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  • Question 1 - You are requested to assess a 25-year-old male patient who has been admitted...

    Correct

    • You are requested to assess a 25-year-old male patient who has been admitted to the hospital with an ascending muscle weakness that started in his toes but has now spread to all his limbs. He is experiencing shallow breathing and has no reflexes, although he has preserved sensation. At present, his cranial nerve examination is normal, and he is fully oriented. He has no medical history except for a bout of diarrhea three weeks ago, and he is not taking any medications. What is the probable diagnosis?

      Your Answer: Guillain-Barré syndrome

      Explanation:

      Guillain-Barré Syndrome

      Guillain-Barré syndrome is a condition where the immune system attacks the peripheral nervous system, causing a demyelinating polyneuropathy. This typically occurs a few weeks after an infection, with a strong association to diarrheal illnesses caused by Campylobacter jejuni. The most common presentation is an ascending paralysis, which can lead to respiratory failure and even death. Treatment involves prompt recognition, respiratory monitoring, and sometimes respiratory support. Intravenous immunoglobulin may also be used, although evidence is limited.

      Miller Fisher syndrome is a variant of Guillain-Barré that presents with cranial nerve palsies. Botulism toxicity can also cause respiratory failure and paralysis, but it typically occurs in a descending fashion. Diphtheritic neuropathy causes palatal weakness and papillary paralysis, while tetanus is rare in immunized individuals but can affect farmers who are at high risk due to their work environment. Tetanus presents with signs of infection and spasms rather than weakness.

      In summary, Guillain-Barré syndrome is a serious condition that can result in paralysis and respiratory failure. Prompt recognition and treatment are essential for a good outcome. Other conditions that can cause similar symptoms include Miller Fisher syndrome, botulism toxicity, diphtheritic neuropathy, and tetanus.

    • This question is part of the following fields:

      • Neurology
      34.4
      Seconds
  • Question 2 - A 20-year-old man comes to your clinic with a concern about a dusky...

    Incorrect

    • A 20-year-old man comes to your clinic with a concern about a dusky discolouration that he has had for as long as he can remember. He mentions that none of his relatives have a similar skin colour and that it seems to be getting darker with time. He reports taking oral isotretinoin on-and-off for four years to manage his acne. Upon examination, his chest sounds normal, but his oxygen saturation by pulse oximetry is 91%. An arterial blood gas test reveals a pO2 of 10.6kPa, FO2Hb of 65%, and metHb of 30%.

      What treatment would you recommend for this young man?

      Your Answer: Methylene blue

      Correct Answer: Ascorbic acid

      Explanation:

      If the cause of congenital methaemoglobinaemia is being treated, the expected outcome is the resolution of cyanosis within a few weeks through the administration of Vitamin C (ascorbic acid).

      In the case of an acquired cause, Methylene blue would be the treatment option, but this is less probable as explained earlier.

      Understanding Methaemoglobinaemia

      Methaemoglobinaemia is a condition where haemoglobin is oxidised from Fe2+ to Fe3+. Normally, NADH methaemoglobin reductase regulates this process by transferring electrons from NADH to methaemoglobin, reducing it to haemoglobin. However, when this process is disrupted, tissue hypoxia occurs as Fe3+ cannot bind oxygen, shifting the oxidation dissociation curve to the left.

      There are congenital causes of methaemoglobinaemia, such as haemoglobin chain variants like HbM and HbH, as well as NADH methaemoglobin reductase deficiency. Acquired causes include drugs like sulphonamides, nitrates (including recreational nitrates like amyl nitrite ‘poppers’), dapsone, sodium nitroprusside, and primaquine, as well as chemicals like aniline dyes.

      Symptoms of methaemoglobinaemia include ‘chocolate’ cyanosis, dyspnoea, anxiety, headache, and in severe cases, acidosis, arrhythmias, seizures, and coma. Despite normal pO2 levels, oxygen saturation is decreased.

      Management of NADH methaemoglobinaemia reductase deficiency involves ascorbic acid, while acquired methaemoglobinaemia can be treated with IV methylthioninium chloride (methylene blue). Understanding the causes and symptoms of methaemoglobinaemia is crucial in its proper diagnosis and management.

    • This question is part of the following fields:

      • Haematology
      70.5
      Seconds
  • Question 3 - A 27-year-old female from the travelling community presents to A&E after experiencing a...

    Incorrect

    • A 27-year-old female from the travelling community presents to A&E after experiencing a seizure. According to her family, she had been suffering from headaches for the past 24 hours and had been feverish and vomiting this morning. Her partner reports that she was unwell with a fever and whole body rash that resolved on its own about a month ago. She has no significant medical history.

      During the examination, she appears drowsy and has a left-sided hemiparesis with bilateral nystagmus. Papiloedema is observed during fundoscopy, but there are no skin rashes.

      What is the most likely underlying diagnosis?

      Your Answer: Progressive multifocal leukoencephalopathy (PML)

      Correct Answer: Acute disseminated encephalomyelitis (ADEM)

      Explanation:

      Understanding Acute Disseminated Encephalomyelitis

      Acute disseminated encephalomyelitis (ADEM) is a type of autoimmune demyelinating disease that affects the central nervous system. It is also known as post-infectious encephalomyelitis and can occur after an individual has been infected with a bacterial or viral pathogen. Common infections that may lead to ADEM include measles, mumps, rubella, and varicella, among others.

      The onset of ADEM is characterized by a sudden and rapid deterioration of neurological symptoms, which may include motor and sensory deficits, oculomotor defects, and brainstem involvement. Non-specific symptoms such as headache, fever, nausea, and vomiting may also be present. The lag time between infection and the onset of ADEM can range from a few days to two months.

      Diagnosis of ADEM is challenging as there are no specific biomarkers available. However, MRI imaging may reveal areas of supra and infra-tentorial demyelination. Treatment typically involves the use of intravenous glucocorticoids, and in cases where this fails, IVIG may be considered.

      In summary, ADEM is a serious autoimmune disease that can occur after an individual has been infected with a bacterial or viral pathogen. The onset of symptoms is sudden and rapid, and diagnosis can be challenging. Early intervention with appropriate treatment is crucial for the management of ADEM.

    • This question is part of the following fields:

      • Neurology
      64
      Seconds
  • Question 4 - A 35-year-old man presents with a history of abdominal discomfort and bloating for...

    Incorrect

    • A 35-year-old man presents with a history of abdominal discomfort and bloating for the past 10 days. Upon examination, he is found to have jaundice, a smooth, 6 cm hepatomegaly, and ascites. There are no signs of chronic liver disease, and he is not taking any regular medication. The following investigations were conducted:

      Haemoglobin (Hb): 140 g/l (normal range: 130-170 g/l)
      White Cell Count (WCC): 10.5 × 109/l (normal range: 4.0-11.0 × 109/l)
      Platelets (PLT): 180 × 109/l (normal range: 150-400 × 109/l)
      Sodium (Na+): 142 mmol/l (normal range: 135-145 mmol/l)
      Potassium (K+): 4.5 mmol/l (normal range: 3.5-5.0 mmol/l)
      Creatinine (Cr): 190 µmol/l (normal range: 50-120 µmol/l)
      Urea: 18 mmol/l (normal range: 2.5-6.5 mmol/l)
      Partial Thromboplastin Time (PTT): 48 s (normal range: 23.0-35.0 s)
      Prothrombin Test (PT): 12 s (normal range: 10.6-14.9 s)

      What is the most likely diagnosis?

      Your Answer: Budd-Chiari syndrome

      Correct Answer:

      Explanation:

      Differential Diagnosis for a Patient with Hepatomegaly and Jaundice

      Hepatomegaly and jaundice can be indicative of various conditions, and a thorough differential diagnosis is necessary to determine the underlying cause. In this case, the prolonged activated partial thromboplastin time (APTT) in the presence of a normal prothrombin time (PT) suggests lupus anticoagulant, which is consistent with anti-phospholipid syndrome and a potential cause of Budd-Chiari syndrome. This rare condition is characterized by occlusion of the hepatic vein and typically presents with abdominal pain, hepatomegaly, and ascites. Treatment options include anticoagulation, surgery, or a transjugular intrahepatic portosystemic shunt (TIPS) procedure.

