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  • Question 1 - A 50-year-old man presents to the emergency department with an acutely swollen and...

    Correct

    • A 50-year-old man presents to the emergency department with an acutely swollen and tender abdomen. He reports that it has been happening over the past few days. The patient appears unkempt and denies any significant medical history, medications, or drug use. He admits to drinking but is unsure of the amount. Upon examination, his abdomen is distended with shifting dullness, he has approximately 10 blanching red spots on his upper chest, and has tortuous dilated veins on his abdomen. The following are his vital signs:

      Temperature: 36.4ºC
      Blood pressure: 134/87 mmHg
      Heart rate: 94 beats/min
      Respiratory rate: 12 breaths/min
      Oxygen saturation: 98% on room air

      What is the most appropriate medication to initiate in this scenario, given the probable diagnosis?

      Your Answer: Spironolactone

      Explanation:

      Patients who have ascites due to liver cirrhosis should receive an aldosterone antagonist, such as spironolactone, as it helps to counteract the secondary hyperaldosteronism that occurs in cirrhosis. This condition attempts to increase intravascular volume, which is lost into the abdomen as ascites. Amiloride is not effective in treating ascites as it does not lead to significant diuresis and has no effect on the aldosterone pathway. Eplerenone is an alternative to spironolactone for patients who cannot tolerate its adverse effects. Furosemide is useful in treating ascites but should be used in conjunction with spironolactone due to the additional benefits of aldosterone blocking. Bendroflumethiazide is not useful in managing or preventing fluid overload conditions such as ascites.

      Understanding Ascites: Causes and Management

      Ascites is a medical condition characterized by the accumulation of abnormal fluid in the abdomen. The causes of ascites can be classified into two groups based on the serum-ascites albumin gradient (SAAG) level. A SAAG level greater than 11g/L indicates portal hypertension, which is commonly caused by liver disorders such as cirrhosis, alcoholic liver disease, and liver metastases. On the other hand, a SAAG level less than 11g/L is caused by hypoalbuminaemia, malignancy, infections, and other factors such as bowel obstruction and biliary ascites.

      The management of ascites involves reducing dietary sodium and fluid restriction, especially if the sodium level is less than 125 mmol/L. Aldosterone antagonists like spironolactone and loop diuretics are often prescribed to patients. In some cases, drainage through therapeutic abdominal paracentesis is necessary. Large-volume paracentesis requires albumin cover to reduce the risk of paracentesis-induced circulatory dysfunction and mortality. Prophylactic antibiotics are also recommended to prevent spontaneous bacterial peritonitis. In severe cases, a transjugular intrahepatic portosystemic shunt (TIPS) may be considered.

      Understanding the causes and management of ascites is crucial in providing appropriate medical care to patients. Proper diagnosis and treatment can help alleviate symptoms and improve the patient’s quality of life.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      72.8
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  • Question 2 - An 18-year-old girl is referred to the Endocrine Clinic with primary amenorrhoea. On...

    Incorrect

    • An 18-year-old girl is referred to the Endocrine Clinic with primary amenorrhoea. On examination, her height and weight are normal. She has moderate hirsutism and acne, small breast buds and an enlarged clitoris. Bimanual pelvic examination is normal. A male cousin was seen in the clinic at the age of nine years with precocious puberty.
      Which is the most likely cause of her primary amenorrhoea?

      Your Answer: Imperforate hymen

      Correct Answer: Congenital adrenal hyperplasia

      Explanation:

      Congenital adrenal hyperplasia is a genetic disorder that affects cortisol production, leading to an increase in adrenocorticotrophic hormone and enlargement of the adrenal glands. There are different types, with classic/severe presenting at birth with ambiguous genitalia or in an acute salt-losing crisis, and milder forms causing hyperandrogenism. The patient and her cousin are likely to have the milder form. Imperforate hymen, hyperprolactinaemia, and Sheehan syndrome are unlikely causes of the patient’s primary amenorrhoea, while Turner syndrome is ruled out due to the absence of characteristic features.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      1
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  • Question 3 - A 32-year-old woman presents to the Emergency Department with complaints of a headache....

    Correct

    • A 32-year-old woman presents to the Emergency Department with complaints of a headache. She has been experiencing flu-like symptoms for the past three days and the headache started gradually yesterday. The headache is described as being all over and worsens when looking at bright light or bending her neck. Upon examination, her temperature is 38.2º, pulse is 96/min, and blood pressure is 116/78 mmHg. There is neck stiffness present, but no focal neurological signs are observed. During a closer inspection, several petechiae are noticed on her torso. The patient has been cannulated and bloods, including cultures, have been taken. What is the most appropriate next step?

      Your Answer: IV cefotaxime

      Explanation:

      Immediate administration of appropriate intravenous antibiotics is crucial for this patient diagnosed with meningococcal meningitis. In light of modern PCR diagnostic techniques, there is no need to delay potentially life-saving treatment by conducting a lumbar puncture in suspected cases of meningococcal meningitis.

      The investigation and management of suspected bacterial meningitis are intertwined due to the potential negative impact of delayed antibiotic treatment. Patients should be urgently transferred to the hospital, and an ABC approach should be taken initially. A lumbar puncture should be delayed in certain circumstances, and IV antibiotics should be given as a priority if there is any doubt. The bloods and CSF should be tested for various parameters, and prophylaxis should be offered to households and close contacts of patients affected with meningococcal meningitis.

    • This question is part of the following fields:

      • Infectious Diseases
      43.6
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  • Question 4 - A 30-year-old woman presents with a productive cough, weight loss, and night sweats,...

    Correct

    • A 30-year-old woman presents with a productive cough, weight loss, and night sweats, four months after returning from India. She is diagnosed with pulmonary tuberculosis and started on appropriate antibiotics. However, six weeks into her treatment, she experiences numbness and tingling in her distal extremities, a known side effect of isoniazid. What medication should have been prescribed alongside her antibiotic regimen to minimize this side effect?

      Your Answer: Pyridoxine

      Explanation:

      To treat active tuberculosis, isoniazid is often prescribed alongside other antibiotics such as rifampicin, ethambutol, or pyrazinamide. However, it is important to note that isoniazid alone does not protect against peripheral neuropathy, a potential side effect of tuberculosis treatment.

      Rifampicin is an antibiotic that can increase the rate of B6 excretion, which may lead to a deficiency in some individuals.

      Ethambutol is another antibiotic used to treat tuberculosis, but it can cause a loss of visual acuity and color blindness.

      Prednisolone is typically only prescribed for meningeal or pericardial tuberculosis and can cause side effects such as mood changes, weight gain, and immunosuppression.

      Pyrazinamide is another antibiotic used to treat tuberculosis, but it can cause liver toxicity.

      Side-Effects and Mechanism of Action of Tuberculosis Drugs

      Rifampicin is a drug that inhibits bacterial DNA dependent RNA polymerase, which prevents the transcription of DNA into mRNA. However, it is a potent liver enzyme inducer and can cause hepatitis, orange secretions, and flu-like symptoms.

      Isoniazid, on the other hand, inhibits mycolic acid synthesis. It can cause peripheral neuropathy, which can be prevented with pyridoxine (Vitamin B6). It can also cause hepatitis and agranulocytosis. Additionally, it is a liver enzyme inhibitor.

