood. Understanding the features and investigations of multiple myeloma is crucial for early detection and effective treatment.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds
  • Question 5 - A 42-year-old Indian man is seen in the renal outpatient clinic. He has...

    Incorrect

    • A 42-year-old Indian man is seen in the renal outpatient clinic. He has been experiencing a gradual decline in his renal function for the past 4 years due to poorly controlled type 2 diabetes mellitus. His eGFR is currently at 8 ml/min, but he is still able to pass urine. Recent ultrasound scans have indicated that he is a suitable candidate for a renal transplant. However, given his ethnicity, there is an uncertain wait for organ suitability should he choose to pursue this option. During the consultation, his 17-year-old daughter offers to donate a kidney due to the high likelihood of compatibility, which the patient is interested in exploring.

      The patient's blood test results are as follows:

      Hb 92 g/l
      Platelets 180 * 109/l
      WBC 7.0 * 109/l

      Na+ 142 mmol/l
      K+ 5.5 mmol/l
      Urea 19.8 mmol/l
      Creatinine 290 µmol/l
      pH 7.30

      What would be the most appropriate course of action at this point?

      Your Answer:

      Correct Answer: Start preparation for haemodialysis and list for renal transplant on national transplant list

      Explanation:

      The patient’s renal dysfunction is a result of uncontrolled diabetes and is not expected to improve on its own. There are no immediate indications for initiating renal replacement therapy. The appropriate timing for renal transplantation is a topic of debate, as the rate of renal function decline can vary among patients. However, it is generally agreed that once the underlying cause is deemed irreversible and the eGFR drops below 30, transplantation should be considered.

      Understanding Renal Replacement Therapy

      Chronic kidney disease affects a significant portion of the population, with around 10% of those with CKD developing renal failure. For patients with renal failure, the options are either renal replacement therapy (RRT) or conservative management. RRT involves taking over the physiology of the kidneys, and there are several types available, including haemodialysis, peritoneal dialysis, and renal transplant. The decision about which RRT option to choose should be made jointly by the patient and their healthcare team, taking into account various factors such as predicted quality of life, life expectancy, patient preference, and co-existing medical conditions.

      Haemodialysis is the most common form of RRT, where the blood is filtered through a dialysis machine in the hospital. Peritoneal dialysis is another option where the filtration occurs within the patient’s abdomen. Renal transplantation involves receiving a kidney from either a live or deceased donor. Each option has its own set of complications, such as site infection, peritonitis, DVT/PE, and more.

      Without adequate RRT, the symptoms of renal failure can be severe, including breathlessness, fatigue, insomnia, pruritus, poor appetite, swelling, weakness, weight gain/loss, abdominal cramps, nausea, muscle cramps, headaches, cognitive impairment, anxiety, depression, and sexual dysfunction. It is crucial for patients and their healthcare team to carefully consider the best RRT option for their individual needs and circumstances.

    • This question is part of the following fields:

      • Renal Medicine
      0
      Seconds
  • Question 6 - A 23-year-old female known with schizophrenia is being reviewed in the emergency department....

    Incorrect

    • A 23-year-old female known with schizophrenia is being reviewed in the emergency department. Her mother claims that she has been 'staring' for the past few hours but has now developed abnormal head movements and has gone 'cross-eyed'. On examination, the patient's neck is extended and positioned to the right. Her eyes are deviated upwards and are slightly converged. Given the likely diagnosis, what is the most appropriate treatment?

      Your Answer:

      Correct Answer: Procyclidine

      Explanation:

      The most probable diagnosis in this patient is an oculogyric crisis, that is most appropriately managed with procyclidine or benztropine (antimuscarinic).

      An oculogyric crisis is a dystonic reaction to certain drugs or medical conditions.

      Features include:
      Restlessness, agitation
      Involuntary upward deviation of the eyes

      Causes:
      Phenothiazines
      Haloperidol
      Metoclopramide
      Postencephalitic Parkinson’s disease

      Management:
      Intravenous antimuscarinic agents like benztropine or procyclidine, alternatively diphenhydramine or ethopropazine maybe used.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 7 - Which one of the following statements regarding interleukin 1 (IL-1) is true? ...

    Incorrect

    • Which one of the following statements regarding interleukin 1 (IL-1) is true?

      Your Answer:

      Correct Answer: It is released mainly by macrophages/monocytes

      Explanation:

      Interleukin 1 alpha and interleukin 1 beta (IL1 alpha and IL1 beta) are cytokines that participate in the regulation of immune responses, inflammatory reactions, and hematopoiesis. It is secreted mainly by macrophages and monocytes and acts as a costimulator of T cell and B cell proliferation.

    • This question is part of the following fields:

      • Clinical Sciences
      0
      Seconds
  • Question 8 - A 50-year-old patient was started on ezetimibe, for his cholesterol a few days...

    Incorrect

    • A 50-year-old patient was started on ezetimibe, for his cholesterol a few days back. Which among the following statements is true regarding ezetimibe?