      Glomerulonephritis is unlikely to explain the hepatomegaly and jaundice. Alcoholic liver disease could account for the presentation, but there is no mention of excessive alcohol intake in the patient’s history. Right heart failure may cause an enlarged liver and ascites, but it would not explain the clotting abnormalities seen in this case. Metastatic liver disease is also unlikely, as a smooth liver would not be expected, and the ascitic fluid tap is more likely to be exudative in malignancy rather than transudative.

    • This question is part of the following fields:

      • Gastroenterology And Hepatology
      129.2
      Seconds
  • Question 5 - A 20-year-old man returning from Zimbabwe presents to the emergency department with complaints...

    Incorrect

    • A 20-year-old man returning from Zimbabwe presents to the emergency department with complaints of severe headache and rigors for the past three days. He has no significant medical history, smoked 10 cigarettes per day, and does not consume alcohol. On examination, he appears anxious and sweaty with a pulse rate of 108/min, blood pressure of 91/58 mmHg, temperature of 39ºC, and respiratory rate of 22/min. The chest is clear, heart sounds normal, and a brief neurological examination is unremarkable. An urgent blood film confirms malarial parasites. What clinical findings would indicate severe malaria infection?

      Your Answer: Bicarbonate < 14 mmol/l

      Correct Answer:

      Explanation:

      According to the World Health Organisation, it is crucial to promptly identify and treat severe malaria to prevent the patient’s condition from rapidly deteriorating and potentially leading to life-threatening complications. These complications may include hypoglycaemia, acidosis, coma, convulsions, severe anaemia, and pulmonary oedema. Cerebral malaria may be indicated by coma or convulsions, and the type of parasite and percentage of parasitaemia are important factors in determining the prognosis and treatment of malaria.

      Understanding Falciparum Malaria and its Complications

      Falciparum malaria is the most common and severe type of malaria. It is characterized by schizonts on a blood film, parasitaemia greater than 2%, hypoglycaemia, acidosis, temperature above 39°C, severe anaemia, and various complications. Complications of falciparum malaria include cerebral malaria, acute renal failure, acute respiratory distress syndrome, hypoglycaemia, and disseminated intravascular coagulation.

      In areas where strains resistant to chloroquine are prevalent, the 2010 WHO guidelines recommend artemisinin-based combination therapies (ACTs) as first-line therapy for uncomplicated falciparum malaria. Examples of ACTs include artemether plus lumefantrine, artesunate plus amodiaquine, artesunate plus mefloquine, artesunate plus sulfadoxine-pyrimethamine, and dihydroartemisinin plus piperaquine.

      For severe falciparum malaria, a parasite count of more than 2% usually requires parenteral treatment regardless of clinical state. The WHO now recommends intravenous artesunate over intravenous quinine. If the parasite count is greater than 10%, exchange transfusion should be considered. Shock may indicate coexistent bacterial septicaemia, as malaria rarely causes haemodynamic collapse.

    • This question is part of the following fields:

      • Infectious Diseases
      199.8
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  • Question 6 - A 28-year-old female patient visits the ENT clinic complaining of hoarseness that has...

    Incorrect

    • A 28-year-old female patient visits the ENT clinic complaining of hoarseness that has persisted for three weeks despite adequate fluid intake. The patient was referred to the clinic by her general practitioner after a phone consultation. Upon examination, a non-painful goiter was observed. The patient denies any symptoms of thyroid dysfunction and reports feeling generally well. She has no difficulty speaking except for the hoarseness and does not experience any breathing difficulties. What is the best course of action to take in this case?

      Your Answer:

      Correct Answer: Two-week wait appointment with an endocrinologist

      Explanation:

      If a person has a goitre and experiences unexplained hoarseness, it is crucial to refer them urgently to an endocrinologist. This combination of symptoms could indicate thyroid cancer. Additionally, if a child has thyroid nodules, or if a person has a rapidly enlarging and painless thyroid mass or a thyroid mass with cervical lymphadenopathy, they should also receive a two-week wait referral for suspected thyroid cancer. In cases where a person has a thyroid swelling and stridor, immediate admission may be necessary. However, if a person has abnormal thyroid function tests or sudden pain in a thyroid lump, they can be referred non-urgently.

      Thyroid cancer rarely causes hyperthyroidism or hypothyroidism as it does not usually secrete thyroid hormones. The most common type of thyroid cancer is papillary carcinoma, which is often found in young females and has an excellent prognosis. Follicular carcinoma is less common, while medullary carcinoma is a cancer of the parafollicular cells that secrete calcitonin and is associated with multiple endocrine neoplasia type 2. Anaplastic carcinoma is rare and not responsive to treatment, causing pressure symptoms. Lymphoma is also rare and associated with Hashimoto’s thyroiditis.

      Management of papillary and follicular cancer involves a total thyroidectomy followed by radioiodine to kill residual cells. Yearly thyroglobulin levels are monitored to detect early recurrent disease. Papillary carcinoma usually contains a mixture of papillary and colloid filled follicles, while follicular adenoma presents as a solitary thyroid nodule and malignancy can only be excluded on formal histological assessment. Follicular carcinoma may appear macroscopically encapsulated, but microscopically capsular invasion is seen. Medullary carcinoma is associated with raised serum calcitonin levels and familial genetic disease in up to 20% of cases. Anaplastic carcinoma is most common in elderly females and is treated by resection where possible, with palliation achieved through isthmusectomy and radiotherapy. Chemotherapy is ineffective.

    • This question is part of the following fields:

      • Endocrinology, Diabetes And Metabolic Medicine
      0
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  • Question 7 - A 23-year-old office worker presents to the clinic with complaints of swollen and...

    Incorrect

    • A 23-year-old office worker presents to the clinic with complaints of swollen and tender finger joints that have been present for a few weeks. She has no significant medical history except for a recent viral illness. She denies any recent travel and reports that some of her colleagues at work have also been sick with a similar illness. On examination, there is swelling and tenderness in the metacarpophalangeal and proximal interphalangeal joints of both hands. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Parvovirus B19 infection

      Explanation:

      Parvovirus B19 is a virus that causes erythema infectiosum in children, but can also lead to more serious complications such as aplastic crisis in patients with haemoglobinopathies. It can also cause a post-infectious arthritis that affects small joints, particularly in adult women. This arthritis does not cause permanent damage to bones or joints and should be considered before diagnosing rheumatoid arthritis, especially if the patient has been around children with viral illnesses.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 8 - A 35-year-old construction worker presents to the Emergency Department with severe pain in...

    Incorrect

    • A 35-year-old construction worker presents to the Emergency Department with severe pain in his left side and dark urine. He denies fever but reports seeing his primary care physician a few days ago for urinary frequency and burning, and was prescribed trimethoprim which resolved the symptoms. The pain suddenly onset and is so intense that he cannot walk. He also experiences nausea and has vomited twice. The pain radiates to his groin. Vital signs are temperature 37.5°C, blood pressure 120/80 mmHg, pulse rate 100 bpm, and respiratory rate 16 breaths per minute. Physical examination of the chest and heart is normal. The abdomen is soft and non-tender, with no guarding. Analgesia is administered.

      Lab results show:
      - Creatinine (Cr): 90 µmol/l (normal range: 60-110 µmol/l)
      - Urea: 6.0 mmol/l (normal range: 2.5-7.5 mmol/l)
      - Hemoglobin (Hb): 130 g/l (normal range: 135-175 g/l)
      - Potassium (K+): 3.8 mmol/l (normal range: 3.5-5.0 mmol/l)
      - Corrected calcium: 2.50 mmol/l (normal range: 2.2-2.7 mmol/l)
      - White cell count (WCC): 12 × 109/l (normal range: 4.0-11.0 × 109/l)
      - Erythrocyte sedimentation rate (ESR): 15 mm/h (normal range: 1-20 mm/h)

      What is the most appropriate initial treatment for this patient?