      Pyrazinamide is converted by pyrazinamidase into pyrazinoic acid, which in turn inhibits fatty acid synthase (FAS) I. However, it can cause hyperuricaemia, leading to gout, as well as arthralgia, myalgia, and hepatitis.

      Lastly, Ethambutol inhibits the enzyme arabinosyl transferase, which polymerizes arabinose into arabinan. It can cause optic neuritis, so it is important to check visual acuity before and during treatment. Additionally, the dose needs adjusting in patients with renal impairment.

      In summary, these tuberculosis drugs have different mechanisms of action and can cause various side-effects. It is important to monitor patients closely and adjust treatment accordingly to ensure the best possible outcomes.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      26.7
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  • Question 5 - A 56-year-old man has just been diagnosed with type 2 diabetes after a...

    Correct

    • A 56-year-old man has just been diagnosed with type 2 diabetes after a routine blood test. He has a history of myocardial infarction and chronic left ventricular systolic dysfunction. The patient is started on metformin and titrated to the maximum tolerated dose. The following are the results of his blood tests:
      - Na+ 138 mmol/L (135 - 145)
      - K+ 3.9 mmol/L (3.5 - 5.0)
      - Urea 4.0 mmol/L (2.0 - 7.0)
      - Creatinine 75 µmol/L (55 - 120)
      - eGFR >90 mL/min (>90)
      - Hba1c 62 mmol/mol (7.8%) (20-41)

      What is the most appropriate medication to initiate for this patient?

      Your Answer: Empagliflozin

      Explanation:

      For this patient with type 2 diabetes mellitus (T2DM) and cardiac comorbidity, the most appropriate medication would be an SGLT-2 inhibitor. This is especially true for patients with established cardiovascular disease (CVD) or those under 40 with one or more cardiovascular risk factors. Studies have shown that SGLT-2 inhibitors have a cardioprotective effect, with the greatest benefit seen in those with CVD. Additionally, these medications have been associated with reduced hospital admissions and mortality in patients with heart failure.

      Gliclazide is not the best option for this patient as there is no evidence that it would have a beneficial effect on their cardiac comorbidity, unlike SGLT-2 inhibitors. While gliclazide is effective at lowering HbA1c, it can cause weight gain. In some cases, gliclazide may be used as rescue therapy for patients with T2DM who have very poor glycemic control and are symptomatic, but this is not the case for this patient.

      Insulin is not necessary at this stage, as there are many other medications available to optimize glycemic control before insulin should be considered. In some cases, insulin may be used as short-term rescue therapy for patients with T2DM who have very poor glycemic control and are symptomatic, but this is not the case for this patient.

      Pioglitazone is not a suitable option for this patient, as it is contraindicated in patients with heart failure due to its potential to worsen fluid retention and edema. Additionally, pioglitazone is associated with an increased risk of fractures. However, pioglitazone does have benefits such as safety in renal impairment and a low risk of hypoglycemia.

      NICE updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022, reflecting advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. The first-line drug of choice remains metformin, which should be titrated up slowly to minimize gastrointestinal upset. HbA1c targets should be agreed upon with patients and checked every 3-6 months until stable, with consideration for relaxing targets on a case-by-case basis. Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates and controlling intake of foods containing saturated fats and trans fatty acids. Blood pressure targets are the same as for patients without type 2 diabetes, and antiplatelets should not be offered unless a patient has existing cardiovascular disease. Only patients with a 10-year cardiovascular risk > 10% should be offered a statin, with atorvastatin 20mg as the first-line choice.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      46.9
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  • Question 6 - As a physician on an elderly care ward, you are tasked with conducting...

    Correct

    • As a physician on an elderly care ward, you are tasked with conducting a cognitive assessment of Harold, an 82-year-old man who is suspected of having dementia. After administering the Addenbrooke's Cognitive Exam-3 (ACE-3), Harold scores 68 out of 100 with a global deficit in all domains tested. Based on this information, what condition do you suspect Harold may have?

      Your Answer: Alzheimer's dementia

      Explanation:

      The Addenbrookes Cognitive Exam (ACE-3) is a reliable tool for detecting dementia, with a score of 82 or less indicating a strong likelihood of dementia. The exam assesses five domains: Memory, Attention, Fluency, Language, and Visuospatial. Alzheimer’s dementia typically results in a global deficit across all domains, with later deficits in memory and attention due to damage in the medial temporal lobe. Frontotemporal dementia primarily affects fluency and language due to damage in the frontal lobe. Vascular dementia deficits vary depending on the location and severity of previous strokes, and there is no consistent pattern seen in ACE-3 examinations. Mild cognitive impairment (MCI) is a precursor to many forms of dementia, with an ACE-3 score of 82-88 indicating MCI. In this scenario, the patient’s score of 68 rules out MCI as a diagnosis.

      Alzheimer’s disease is a type of dementia that gradually worsens over time and is the most common form of dementia in the UK. The risk factors for Alzheimer’s disease include increasing age, family history of the disease, and certain genetic mutations. Inherited forms of the disease are caused by mutations in the amyloid precursor protein, presenilin 1, and presenilin 2 genes. Additionally, the apoprotein E allele E4 and Caucasian ethnicity are also risk factors for Alzheimer’s disease.

      The pathological changes associated with Alzheimer’s disease include widespread cerebral atrophy, particularly in the cortex and hippocampus. Microscopically, cortical plaques and intraneuronal neurofibrillary tangles are present due to the deposition of type A-Beta-amyloid protein and abnormal aggregation of the tau protein. The hyperphosphorylation of the tau protein has been linked to Alzheimer’s disease. Furthermore, there is a deficit of acetylcholine due to damage to an ascending forebrain projection.

      Neurofibrillary tangles are partly made from a protein called tau, which interacts with tubulin to stabilize microtubules and promote tubulin assembly into microtubules. In Alzheimer’s disease, tau proteins are excessively phosphorylated, impairing their function.

    • This question is part of the following fields:

      • Neurology
      26.3
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  • Question 7 - A 45-year-old woman with a 30-pack-year history of smoking visits her General Practitioner...

    Incorrect

    • A 45-year-old woman with a 30-pack-year history of smoking visits her General Practitioner with complaints of dark urine, nausea and overall weakness. She reports experiencing a seizure and was admitted to the hospital where she was diagnosed with a 'hormone tumor'. What is the most probable diagnosis?

      Your Answer: Bronchial carcinoid tumour

      Correct Answer: Small-cell carcinoma of the lung (SCLC)

      Explanation:

      Small-cell carcinoma of the lung (SCLC) is a type of lung cancer that is often associated with a condition called syndrome of inappropriate antidiuretic hormone syndrome (SIADH). SIADH is caused by the abnormal release of anti-diuretic hormone (ADH), which leads to impaired water excretion and hyponatremia. This can result in symptoms such as nausea, weakness, confusion, and seizures. While SCLC is the most common cause of SIADH, it can also be caused by other types of cancer, certain drugs, intracranial lesions, and infections. Squamous-cell carcinoma (SCC) of the lung, on the other hand, does not typically result in SIADH as it does not originate from neuroendocrine cells. Pancreatic cancer can also cause SIADH, but it is less common than in SCLC. Prostate cancer, which is the second most common cancer globally, does not usually present with hormonal effects but rather with lower urinary tract symptoms. Bronchial carcinoid tumors, which are neuroendocrine tumors of the lung, can cause hormonal effects such as weight gain, high blood pressure, and hirsutism, but these symptoms are not indicated in the scenario given.