      Your Answer:

      Correct Answer: Its principal action is to reduce intestinal cholesterol absorption

      Explanation:

      Ezetimibe is a cholesterol-lowering agent that acts to prevent cholesterol absorption by directly inhibiting cholesterol receptors on enterocytes.
      It does not affect the absorption of drugs (e.g. digoxin, thyroxine) or fat-soluble vitamins (A, D and K) as the anion-exchange resins do. It does not affect the cytochrome P450 enzyme system.
      The increased risk of myositis associated with the statins is not seen with ezetimibe.
      The most common adverse effects include headache, runny nose, and sore throat.
      Less common reactions include body aches, back pain, chest pain, diarrhoea, joint pain, fatigue, and weakness.

    • This question is part of the following fields:

      • Pharmacology
      0
      Seconds
  • Question 9 - A 35-year-old woman presents to the Emergency Department with a first episode of...

    Incorrect

    • A 35-year-old woman presents to the Emergency Department with a first episode of generalised tonic-clonic seizure. She is accompanied by her husband, who says she collapsed after coming home from work and suffered 3 minutes of generalised limb jerking, some foaming at the mouth and incontinence of urine.
      Further collateral history revealed that she had been vacant on a number of occasions for a few minutes. This also involved lip-smacking. She describes a feeling of déjà vu and a feeling of anxiety in her abdomen and chest area immediately prior to these episodes. On a number of these occasions, she seemed to lose track of where she was for some minutes.
      Past medical history includes migraines. There is no family history of note. Neurological examination in the clinic is unremarkable.
      Investigations:

      Haemoglobin 145 g/l 135–175 g/l
      White cell count (WCC) 7.2 × 109/l 4–11 × 109/l
      Platelets 190 × 109/l 150–400 × 109/l
      Sodium (Na+) 142 mmol/l 135–145 mmol/l
      Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
      Creatinine 90 µmol/l 50–120 µmol/l
      CT Head Normal
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Temporal lobe epilepsy

      Explanation:

      Differentiating Temporal Lobe Epilepsy from Other Types of Epilepsy

      Temporal lobe epilepsy is a type of partial seizure that can be identified by specific symptoms. These symptoms include déjà vu, epigastric sensation, loss of consciousness, and oral automatisms such as lip-smacking. Patients with a history of febrile convulsions may be at risk for hippocampal sclerosis, a common cause of medial temporal lobe epilepsy. Brain imaging, including specific hippocampal views, should be performed to rule out malignancy and identify any underlying pathology. Patients diagnosed with temporal lobe epilepsy should inform the DVLA and refrain from driving until they have been seizure-free for a year.

      Other types of epilepsy, such as frontal lobe epilepsy, parietal lobe epilepsy, juvenile myoclonic epilepsy, and juvenile absence epilepsy, have different semiologies of partial seizures. However, the symptoms described in the question, including déjà vu and oral automatisms, are most indicative of temporal lobe epilepsy. It is important to differentiate between these types of epilepsy to ensure proper diagnosis and treatment.

    • This question is part of the following fields:

      • Neurology
      0
      Seconds
  • Question 10 - Out of the following, which tumour cells are found in patients with Hodgkin...

    Incorrect

    • Out of the following, which tumour cells are found in patients with Hodgkin disease?

      Your Answer:

      Correct Answer: Reed-Sternberg cells

      Explanation:

      The diagnosis of Hodgkin disease requires the identification of Reed-Sternberg cells in a characteristic cellular background. The normal cell of origin for the Reed-Sternberg cells remains unclear, with the predominance of evidence indicating a B or T lymphocyte.

    • This question is part of the following fields:

      • Haematology & Oncology
      0
      Seconds
  • Question 11 - A 60-year-old man known to have type 2 diabetes comes for regular follow...

    Incorrect

    • A 60-year-old man known to have type 2 diabetes comes for regular follow up. He is on metformin 2 g per day and gliclazide 160 mg per day. His recent HbA1c was 8.4% and his blood pressure was 140/75 mmHg. Eye examination reveals dot and blot haemorrhages and microaneurysms. None are close to the macula. Which of the following defines his eye condition?

      Your Answer:

      Correct Answer: Background diabetic retinopathy

      Explanation:

      Patients with diabetes often develop ophthalmic complications, the most common and potentially most blinding of these complications is diabetic retinopathy.
      The following are the 5 stages in the progression of diabetic retinopathy:
      1. Dilation of the retinal venules and formation of retinal capillary microaneurysms.
      2. Increased vascular permeability.
      3. Vascular occlusion and retinal ischemia.
      4. Proliferation of new blood vessels on the surface of the retina.
      5. Vitreous haemorrhage and contraction of the fibrovascular proliferation.
      The first 2 stages of diabetic retinopathy are known as background or nonproliferative retinopathy. Initially, the retinal venules dilate, then microaneurysms (tiny red dots on the retina that cause no visual impairment) appear. As the microaneurysms or retinal capillaries become more permeable, hard exudates appear, reflecting the leakage of plasma.

      Mild nonproliferative diabetic retinopathy (NPDR) or background diabetic retinopathy is indicated by the presence of at least 1 microaneurysm, while neovascularization is the hallmark of Proliferative Diabetic Retinopathy (PDR).

    • This question is part of the following fields:

      • Endocrinology
      0
      Seconds
  • Question 12 - A 75-year-old man with a history of type 2 diabetes mellitus and alcohol...