      Your Answer:

      Correct Answer: Hydration

      Explanation:

      Kidney stones can form when there is an excess of calcium, oxalate, or uric acid in the urine, a lack of citrate, or insufficient water in the kidneys to dissolve waste products. Dehydration can lead to the formation of crystals that gradually build up into kidney stones. Urine typically contains chemicals that prevent crystal formation, but low levels of these inhibitors can contribute to stone formation. Most kidney stones pass on their own, but some patients may require hospitalization due to severe pain, inability to retain fluids, infection, or inability to pass the stone. Treatment involves hydration and pain relief, with methods of stone removal considered for those who do not pass the stone naturally. Intravenous furosemide and broad-spectrum antibiotics are not recommended unless there is a specific indication.

    • This question is part of the following fields:

      • Renal Medicine
      0
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  • Question 9 - You receive a request for a second opinion from a GP who has...

    Incorrect

    • You receive a request for a second opinion from a GP who has performed a general physical check on one of their new patients. He is a 52-year-old man who is from Thailand. He had been complaining of low mood, fatigue and sensitivity to the cold. His body mass index is 31 kg/m². The following is a list of investigations performed by the GP.

      Na+ 141 mmol/l
      K+ 4.8 mmol/l
      Urea 9.8 mmol/l
      Creatinine 142 µmol/l
      CRP 4 mg/l

      Bilirubin 14 µmol/l
      ALP 86 u/l
      ALT 27 u/l
      Calcium 2.89 mmol/l
      Albumin 39 g/l
      TSH 24.0 mU/l
      Free T4 0.8 pmol/l
      Free T3 0.4 pmol/l

      ECG: Heart rate 68, sinus rhythm, QRS width 128ms, flattened T waves V1 to V6

      The patient has told the GP that he takes one medication regularly but is unable to give the name. Which medication is most likely to cause the following abnormalities?

      Your Answer:

      Correct Answer: Lithium

      Explanation:

      Lithium is the correct answer. Prolonged use of Lithium can lead to hypothyroidism in around one-third of patients, with middle-aged women being the most susceptible. Lithium therapy can also cause hypercalcaemia and hyperparathyroidism. Renal impairment is a well-known side effect of long-term Lithium use, and weight gain is also common. While cardiac side effects are rare, flattened T waves and a widened QRS complex are the most common ECG changes, and a modified Brugada pattern may be observed.

      Lithium is a drug used to stabilize mood in patients with bipolar disorder and refractory depression. It has a narrow therapeutic range of 0.4-1.0 mmol/L and is primarily excreted by the kidneys. Lithium toxicity occurs when the concentration exceeds 1.5 mmol/L, which can be caused by dehydration, renal failure, and certain drugs such as diuretics, ACE inhibitors, NSAIDs, and metronidazole. Symptoms of toxicity include coarse tremors, hyperreflexia, acute confusion, polyuria, seizures, and coma.

      To manage mild to moderate toxicity, volume resuscitation with normal saline may be effective. Severe toxicity may require hemodialysis. Sodium bicarbonate may also be used to increase the alkalinity of the urine and promote lithium excretion, but there is limited evidence to support its use. It is important to monitor lithium levels closely and adjust the dosage accordingly to prevent toxicity.

    • This question is part of the following fields:

      • Clinical Pharmacology And Therapeutics
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  • Question 10 - A 68-year-old man presents to the Emergency department with shortness of breath. He...

    Incorrect

    • A 68-year-old man presents to the Emergency department with shortness of breath. He has a medical history of end stage renal failure secondary to hypertension and renovascular disease.
      He is currently receiving haemodialysis as renal replacement therapy and it has been three days since he last dialysed.

      On examination, he is tachypnoeic, his jugular venous pressure can be seen 1 cm above the clavicle and there are sparse fine crepitations at the lung bases.

      An arterial blood gas on air reveals:
      pH 7.32 (7.36-7.44)
      pO2 11.9 kPa (11.3-12.6)
      pCO2 2.9 kPa (4.7-6.0 kPa)
      Bicarbonate 12 mmol/L (20-28)
      Sodium 136 mmol/L (137-144)
      Potassium 7.5 mmol/L (3.5-4.9)

      An ECG reveals first degree heart block and peaked T waves.

      What is the most appropriate initial management of this patient's hyperkalaemia?

      Your Answer:

      Correct Answer: Calcium gluconate

      Explanation:

      The patient has severe hyperkalaemia and needs immediate treatment to stabilize the myocardium. Calcium gluconate should be administered first, followed by definitive treatment such as haemodialysis. Holding measures like insulin/dextrose infusions may not be necessary if dialysis can be organized quickly. Nebulized salbutamol may be effective in lowering serum potassium, but it may not work for all patients. Sodium bicarbonate is not recommended for acute hyperkalaemia treatment due to potential side effects. The patient also has metabolic acidosis related to renal failure.

    • This question is part of the following fields:

      • Renal Medicine
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  • Question 11 - A 45-year-old man presents with complaints of epigastric pain. He has a history...

    Incorrect

    • A 45-year-old man presents with complaints of epigastric pain. He has a history of occasional alcohol consumption and smoking 20 cigarettes a day. Despite being generally healthy, he has been experiencing back pain and has been taking ibuprofen for the past few months. Additionally, he has been under significant stress and has had to take time off work.

      During examination, the patient is stable but experiences tenderness in the epigastric region. His GP prescribed omeprazole 40 mg od, which he has been taking regularly for the past month. While the medication has provided some relief, he has not experienced complete resolution of his symptoms. An endoscopy is scheduled, which reveals duodenal ulceration.

      What is a characteristic clinical feature of a duodenal ulcer?

      Your Answer:

      Correct Answer: Abdominal pain relieved by eating

      Explanation:

      Peptic Ulceration and its Risk Factors

      Peptic ulceration is a condition that affects the stomach and duodenum, causing discomfort and pain. Patients with gastric ulceration often experience anorexia and weight loss, while those with duodenal ulceration tend to maintain or gain weight. However, the most characteristic clinical feature of duodenal ulceration is abdominal pain that is relieved by eating. To confirm the presence of ulceration, endoscopy should be performed.

      Several risk factors contribute to the development of peptic ulceration. One of the most common is Helicobacter pylori (H. pylori) infection, which can cause inflammation and damage to the stomach lining. Non-steroidal anti-inflammatory drugs (NSAIDs) are another risk factor, as they can irritate the stomach and increase the risk of ulceration. Cigarette smoking is also associated with an increased risk of peptic ulceration. Additionally, genetic factors such as Lewis blood group antigens can facilitate H. pylori attachment to the mucosa.

      In summary, the risk factors for peptic ulceration and recognizing its characteristic clinical features can aid in the diagnosis and management of this condition.

    • This question is part of the following fields:

      • Gastroenterology And Hepatology
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  • Question 12 - A 23-year-old female patient complains of repeated episodes of breathlessness and cough with...

    Incorrect

    • A 23-year-old female patient complains of repeated episodes of breathlessness and cough with foul-smelling sputum. She has a medical history of recurrent colicky abdominal pain over the past four years. Upon investigation, sputum culture reveals a significant growth of Pseudomonas aeruginosa and Haemophilus influenzae. Additionally, her chest X-ray shows tramline and ring shadows. What is the probable cause of her symptoms?

      Your Answer:

      Correct Answer: Cystic fibrosis

      Explanation:

      Causes of Chronic Lung Disease

      Cystic fibrosis (CF) is a disease that usually appears in childhood, but it can also present in early adulthood. Pseudomonas and H. influenzae are common pathogens in chronic lung disease, causing foul-smelling sputum and recurrent infections. However, abdominal pain in CF patients is likely due to distal intestinal obstruction syndrome. Chronic granulomatous disease (CGD) is an inherited disorder that leads to recurrent life-threatening bacterial and fungal infections, but CGD neutrophils are able to kill P. aeruginosa organisms by nonoxidative mechanisms. T cell deficiencies are typically associated with viral and fungal pathogens, while hypogammaglobulinaemia makes patients susceptible to recurrent respiratory tract infections caused by encapsulated bacteria. Primary ciliary dyskinesia is associated with recurrent respiratory tract infections due to ineffective secretion clearance and infertility.

      Overall, chronic lung disease can have various causes, including genetic disorders, immune deficiencies, and recurrent infections. the underlying mechanisms of these diseases can help with diagnosis and treatment.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 13 - A 50-year-old female patient visits the clinic complaining of right-sided flank pain. A...

