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Question 1
Correct
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Which of the following relating to St John's Wort is not true?
Your Answer: Causes inhibition of the P450 system
Explanation:The P450 system is known to be induced by St John’s Wort.
St John’s Wort: An Alternative Treatment for Mild-Moderate Depression
St John’s Wort has been found to be as effective as tricyclic antidepressants in treating mild-moderate depression. Its mechanism of action is thought to be similar to SSRIs, although it has also been shown to inhibit noradrenaline uptake. However, the National Institute for Health and Care Excellence (NICE) advises against its use due to uncertainty about appropriate doses, variation in the nature of preparations, and potential serious interactions with other drugs.
In clinical trials, the adverse effects of St John’s Wort were similar to those of a placebo. However, it can cause serotonin syndrome and is an inducer of the P450 system, which can lead to decreased levels of drugs such as warfarin and ciclosporin. Additionally, the effectiveness of the combined oral contraceptive pill may be reduced.
Overall, St John’s Wort may be a viable alternative treatment for those with mild-moderate depression. However, caution should be exercised due to potential interactions with other medications and the lack of standardization in dosing and preparation. It is important to consult with a healthcare professional before starting any new treatment.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 2
Incorrect
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A 28-year-old G1P0 woman attends her routine antenatal appointment at 12 weeks gestation and reports experiencing burning retrosternal pain. Omeprazole is prescribed, and a urine sample is taken. The urinalysis shows trace protein with no haematuria, nitrates, or white cells, and the patient denies any urinary symptoms. During the appointment, her blood pressure is measured at 135/88 mmHg. Upon further testing, the urine sample is found to have scant growth of Escherichia coli. What is the most appropriate course of action?
Your Answer: Reassure and advise the woman to reattend for antibiotics if she develops urinary symptoms
Correct Answer: Prescribe a 7 day course of nitrofurantoin
Explanation:Asymptomatic bacteriuria in pregnant women should be treated promptly with antibiotics. The recommended treatment is a 7-day course of nitrofurantoin. This is important to prevent the development of symptomatic urinary tract infection or pyelonephritis. Nitrofurantoin is safe to use in the first and second trimester, but should be avoided in the third trimester due to the risk of neonatal haemolysis. The patient’s blood pressure is within normal range and does not require treatment. The trace of protein in her urine is likely related to her asymptomatic bacteriuria and should be monitored with subsequent urine dips. Antihypertensive treatment is not necessary based on the trace of protein alone. Prescribing a 7-day course of trimethoprim is not recommended as it is contraindicated in the first trimester of pregnancy due to the increased risk of neural-tube defects. Prescribing aspirin, labetalol, and a 7-day course of nitrofurantoin is not necessary as the patient does not meet the diagnostic criteria for pre-eclampsia or pregnancy-induced hypertension. Similarly, prescribing aspirin, labetalol, and a 7-day course of trimethoprim is not recommended for the same reasons.
Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is teratogenic in the first trimester. Asymptomatic bacteriuria in pregnant women should also be treated to prevent progression to acute pyelonephritis. Men with UTIs should be offered a seven-day course of trimethoprim or nitrofurantoin unless prostatitis is suspected. A urine culture should be sent before antibiotics are started. Catheterised patients should not be treated for asymptomatic bacteria, but if symptomatic, a seven-day course of antibiotics should be given. Acute pyelonephritis requires hospital admission and treatment with a broad-spectrum cephalosporin or quinolone for 10-14 days. Referral to urology is not routinely required for men who have had one uncomplicated lower UTI.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 3
Incorrect
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A 30-year-old woman has delivered a baby boy at 40 + 2 weeks gestation. She is now 3 weeks postpartum and is exclusively breastfeeding with plans to continue for at least 6 months. What contraceptive method should she avoid due to absolute contraindication?
Your Answer: Natural birth control
Correct Answer: Combined contraceptive pill
Explanation:Understanding Contraception: A Basic Overview
Contraception has come a long way in the past 50 years, with the development of effective methods being one of the most significant advancements in medicine. There are various types of contraception available, including barrier methods, daily methods, and long-acting methods of reversible contraception (LARCs).
Barrier methods, such as condoms, physically block sperm from reaching the egg. While they can help protect against sexually transmitted infections (STIs), their success rate is relatively low, particularly when used by young people.