    Incorrect

    • A 75-year-old man with a history of type 2 diabetes mellitus and alcohol misuse comes in with a fever and productive cough. He denies any weight loss or coughing up blood. He was born and raised in the United States and has never traveled abroad. He has never been a smoker. During the examination, he has crackles in his left upper lobe but is otherwise stable. A chest X-ray shows consolidation that is cavitating in his left upper lobe. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Klebsiella pneumonia

      Explanation:

      The upper lobe pneumonia caused by Klebsiella is commonly observed in individuals with diabetes and alcoholism, and often results in cavitation. Other possible diagnoses for this patient may include tuberculosis or lung cancer, but these are typically accompanied by weight loss and a history of travel to Eastern Europe or Asia.

      Understanding Klebsiella Pneumoniae

      Klebsiella pneumoniae is a type of bacteria that is commonly found in the gut flora of humans. However, it can also cause various infections such as pneumonia and urinary tract infections. It is more prevalent in individuals who have alcoholism or diabetes. Aspiration is a common cause of pneumonia caused by Klebsiella pneumoniae. One of the distinct features of this type of pneumonia is the production of red-currant jelly sputum. It usually affects the upper lobes of the lungs.

      The prognosis for Klebsiella pneumoniae infections is not good. It often leads to the formation of lung abscesses and empyema, which can be fatal. The mortality rate for this type of infection is between 30-50%.

    • This question is part of the following fields:

      • Respiratory Medicine
      0
      Seconds
  • Question 13 - A 47 year old woman presents with joint pains and a history of...

    Incorrect

    • A 47 year old woman presents with joint pains and a history of recurrent infections over the past few months. Labs reveal a positive rheumatoid factor and low white cell count. Given the likely diagnosis, which of the following features would be present in her case?

      Your Answer:

      Correct Answer: Splenomegaly

      Explanation:

      Felty syndrome is a severe subtype of seropositive Rheumatoid arthritis. Clinical triad consists of arthritis, splenomegaly, and neutropenia (leads to an increased risk of recurrent bacterial infections). Other symptoms include skin ulcers of the lower limbs (indicating vasculitis), hepatomegaly, fever, and chest pain (indicating pleuritis or pericarditis). It is associated with increased risk of developing non-Hodgkin lymphoma.

    • This question is part of the following fields:

      • Rheumatology
      0
      Seconds
  • Question 14 - A 20 year-old female with neuropsychiatric Wilson's disease starts chelation therapy. After one...

    Incorrect

    • A 20 year-old female with neuropsychiatric Wilson's disease starts chelation therapy. After one month, she complains of fatigue, widespread joint pain, and a red rash on her face, neck, shoulders, and arms. What is the most specific test for the suspected diagnosis?

      Your Answer:

      Correct Answer: Anti-histone antibodies

      Explanation:

      Penicillamine chelation therapy can lead to drug-induced lupus, which is characterized by the presence of anti-histone antibodies. This treatment may also cause uncommon side-effects such as membranous glomerulonephritis and a myasthenia-like syndrome. Other medications that can cause drug-induced lupus include procainamide, minocycline, hydralazine, and isoniazid. Limited systemic sclerosis is associated with anti-centromere antibodies, while diffuse systemic sclerosis is linked to anti-Scl70 antibodies. Primary biliary cirrhosis is identified by the presence of anti-mitochondrial antibodies.

      Drug-induced lupus is a condition that differs from systemic lupus erythematosus in that it does not typically involve renal or nervous system complications. This condition can be resolved by discontinuing the medication that caused it. Symptoms of drug-induced lupus include joint and muscle pain, skin rashes (such as a malar rash), and pleurisy. Patients with this condition will test positive for ANA, but negative for dsDNA. Anti-histone antibodies are found in 80-90% of cases, while anti-Ro and anti-Smith are only present in around 5%. The most common causes of drug-induced lupus are procainamide and hydralazine, while less common causes include isoniazid, minocycline, and phenytoin.

    • This question is part of the following fields:

      • Rheumatology
      0
      Seconds
  • Question 15 - A 35-year-old woman presented to the Emergency Department with a 3-day history of...

    Incorrect

    • A 35-year-old woman presented to the Emergency Department with a 3-day history of abdominal pains and bloody diarrhoea. She had returned from Kenya one week ago. During her 5 weeks stay in Kenya, she was asymptomatic.

      On examination, her temperature was 37.8°C. Her abdomen was generally tender to touch but no masses could be felt, and she had active bowel sounds.