    • This question is part of the following fields:

      • Haematology/Oncology
      43.5
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  • Question 8 - A 52-year-old woman presents to her general practitioner (GP) with symptoms of a...

    Correct

    • A 52-year-old woman presents to her general practitioner (GP) with symptoms of a urinary tract infection. There is a history of multiple attendances and a previous neurology referral for migraine. She admits to taking multiple painkillers for her headaches. Blood pressure is 160/90 mmHg. Urinalysis reveals haematuria, and the GP commences her on a 2-week course of nitrofurantoin. She returns, still complaining of symptoms, at which point the presence of a normochromic normocytic anaemia is noted, along with a serum creatinine level of 230 μmol/l (reference range 44–97 μmol/l).
      What diagnosis fits best with this clinical picture?

      Your Answer: Analgesic nephropathy

      Explanation:

      Possible Diagnosis for a Patient with Excessive Analgesic Consumption

      Excessive consumption of analgesic medications such as aspirin and paracetamol can lead to kidney injury, a condition known as analgesic nephropathy. This is caused by decreased blood flow to the kidney, rapid consumption of antioxidants, and subsequent oxidative damage to the kidney, resulting in renal papillary necrosis and chronic interstitial nephritis. The kidney injury may lead to progressive chronic kidney disease, abnormal urinalysis results, hypertension, and normochromic normocytic anaemia.

      Other possible diagnoses for renal damage include reflux nephropathy, acute nephritis, renal failure secondary to sepsis, and hypertensive renal disease. Reflux nephropathy is characterized by renal damage due to the backflow of urine from the bladder towards the kidneys, while acute nephritis is caused by infections or drug-associated hypersensitivity. Renal failure secondary to sepsis is associated with systemic inflammatory response syndrome, and hypertensive renal disease is defined by the coexistence of renal arterial vascular disease and hypertension.

      In the given clinical scenario, the most likely diagnosis is analgesic nephropathy due to the patient’s history of excessive analgesic consumption. However, other diagnoses cannot be ruled out without further evaluation.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      31.7
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  • Question 9 - A 27-year-old woman presents with new-onset diabetes. She has no past drug or...

    Incorrect

    • A 27-year-old woman presents with new-onset diabetes. She has no past drug or treatment history. Her fasting blood glucose is 7.3 mmol/l. Other significant medical history included occasional diarrhoea in the last four months, for which she took repeated courses of tinidazole. She also had an episode of severe leg pain three months ago, for which she takes warfarin. She is presently very depressed, as her sister has had renal calculus surgery, which has not gone well; she is in the Intensive Care Unit (ICU) with sepsis.
      What is the most appropriate next test?

      Your Answer: C-peptide assay

      Correct Answer: Genetic study

      Explanation:

      Diagnostic Tests for Various Medical Conditions

      Multiple Endocrine Neoplasia (MEN) 1 Syndrome: A genetic study to detect MEN 1 gene mutation on chromosome 11 is the best diagnostic test for patients with new-onset diabetes, diarrhea, and a past episode of deep vein thrombosis (DVT) who have a family history of renal calculi at a young age. This autosomal dominant disease is characterized by endocrine hyperfunction in various glands, with the parathyroid gland being the most common gland affected. Enteropancreatic tumors are the second most common, with gastrinoma and insulinoma being the two most common tumors. Glucagonoma can also occur, but rarely. Plasma glucagon and ghrelin levels are elevated in these cases.

      Giardiasis: A blood test for Giardia antigen is recommended for patients with watery, sometimes foul-smelling, diarrhea that may alternate with soft, greasy stools, fatigue or malaise, abdominal cramps and bloating, gas or flatulence, nausea, and weight loss. Tinidazole should have eliminated Giardia, but if symptoms persist, a blood test for Giardia antigen can confirm the diagnosis.

      Diabetes: A C-peptide assay can help distinguish type I diabetes from type II diabetes or maturity-onset diabetes of the young (MODY) by measuring how much of their own natural insulin a person is producing. This is useful if a patient receives insulin injections. The C-peptide assay will help clarify the cause of diabetes, but it will not help in detecting the underlying disease.

      Colonoscopy: Colonoscopy is not needed for the occasional diarrhea at present.

      Deep Vein Thrombosis (DVT): Protein C measurement will not help in the diagnosis of DVT. DVT occurs as a rare complication of glucagonoma, and treatment for glucagonoma includes octreotide, surgery, and streptozotocin (rarely).

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      68.8
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  • Question 10 - A 3-day-old infant is presented to the Emergency Department due to increased irritability,...

    Incorrect

    • A 3-day-old infant is presented to the Emergency Department due to increased irritability, poor feeding, and decreased muscle tone as observed by the mother in the last 24 hours. Meningitis is confirmed through lumbar puncture. What is the probable causative agent in this scenario?

      Your Answer: Streptococcus pneumoniae

      Correct Answer: Group B streptococcus

      Explanation:

      Meningitis poses a higher risk to neonates, particularly those with low birth weight, prematurity, traumatic delivery, fetal hypoxia, and maternal peripartum infection. The initial symptoms are usually vague and may include elevated body temperature, respiratory distress, apnea, episodes of bradycardia, low blood pressure, difficulty feeding, irritability, and decreased activity.

      Organisms causing meningitis in children

      Meningitis is a serious condition that can affect children of all ages. The organisms that cause meningitis vary depending on the age of the child. In neonates up to 3 months old, Group B Streptococcus is the most common cause, which is usually acquired from the mother during birth. E. coli and other Gram-negative organisms, as well as Listeria monocytogenes, can also cause meningitis in this age group.

      From 1 month to 6 years old, Neisseria meningitidis (meningococcus), Streptococcus pneumoniae (pneumococcus), and Haemophilus influenzae are the most common organisms that cause meningitis. In children over 6 years old, Neisseria meningitidis and Streptococcus pneumoniae are the most common causes.

      It is important for parents to be aware of the signs and symptoms of meningitis, such as fever, headache, stiff neck, and sensitivity to light. If a child is showing these symptoms, they should be taken to a doctor immediately for evaluation and treatment. Early diagnosis and treatment can help prevent serious complications and improve outcomes.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 11 - A characteristic clinical finding of opioid overdose is: ...

    Incorrect

    • A characteristic clinical finding of opioid overdose is:

      Your Answer: Hypothermia

      Correct Answer: Bradycardia

      Explanation:

      Understanding the Symptoms of Opioid Overdose: The Opioid Overdose Triad

      Opioid overdose is a serious and potentially life-threatening condition that can result from the misuse or abuse of opioids. It is important to recognize the symptoms of opioid overdose in order to provide prompt and effective treatment. The opioid overdose triad is a set of three hallmark symptoms that are commonly seen in opioid overdose: decreased level of consciousness, pinpoint pupils, and respiratory depression.

      Bradycardia, or a slow heart rate, is a common side effect of opioid overdose. However, hypothermia is not typically seen in opioid overdose and is more commonly associated with barbiturate overdose. Tachypnoea, or rapid respiration, is not a symptom of opioid overdose; instead, respiratory depression, or slow and shallow breathing, is a key feature. Prolonged hypoxia from respiratory depression can lead to permanent damage to the central nervous system or even death, even if treatment with naloxone is given. It is important to note that alcohol can also cause respiratory depression and increase the risk of overdose when taken with opioids.