Daily methods include the combined oral contraceptive pill, which inhibits ovulation, and the progesterone-only pill, which thickens cervical mucus. However, the combined pill increases the risk of venous thromboembolism and breast and cervical cancer.
LARCs include implantable contraceptives and injectable contraceptives, which both inhibit ovulation and thicken cervical mucus. The implantable contraceptive lasts for three years, while the injectable contraceptive lasts for 12 weeks. The intrauterine system (IUS) and intrauterine device (IUD) are also LARCs, with the IUS preventing endometrial proliferation and thickening cervical mucus, and the IUD decreasing sperm motility and survival.
It is important to note that each method of contraception has its own set of benefits and risks, and it is essential to consult with a healthcare provider to determine the best option for individual needs and circumstances.
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This question is part of the following fields:
- Reproductive Medicine
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Question 4
Correct
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A 35-year-old man presents with a swollen, erythematous finger and right axillary tenderness, 24 hours after being bitten by his pet dog.
Which of the following is the best treatment?Your Answer: Co-amoxiclav
Explanation:Antibiotics for Dog Bite Infections: Recommended and Not Recommended Options
Dog bites can lead to infections caused by various micro-organisms, including anaerobic mouth flora and bacteria. Co-amoxiclav, a combination of amoxicillin and clavulanic acid, is the recommended antibiotic for dog bite-related infections, as it is effective against the most likely organisms. Fluconazole, an antifungal agent, is not indicated for such infections, as fungal micro-organisms in dogs usually cause only superficial skin rashes. Metronidazole, although effective against anaerobic bacteria, is not recommended for dog bite-related infections, except for patients allergic to penicillin. Aciclovir is not used for dog bite-related infections, as it is restricted to treating varicella-zoster and herpes zoster. Flucloxacillin, although recommended for skin infections, is not active against anaerobic bacteria and is not recommended for dog bite-related infections.
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This question is part of the following fields:
- Infectious Diseases
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Question 5
Correct
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A 25-year-old woman presents to her GP with recurrent, foul-smelling discharge from her right ear and decreased hearing on that side. She has been experiencing these episodes every few months, but now notices the discharge on most days. During childhood, she frequently swam and had grommet insertion for glue ear, which fell out when she was around 10 years old. She has no significant medical history and takes only the combined oral contraceptive pill.
After conducting hearing tests, the following results were obtained:
- Rinne's test (right side): bone conduction > air conduction
- Rinne's test (left side): air conduction > bone conduction
- Weber's test: lateralisation to the right
What is the likely diagnosis?Your Answer: Cholesteatoma
Explanation:The patient is experiencing a conductive hearing loss on the right side, as evidenced by Rinne’s test showing bone conduction > air conduction in the affected ear and Weber’s test lateralizing to the right ear. The most likely diagnosis is cholesteatoma, which is associated with recurrent ear discharge and glue ear. Cholesteatoma occurs when squamous epithelium forms pockets on the tympanic membrane, leading to cyst-like growths that produce keratin and slough over time. This causes erosion in the middle ear, creating an environment for anaerobic bacterial growth.
Acoustic neuroma, on the other hand, causes sensorineural hearing loss, which is characterized by air conduction > bone conduction in both ears and Weber test lateralizing to the unaffected ear. It is associated with dizziness and typically causes unilateral hearing loss. As the tumor grows, patients may develop neurological symptoms that can be predicted by the affected cranial nerves.
Otitis externa is an acute infection of the outer ear that can cause conductive hearing loss, but as the patient has a chronic history and lacks ear pain, this diagnosis is less likely. Otosclerosis, which presents with progressive conductive hearing loss and tinnitus, is an autosomal dominant trait that typically affects individuals aged 20-40 years with a family history of early-onset hearing loss. As it does not typically present with smelly ear discharge, other diagnoses should be considered first.
Rinne’s and Weber’s Test for Differentiating Conductive and Sensorineural Deafness
Rinne’s and Weber’s tests are two diagnostic tools used to differentiate between conductive and sensorineural deafness. Rinne’s test involves placing a tuning fork over the mastoid process until the sound is no longer heard, then repositioning it just over the external acoustic meatus. A positive test indicates that air conduction (AC) is better than bone conduction (BC), while a negative test suggests conductive deafness if BC is greater than AC.