      Investigations:
      Haemoglobin (Hb) - 129 g/l (normal values: 135 - 175 g/l)
      White cell count (WCC) - 11.5 × 109/l (normal values: 4.0 - 11.0 × 109/l)
      Platelets (PLT) - 320 × 109/l (normal values: 150 - 400 × 109/l)
      Sodium (Na+) - 138 mmol/l (normal values: 135 - 145 mmol/l)
      Potassium (K+) - 5.2 mmol/l (normal values: 3.5 - 5.0 mmol/l)
      Urea - 7.8 mmol/l (normal values: 2.5 - 6.5 mmol/l)
      Creatinine (Cr) - 75 µmol/l (normal values: 50 - 120 µmol/l)

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Amoebic dysentery

      Explanation:

      Comparison of Different Causes of Diarrhoea in a Returning Traveller

      When a patient presents with diarrhoea after returning from travel, it is important to consider the different possible causes. In this case, the patient’s symptoms and travel history suggest amoebic dysentery as the most likely cause. Ischaemic colitis is unlikely due to the patient’s age and lack of risk factors. Campylobacter enterocolitis typically causes high fever and constitutional upset, which this patient does not have. Giardiasis does not cause bloody diarrhoea, and pseudomembranous colitis is associated with institutionalisation or antibiotic use, neither of which apply to this patient. Therefore, based on the patient’s symptoms and travel history, amoebic dysentery is the most probable diagnosis. Diagnosis can be confirmed through microscopic examination of stool samples or PCR testing.

    • This question is part of the following fields:

      • Infectious Diseases
      0
      Seconds
  • Question 16 - A 75-year-old man visits his doctor to discuss his medication. He reports feeling...

    Incorrect

    • A 75-year-old man visits his doctor to discuss his medication. He reports feeling more fatigued and getting easily tired than before, and he experiences shortness of breath after climbing stairs, which was not a problem until about 4 months ago. He also thinks he has gained a few kilograms of weight, despite having a poor appetite lately. He denies any history of chest pain.

      During the physical examination, the patient's heart rate is 68 beats per minute with a regular rhythm, and his blood pressure is 110/90 mmHg. His extremities are cool, and his carotid pulse is difficult to feel. Upon auscultation of his precordium, the doctor notes an inaudible 2nd heart sound and a crescendo-decrescendo murmur that is loudest at the right upper sternal border and radiates to his neck. The doctor also hears audible crepitations bi-basally, and the patient has 1+ peripheral edema.

      Which of the following management strategies would have the greatest impact on this patient's prognosis?

      Your Answer:

      Correct Answer: Referral to cardiothoracic surgery for aortic valve replacement

      Explanation:

      Patients who exhibit signs and symptoms of heart failure along with severe aortic stenosis should be referred for consideration of aortic valve replacement surgery. This patient has a narrow pulse pressure, an absent 2nd heart sound, and a crescendo-decrescendo murmur that radiates into his neck, all of which suggest severe aortic stenosis. Additionally, he is experiencing fatigue, weight gain, and shortness of breath on exertion, as well as pulmonary and peripheral edema, all of which are indicative of heart failure. Aortic valve replacement surgery has been shown to improve mortality in such cases.

      While loop diuretics such as furosemide can help alleviate fluid overload and improve symptoms, they do not affect prognosis in heart failure patients.

      An echocardiogram would be useful in this case to further evaluate the severity of the aortic stenosis and assess the patient’s ejection fraction. However, it will not impact his prognosis as we already know from the physical examination that he has severe aortic stenosis.

      An ECG and troponin test would be appropriate for patients presenting with symptoms of acute coronary syndrome. However, this patient’s symptoms are more consistent with decompensated congestive heart failure related to severe aortic stenosis. Therefore, aortic valve replacement surgery is the best course of action to improve his prognosis.

      Aortic stenosis is a condition characterized by the narrowing of the aortic valve, which can lead to various symptoms. These symptoms include chest pain, dyspnea, syncope or presyncope, and a distinct ejection systolic murmur that radiates to the carotids. Severe aortic stenosis can cause a narrow pulse pressure, slow rising pulse, delayed ESM, soft/absent S2, S4, thrill, duration of murmur, and left ventricular hypertrophy or failure. The condition can be caused by degenerative calcification, bicuspid aortic valve, William’s syndrome, post-rheumatic disease, or subvalvular HOCM.

      Management of aortic stenosis depends on the severity of the condition and the presence of symptoms. Asymptomatic patients are usually observed, while symptomatic patients require valve replacement. Surgical AVR is the preferred treatment for young, low/medium operative risk patients, while TAVR is used for those with a high operative risk. Balloon valvuloplasty may be used in children without aortic valve calcification and in adults with critical aortic stenosis who are not fit for valve replacement. If the valvular gradient is greater than 40 mmHg and there are features such as left ventricular systolic dysfunction, surgery may be considered even if the patient is asymptomatic.

    • This question is part of the following fields:

      • Cardiology
      0
      Seconds
  • Question 17 - A 50 yr. old smoker with a history of hypertension presented with acute...

    Incorrect

    • A 50 yr. old smoker with a history of hypertension presented with acute severe chest pain and acute myocardial infarction was diagnosed. Which of the following is a contraindication for thrombolysis?

      Your Answer:

      Correct Answer: History of likely ischaemic stroke within the past month

      Explanation:

      Absolute contraindications for fibrinolytic use in STEMI

      Prior intracranial haemorrhage (ICH)
      Known structural cerebral vascular lesion
      Known malignant intracranial neoplasm
      Ischemic stroke within 3 months
      Suspected aortic dissection
      Active bleeding or bleeding diathesis (excluding menses)
      Significant closed head trauma or facial trauma within 3 months
      Intracranial or intraspinal surgery within 2 months
      Severe uncontrolled hypertension (unresponsive to emergency therapy)
      For streptokinase, prior treatment within the previous 6 months

    • This question is part of the following fields:

      • Cardiology
      0
      Seconds
  • Question 18 - A 52 year old shopkeeper presents with pain in her hands. Examination reveals...