      Sweating and lacrimation, or excessive sweating and tearing, are frequently seen in early opioid withdrawal but are not symptoms of overdose. Pupillary constriction, or pinpoint pupils, is a hallmark feature of opioid overdose, while pupillary dilatation is not.

      Recognizing the symptoms of opioid overdose, including the opioid overdose triad, is crucial for prompt and effective treatment. If you suspect someone is experiencing an opioid overdose, call for emergency medical assistance immediately.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 12 - A 82-year-old man and his daughter visit you for a medication review. The...

    Correct

    • A 82-year-old man and his daughter visit you for a medication review. The patient has been experiencing memory loss and was diagnosed with Alzheimer's dementia at a memory clinic three months ago. He also has a medical history of osteoporosis, ischaemic heart disease, and atrial fibrillation. Considering his dementia, which medication should you contemplate discontinuing?

      Your Answer: Amitriptyline

      Explanation:

      Dementia has several causes, most of which are irreversible and progressive. Although medications can slow down the progression, healthcare providers must ensure that their patients are not taking drugs that could exacerbate the condition. The STOPP-START Criteria (Gallagher et al., 2008) provides guidelines for withdrawing medications that may be harmful to the elderly. For instance, tricyclic antidepressants should not be prescribed to patients with dementia as they can worsen cognitive impairment.

      Understanding Dementia: Features and Management

      Dementia is a condition that affects a significant number of people in the UK, with Alzheimer’s disease being the most common cause followed by vascular and Lewy body dementia. However, diagnosing dementia can be challenging and often delayed. To aid in the assessment of dementia, NICE recommends the use of cognitive screening tools such as the 10-point cognitive screener (10-CS) and the 6-Item cognitive impairment test (6CIT) in non-specialist settings. On the other hand, assessment tools such as the abbreviated mental test score (AMTS), General practitioner assessment of cognition (GPCOG), and the mini-mental state examination (MMSE) are not recommended for non-specialist settings.

      In primary care, blood screening is usually conducted to exclude reversible causes of dementia such as hypothyroidism. NICE recommends several tests including FBC, U&E, LFTs, calcium, glucose, ESR/CRP, TFTs, vitamin B12, and folate levels. Patients are often referred to old-age psychiatrists working in memory clinics for further management. In secondary care, neuroimaging is performed to exclude other reversible conditions and provide information on the aetiology of dementia to guide prognosis and management. The 2011 NICE guidelines state that structural imaging is essential in the investigation of dementia.

      In summary, dementia is a complex condition that requires careful assessment and management. The use of appropriate screening tools and tests can aid in the diagnosis and management of dementia, while neuroimaging can provide valuable information on the underlying causes of the condition.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
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  • Question 13 - Maria is a 56-year-old Greek woman who has recently undergone an NHS health...

    Incorrect

    • Maria is a 56-year-old Greek woman who has recently undergone an NHS health check and has contacted her GP for the results. The health check included a blood pressure check, routine blood test, and a urine dip. Her blood pressure is 125/78 mmHg, and her urine dip is negative. The blood test results are as follows:

      - Hb 124 g/L (Female: 115 - 160)
      - Platelets 300 * 109/L (150 - 400)
      - WBC 4.5 * 109/L (4.0 - 11.0)
      - Na+ 138 mmol/L (135 - 145)
      - K+ 5.0 mmol/L (3.5 - 5.0)
      - Urea 4.2 mmol/L (2.0 - 7.0)
      - Creatinine 82 µmol/L (55 - 120)
      - eGFR 63 mL/min/1.73 m²

      What is the correct stage of Chronic Kidney Disease (CKD) for this patient?

      Your Answer: 2

      Correct Answer: No CKD

      Explanation:

      Diagnosing stages 1 and 2 of CKD should only be done if there is accompanying evidence to support the eGFR.

      Understanding Chronic Kidney Disease: eGFR and Classification

      Chronic kidney disease (CKD) is a condition that affects the kidneys’ ability to filter waste products from the blood. Serum creatinine, a commonly used measure of kidney function, may not provide an accurate estimate due to differences in muscle mass. To address this, formulas such as the Modification of Diet in Renal Disease (MDRD) equation were developed to estimate the glomerular filtration rate (eGFR). The MDRD equation takes into account variables such as serum creatinine, age, gender, and ethnicity.

      It is important to note that certain factors may affect the accuracy of eGFR results, such as pregnancy, muscle mass, and recent consumption of red meat. CKD can be classified based on eGFR, with stage 1 indicating a GFR greater than 90 ml/min with some sign of kidney damage on other tests. Stage 2 indicates a GFR of 60-90 ml/min with some sign of kidney damage, while stage 3a and 3b indicate a moderate reduction in kidney function with GFR ranges of 45-59 ml/min and 30-44 ml/min, respectively. Stage 4 indicates a severe reduction in kidney function with a GFR range of 15-29 ml/min, while stage 5 indicates established kidney failure with a GFR less than 15 ml/min, which may require dialysis or a kidney transplant. It is important to note that if all kidney tests are normal, there is no CKD.

    • This question is part of the following fields:

      • Renal Medicine/Urology
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  • Question 14 - A 25-year-old man arrived at the Emergency Department complaining of sudden eye pain,...

    Incorrect

    • A 25-year-old man arrived at the Emergency Department complaining of sudden eye pain, sensitivity to light, and feeling like there was something in his right eye after taking out his contact lens. Upon fluorescein examination, the cornea showed uptake. What is the initial treatment recommended for this patient's condition?

      Your Answer: Topical lubricant

      Correct Answer: Topical antibiotic

      Explanation:

      To prevent secondary bacterial infection, topical antibiotics should be administered for a patient with a likely diagnosis of corneal abrasion. It is crucial to use fluorescein to confirm the integrity of the corneal epithelium. While topical lubricant can be used, it is not the primary treatment. Topical anaesthesia is not recommended as it may cause further corneal abrasion due to loss of sensation. Topical steroid is not used to treat corneal abrasion. Simply observing and waiting for the condition to improve is not an appropriate approach.

      Understanding Corneal Abrasion

      Corneal abrasion is a condition that occurs when there is damage to the corneal epithelium, which is the outermost layer of the cornea. This type of injury is often caused by local trauma, such as scratching the eye with fingernails or getting hit by a branch. The symptoms of corneal abrasion include eye pain, tearing, sensitivity to light, a feeling of having a foreign object in the eye, and redness of the conjunctiva. In addition, the affected eye may experience a decrease in visual acuity.

      To diagnose corneal abrasion, doctors typically use fluorescein staining. This involves placing a special dye in the eye that will highlight any areas of damage to the cornea. The abrasion will appear as a yellow-stained area on the surface of the eye. To enhance visualization, doctors may use a cobalt blue filter or a Wood’s lamp.

      The treatment for corneal abrasion typically involves the use of topical antibiotics to prevent secondary bacterial infections.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 15 - A 29-year-old female patient visits her general practitioner complaining of muscle cramps and...

    Correct

    • A 29-year-old female patient visits her general practitioner complaining of muscle cramps and numbness in her hands and feet for the past 5 days. She also reports a tingling sensation around her mouth. The patient was diagnosed with epilepsy 8 weeks ago and has been prescribed phenytoin. What abnormality is most likely to be observed in her blood test results?