    Incorrect

    • A 50-year-old female patient visits the clinic complaining of right-sided flank pain. A CT KUB scan confirms the presence of a kidney stone on the right side. The patient has a medical history of asthma, rheumatoid arthritis, and Sjögren's syndrome. She is currently taking salbutamol, methotrexate, and hydroxychloroquine.

      The patient's blood test results show a hemoglobin level of 115 g/l, platelet count of 460 * 109/l, bicarbonate level of 16 mEq/L (normal range is 22-28), urea level of 7.8 mmol/l, chloride level of 115 mmol/l, and creatinine level of 76 µmol/l.

      What measures can be taken to prevent the formation of further kidney stones?

      Your Answer:

      Correct Answer: Sodium bicarbonate

      Explanation:

      The recommended treatment for RTA involves correcting the acidaemia through the use of oral sodium bicarbonate, sodium citrate, or potassium citrate. In cases where a patient has a low bicarbonate level, it is important to determine the anion gap to aid in diagnosis. A normal anion gap metabolic acidosis (NAGMA) is typically caused by Addison’s disease, bicarbonate loss via the GI or renal tract, chloride excess, or drugs such as acetazolamide. On the other hand, a high anion gap metabolic acidosis (HAGMA) is usually caused by ketoacidosis, uraemia, lactic acidosis, or toxins like salicylates, ethylene glycol, or methanol. In this particular case, the presence of NAGMA, hypokalaemia, and renal stones suggests the possibility of renal tubular acidosis (RTA), with type 1 (distal) being the most likely diagnosis due to the patient’s medical history of Sjögren’s syndrome and rheumatoid arthritis.

      Renal tubular acidosis (RTA) is a condition that results in hyperchloraemic metabolic acidosis, which is characterized by a normal anion gap. There are three types of RTA, each with its own unique set of causes and complications. Type 1 RTA, also known as distal RTA, is caused by an inability to generate acid urine in the distal tubule, leading to hypokalaemia. This type of RTA can be caused by a variety of factors, including rheumatoid arthritis, SLE, and amphotericin B toxicity. Complications may include nephrocalcinosis and renal stones.

      Type 2 RTA, or proximal RTA, is characterized by a decreased reabsorption of HCO3- in the proximal tubule, which also leads to hypokalaemia. This type of RTA can be caused by a variety of factors, including Wilson’s disease and outdated tetracyclines. Complications may include osteomalacia.

      Type 3 RTA, or mixed RTA, is an extremely rare form of the condition that is caused by carbonic anhydrase II deficiency. This results in hypokalaemia.

      Type 4 RTA, or hyperkalaemic RTA, is caused by a reduction in aldosterone, which leads to a reduction in proximal tubular ammonium excretion. This type of RTA can be caused by hypoaldosteronism and diabetes, and it results in hyperkalaemia.

      Overall, RTA is a complex condition that can have a variety of causes and complications. It is important to work with a healthcare provider to determine the underlying cause of the condition and develop an appropriate treatment plan.

    • This question is part of the following fields:

      • Endocrinology, Diabetes And Metabolic Medicine
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  • Question 14 - A 12-year-old female presented to her GP after collapsing at school. Her friends...

    Incorrect

    • A 12-year-old female presented to her GP after collapsing at school. Her friends reported that while she was playing basketball, she suddenly collapsed and lost consciousness for a few seconds. This was her first episode of collapse, and no seizure activity was observed. She made a full and spontaneous recovery shortly after. Other than occasional palpitations upon exertion, she denied the presence of prodromal symptoms and was otherwise healthy. She had a history of cochlear implant insertion in early childhood for congenital hearing impairment but had no other significant medical history and was not taking any medications. There was no notable family history.

      Upon examination, the patient appeared to be a healthy and athletic 12-year-old female. Her heart rate was 60 bpm and regular, and her blood pressure was 110/80 mmHg. Cardiovascular examination revealed a JVP of 3cm and was otherwise unremarkable with normal heart sounds. Gastrointestinal and neurological examinations were also unremarkable.

      Initial investigations revealed the following results:

      ECG: 60 bpm normal, sinus rhythm QRS 110 ms, PR 120ms, QTc 500ms, normal ST and T wave morphology.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Jervell & Lange-Nielsen syndrome

      Explanation:

      This woman is diagnosed with long QT syndrome (LQTS) based on her ECG results and a history of collapsing during physical activity. The primary differential diagnosis is Romano-Ward syndrome, which is also a form of LQTS but does not involve deafness. In contrast, Jervell and Lange-Nielsen syndrome is associated with deafness. If her cardiac examination is normal and there is no evidence of hypertrophy on her ECG, it is less likely that she has hypertrophic obstructive cardiomyopathy.

      Long QT syndrome (LQTS) is a genetic condition that causes a delay in the ventricles’ repolarization. This delay can lead to ventricular tachycardia/torsade de pointes, which can cause sudden death or collapse. The most common types of LQTS are LQT1 and LQT2, which are caused by defects in the alpha subunit of the slow delayed rectifier potassium channel. A normal corrected QT interval is less than 430 ms in males and 450 ms in females.

      There are various causes of a prolonged QT interval, including congenital factors, drugs, and other conditions. Congenital factors include Jervell-Lange-Nielsen syndrome and Romano-Ward syndrome. Drugs that can cause a prolonged QT interval include amiodarone, sotalol, tricyclic antidepressants, and selective serotonin reuptake inhibitors. Other factors that can cause a prolonged QT interval include electrolyte imbalances, acute myocardial infarction, myocarditis, hypothermia, and subarachnoid hemorrhage.

      LQTS may be detected on a routine ECG or through family screening. Long QT1 is usually associated with exertional syncope, while Long QT2 is often associated with syncope following emotional stress, exercise, or auditory stimuli. Long QT3 events often occur at night or at rest and can lead to sudden cardiac death.

      Management of LQTS involves avoiding drugs that prolong the QT interval and other precipitants if appropriate. Beta-blockers are often used, and implantable cardioverter defibrillators may be necessary in high-risk cases. It is important to note that sotalol may exacerbate LQTS.

    • This question is part of the following fields:

      • Cardiology
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  • Question 15 - A 56-year-old man with a history of alcoholic liver disease and cirrhosis is...

    Incorrect

    • A 56-year-old man with a history of alcoholic liver disease and cirrhosis is being reviewed on the ward. He was admitted one week ago with decompensated liver disease and had an ascitic drain sited, which has drained 8 litres. His current medications include furosemide, lactulose, and spironolactone. On examination, he appears hypovolemic with a blood pressure of 88/65 mmHg and heart rate of 110 beats per minute. His abdomen is soft and non-tender, and his chest sounds clear.

      Blood results from 7 days ago show a Hb of 115 g/l, Na+ of 138 mmol/l, and Bilirubin of 116 µmol/l, among other values. Blood results from today show a decrease in Hb to 112 g/l, Na+ to 128 mmol/l, and Albumin to 11 g/l, among other values. The ascitic tap results show a neutrophil count of 140 cells per mm^3.

      What is the most likely diagnosis for this 56-year-old man?

      Your Answer:

      Correct Answer: Paracentesis induced circulatory dysfunction

      Explanation:

      Ascites is a medical condition characterized by the accumulation of abnormal amounts of fluid in the abdominal cavity. The causes of ascites can be classified into two groups based on the serum-ascites albumin gradient (SAAG) level. If the SAAG level is greater than 11g/L, it indicates portal hypertension, which is commonly caused by liver disorders such as cirrhosis, alcoholic liver disease, and liver metastases. Other causes of portal hypertension include cardiac conditions like right heart failure and constrictive pericarditis, as well as infections like tuberculous peritonitis. On the other hand, if the SAAG level is less than 11g/L, ascites may be caused by hypoalbuminaemia, malignancy, pancreatitis, bowel obstruction, and other conditions.