    Incorrect

    • A 52 year old shopkeeper presents with pain in her hands. Examination reveals plaques on the extensor surfaces of her upper limbs and a telescoping deformity of both index fingers. Nails show pitting and horizontal ridging. The patient is most likely suffering from which of the following?

      Your Answer:

      Correct Answer: Arthritis mutilans

      Explanation:

      Arthritis mutilans is a rare (occurs in only 5% of the patients) and extremely severe form psoriatic arthritis characterized by resorption of bones and the consequent collapse of soft tissue. When this affects the hands, it can cause a phenomenon sometimes referred to as ‘telescoping fingers.’ The associated nail changes are also characteristic of arthritis.

    • This question is part of the following fields:

      • Rheumatology
      0
      Seconds
  • Question 19 - A 35-year-old woman presents to the clinic with a 4-month history of fatigue...

    Incorrect

    • A 35-year-old woman presents to the clinic with a 4-month history of fatigue and occasional fevers. She reports frequent respiratory infections and has recently been treated for a vaginal yeast infection. Her medical history includes asthma, which is managed with albuterol as needed.
      After running some tests, it is discovered that she is HIV positive. She is started on a HAART regimen consisting of lamivudine, tenofovir, and efavirenz.
      What is the most common adverse effect of lamivudine?

      Your Answer:

      Correct Answer: Bone marrow suppression

      Explanation:

      Lamivudine is a type of medication called a nucleoside reverse transcriptase inhibitor (NRTI) that is used to treat HIV and hepatitis B. While it is generally well-tolerated, there are some potential side-effects to be aware of. One of the most common side-effects of NRTIs in general is bone marrow suppression, which can lead to anaemia, leucopenia, and thrombocytopenia. Lamivudine can also rarely cause peripheral neuropathy, which is a type of nerve damage that can cause tingling or numbness in the hands and feet. Pancreatitis is another rare side-effect of NRTIs, including lamivudine. Renal calculi, or kidney stones, are a side-effect of some HIV medications, but specifically due to the protease inhibitor indinavir rather than NRTIs. Finally, while insulin resistance is not a common side-effect of NRTIs, it can occur with some protease inhibitors. It is important to discuss any potential side-effects with your healthcare provider and report any concerning symptoms.

    • This question is part of the following fields:

      • Infectious Diseases
      0
      Seconds
  • Question 20 - A 67-year-old male presents to the emergency department with a 4-day history of...

    Incorrect

    • A 67-year-old male presents to the emergency department with a 4-day history of haemoptysis, fever, and joint pains. He has a medical history of hypertension and chronic sinusitis, and takes amlodipine. He smokes 10 cigarettes daily and drinks wine 1-2x/week. He recently returned from a trip to Goa.

      On examination, his heart rate is 101 beats per minute, blood pressure is 167/94 mmHg, oxygen saturations are 94%, respiratory rate is 21/minute, and temperature is 37.9ºC. Chest auscultation reveals scattered crackles and decreased air entry at the right base. There is mild tenderness and swelling at the wrists bilaterally. Abdominal examination is normal, and there is no peripheral oedema.

      Urinalysis shows protein +++ and blood +++ but is negative for leucocytes, nitrites, and glucose. Blood tests reveal a low Hb level, elevated creatinine, and a high CRP level. A chest x-ray shows patchy airspace opacification in the lung fields bilaterally.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Granulomatosis with polyangiitis

      Explanation:

      Consider ANCA associated vasculitis if the patient presents with renal impairment, respiratory symptoms, joint pain, and systemic features. In this case, the most likely diagnosis is granulomatosis with polyangiitis due to the patient’s haemoptysis, fever, polyarthralgia, potential glomerulonephritis, acute kidney injury, and pulmonary haemorrhage, with a background of sinusitis.

      Goodpasture’s syndrome is less likely as it typically presents with pulmonary-renal syndrome without joint and sinus involvement.

      Churg-Strauss syndrome is also less likely as the eosinophil count is normal, which essentially rules out this diagnosis. However, it can still cause a pulmonary-renal syndrome.

      ANCA Associated Vasculitis: Types, Symptoms, and Management

      ANCA associated vasculitis is a group of small-vessel vasculitides that are associated with anti-neutrophil cytoplasmic antibodies (ANCA). These include granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome), and microscopic polyangiitis. ANCA associated vasculitis is more common in older individuals and presents with symptoms such as renal impairment, respiratory symptoms, systemic symptoms, vasculitic rash, and ear, nose, and throat symptoms.

      To diagnose ANCA associated vasculitis, first-line investigations include urinalysis for haematuria and proteinuria, blood tests for renal impairment, full blood count, CRP, and ANCA testing. There are two main types of ANCA – cytoplasmic (cANCA) and perinuclear (pANCA) – with cANCA being associated with granulomatosis with polyangiitis and pANCA being associated with eosinophilic granulomatosis with polyangiitis and other conditions.