      Your Answer: Corrected calcium of 1.5 mmol/L

      Explanation:

      The patient is displaying typical symptoms of hypocalcaemia, including perioral paraesthesia, cramps, tetany, and convulsions. This condition can be a side effect of taking phenytoin, and if left untreated, it can lead to seizures due to changes in neuromuscular excitability. Mild cases of hypocalcaemia can be managed with oral supplementation, while more severe cases may require intravenous replacement.

      It’s important to note that hypercalcaemia can cause bone pain, renal calculi, constipation, polyuria, fatigue, depression, and confusion. However, the patient does not display any of these symptoms.

      Hyperkalaemia can cause muscle weakness and cardiac arrhythmias, but the patient does not have these symptoms. Hypokalaemia can also cause muscle weakness and cardiac arrhythmias, but the patient’s symptoms do not fit this condition.

      Finally, hypernatraemia can cause nausea, vomiting, headache, and confusion, but the patient is not experiencing these symptoms.

      Hypocalcaemia: Symptoms and Signs

      Hypocalcaemia is a condition characterized by low levels of calcium in the blood. Since calcium is essential for proper muscle and nerve function, many of the symptoms and signs of hypocalcaemia are related to neuromuscular excitability. The most common features of hypocalcaemia include muscle twitching, cramping, and spasms, as well as perioral paraesthesia. In chronic cases, patients may experience depression and cataracts.

      An electrocardiogram (ECG) may show a prolonged QT interval, while Trousseau’s sign may be present when the brachial artery is occluded by inflating the blood pressure cuff and maintaining pressure above systolic. This causes wrist flexion and fingers to be drawn together, and is seen in around 95% of patients with hypocalcaemia and around 1% of normocalcaemic people. Chvostek’s sign, which is seen in around 70% of patients with hypocalcaemia and around 10% of normocalcaemic people, involves tapping over the parotid gland to cause facial muscles to twitch.

      In summary, hypocalcaemia can cause a range of symptoms and signs related to neuromuscular excitability, including muscle twitching, cramping, and spasms, as well as perioral paraesthesia, depression, and cataracts. Trousseau’s sign and Chvostek’s sign are also commonly observed in patients with hypocalcaemia.

    • This question is part of the following fields:

      • Neurology
      21.7
      Seconds
  • Question 16 - A 38-year-old woman presents to her GP with a complaint of difficulty moving...

    Correct

    • A 38-year-old woman presents to her GP with a complaint of difficulty moving her eyes horizontally. She reports that this is more pronounced after she has been conversing.
      What is the most probable reason for her symptoms?

      Your Answer: Myasthenia gravis

      Explanation:

      Differential Diagnosis of Ocular Weakness: Myasthenia Gravis, Mononeuritis Multiplex, Guillain-Barré Syndrome, Multiple Sclerosis, and Polymyositis

      Ocular weakness can be caused by a variety of conditions, including myasthenia gravis (MG), mononeuritis multiplex, Guillain-Barré syndrome (GBS), multiple sclerosis (MS), and polymyositis. MG is an autoimmune disorder that affects the neuromuscular junction, causing fatigable weakness of the periocular, facial, bulbar, and girdle muscles. Mononeuritis multiplex is a rare condition that involves neuropathy of multiple peripheral and/or cranial nerves, often caused by systemic disorders such as diabetes or granulomatosis with polyangiitis. GBS is an acute, post-infectious polyneuropathy that presents with progressive, ascending weakness, while MS is a chronic, immune-mediated inflammatory condition of the CNS that typically presents with relapsing-remitting disease and transient episodes of visual change or limb weakness. Polymyositis is a connective tissue disease that causes symmetrical proximal muscle weakness, often accompanied by dermatitis. Understanding the key features of each condition can aid in accurate diagnosis and appropriate treatment.

    • This question is part of the following fields:

      • Neurology
      36.3
      Seconds
  • Question 17 - A 57-year-old man presents with a 4 weeks-history of productive cough, dyspnoea, and...

    Correct

    • A 57-year-old man presents with a 4 weeks-history of productive cough, dyspnoea, and pleuritic chest pain. He has had associated lethargy, weight loss, a swinging fever and night sweats. He had a stroke two years ago.

      Sputum and blood cultures are collected. After a chest x-ray revealed a fluid-filled space within an area of consolidation in his left lung, he was given IV antibiotics.

      However, the patient's condition has not improved and instead appears to be worsening. What is the most appropriate next step in his management?

      Your Answer: Arrange CT-guided percutaneous drainage

      Explanation:

      If a lung abscess is not responding to intravenous antibiotics, percutaneous drainage should be considered as an option.

      Correct: Arrange CT-guided percutaneous drainage. This is because the patient’s symptoms, such as swinging fevers, night sweats, pleuritic chest pain, dyspnoea, and cough, are consistent with a lung abscess. The chest x-ray also supports this diagnosis by showing a fluid-filled space within an area of consolidation. If IV antibiotics are not effective, percutaneous drainage can be guided by a CT scan or ultrasound. IV antibiotics may not be able to penetrate the abscess wall, which is why some patients do not respond to this treatment.

      Incorrect: Arrange bronchoscopy. This is not commonly used for lung abscesses and is only indicated if an underlying tumour or foreign body is suspected. It is performed for diagnosis only, not drainage.

      Incorrect: Arrange sputum cytology. Sputum cultures have already been collected, and a diagnosis of lung abscess has been established. This option could be considered later if the patient still does not respond to treatment to rule out an underlying malignancy.

      Incorrect: Prescribe broad-spectrum IV antibiotics. This option is unlikely to be effective since the patient has already received IV antibiotics without success. The next step would be to manually drain the abscess.

      Understanding Lung Abscess

      A lung abscess is a localized infection that occurs within the lung tissue. It is commonly caused by aspiration pneumonia, which can be triggered by poor dental hygiene, reduced consciousness, or previous stroke. Other potential causes include haematogenous spread, direct extension, and bronchial obstruction. The infection is typically polymicrobial, with Staphylococcus aureus, Klebsiella pneumonia, and Pseudomonas aeruginosa being the most common monomicrobial causes.

      The symptoms of lung abscess are similar to pneumonia, but they tend to develop more slowly over several weeks. Patients may experience fever, productive cough, foul-smelling sputum, chest pain, and dyspnea. Some may also have systemic features such as night sweats and weight loss, while a minority may experience haemoptysis. Physical examination may reveal dull percussion and bronchial breathing, as well as clubbing in some cases.

      To diagnose lung abscess, a chest x-ray is usually performed, which shows a fluid-filled space within an area of consolidation. Sputum and blood cultures should also be obtained to identify the causative organism. Treatment typically involves intravenous antibiotics, but if the infection does not resolve, percutaneous drainage or surgical resection may be required in rare cases.

    • This question is part of the following fields:

      • Respiratory Medicine
      103.2
      Seconds
  • Question 18 - A 45-year-old man is diagnosed with end-stage renal disease. What is the most...

    Incorrect

    • A 45-year-old man is diagnosed with end-stage renal disease. What is the most frequent complication that may arise when considering long-term peritoneal dialysis for this patient?