      The management of ascites involves reducing dietary sodium and sometimes fluid restriction if the sodium level is less than 125 mmol/L. Aldosterone antagonists like spironolactone are often prescribed, and loop diuretics may be added if necessary. Therapeutic abdominal paracentesis may be performed for tense ascites, and large-volume paracentesis requires albumin cover to reduce the risk of complications. Prophylactic antibiotics may also be given to prevent spontaneous bacterial peritonitis. In some cases, a transjugular intrahepatic portosystemic shunt (TIPS) may be considered.

    • This question is part of the following fields:

      • Gastroenterology And Hepatology
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  • Question 16 - A 70-year-old male diabetic presents with weakness and lethargy. He has been diagnosed...

    Incorrect

    • A 70-year-old male diabetic presents with weakness and lethargy. He has been diagnosed with type 2 diabetes mellitus for 10 years and is currently taking gliclazide, metformin, and atenolol for hypertension. On examination, there are no significant findings except for the following results: blood pressure of 160/90 mmHg while lying and standing, serum sodium of 135 mmol/L (137-144), non-haemolysed serum potassium of 5.7 mmol/L (3.5-5.5), urea of 8.3 mmol/L (2.5-7.5), serum creatinine of 141 µmol/L (60-110), plasma glucose of 10.1 mmol/L (3.0-6.0), and HbA1c of 62 mmol/mol (20-42) or 7.8% (3.8-6.4). He also has loss of pin prick and vibration sensation to the ankle in both legs and a background diabetic retinopathy. What could be the possible cause of these electrolyte abnormalities?

      Your Answer:

      Correct Answer: Hyporeninaemic hypoaldosteronism

      Explanation:

      Chronic Kidney Disease and Hyporeninaemic Hypoaldosteronism in Diabetic Patients

      Chronic kidney disease in diabetic patients is often related to diabetic nephropathy and hypertension. Electrolyte abnormalities, such as low sodium and high potassium levels, suggest a diagnosis of hyporeninaemic hypoaldosteronism, also known as type IV renal tubular acidosis. This condition is common in elderly diabetic patients and is associated with nephropathy. Hyperkalaemia, although usually mild, can be worsened by medications like beta blockers and ACE inhibitors.

      Diabetic nephropathy primarily affects the glomeruli and decreases renin production. Patients with diabetes may also have impaired potassium homeostasis due to insulin deficiency and autonomic neuropathy, which impairs beta2-mediated potassium influx into cells.

      Conservative measures like avoiding provocative agents and following a low potassium diet are usually effective in treating hyporeninaemic hypoaldosteronism. In refractory cases, small doses of fludrocortisone may be considered.

    • This question is part of the following fields:

      • Endocrinology, Diabetes And Metabolic Medicine
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  • Question 17 - A 49-year-old patient presents with a two-day history of worsening breathlessness and productive...

    Incorrect

    • A 49-year-old patient presents with a two-day history of worsening breathlessness and productive cough with purulent sputum. The patient has been smoking 20 cigarettes a day since the age of 18 and was recently diagnosed with chronic obstructive pulmonary disease by their general practitioner. This is the patient's first hospital admission. On examination, the patient is alert and oriented but cyanosed with a respiratory rate of 26 breaths per minute. The patient's temperature is 37.8°C, pulse is 100/minute, and blood pressure is 150/100 mmHg. Bilaterally reduced air entry is noted on chest auscultation, and the chest radiograph shows hyperinflated lung fields with a normal heart size and no pneumonic consolidation. Arterial blood gases on admission with 24% oxygen by nasal cannulae reveal a pH of 7.34, pO2 of 6.5 kPa, pCO2 of 6.8 kPa, and standard bicarbonate of 27 mmol/L. Nebulised bronchodilators are administered, and the FIO2 is increased to 28%. Repeat arterial blood gases after 30 minutes show a pH of 7.30, pO2 of 7.0 kPa, pCO2 of 8.5 kPa, and standard bicarbonate of 28 mmol/L. What is the next step in management for this patient?

      Your Answer:

      Correct Answer: Non-invasive positive pressure ventilation (NIPPV/NIV)

      Explanation:

      Treatment for Deteriorating ABGs and Respiratory Acidosis

      When a patient’s ABGs are deteriorating and they are experiencing an increasingly severe respiratory acidosis, it is important to act quickly. However, if the patient is still alert and haemodynamically stable, non-invasive ventilation (NIV) is the preferred treatment option. This can be achieved through the use of BiPAP, which should be initiated without delay. By providing NIV, the patient’s respiratory function can be supported and improved, helping to prevent further deterioration of their ABGs and respiratory acidosis. It is important to act quickly and effectively in these situations to ensure the best possible outcome for the patient.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 18 - A 35-year-old man presents with sudden fatigue and difficulty breathing. He reports injuring...

    Incorrect

    • A 35-year-old man presents with sudden fatigue and difficulty breathing. He reports injuring his foot on a rusty nail and noticing a red, spreading area around the wound. Two days later, he began experiencing chills and was brought to the hospital by his family.

      During the examination, the patient appears pale and sweaty with a capillary refill time of 4 seconds. His chest is clear, but he is breathing rapidly and shallowly. His heart rate is 123 beats per minute and regular, while his blood pressure is 85/65 mmHg. The wound on his foot is now raised and discolored, with pus collecting under the skin. His cannula site is also bleeding. He is given three liters of intravenous fluid and started on vancomycin and gentamicin.

      Hemoglobin: 130 g/L
      Platelets: 110 * 10^9/L
      White blood cells: 34.0 * 10^9/L
      C-reactive protein: 459 ng/mL
      Prothrombin time: 18 seconds
      Activated partial thromboplastin time: 45 seconds
      Fibrinogen: 0.1 g/L
      Chest X-ray: patchy bilateral infiltrates
      Wound swab: Streptococcus pyogenes

      What is the cause of the patient's abnormal coagulation?

      Your Answer:

      Correct Answer: Disseminated intravascular coagulopathy (DIC)

      Explanation:

      DIC is a possible consequence of sepsis-induced coagulation abnormalities.

      In the case of this patient, their coagulation has been affected by sepsis. It is unlikely that haemodilution would cause a significant decrease in fibrinogen levels. Haemophilia A is not a likely explanation for their condition.

      Understanding Disseminated Intravascular Coagulation

      Under normal conditions, the coagulation and fibrinolysis processes work together to maintain hemostasis. However, in cases of disseminated intravascular coagulation (DIC), these processes become dysregulated, leading to widespread clotting and bleeding. One of the critical factors in the development of DIC is the release of tissue factor (TF), a glycoprotein found on the surface of various cell types. TF is normally not in contact with the circulation but is exposed after vascular damage or in response to cytokines and endotoxins. Once activated, TF triggers the extrinsic pathway of coagulation, leading to the activation of the intrinsic pathway and the formation of clots.

      DIC can be caused by various factors, including sepsis, trauma, obstetric complications, and malignancy. Diagnosis of DIC typically involves a blood test that shows decreased platelet count and fibrinogen levels, prolonged prothrombin time and activated partial thromboplastin time, and increased fibrinogen degradation products. Microangiopathic hemolytic anemia may also be present, leading to the formation of schistocytes.

      Overall, understanding the pathophysiology and diagnosis of DIC is crucial for prompt and effective management of this potentially life-threatening condition.

    • This question is part of the following fields:

      • Haematology
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  • Question 19 - A 30-year-old female presents with a significant upper gastrointestinal bleed. She has been...

    Incorrect

    • A 30-year-old female presents with a significant upper gastrointestinal bleed. She has been vomiting frank blood over the past 48 hours. She has a history of chronic back pain and admits to taking ibuprofen over the recommended daily dosage, especially over the past three weeks due to a flare up of her pain.

      Upon examination, she appears pale and her abdomen is soft with localised tenderness to the epigastric region. Her blood pressure is 90/60 mmHg and pulse rate is 105 bpm.

      Hb 60 g/l
      Platelets 65 *109/l
      WBC 4.5 *109/l

      What is the optimal pre-endoscopy target haemoglobin range for blood transfusion in this patient's case to achieve the best overall outcome?