      Once suspected, ANCA associated vasculitis should be managed by specialist teams to allow an exact diagnosis to be made. The mainstay of management is immunosuppressive therapy. Kidney or lung biopsies may be taken to aid the diagnosis.

    • This question is part of the following fields:

      • Rheumatology
      0
      Seconds
  • Question 21 - A 16-year-old boy visits his GP with complaints of experiencing shortness of breath...

    Incorrect

    • A 16-year-old boy visits his GP with complaints of experiencing shortness of breath during physical activity. His mother accompanies him and reports that his exercise capacity has been gradually decreasing, and he is no longer able to participate in Saturday morning football games. Upon examination, the GP refers the patient to a cardiologist. The cardiologist performs a cardiac catheterization and obtains the following pressure and oxygen saturation data:

      Anatomical site: Oxygen saturation (%), Pressure (mmHg), End systolic/End diastolic
      - Superior vena cava: 74, -
      - Right atrium (mean): 75, 7
      - Right ventricle: 87, 50/12
      - Pulmonary capillary wedge pressure: -, 16
      - Left ventricle: 96, 140/12
      - Aorta: 97, 110/60

      What is the diagnosis?

      Your Answer:

      Correct Answer: Ventricular septal defect

      Explanation:

      The oxygen saturation increases between the RA and RV, indicating an abnormal connection between the two chambers through a VSD, which is supported by elevated right ventricular pressures.

    • This question is part of the following fields:

      • Cardiology
      0
      Seconds
  • Question 22 - A 50-year-old man presents to the Emergency Department with fresh haematemesis. He has...

    Incorrect

    • A 50-year-old man presents to the Emergency Department with fresh haematemesis. He has a history of alcoholic liver disease and was found to have grade 1 oesophageal varices on endoscopy three years ago. His only medication is thiamine. On examination, he is unwell with a blood pressure of 90/50 mmHg and a heart rate of 120 bpm. Investigations reveal a low haemoglobin level, elevated white cell count, and low platelet count. He is actively resuscitated with fluids and blood products while awaiting urgent upper gastrointestinal endoscopy. During endoscopy, band ligation is performed to control the bleeding, but it is unsuccessful. What is the next best therapeutic option to control this patient's acute variceal bleed?

      Your Answer:

      Correct Answer: Transjugular intrahepatic portosystemic shunt (TIPS)

      Explanation:

      Treatment options for acute variceal bleeding

      Acute variceal bleeding is a serious complication of liver cirrhosis that requires prompt treatment. The most effective approach is a combination of banding and terlipressin, which has been shown to control bleeding, reduce rebleeding rates, and minimize early complications. If banding fails to control bleeding, a transjugular intrahepatic portosystemic shunt procedure may be considered as an alternative option.

      Non-selective beta-blockers and nitrates are useful in reducing portal pressure and the risk of rebleeding, but they are not recommended in the acute setting due to the risk of hypotension. Sclerotherapy is another option, but it has marginally less favorable outcomes compared to banding.

      Balloon tamponade can be used acutely to control catastrophic hemorrhage, but it is less effective than banding as it does not directly target varices.

      It is important to continue variceal banding until the bleeding ceases. If banding fails to control bleeding, a transjugular intrahepatic portosystemic shunt procedure should be considered. Variceal sclerotherapy is an alternative option, but banding is preferred as it achieves a resolution of large varices in fewer treatment sessions.

    • This question is part of the following fields:

      • Gastroenterology And Hepatology
      0
      Seconds
  • Question 23 - A 28 year old woman presents with painful genital ulceration. She reports that...

    Incorrect

    • A 28 year old woman presents with painful genital ulceration. She reports that these attacks have been recurrent over the past 4 years. She has been treated previously with oral acyclovir but this has had little effect on the duration of her symptoms. Over the past year, she has noticed almost weekly attacks of mouth ulcers that heal slowly. Past medical history is significant for treatment of thrombophlebitis two years ago. Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Behcet's syndrome

      Explanation:

      Behçet disease is a rare vasculitic disorder that is characterized by a triple-symptom complex of recurrent oral aphthous ulcers, genital ulcers, and uveitis. The systemic manifestations can be variable. Ocular disease has the greatest morbidity, followed by vascular disease generally from active vasculitis. Cutaneous manifestations can occur in up 75% of patients with Behcet disease and can range from acneiform lesions, to nodules and erythema nodosum. GI manifestations can be severe. Differentiating Behçet disease from active inflammatory bowel disease can be clinically difficult. Herpes would have ideally responded to acyclovir. Sarcoidosis does not have genital and oral ulcerations.

    • This question is part of the following fields:

      • Rheumatology
      0
      Seconds
  • Question 24 - A 54-year-old woman presents to her GP with concerns from her carer about...