On the other hand, Weber’s test involves placing a tuning fork in the middle of the forehead equidistant from the patient’s ears and asking which side is loudest. In unilateral sensorineural deafness, sound is localized to the unaffected side, while in unilateral conductive deafness, sound is localized to the affected side.
To interpret the results of Rinne’s and Weber’s tests, a normal result indicates that AC is greater than BC bilaterally, and the sound is midline in Weber’s test. Conductive hearing loss is indicated by BC being greater than AC in the affected ear, while AC is greater than BC in the unaffected ear, and the sound lateralizes to the affected ear in Weber’s test. Sensorineural hearing loss is indicated by AC being greater than BC bilaterally, and the sound lateralizes to the unaffected ear in Weber’s test.
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This question is part of the following fields:
- ENT
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Question 6
Correct
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The parents of a 15-month-old boy visit their GP with concerns about his eyes. They have noticed that in some photos there is no 'red eye' on the right side. Upon examination, the boy is found to have an esotropic strabismus and a loss of the red-reflex in the right eye. There is a family history of a grandparent who had an enucleation as a child.
What is the probable diagnosis?Your Answer: Retinoblastoma
Explanation:The absence of the red-reflex may be a symptom of a congenital cataract, but this condition is typically identified at birth or during routine infant screenings. Additionally, a congenital cataract would not account for the familial history of enucleation.
Retinoblastoma is a prevalent type of eye cancer that is commonly found in children, with an average age of diagnosis at 18 months. It is caused by a loss of function of the retinoblastoma tumor suppressor gene on chromosome 13, which is inherited in an autosomal dominant pattern. About 10% of cases are hereditary. The most common presenting symptom is the absence of red-reflex, which is replaced by a white pupil (leukocoria). Other possible features include strabismus and visual problems.
When it comes to managing retinoblastoma, enucleation is not the only option. Depending on how advanced the tumor is, other treatment options include external beam radiation therapy, chemotherapy, and photocoagulation. The prognosis for retinoblastoma is excellent, with over 90% of patients surviving into adulthood.
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This question is part of the following fields:
- Paediatrics
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Question 7
Correct
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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.
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This question is part of the following fields:
- Cardiovascular
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Question 8
Correct
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A 75-year-old woman with age-related macular degeneration (AMD) presented to the emergency department with a painless bloodshot right eye. She was very worried about her condition. The previous day, she had received an intravitreal injection for the treatment of AMD. Upon examination, her visual acuity had not decreased further, but there was bleeding under the conjunctiva around the injection site. What is the probable diagnosis?
Your Answer: Subconjunctival haemorrhage
Explanation:It is important to inform patients about the possibility of developing subconjunctival haemorrhage after receiving intravitreal injections, as it is a common iatrogenic complication. This condition causes a red eye but is not painful and typically resolves within a couple of weeks.
Understanding Subconjunctival Haemorrhage
Subconjunctival haemorrhage occurs when blood vessels bleed into the subconjunctival space, usually those that supply the conjunctiva or episclera. Trauma is the most common cause, followed by spontaneous idiopathic cases, Valsalva manoeuvres, and several systemic diseases. Although subconjunctival haemorrhages can look alarming, they are rarely an indicator of anything sinister.
Subconjunctival haemorrhages are more common in women than in men when there has been no history of trauma. The annual incidence of non-traumatic subconjunctival haemorrhages is 0.6%, and the risk increases with age as the risk factors are more common in elderly patients. Newborns are also more susceptible. The incidence of both traumatic and non-traumatic subconjunctival haemorrhages is 2.6%.
The most common causes of subconjunctival haemorrhages are trauma and contact lens usage, which are often the sole risk factor in younger patients. Other risk factors include idiopathic causes, Valsalva manoeuvre, hypertension, bleeding disorders, drugs such as aspirin, NSAIDs and anticoagulants, diabetes, arterial disease, and hyperlipidaemia.
Subconjunctival haemorrhages are mostly asymptomatic, but patients may experience mild irritation. The main sign is a flat, red patch on the conjunctiva with well-defined edges and normal conjunctiva surrounding it. Traumatic haemorrhages are most common in the temporal region, with the inferior conjunctiva as the next most commonly affected area. Vision should be normal, including acuity, visual fields, and range of eye movements. On examination, the fundus should be normal.