      Your Answer:

      Correct Answer: Target haemoglobin 70-80 g/l

      Explanation:

      Recent studies indicate that a conservative approach to blood transfusion during acute upper gastrointestinal bleeding leads to superior results when compared to a liberal approach. Notably, the restrictive transfusion strategy was found to enhance survival rates, decrease the likelihood of additional bleeding, lower the need for rescue therapy, and reduce the incidence of complications. Villanueva et al discovered that patients who received blood transfusions when their haemoglobin levels were below 70g/dL experienced better outcomes than those who were transfused when their levels were below 10g/dL.

      Acute upper gastrointestinal bleeding is a common and significant medical issue that can be caused by various conditions, with oesophageal varices and peptic ulcer disease being the most common. The main symptoms include haematemesis (vomiting of blood), melena (passage of altered blood per rectum), and a raised urea level due to the protein meal of the blood. The diagnosis can be determined by identifying the specific features associated with a particular condition, such as stigmata of chronic liver disease for oesophageal varices or abdominal pain for peptic ulcer disease.

      The differential diagnosis for acute upper gastrointestinal bleeding includes oesophageal, gastric, and duodenal causes. Oesophageal varices may present with a large volume of fresh blood, while gastric ulcers may cause low volume bleeds that present as iron deficiency anaemia. Duodenal ulcers are usually posteriorly sited and may erode the gastroduodenal artery. Aorto-enteric fistula is a rare but important cause of major haemorrhage associated with high mortality in patients with previous abdominal aortic aneurysm surgery.

      The management of acute upper gastrointestinal bleeding involves risk assessment using the Glasgow-Blatchford score, which helps clinicians decide whether patients can be managed as outpatients or not. Resuscitation involves ABC, wide-bore intravenous access, and platelet transfusion if actively bleeding platelet count is less than 50 x 10*9/litre. Endoscopy should be offered immediately after resuscitation in patients with a severe bleed, and all patients should have endoscopy within 24 hours. Treatment options include repeat endoscopy, interventional radiology, and surgery for non-variceal bleeding, while terlipressin and prophylactic antibiotics should be given to patients with variceal bleeding. Band ligation should be used for oesophageal varices, and injections of N-butyl-2-cyanoacrylate for patients with gastric varices. Transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures.

    • This question is part of the following fields:

      • Gastroenterology And Hepatology
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  • Question 20 - A 72-year-old woman who has been on long-term amiodarone therapy for paroxysmal AF...

    Incorrect

    • A 72-year-old woman who has been on long-term amiodarone therapy for paroxysmal AF presents to the clinic with complaints of increasing palpitations, weight loss, and heat intolerance over the past few months. During the examination, her blood pressure is 149/89 mmHg, pulse is 85 and regular, and she appears sweaty with a tremor. A TSH test reveals a measurement of 0.1 IU/L. What is the most effective way to differentiate between type 1 and type 2 Amiodarone-induced thyrotoxicosis (AIT)?

      Your Answer:

      Correct Answer: Colour flow Doppler of the thyroid

      Explanation:

      Differentiating Type 1 and Type 2 Autoimmune Thyroiditis

      Autoimmune thyroiditis (AIT) can be classified into two types: type 1 and type 2. Type 2 AIT is an autoimmune disorder that affects the thyroid gland. To differentiate between the two types, various diagnostic tools have been investigated, including colour flow Doppler and interleukin 6 (IL-6) levels. Studies have shown that colour flow Doppler is a superior tool compared to IL-6 in distinguishing between the two types of AIT. Although IL-6 levels may be elevated in type 2 AIT, it is not always the case and may also be raised by other non-thyroidal illnesses. On the other hand, IL-1, free T3, and TBG are not as useful in differentiating between the two types of AIT. It is important to differentiate between type 1 and type 2 AIT as it affects the choice of therapy, particularly the use of corticosteroids.

    • This question is part of the following fields:

      • Endocrinology, Diabetes And Metabolic Medicine
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  • Question 21 - A 32-year-old man presents with fatigue, weight loss, and lethargy. He recently lost...

    Incorrect

    • A 32-year-old man presents with fatigue, weight loss, and lethargy. He recently lost his job and has been prescribed citalopram for depression. He has no significant medical history and follows a vegetarian diet. Blood tests reveal a hemoglobin level of 108 g/L, mean corpuscular volume of 81 fL, and ferritin level of 15 µg/L. The patient is worried about his anemia and wants to know the best course of action based on the British Society of Gastroenterology guidelines for managing iron deficiency anemia.

      What is the most appropriate management plan for this patient?

      Your Answer:

      Correct Answer: Refer for further investigation

      Explanation:

      Evaluation and Investigation for Iron Deficiency Anaemia

      This individual is experiencing significant anaemia and has biochemical evidence of iron deficiency, as indicated by low serum ferritin levels. It is important to note that Postmenopausal women and all men with evidence of iron deficiency anaemia require further evaluation and investigation to exclude gastrointestinal cancer.

      According to the British Society of Gastroenterology guidance, patients with marked anaemia (less than 120 g/L in men and less than 100 g/L in women) should be referred urgently as lower levels of haemoglobin reflect more severe disease. It is unlikely that an iron deficient diet can explain the degree of anaemia and iron deficiency in this man. However, vegetarian diets can provide sufficient iron if they are varied enough.

      Reassurance or watch-and-wait approaches are not appropriate options for this gentleman who has a marked iron deficiency anaemia. While a trial of oral iron may improve haematological and biochemical markers, it will not help determine the underlying cause, which must be identified.

    • This question is part of the following fields:

      • Gastroenterology And Hepatology
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  • Question 22 - A 72-year-old male presents as an acute admission at 2 am with confusion...

    Incorrect

    • A 72-year-old male presents as an acute admission at 2 am with confusion and diarrhoea. Little is known of his past medical history except that it is noted on the GP letter that he is receiving treatment for manic depression and hypothyroidism.

      Examination reveals that he has a Glasgow coma scale of 14 as he is confused. He is thin, unkempt and dehydrated with a temperature of 37°C. He has a pulse of 82 beats per minute in a regular rhythm and a blood pressure of 112/72 mmHg. He is noted to have a coarse tremor and dysarthric speech.

      What investigations would be helpful in the immediate setting?

      Your Answer:

      Correct Answer: Serum electrolytes and renal function

      Explanation:

      Possible Causes of Electrolyte Disturbance in a Patient with Bipolar Disorder

      This patient is experiencing electrolyte disturbance, which could be caused by various factors. One possible cause is dehydration resulting from diarrhoea. However, the patient is also undergoing treatment for bipolar disorder, which may involve lithium therapy. Lithium toxicity can lead to diarrhoea, as well as other symptoms such as tremors and dysarthria. In this case, all of the patient’s symptoms could be attributed to lithium toxicity, which may be exacerbated by dehydration. While taking lithium levels can help diagnose the issue, it may not be entirely reliable in the acute setting, especially with sustained release preparations.

      The management of lithium toxicity is primarily supportive. The first step is to assess the patient’s renal function and correct any electrolyte imbalances. This is crucial in determining the patient’s ability to excrete lithium. With proper management, the patient’s symptoms can be alleviated, and their electrolyte levels can be restored to normal.

    • This question is part of the following fields:

      • Clinical Pharmacology And Therapeutics
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  • Question 23 - A 75-year-old man is brought to the hospital in cardiac arrest. He has...

    Incorrect

    • A 75-year-old man is brought to the hospital in cardiac arrest. He has a history of hypertension and diabetes and was found by his daughter on the floor at home. She called the emergency services, and when the paramedics arrived, the patient was unconscious with no respiratory effort or cardiac output. He was cannulated and intubated while automated defibrillator paddles were attached. He is brought immediately to the Emergency department.

      The patient is transferred onto the Emergency department trolley in the resuscitation area. The monitor is reattached, and the patient remains in VF. The Emergency department nurse is providing good chest compressions. The paramedics hand over that they have not yet administered any shocks. As the team leader, you instruct one shock to be given, after confirming the rhythm.

      What is the next immediate management step in this resuscitation situation after the shock is given?