    Incorrect

    • A 54-year-old woman presents to her GP with concerns from her carer about her increasingly prominent gums over the past few months. The patient has learning difficulties and lives in a care home. She has had three recent infections and has been experiencing fatigue and shortness of breath with minimal activity. On examination, she has hypertrophic bleeding gums, anaemia, multiple bruises, a flow murmur, and mild splenomegaly. Blood tests reveal a raised white cell count, low neutrophil count, thrombocytopenia, and increased blast cells with Auer rods. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Acute myeloid leukaemia (AML)

      Explanation:

      Acute myeloid leukemia (AML) is a type of cancer that affects the bone marrow and causes abnormal growth of blast cells derived from myeloid marrow elements. It is identified by the presence of more than 20% blasts in the blood and/or bone marrow. AML is more common in men and increases with age, but can affect people of all ages. Symptoms include anemia, infections, bleeding, bone pain, hepatosplenomegaly, gum hypertrophy, weakness, fever, and lethargy. Auer rods, which are eosinophilic needle-like cytoplasmic inclusions found in blast cells, are pathognomonic of AML and differentiate it from acute lymphoblastic leukemia (ALL). Chronic myeloid leukemia (CML) is a myeloproliferative disorder characterized by the proliferation of white blood cell precursors that retain the ability to differentiate. Chronic lymphoid leukemia (CLL) is identified by lymphocytosis in the peripheral blood and bone marrow. Chronic myelomonocytic leukemia (CMML) is characterized by a progressive cytopenia in the presence of a hypercellular bone marrow and usually involves all three cell lines.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds
  • Question 25 - A 16-year-old male from India presents with a 10-hour history of priapism. He...

    Incorrect

    • A 16-year-old male from India presents with a 10-hour history of priapism. He has a medical history of intermittent back and abdominal pain. During examination, he appears pale and has a fever of 39°C. He also has an enlarged smooth liver and a painful engorged penis. Laboratory tests reveal a haemoglobin level of 85 g/L (130-180), MCV of 81 fL (80-96), white cell count of 12.2 ×109/L (4-11), and platelets of 450 ×109/L (150-400). What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Sickle cell anaemia

      Explanation:

      Priapism and its Causes

      Priapism is a medical condition that is often caused by the thrombosis of the prostatic venous plexus, although it can also be caused by other factors such as leukaemia, sickle-cell anaemia, and carcinomatosis. Sickle-cell anaemia is most commonly found in African blacks, as well as in people from Mediterranean, Middle-Eastern, and Indian backgrounds. This condition can cause occlusive sickling crisis, which may initially present as pain in the back, abdomen, or long bones.

      Priapism is a common occurrence in individuals with this condition, and if left untreated, it can lead to permanent impotence. While an elevated white blood cell count may be present in individuals with priapism, it is typically a reflection of the body’s stress response rather than a sign of a more serious underlying condition.

    • This question is part of the following fields:

      • Haematology
      0
      Seconds
  • Question 26 - A number of tests have been ordered for a 49 year old male...

    Incorrect

    • A number of tests have been ordered for a 49 year old male who has systemic lupus erythematosus (SLE). He was referred to the clinic because he has increased shortness of breath. One test in particular is transfer factor of the lung for carbon monoxide (TLCO), which is elevated. Which respiratory complication of SLE is associated with this finding?

      Your Answer:

      Correct Answer: Alveolar haemorrhage

      Explanation:

      Alveolar haemorrhage (AH) is a rare, but serious manifestation of SLE. It may occur early or late in disease evolution. Extrapulmonary disease may be minimal and may be masked in patients who are already receiving immunosuppressants for other symptoms of SLE.

      DLCO or TLCO (diffusing capacity or transfer factor of the lung for carbon monoxide (CO)) is the extent to which oxygen passes from the air sacs of the lungs into the blood.
      Factors that can increase the DLCO include polycythaemia, asthma (can also have normal DLCO) and increased pulmonary blood volume as occurs in exercise. Other factors are left to right intracardiac shunting, mild left heart failure (increased blood volume) and alveolar haemorrhage (increased blood available for which CO does not have to cross a barrier to enter).

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 27 - A 24 year old male, known case of hereditary angioneurotic oedema presents with...

    Incorrect

    • A 24 year old male, known case of hereditary angioneurotic oedema presents with recurrent fever and arthralgia which is accompanied by a rash on face and upper chest. These attacks have been refractory to treatment and have occurred recurrently requiring adrenaline on several occasions. Lab results reveal persistently reduced C4 levels. Which of the following is most likely causing his current symptoms?

      Your Answer:

      Correct Answer: Systemic lupus erythematosus

      Explanation:

      Angioedema secondary to C1 inhibitor deficiency has been rarely reported to be associated with systemic lupus erythematosus. A genetic defect of C1 inhibitor produces hereditary angioedema, which is usually presented with cutaneous painless oedema, but oedema of the genital area, gastrointestinal and laryngeal tracts have also been reported. In lupus patients, angioedema may be the result of an acquired type of C1 inhibitor deficiency, most probably due to antibody formation directed against the C1 inhibitor molecule.

    • This question is part of the following fields:

      • Rheumatology
      0
      Seconds
  • Question 28 - A 49-year-old woman visits her GP complaining of hot flushes and night sweats...

    Incorrect

    • A 49-year-old woman visits her GP complaining of hot flushes and night sweats for the past few weeks. She also mentions difficulty concentrating and disturbed sleep at night. Her husband reports mood swings. On examination, her blood pressure is 122/78 mmHg, heart rate is 78 bpm, and BMI is 23 kg/m2. Abdominal examination is normal. She is prescribed hormone replacement therapy and asks about its benefits. What is associated with hormone replacement therapy?