The diagnosis of a subconjunctival haemorrhage is a clinical one. If there is no obvious traumatic cause, check the patient’s blood pressure. If raised, refer the patient appropriately. If the patient is taking warfarin, check the INR. If raised, refer for appropriate adjustments to the dose to bring the INR back into the target range. Recurrent or spontaneous, bilateral subconjunctival haemorrhages warrant investigations for bleeding disorders or other pathology.
Reassure the patient that subconjunctival haemorrhage is a benign condition that will resolve on its own in 2 to
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This question is part of the following fields:
- Ophthalmology
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Question 9
Correct
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A 50-year-old woman, who is currently four weeks into a course of postoperative radiotherapy for locally advanced cervical carcinoma, is admitted with abdominal pain and diarrhoea.
Which of the following is the most likely cause of the clinical picture?Your Answer: Radiation enteritis
Explanation:Understanding Radiation Enteritis and Other Possible Causes of Bowel Symptoms
Radiation enteritis is a condition that occurs when the bowel becomes inflamed due to radiation therapy. It can manifest as ileitis, colitis, or proctitis, and can be acute or chronic. Acute radiation enteritis typically occurs during therapy and presents with symptoms such as anorexia, diarrhoea, and abdominal pain. Chronic radiation enteritis, on the other hand, can develop months or years after treatment and may cause weight loss, steatorrhoea, and small bowel obstruction.
While radiation enteritis is a likely cause of bowel symptoms in patients who have undergone radiation therapy, other conditions should also be considered. Bowel obstruction, for example, can cause nausea, vomiting, and bloating, but does not typically cause diarrhoea. Local malignant infiltration to the bowel may present with obstruction, while bowel perforation is a medical emergency that causes peritonitis and sepsis.
In summary, understanding the possible causes of bowel symptoms is important in determining the appropriate treatment for patients. While radiation enteritis is a common consequence of radiation therapy, other conditions such as bowel obstruction, local malignant infiltration, and bowel perforation should also be considered.
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This question is part of the following fields:
- Haematology/Oncology
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Question 10
Correct
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A 70-year-old man presents to his GP with a nodular change on his back. He complains that it has become itchy and bleeding over the past two months. On examination, it appears black and blue in colour with a slightly irregular border.
Which of the following is the most likely cause?
Your Answer: Malignant melanoma
Explanation:Common Skin Lesions and Malignancies: Types and Characteristics
Skin lesions and malignancies are common conditions that affect people of all ages. Among the most prevalent types are malignant melanoma, actinic keratosis, guttate psoriasis, lentigo maligna, and seborrhoeic keratosis. Each of these conditions has distinct characteristics that can help in their diagnosis and management.
Malignant Melanoma: This is a type of skin cancer that arises from melanocytes in the skin. It can present as a black or brown lesion with asymmetrical shape, irregular border, multiple colors, and diameter greater than 6mm. Any change in size, shape, color, or symptoms such as bleeding or itching should be evaluated promptly.
Actinic Keratosis: This is a sun-induced lesion that can become malignant. It appears as a scaly or hyperkeratotic lesion with a brown or hyperpigmented base. It commonly occurs on the head, neck, forearms, and hands.
Guttate Psoriasis: This is a skin condition that causes multiple lesions. It can present as scaly, hyperpigmented, or scaly lesions that are usually brown with a scaly base.
Lentigo Maligna: This is an early form of melanoma that is confined to the epidermis. It presents as a slowly growing or changing patch of discolored skin that resembles freckles or brown marks. It can grow to several centimeters over several years or decades.
Seborrhoeic Keratosis: This is a harmless, pigmented growth that commonly occurs with age. It appears as a raised, often pigmented lesion that rarely causes bleeding.
In summary, skin lesions and malignancies can have various presentations and characteristics. It is important to be aware of their features and seek medical attention if any changes or symptoms occur. Regular skin checks and sun protection can help prevent and detect these conditions early.
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This question is part of the following fields:
- Dermatology
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Question 11
Correct
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A 30-year-old homeless woman with drug addiction presents with fever, rash and progressive swelling of the left side of her face, which began with an itchy scab on her left cheek 24 hours ago. Her temperature is 38.5 °C, and she is unable to open her left eye because of the swelling.