      Your Answer:

      Correct Answer: Immediately restart chest compressions

      Explanation:

      UK Resuscitation Council Guidelines for ALS Shockable Rhythm Algorithms

      The UK Resuscitation Council published new guidelines in 2010, which replaced the 2005 guidelines for ALS shockable rhythm algorithms. However, the current guidelines are broadly in line with the previous ones. According to the guidelines, the best chance of survival is with rapid defibrillation (when appropriate) and minimal interruption of chest compressions. After the first shock (and each subsequent shock), chest compressions should be restarted immediately, and pulse and rhythm should be reassessed after two minutes.

      Adrenaline is given after the third shock and then every three to five minutes. Amiodarone is given after the third shock. These guidelines emphasize the importance of timely and effective interventions to improve the chances of survival in patients with shockable rhythms. By following these guidelines, healthcare professionals can provide optimal care to patients in cardiac arrest.

    • This question is part of the following fields:

      • Cardiology
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  • Question 24 - A 39-year-old man is admitted to the hospital after ingesting a staggered paracetamol...

    Incorrect

    • A 39-year-old man is admitted to the hospital after ingesting a staggered paracetamol overdose during a heated argument with his partner. He initially appears stable and is given N-acetylcysteine. However, after 24 hours, he becomes confused and his condition worsens. The medical team is awaiting the results of further blood tests and considering the possibility of a liver transplant. What specific factor would warrant this course of action?

      Your Answer:

      Correct Answer:

      Explanation:

      The correct criterion for considering liver transplantation in cases of paracetamol overdose is an arterial pH level below 7.3. The King’s College Hospital criteria identify two groups of patients with poor prognosis after paracetamol overdose: those with an arterial pH level below 7.3 more than 24 hours after ingestion, and those with elevated creatinine levels (>300 µmol/l), prolonged prothrombin time (>100 seconds), and grade III/IV encephalopathy. Therefore, only an arterial pH level below 7.3 alone would warrant consideration for transplantation. Elevated creatinine levels, grade III/IV encephalopathy, and prolonged prothrombin time must all be present together to meet the criteria. The criteria do not take into account whether the overdose was staggered or required N-acetylcysteine infusion.

      Paracetamol overdose management guidelines were reviewed by the Commission on Human Medicines in 2012. The new guidelines removed the ‘high-risk’ treatment line on the nomogram, meaning that all patients are treated the same regardless of risk factors for hepatotoxicity. However, the National Poisons Information Service/TOXBASE should be consulted for situations outside of the normal parameters. Activated charcoal may be given to patients who present within 1 hour to reduce drug absorption. Acetylcysteine should be given if the plasma paracetamol concentration is on or above a single treatment line, there is a staggered overdose, or patients present 8-24 hours after ingestion of an acute overdose of more than 150 mg/kg of paracetamol. Acetylcysteine should also be continued if the paracetamol concentration or ALT remains elevated while seeking specialist advice. The infusion time for acetylcysteine has been increased to 1 hour to reduce adverse effects. Anaphylactoid reactions to IV acetylcysteine are generally treated by stopping the infusion and restarting at a slower rate. The King’s College Hospital criteria for liver transplantation in paracetamol liver failure include arterial pH < 7.3, prothrombin time > 100 seconds, creatinine > 300 µmol/l, and grade III or IV encephalopathy.

    • This question is part of the following fields:

      • Clinical Pharmacology And Therapeutics
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  • Question 25 - A 65-year-old male patient presents to the outpatient department with complaints of tiredness,...

    Incorrect

    • A 65-year-old male patient presents to the outpatient department with complaints of tiredness, lethargy, sweats, and weight loss over the past six months. He also reports diminished libido and erectile dysfunction. On examination, he appears pale with a resting pulse of 108 bpm and a bounding pulse. His blood pressure is 122/82 mmHg, and he has a smooth goitre. The GP has conducted several investigations, including haemoglobin, white cell count, platelets, sodium, potassium, urea, creatinine, alkaline phosphatase, calcium, TSH, free T4, and free T3. Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: TSH secreting pituitary tumour

      Explanation:

      Thyrotropinoma: A Rare Type of Pituitary Tumour

      Thyrotropinoma is a rare type of pituitary tumour that accounts for less than 1% of cases. The majority of cases are macroadenomas. Patients with thyrotropinoma typically present with features of thyrotoxicosis, including sweating, weight loss, lethargy, tachycardia, potential hypopituitarism, erectile dysfunction, diminished libido, and hyponatraemia. Biochemical features that suggest the diagnosis include elevated thyroid-stimulating hormone (TSH) in the context of elevated thyroxine (T4) and tri-iodothyronine (T3). Elevated alkaline phosphatase is consistent with thyrotoxicosis, and hyponatraemia suggests hypoadrenalism.

      The appropriate management for thyrotropinoma includes biochemical evaluation of pituitary function, MRI imaging of the pituitary gland, and formal evaluation of visual fields. It is important to note that the biochemistry is not consistent with Graves’ disease, where a suppressed TSH would be expected.

    • This question is part of the following fields:

      • Endocrinology, Diabetes And Metabolic Medicine
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  • Question 26 - An 82-year-old man presents to the respiratory clinic with poorly controlled COPD despite...

    Incorrect

    • An 82-year-old man presents to the respiratory clinic with poorly controlled COPD despite being prescribed inhaled salbutamol. He reports consistent breathlessness on minimal exertion, which is limiting his daily activities. There is no diurnal variation in his symptoms. He has a significant smoking history of 50 pack years and a past medical history of hypertension treated with ramipril. Recent blood tests show normal hemoglobin, platelets, and white blood cell count with a slightly elevated neutrophil count. The lymphocyte and eosinophil counts are within normal limits.

      What would be the most appropriate initial management for this patient?

      Your Answer:

      Correct Answer: Add a long acting beta agonist + muscarinic antagonist (LABA + LAMA)

      Explanation:

      If a patient with COPD is still experiencing breathlessness despite using a SABA/SAMA, the next step in management depends on whether they exhibit asthma/steroid-responsive features. In the absence of any history of asthma/atopy, diurnal variation in symptoms, or an elevated eosinophil count, it is unlikely that the patient is steroid responsive. Therefore, the most appropriate second-line treatment would be to add a LABA + LAMA, rather than using leukotriene receptor antagonists or ICS. Prophylactic antibiotics may be considered for patients with recurrent infective exacerbations, but this is not applicable in this case. It is premature to assess for long-term oxygen therapy until the patient is on optimal medical therapy.

      The National Institute for Health and Care Excellence (NICE) updated its guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2018. The guidelines recommend general management strategies such as smoking cessation advice, annual influenza vaccination, and one-off pneumococcal vaccination. Pulmonary rehabilitation is also recommended for patients who view themselves as functionally disabled by COPD.

      Bronchodilator therapy is the first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators. The next step is determined by whether the patient has asthmatic features or features suggesting steroid responsiveness. NICE suggests several criteria to determine this, including a previous diagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time, and substantial diurnal variation in peak expiratory flow.

      If the patient does not have asthmatic features or features suggesting steroid responsiveness, a long-acting beta2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) should be added. If the patient is already taking a short-acting muscarinic antagonist (SAMA), it should be discontinued and switched to a short-acting beta2-agonist (SABA). If the patient has asthmatic features or features suggesting steroid responsiveness, a LABA and inhaled corticosteroid (ICS) should be added. If the patient remains breathless or has exacerbations, triple therapy (LAMA + LABA + ICS) should be offered.

      NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients who have optimised standard treatments and continue to have exacerbations. Mucolytics should be considered in patients with a chronic productive cough and continued if symptoms improve.

      Cor pulmonale features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, and loud P2. Loop diuretics should be used for oedema, and long-term oxygen therapy should be considered. Smoking cessation, long-term oxygen therapy in eligible patients, and lung volume reduction surgery in selected patients may improve survival in patients with stable COPD. NICE does not recommend the use of ACE-inhibitors, calcium channel blockers, or alpha blockers

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 27 - A 32-year-old woman presents to the endocrinology department with neck pain and abnormal...

    Incorrect

    • A 32-year-old woman presents to the endocrinology department with neck pain and abnormal thyroid function tests. She has a medical history of bipolar disorder and takes lithium. She smokes five cigarettes daily and is currently unemployed. Six weeks ago, she gave birth to her first child and has recently recovered from a cold. She is not breastfeeding. On examination, there is a tender swelling in her neck, and she is sweaty, mildly tremulous, and tachycardic. Blood tests reveal a low TSH and high free T4, and a radioactive iodine uptake scan shows globally reduced uptake of iodine-131. What is the likely diagnosis?