      Your Answer:

      Correct Answer: Decreases the risk of colorectal cancer

      Explanation:

      Effects of Hormone Replacement Therapy on Health

      Hormone replacement therapy (HRT) has various effects on health. One of the benefits of HRT is a decreased risk of colorectal cancer in women. However, if colorectal tumors do occur, they are found at a more advanced stage. The mechanism behind this alteration in the pathophysiology of colorectal cancer remains unknown. HRT also decreases the risk of osteoporosis and fractures, with a 33% decreased risk for hip fracture. On the other hand, HRT increases the risk of cholecystitis, with a 57% increased risk. For every 185 patients treated with HRT, it is estimated that one extra patient will require a cholecystectomy. However, HRT decreases the risk of type II diabetes mellitus by up to 19%, possibly due to a reduction in insulin resistance. There is no consistent, statistically significant evidence of changes to the risk of dementia in patients taking HRT.

    • This question is part of the following fields:

      • Endocrinology, Diabetes And Metabolic Medicine
      0
      Seconds
  • Question 29 - A 38-year-old woman presents with rapidly worsening lower limb edema. She complains of...

    Incorrect

    • A 38-year-old woman presents with rapidly worsening lower limb edema. She complains of dull left loin pain. She has a history of two previous deep vein thromboses, one which occurred after a long plane flight, and the other in her first pregnancy. Her only regular medication is the progesterone only pill.

      On examination, her BP is 150/90 mmHg, her pulse is 72 and regular. You confirm that she has dull left loin pain and bilateral pitting edema affecting both legs.

      Investigations show:

      Haemoglobin 122 g/L (115-165)

      White cell count 8.8 ×109/L (4-11)

      Platelets 210 ×109/L (150-400)

      Serum sodium 141 mmol/L (135-146)

      Serum potassium 5.2 mmol/L (3.5-5)

      Creatinine 202 µmol/L (79-118)

      Renal ultrasound Bilateral normal sized kidneys

      Urine Protein ++

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Renal vein thrombosis

      Explanation:

      Renal Vein Thrombosis: A Silent Condition with Pertinent Clues

      Renal vein thrombosis is a condition that often goes unnoticed, but it can have serious consequences. This condition is associated with a hypercoagulable state, peripheral leg edema, and flank pain in patients presenting with acute kidney injury. The patient’s history of two previous deep vein thromboses raises the possibility of a coagulation disorder, despite the fact that the events were linked to medical states that may predispose to DVT.

      Patients with renal vein thrombosis usually experience rapidly worsening peripheral leg edema and may report dull loin pain from the affected kidney. It is important to screen patients with this condition for inherited and acquired disorders of coagulation and anticoagulation. Lifelong warfarinization may be necessary to manage this condition effectively. Therefore, early diagnosis and prompt treatment are crucial to prevent further complications.

    • This question is part of the following fields:

      • Renal Medicine
      0
      Seconds
  • Question 30 - A 67-year-old woman visits a geriatric clinic due to frequent falls at home....

    Incorrect

    • A 67-year-old woman visits a geriatric clinic due to frequent falls at home. She has never been to the clinic before. Two weeks ago, she had a CT scan of her head, cervical spine, and right hip, which showed no acute injury. However, she has been experiencing worsening pain in her right hip for the past year, especially during activity and in the evenings. On examination, she is tender to deep palpation and experiences painful internal and external rotation. She reports being otherwise healthy, with a medical history of obesity and type 2 diabetes mellitus. Her general practitioner has advised her to lose weight.

      What is the most appropriate additional advice for managing her hip pain?

      Your Answer:

      Correct Answer: Muscle strengthening exercises and aerobic fitness

      Explanation:

      Local muscle strengthening exercises and improving general aerobic fitness are crucial for managing knee and hip osteoarthritis. In the case of this woman with chronic hip pain, acute injury is unlikely based on recent negative imaging. Therefore, as per the latest NICE guidance, she should be offered weight loss assistance and advised on local muscle strengthening exercises and general aerobic fitness. While elevating limbs can reduce acute swelling in acute injuries, it will not benefit this woman’s osteoarthritis. Similarly, reducing alcohol intake is a preventative measure for gout and not effective in this case. While regular rest throughout the day may provide temporary relief, it will not result in lasting improvement and may be debilitating.

      The Role of Glucosamine in Osteoarthritis Management

      Glucosamine is a natural component found in cartilage and synovial fluid. Several double-blind randomized controlled trials have reported significant short-term symptomatic benefits of glucosamine in knee osteoarthritis, including reduced joint space narrowing and improved pain scores. However, more recent studies have produced mixed results. The 2008 NICE guidelines do not recommend the use of glucosamine, and a Drug and Therapeutics Bulletin review advised against prescribing it on the NHS due to limited evidence of cost-effectiveness. Despite this, some patients may still choose to use glucosamine as a complementary therapy for osteoarthritis management. It is important for healthcare professionals to discuss the potential benefits and risks of glucosamine with their patients and to consider individual patient preferences and circumstances.

    • This question is part of the following fields:

      • Rheumatology
      0
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Infectious Diseases (0/1) 0%
Passmed