Which of the following is the most likely causal organism?Your Answer: Group A Streptococcus
Explanation:Bacterial Skin Infections: Understanding the Causes and Symptoms
Erysipelas, a bacterial skin infection, is characterized by a tender, intensely erythematous, indurated plaque with a sharply demarcated border. It is caused by Streptococcus pyogenes, which is often sourced from the host’s nasopharynx. Prodromal symptoms such as malaise, chills, and high fever often precede the onset of skin lesions. Haemophilus influenzae can also cause cellulitis, but the skin lesion described in erysipelas is more consistent with this condition. Herpes simplex viruses cause a wide variety of disease states, including oropharyngeal infections and cold sores. Meningococcaemia, caused by Neisseria meningitidis, presents with a characteristic petechial skin rash on the trunk and legs. Understanding the causes and symptoms of these bacterial skin infections is crucial for proper diagnosis and treatment.
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This question is part of the following fields:
- Infectious Diseases
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Question 12
Correct
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A 26-year-old woman is recuperating from a kidney transplant. Within 24 hours of the surgery, she complains of increased discomfort at the transplant site. Upon examination, she has a fever, tenderness at the transplant site, and has not produced urine since the procedure. Her creatinine levels have significantly increased in the past 24 hours. What is the fundamental mechanism behind her rejection?
Your Answer: Pre-existing antibodies against ABO or HLA antigens
Explanation:Understanding HLA Typing and Graft Failure in Renal Transplants
The human leucocyte antigen (HLA) system, also known as the major histocompatibility complex (MHC), is located on chromosome 6 and plays a crucial role in renal transplants. The HLA system includes class 1 antigens (A, B, and C) and class 2 antigens (DP, DQ, and DR), with DR being the most important for HLA matching in renal transplants. Graft survival rates for cadaveric transplants are 90% at 1 year and 60% at 10 years, while living-donor transplants have a 95% survival rate at 1 year and 70% at 10 years.
Post-operative problems may include acute tubular necrosis of the graft, vascular thrombosis, urine leakage, and urinary tract infections. Hyperacute rejection, which occurs within minutes to hours, is caused by pre-existing antibodies against ABO or HLA antigens and leads to widespread thrombosis of graft vessels, resulting in the need for graft removal. Acute graft failure, which occurs within 6 months, is usually due to mismatched HLA and is picked up by a rising creatinine, pyuria, and proteinuria. Chronic graft failure, which occurs after 6 months, is caused by both antibody and cell-mediated mechanisms and leads to fibrosis of the transplanted kidney, with recurrence of the original renal disease being a common cause.
In summary, understanding the HLA system and its role in renal transplants is crucial for successful outcomes. Monitoring for post-operative problems and early detection of graft failure can help improve long-term survival rates.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 13
Correct
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Which of the following is less frequent in women who use the combined oral contraceptive pill?
Your Answer: Endometrial cancer
Explanation:The combined oral contraceptive pill is associated with a higher likelihood of developing breast and cervical cancer, but it can also provide protection against ovarian and endometrial cancer.
Pros and Cons of the Combined Oral Contraceptive Pill
The combined oral contraceptive pill is a highly effective method of birth control with a failure rate of less than 1 per 100 woman years. It does not interfere with sexual activity and its contraceptive effects are reversible upon stopping. Additionally, it can make periods regular, lighter, and less painful, and may reduce the risk of ovarian, endometrial, and colorectal cancer. It may also protect against pelvic inflammatory disease, ovarian cysts, benign breast disease, and acne vulgaris.
However, there are also some disadvantages to the combined oral contraceptive pill. One of the main issues is that people may forget to take it, which can reduce its effectiveness. It also offers no protection against sexually transmitted infections. There is an increased risk of venous thromboembolic disease, breast and cervical cancer, stroke, and ischaemic heart disease, especially in smokers. Temporary side-effects such as headache, nausea, and breast tenderness may also be experienced.
It is important to weigh the pros and cons of the combined oral contraceptive pill before deciding if it is the right method of birth control for you. While some users report weight gain while taking the pill, a Cochrane review did not support a causal relationship. Overall, the combined oral contraceptive pill can be an effective and convenient method of birth control, but it is important to discuss any concerns or potential risks with a healthcare provider.