      Your Answer: Congestive heart failure

      Correct Answer: Carpal tunnel syndrome

      Explanation:

      Chronic dialysis patients may experience median nerve compression, which can be caused by oedema or vascular insufficiency related to a dialysis shunt or fistula. Amyloid disease, which can infiltrate the synovium within the carpal tunnel, may also contribute to nerve compression in patients with renal failure. Anaemia is a common complication of chronic kidney disease, resulting from decreased renal synthesis of erythropoietin. This type of anaemia is normochromic normocytic and can lead to the development of new-onset heart failure. However, the use of erythropoiesis-stimulating agents has reduced the incidence of congestive heart failure due to anaemia. Squamous cell skin cancer is a type of skin cancer that is strongly associated with high total exposure to ultraviolet radiation from the sun. Individuals who have received solid organ transplants and are taking chronic immunosuppressive medication are at a significantly increased risk of developing this type of cancer, particularly squamous cell carcinoma. There is no known increased risk of gastrointestinal malignancy in patients on long-term haemodialysis. Immunosuppression, such as in the case of kidney transplant recipients, is associated with an increased risk of non-Hodgkin’s lymphoma.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      48.2
      Seconds
  • Question 19 - A 28-year-old woman complains of lumpy breasts. She notices the lumps are more...

    Correct

    • A 28-year-old woman complains of lumpy breasts. She notices the lumps are more prominent before her period. There is no family history of breast cancer.
      Which of the following is the most likely diagnosis?

      Your Answer: Diffuse cystic mastopathy

      Explanation:

      Breast Masses: Differential Diagnosis and Clinical Features

      Breast masses are a common concern for women, and it is important to differentiate between benign and malignant causes. Here, we discuss the clinical features and differential diagnosis of various breast masses.

      Diffuse cystic mastopathy is a benign condition that affects a significant proportion of women. It is characterized by the formation of cysts in the breast lobules due to hormonal changes in the menstrual cycle. The lumps are smooth, mobile, and tend to peak in size before each period. Diagnosis is primarily based on clinical examination, but a biopsy may be needed to confirm the diagnosis.

      Fat necrosis is another benign condition that can occur due to direct trauma or surgery. It is characterized by the formation of firm, round, and painless masses in the breast. The skin around the lump may be red or bruised, and a biopsy may be needed to differentiate it from breast cancer.

      Breast abscesses are characterized by local inflammation, pain, and fever. They may be associated with previous breast infections and may require drainage. However, there is no evidence of an infectious process in this patient.

      Breast cancer is a concern in any patient with a breast mass, but early breast cancer is often asymptomatic. Physical findings that may indicate the possible presence of breast cancer include changes in breast size or shape, skin dimpling or changes, nipple abnormalities, and axillary lumps. However, none of these symptoms are present in this patient.

      Fibroadenoma is the most common cause of breast mass in women under 35 years of age. It is characterized by a singular, firm, rubbery, smooth, and mobile mass. However, this patient reports multiple lumps, making a diagnosis of fibroadenoma less likely.

      In conclusion, the cyclic nature of this patient’s breast masses makes diffuse cystic mastopathy the most likely diagnosis. However, a biopsy may be needed to confirm the diagnosis and rule out other causes.

    • This question is part of the following fields:

      • Reproductive Medicine
      15.3
      Seconds
  • Question 20 - A 55 year old woman presents to the Emergency Department complaining of a...

    Correct

    • A 55 year old woman presents to the Emergency Department complaining of a cough with green sputum and palpitations. She reports feeling very sick, feverish, and tired. Upon examination, she exhibits bronchial breathing at her right base, with a respiratory rate of 25 breaths per minute and oxygen saturation of 95% on room air. Her heart sounds are normal, but her heartbeat is irregularly irregular, with a heart rate of 120 beats per minute and blood pressure of 90/40 mmHg. An ECG reveals atrial fibrillation with a fast ventricular rate. The patient has no prior history of atrial fibrillation. What is the initial treatment that should be administered?

      Your Answer: Intravenous fluids

      Explanation:

      Patient is septic from pneumonia and has developed atrial fibrillation. Treatment should focus on resolving the sepsis with IV fluids and antibiotics, which may also resolve the AF. If AF persists, other treatment options may be considered.

      Understanding Sepsis: Classification and Management

      Sepsis is a life-threatening condition caused by a dysregulated host response to an infection. In recent years, the classification of sepsis has changed, with the old category of severe sepsis no longer in use. Instead, the Surviving Sepsis Guidelines now recognize sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, and septic shock as a more severe form of sepsis. The term ‘systemic inflammatory response syndrome (SIRS)’ has also fallen out of favor.

      To manage sepsis, it is important to identify and treat the underlying cause of the infection and support the patient regardless of the cause or severity. However, if any red flags are present, the ‘sepsis six’ should be started immediately. This includes administering oxygen, taking blood cultures, giving broad-spectrum antibiotics, giving intravenous fluid challenges, measuring serum lactate, and measuring accurate hourly urine output.

      NICE released its own guidelines in 2016, which focus on the risk stratification and management of patients with suspected sepsis. For risk stratification, NICE recommends using red flag and amber flag criteria. If any red flags are present, the sepsis six should be started immediately. If any amber flags are present, the patient should be closely monitored and managed accordingly.

      To help identify and categorize patients, the Sequential (Sepsis-Related) Organ Failure Assessment Score (SOFA) is increasingly used. The score grades abnormality by organ system and accounts for clinical interventions. A SOFA score of 2 or more reflects an overall mortality risk of approximately 10% in a general hospital population with suspected infection. Even patients presenting with modest dysfunction can deteriorate further, emphasizing the seriousness of this condition and the need for prompt and appropriate intervention.

    • This question is part of the following fields:

      • Cardiovascular
      28.8
      Seconds
  • Question 21 - A 4-month-old girl presents with vomiting, yellowing of the skin and dehydration. Tests...

    Correct

    • A 4-month-old girl presents with vomiting, yellowing of the skin and dehydration. Tests show low potassium levels and metabolic alkalosis.
      What is the best initial course of action?

      Your Answer: Correction of metabolic derangements

      Explanation:

      Management of Infantile Pyloric Stenosis: Correction of Metabolic Derangements

      Infantile pyloric stenosis is a common condition in newborns, characterized by a hypertrophied pylorus that causes projectile vomiting and hungry feeding. The electrolyte abnormality associated with this condition is hypokalaemic hypochloraemic alkalosis. Before undergoing surgery, it is crucial to correct these metabolic abnormalities in consultation with a pediatrician and anesthetist. Ramstedt’s pyloromyotomy is the definitive surgical treatment for infantile pyloric stenosis. Upper GI endoscopy is not necessary for diagnosis if the clinical presentation is clear. Feeding jejunostomy and total parenteral nutrition are not appropriate initial management options. During surgery, the umbilicus should be excluded from the operative field to prevent staphylococcus aureus infection.

    • This question is part of the following fields:

      • Paediatrics
      29.3
      Seconds
  • Question 22 - A 63-year-old man presents to the haematology clinic with fatigue, significant weight loss,...

    Incorrect

    • A 63-year-old man presents to the haematology clinic with fatigue, significant weight loss, and easy bruising over the past 2 years. His blood test results are as follows:
      - Hemoglobin: 90 g/L (normal range for males: 135-180 g/L; females: 115-160 g/L)
      - Platelets: 85 * 109/L (normal range: 150-400 * 109/L)
      - White blood cells: 70.5 * 109/L (normal range: 4.0-11.0 * 109/L)
      - Neutrophils: 61.8 * 109/L (normal range: 2.0-7.0 * 109/L)
      - Lymphocytes: 1.2 * 109/L (normal range: 1.0-3.5 * 109/L)
      - Monocytes: 3.0 * 109/L (normal range: 0.2-0.8 * 109/L)
      - Eosinophils: 2.5 * 109/L (normal range: 0.0-0.4 * 109/L)
      The blood film shows obvious leucocytosis with eosinophilia and basophilia visible. There are also large numbers of immature granulocytes, but no blast cells are visible. What is the most appropriate first-line treatment for this patient?