      Your Answer:

      Correct Answer: De Quervain's thyroiditis

      Explanation:

      The correct diagnosis for this woman is De Quervain’s thyroiditis, which is characterized by initial hyperthyroidism, painful goitre, and globally reduced uptake of iodine-131. These symptoms are consistent with viral subacute thyroiditis, which is often preceded by a coryzal illness and elevated inflammatory markers such as CRP. Factitious hyperthyroidism, Grave’s disease, and lithium-associated thyroiditis are not the correct diagnoses based on the presented symptoms.

      Understanding Subacute (De Quervain’s) Thyroiditis

      Subacute thyroiditis, also known as De Quervain’s thyroiditis and subacute granulomatous thyroiditis, is a condition that is believed to occur after a viral infection. It is characterized by hyperthyroidism, a painful goitre, and raised ESR during the first phase, which lasts for 3-6 weeks. The second phase, which lasts for 1-3 weeks, is characterized by euthyroidism, while the third phase, which lasts for weeks to months, is characterized by hypothyroidism. The fourth phase is when the thyroid structure and function return to normal.

      To diagnose subacute thyroiditis, a thyroid scintigraphy is usually performed, which shows a globally reduced uptake of iodine-131. Treatment for subacute thyroiditis is usually not required, as the condition is self-limiting. However, if thyroid pain is present, it may respond to aspirin or other NSAIDs. In more severe cases, steroids may be used, particularly if hypothyroidism develops.

      It is important to note that many causes of hypothyroidism may have an initial thyrotoxic phase, as shown in the Venn diagram. Therefore, it is crucial to seek medical attention if any symptoms of thyroid dysfunction are present.

    • This question is part of the following fields:

      • Endocrinology, Diabetes And Metabolic Medicine
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  • Question 28 - A 26-year-old woman is ready to leave the hospital after being admitted for...

    Incorrect

    • A 26-year-old woman is ready to leave the hospital after being admitted for four days due to feeling unwell for a month with symptoms of vomiting, postural dizziness, and weight loss. Addison's disease was diagnosed after a Synacthen test, and she was prescribed hydrocortisone three times a day and fludrocortisone daily. She has no medical history or prior treatments. Her hydrocortisone doses are 10mg at 09:00 and 5mg at 12:00 and 15:00. She mentions to the medical team that she occasionally works night shifts. What is the appropriate advice regarding steroid dosing for night shifts?

      Your Answer:

      Correct Answer: Adjust to take first dose at waking, then doses at three hours and six hours from starting

      Explanation:

      Patients with Addison’s disease require replacement of both glucocorticoid and mineralocorticoid. As cortisol levels follow a diurnal rhythm, with the highest levels in the morning and lowest levels between midnight and 4 am, replacement therapy should aim to mimic this natural pattern. Typically, replacement doses are divided into three, with the first dose taken upon waking, followed by doses at midday and early afternoon. When patients have a shift in their daily routine, such as working night shifts or traveling, they should continue to take their morning dose upon waking and maintain the same dosing schedule. Patients should be advised against skipping doses and encouraged to ensure they always have an adequate supply of medication.

      Addison’s disease is a condition that requires patients to undergo glucocorticoid and mineralocorticoid replacement therapy. This treatment involves taking a combination of hydrocortisone and fludrocortisone. Hydrocortisone is usually given in 2 or 3 divided doses, with patients requiring 20-30 mg per day, mostly in the first half of the day. Fludrocortisone is also included in the treatment regimen. Patient education is crucial in managing Addison’s disease. Patients should be reminded not to miss glucocorticoid doses, and they may consider wearing Medic Alert bracelets and steroid cards. Additionally, patients should be provided with hydrocortisone for injection with needles and syringes to treat an adrenal crisis. It is also important to discuss how to adjust the glucocorticoid dose during an intercurrent illness.

      During an intercurrent illness, the glucocorticoid dose should be doubled, while the fludrocortisone dose remains the same. The Addison’s Clinical Advisory Panel has produced guidelines that detail specific scenarios for managing intercurrent illness. These guidelines can be found on the CKS link for more information. Proper management of Addison’s disease is essential to ensure that patients receive the appropriate treatment and care they need to manage their condition effectively.

    • This question is part of the following fields:

      • Endocrinology, Diabetes And Metabolic Medicine
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  • Question 29 - A 62-year-old male with known myasthenia gravis reports a recent increase in fatigue...

    Incorrect

    • A 62-year-old male with known myasthenia gravis reports a recent increase in fatigue and decreased ability to exercise. During the examination, he presents with a weak voice, difficulty completing sentences, and a slightly slumped posture. What is the primary investigation needed during this acute phase?

      Your Answer:

      Correct Answer: Forced vital capacity (FVC)

      Explanation:

      The patient is at risk of a myasthenic crisis, which can lead to respiratory distress due to respiratory muscle failure. Other symptoms may include weakness, dysphonia, and dysphagia. Forced vital capacity is the most reliable way to assess inspiratory and expiratory mechanisms, while FEV1 is better suited for detecting obstructive rather than respiratory muscle strength. While blood tests and chest radiography may help identify an underlying infection, the immediate concern is the potential for respiratory deterioration, which may require intubation.

      Myasthenia gravis is an autoimmune disorder that results in muscle weakness and fatigue, particularly in the eyes, face, neck, and limbs. It is more common in women and is associated with thymomas and other autoimmune disorders. Diagnosis is made through electromyography and testing for antibodies to acetylcholine receptors. Treatment includes acetylcholinesterase inhibitors and immunosuppression, and in severe cases, plasmapheresis or intravenous immunoglobulins may be necessary.

    • This question is part of the following fields:

      • Respiratory Medicine
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  • Question 30 - A 30-year-old woman has been diagnosed with hereditary angioedema and is scheduled for...

    Incorrect

    • A 30-year-old woman has been diagnosed with hereditary angioedema and is scheduled for an elective meniscal repair on her left knee. She has not experienced any recent changes in her health or medication. What is the preferred prophylactic drug for hereditary angioedema before her procedure?

      Your Answer:

      Correct Answer: Tranexamic acid

      Explanation:

      Tranexamic acid is the most appropriate medication for hereditary angioedema.

      When treating hereditary angioedema, the following medications can be used:
      C1-esterase inhibitor can be used for short-term prophylaxis before procedures or to stop acute attacks of hereditary angioedema. Conestat alfa and icatibant are approved for treating acute attacks of hereditary angioedema in adults with C1-esterase inhibitor deficiency. Tranexamic acid and danazol are used for short-term and long-term prophylaxis.

      Glucocorticoids have no role in this case.

      Understanding Hereditary Angioedema

      Hereditary angioedema (HAE) is a genetic condition that is inherited in an autosomal dominant manner. It is characterized by low levels of the C1 inhibitor protein, which is responsible for regulating the release of bradykinin in the body. When there is uncontrolled release of bradykinin, it can lead to swelling of tissues, causing painful and non-pruritic swelling of subcutaneous/submucosal tissues. HAE attacks can affect various parts of the body, including the upper airways, skin, and abdominal organs.

      To diagnose HAE, doctors typically measure the levels of C1-INH, C2, and C4 proteins in the blood. During an attack, the C1-INH level is usually low, while low C2 and C4 levels can be seen even between attacks. Serum C4 is the most reliable and widely used screening tool.

      When it comes to managing HAE, there is no cure for the condition. However, there are treatments available to help manage the symptoms. During an acute attack, HAE does not respond to adrenaline, antihistamines, or glucocorticoids. Instead, IV C1-inhibitor concentrate or fresh frozen plasma (FFP) may be used. For prophylaxis, anabolic steroid Danazol may be prescribed to help prevent attacks.

      Overall, understanding HAE is important for individuals who may be at risk for the condition. By recognizing the symptoms and seeking appropriate medical care, individuals with HAE can manage their condition and improve their quality of life.

    • This question is part of the following fields:

      • Haematology
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