      Your Answer: Rituximab

      Correct Answer: Imatinib

      Explanation:

      The patient’s history and blood results suggest that they have chronic myeloid leukaemia (CML), which is characterized by a high white cell count due to an excess of myeloid cells and a chronic presentation. The absence of blast cells indicates that this is not acute leukaemia. The patient’s anaemia and thrombocytopenia are likely due to bone marrow dysfunction caused by myelofibrosis, indicating a need for treatment. The first-line treatment for CML is imatinib, a tyrosine kinase inhibitor that is taken as a daily tablet and has shown excellent results in treating CML.

      Given the patient’s signs of bone marrow dysfunction, conservative management is not appropriate. While there may be a role for no treatment in early disease detected incidentally on a blood test, this patient requires treatment at this point.

      It is important to note that fludarabine and cyclophosphamide are chemotherapy agents used in treating chronic lymphocytic leukaemia (CLL) and have no role in managing CML. The blood test abnormalities expected in CLL are similar to those seen in CML, but with a differential showing normal or low neutrophil and high lymphocyte counts.

      Prednisolone, a glucocorticoid used to treat various conditions, is often used in treating different forms of lymphoma but is not effective in managing CML.

      Understanding Chronic Myeloid Leukaemia and its Management

      Chronic myeloid leukaemia (CML) is a type of cancer that affects the blood and bone marrow. It is characterized by the presence of the Philadelphia chromosome in more than 95% of patients. This chromosome is formed due to a translocation between chromosomes 9 and 22, resulting in the fusion of the ABL proto-oncogene and the BCR gene. The resulting BCR-ABL gene produces a fusion protein that has excessive tyrosine kinase activity.

      CML typically affects individuals between 60-70 years of age and presents with symptoms such as anaemia, weight loss, sweating, and splenomegaly. The condition is also associated with an increase in granulocytes at different stages of maturation and thrombocytosis. In some cases, CML may undergo blast transformation, leading to acute myeloid leukaemia (AML) or acute lymphoblastic leukaemia (ALL).

      The management of CML involves various treatment options, including imatinib, which is considered the first-line treatment. Imatinib is an inhibitor of the tyrosine kinase associated with the BCR-ABL defect and has a very high response rate in the chronic phase of CML. Other treatment options include hydroxyurea, interferon-alpha, and allogenic bone marrow transplant. With proper management, individuals with CML can lead a normal life.

    • This question is part of the following fields:

      • Haematology/Oncology
      43.8
      Seconds
  • Question 23 - What is the factor that is most likely to stimulate renin? ...

    Correct

    • What is the factor that is most likely to stimulate renin?

      Your Answer: Hypovolaemia

      Explanation:

      Hormones and their roles in regulating fluid balance

      Renin, ACTH, ANP, and ADH are hormones that play important roles in regulating fluid balance in the body. Renin is secreted by the kidneys in response to a decrease in blood volume, and it stimulates the renin-angiotensin-aldosterone system to increase extracellular volume and arterial vasoconstriction. ACTH, secreted by the pituitary gland, increases production and release of cortisol by the adrenal gland. ANP, secreted by heart myocytes, acts as a vasodilator to reduce water, sodium, and adipose loads on the circulatory system, counteracting the effects of the renin-angiotensin system. ADH, also known as vasopressin, increases water permeability in the kidneys and increases peripheral vascular resistance to increase arterial blood pressure. Understanding the roles of these hormones is crucial in maintaining proper fluid balance in the body.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      27
      Seconds
  • Question 24 - A 28-week pregnant woman is referred to the pregnancy clinic with gestational hypertension....

    Incorrect

    • A 28-week pregnant woman is referred to the pregnancy clinic with gestational hypertension. There is no evidence of protein in her urine.
      Which of the following is the most suitable treatment?

      Your Answer: Indapamide

      Correct Answer: Labetalol

      Explanation:

      Safe and Unsafe Hypertension Medications During Pregnancy

      Gestational hypertension, which is characterized by new hypertension after 20 weeks without significant proteinuria, can be treated with various medications. However, not all hypertension medications are safe during pregnancy. Thiazide diuretics, such as bendroflumethiazide and thiazide-like diuretics like indapamide, should be avoided as they can cause complications in the fetus. Angiotensin receptor blockers (ARBs) like losartan and angiotensin-converting enzyme (ACE) inhibitors like ramipril can also affect fetal blood pressure control and should be avoided unless essential. Labetalol is recommended as the first-line treatment for gestational hypertension, with methyldopa and nifedipine as other safe options. Hypertension is defined as a diastolic BP >90 mmHg or a systolic BP >140 mmHg.

    • This question is part of the following fields:

      • Cardiovascular
      36.4
      Seconds
  • Question 25 - A senior citizen who is taking digoxin asks you about the toxic effects...

    Incorrect

    • A senior citizen who is taking digoxin asks you about the toxic effects of digoxin therapy, having read about it on the internet.
      Which of the following is associated with digoxin toxicity?

      Your Answer: Gum hypertrophy

      Correct Answer: Premature ventricular beats

      Explanation:

      Understanding Digoxin Toxicity: Symptoms and Risk Factors

      Digoxin toxicity can occur suddenly in cases of overdose or gradually during long-term treatment. It is a common issue among elderly patients and is often associated with risk factors such as hypokalemia, hypomagnesemia, and hypercalcemia. The most common and earliest dysrhythmia in digoxin toxicity is the finding of premature ventricular beats on an ECG, along with sinus bradycardia. Other ECG changes may include depressed conduction, bigeminal and trigeminal rhythms, ventricular bigeminy, and bidirectional ventricular tachycardia. Hair loss is not associated with digoxin toxicity, but gum/gingival hypertrophy can be caused by other drugs. Loss of appetite, vomiting, anorexia, and fatigue are common symptoms reported by patients. It is important to understand the symptoms and risk factors associated with digoxin toxicity to ensure proper treatment and management.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      21.2
      Seconds
  • Question 26 - A 27-year-old female presents to a dermatology appointment with several new scaly plaques...

    Correct

    • A 27-year-old female presents to a dermatology appointment with several new scaly plaques on her scalp that are causing itching and redness, especially around the occipital region. She has a past medical history of chronic plaque psoriasis that is typically managed well with topical treatment and emollients. The dermatologist confirms a diagnosis of scalp psoriasis. What is the best course of action for treating her recent diagnosis?

      Your Answer: Topical betamethasone valerate

      Explanation:

      When it comes to managing scalp psoriasis, the approach is slightly different from managing plaque psoriasis. The first-line treatment typically involves using potent corticosteroids topically. Among the options, betamethasone valerate is the best answer as it is a potent corticosteroid that can be prescribed as a shampoo or mousse for easier application. For severe and extensive psoriasis, oral methotrexate may be recommended, but this is not applicable to the patient in question. Phototherapy is also an option for extensive psoriasis, but not for this patient who has well-controlled chronic plaque psoriasis. If no improvement is seen after 8 weeks of using a topical potent corticosteroid, second-line treatment may involve using topical vitamin D.

      NICE recommends a step-wise approach for chronic plaque psoriasis, starting with regular emollients and then using a potent corticosteroid and vitamin D analogue separately, followed by a vitamin D analogue twice daily, and then a potent corticosteroid or coal tar preparation if there is no improvement. Phototherapy, systemic therapy, and topical treatments are also options for management. Topical steroids should be used cautiously and vitamin D analogues may be used long-term. Dithranol and coal tar have adverse effects but can be effective.

    • This question is part of the following fields:

      • Dermatology
      49.5
      Seconds
  • Question 27 - Samantha is a 28-year-old who comes to your GP clinic seeking information about...

    Correct

    • Samantha is a 28-year-old who comes to your GP clinic seeking information about cystic fibrosis. She is in a committed relationship and wants to start a family. Samantha mentions that her partner's family has a history of cystic fibrosis and she wants to know more about it. She has already done some research and knows that cystic fibrosis is caused by mutations in the CF transmembrane conductance regulator gene (CFTR) on chromosome 7. Samantha asks you to explain how cystic fibrosis is inherited.

      Can you help her understand the inheritance pattern of cystic fibrosis?

      Your Answer: Autosomal recessive inheritance

      Explanation:

      Cystic fibrosis is a genetic disorder that follows an autosomal recessive pattern of inheritance. The carrier frequency is estimated to be 1 in 25 individuals, while the prevalence of the disease is 1 in 2500 newborns. Having a positive family history is the only known risk factor for CF, and parents should receive appropriate counseling before conception or during pregnancy if they are carriers.

      Understanding Cystic Fibrosis and the Organisms that Affect Patients

      Cystic fibrosis is a genetic disorder that causes thickened secretions in the lungs and pancreas. This condition is caused by a defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which regulates chloride channels. In the UK, 80% of CF cases are due to delta F508 on chromosome 7, and the carrier rate is approximately 1 in 25.

      CF patients are susceptible to colonization by certain organisms, including Staphylococcus aureus, Pseudomonas aeruginosa, Burkholderia cepacia, and Aspergillus. These organisms can cause infections and exacerbate symptoms in CF patients. It is important for healthcare providers to monitor and manage these infections to improve patient outcomes. By understanding the genetic basis of CF and the organisms that affect patients, healthcare providers can provide better care for those with this condition.

    • This question is part of the following fields:

      • Paediatrics
      120.9
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  • Question 28 - A 65-year-old man experiences percutaneous coronary intervention for an ST-elevation myocardial infarction. After...

    Incorrect

    • A 65-year-old man experiences percutaneous coronary intervention for an ST-elevation myocardial infarction. After 12 hours, he develops symptoms of paleness, clamminess, and bradycardia, and the ECG reveals complete disassociation between the atria and ventricles. Which coronary artery is the most probable culprit?

      Your Answer: Left circumflex artery

      Correct Answer: Right coronary artery

      Explanation:

      The left main coronary artery is not the cause of heart block. It usually results in anterior myocardial infarction.

      Understanding Heart Blocks and their Features

      Heart blocks are a type of cardiac conduction disorder that can lead to a range of symptoms and complications. There are three types of heart blocks, each with distinct features and characteristics. First-degree heart block is characterized by a prolonged PR interval, while second-degree heart block can be further divided into two subtypes: Mobitz I and Mobitz II. Mobitz I is characterized by a progressive prolongation of the PR interval until a dropped beat occurs, while Mobitz II is characterized by a constant PR interval but often not followed by a QRS complex.

      The most severe form of heart block is third-degree or complete heart block, which is characterized by a complete dissociation between the P waves and QRS complexes. This can lead to a range of symptoms, including syncope, heart failure, regular bradycardia, and wide pulse pressure. Other features of complete heart block include cannon waves in the neck and variable intensity of S1.

    • This question is part of the following fields:

      • Cardiovascular
      37.9
      Seconds
  • Question 29 - A 28-year-old woman with a history of thyroid disorder presents to the clinic...

    Correct

    • A 28-year-old woman with a history of thyroid disorder presents to the clinic with concerns about darkened skin on her neck.
      Which of the following is the most probable cause?

      Your Answer: Acanthosis nigricans

      Explanation:

      Common Skin Conditions: A Brief Overview

      Acanthosis Nigricans: A condition characterized by darkened patches of thickened skin, often described as velvet-like. It is usually benign but can sometimes be associated with underlying autoimmune conditions or gastric cancer.

      Dermatitis: Inflammation of the skin that can cause blistering, oozing, crusting, or flaking. Examples include eczema, dandruff, and rashes caused by contact with certain substances.

      Hidradenitis Suppurativa: A chronic condition that affects the apocrine glands in skin folds, causing painful nodules that can develop into pustules and eventually rupture. Scarring is common.

      Intertrigo: An inflammatory condition of skin folds caused by friction, often leading to secondary bacterial or fungal infections. Commonly found in the groin, axillae, and inframammary folds.

      Cowden’s Syndrome: An autosomal dominant condition characterized by hair follicle tumors, a cobblestone appearance of the oral epithelium, oral papillomas, and multiple skin tags. Associated with a high incidence of breast, thyroid, and gastrointestinal cancers.

    • This question is part of the following fields:

      • Dermatology
      14.6
      Seconds
  • Question 30 - What is a not a cause of hypertension in adolescents? ...

    Correct

    • What is a not a cause of hypertension in adolescents?

      Your Answer: Bartter's syndrome

      Explanation:

      Bartter’s syndrome is a genetic condition that typically follows an autosomal recessive pattern of inheritance. It results in severe hypokalaemia due to a defect in the absorption of chloride at the Na+ K+ 2Cl- cotransporter in the ascending loop of Henle. Unlike other endocrine causes of hypokalaemia such as Conn’s, Cushing’s and Liddle’s syndrome, Bartter’s syndrome is associated with normotension. The condition usually presents in childhood and is characterized by symptoms such as failure to thrive, polyuria, polydipsia, hypokalaemia, and weakness.

      Hypertension, or high blood pressure, can also affect children. To measure blood pressure in children, it is important to use a cuff size that is approximately 2/3 the length of their upper arm. The 4th Korotkoff sound is used to measure diastolic blood pressure until adolescence, when the 5th Korotkoff sound can be used. Results should be compared with a graph of normal values for their age.

      In younger children, secondary hypertension is the most common cause, with renal parenchymal disease accounting for up to 80% of cases. Other causes of hypertension in children include renal vascular disease, coarctation of the aorta, phaeochromocytoma, congenital adrenal hyperplasia, and essential or primary hypertension, which becomes more common as children get older. It is important to identify the underlying cause of hypertension in children in order to provide appropriate treatment and prevent complications.

    • This question is part of the following fields:

      • Paediatrics
      19.9
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Gastroenterology/Nutrition (1/1) 100%
Endocrinology/Metabolic Disease (1/3) 33%
Infectious Diseases (1/1) 100%
Pharmacology/Therapeutics (2/4) 50%
Neurology (3/3) 100%
Haematology/Oncology (0/2) 0%
Renal Medicine/Urology (2/4) 50%
Paediatrics (3/4) 75%
Ophthalmology (0/1) 0%
Respiratory Medicine (1/1) 100%
Reproductive Medicine (1/1) 100%
Cardiovascular (1/3) 33%
Dermatology (2/2) 100%
Passmed