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This question is part of the following fields:
- Reproductive Medicine
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Question 14
Correct
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Left bundle branch block is associated with which one of the following conditions?
Your Answer: Ischaemic heart disease
Explanation:ECG Findings in Various Cardiovascular Conditions
New-onset left bundle branch block may indicate ischaemic heart disease and could be a sign of STEMI if the patient’s symptoms match the diagnosis. Pericarditis typically causes widespread ST elevation on an ECG. Mitral stenosis can lead to left atrial enlargement and potentially atrial fibrillation. Pulmonary embolism often results in a right bundle branch block or a right ventricular strain pattern of S1Q3T3. Tricuspid stenosis can also cause right ventricular strain. It’s worth noting that mitral stenosis, tricuspid stenosis, and secondary pulmonary hypertension due to PE are associated with right ventricular strain and hypertrophy with partial or complete right bundle branch block, while pericarditis is not typically associated with bundle branch block.
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This question is part of the following fields:
- Cardiovascular
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Question 15
Correct
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A 35-year-old woman presents to the Emergency Department with a 2-month history of lethargy and generalised weakness. On examination, she is found to have a blood pressure of 170/100 mmHg. The rest of the examination is unremarkable.
Routine blood tests show a hypokalaemic metabolic alkalosis, along with a hypernatraemia of 152 mmol/l (135–145 mmol/l). Primary aldosteronism is suspected and investigations reveal bilateral idiopathic adrenal hyperplasia.
Which of the following is the best treatment option?
Select the SINGLE most appropriate treatment from the list below.
Your Answer: Spironolactone
Explanation:The patient’s hypertension, hypokalaemia, and hypernatremia suggest a diagnosis of hyperaldosteronism, where high levels of aldosterone cause increased water and sodium reabsorption in the kidneys and potassium loss. The recommended treatment for primary hyperaldosteronism due to bilateral adrenal disease is a mineralocorticoid antagonist, with spironolactone as the primary agent and eplerenone as an alternative. Losartan, an angiotensin receptor blocker, is an alternative to angiotensin-converting enzyme inhibitors for managing primary hypertension in patients under 55 years of age who are not Afro-Caribbean or diabetic. Nifedipine, a calcium-channel blocker, is a first-line drug for essential hypertension in patients aged 55 years or older or Afro-Caribbean patients. Perindopril, an ACEi, is a first-line drug for managing primary hypertension in patients under 55 years of age who are not Afro-Caribbean or diabetic. However, it is not appropriate for treating hyperaldosteronism, where spironolactone is the preferred option. Unilateral laparoscopic adrenalectomy is recommended for cases of hyperaldosteronism due to unilateral adrenal diseases, but not for bilateral adrenal disease like in this patient.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 16
Incorrect
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A 7-year-old boy is presented for surgery due to recurring headaches. What is the primary reason for headaches in children?
Your Answer: Refractive errors
Correct Answer: Migraine
Explanation:In children, primary headache is most commonly caused by migraine.
Understanding Headaches in Children
Headaches are a common occurrence in children, with up to 50% of 7-year-olds and 80% of 15-year-olds experiencing at least one headache. Migraine without aura is the most common cause of primary headache in children, with a strong female preponderance after puberty. The International Headache Society has produced criteria for diagnosing pediatric migraine without aura, which includes headache attacks lasting 4-72 hours, with at least two of four specific features and accompanying symptoms such as nausea and vomiting.
When it comes to acute management, ibuprofen is considered more effective than paracetamol for pediatric migraine. Triptans may be used in children over 12 years old, but follow-up is required, and only sumatriptan nasal spray is licensed for use in young people. However, oral triptans are not currently licensed for those under 18 years old, and side effects may include tingling, heat, and pressure sensations.
Prophylaxis for pediatric migraine is limited, with no clear consensus guidelines. Pizotifen and propranolol are recommended as first-line preventatives, while valproate, topiramate, and amitriptyline are considered second-line preventatives. Tension-type headache is the second most common cause of headache in children, with diagnostic criteria including at least 10 previous headache episodes lasting from 30 minutes to 7 days, with specific pain characteristics and the absence of nausea or vomiting.
In summary, headaches in children are common, and migraine without aura is the most common primary headache. Acute management includes ibuprofen and triptans, while prophylaxis is limited. Tension-type headache is also a common cause of headache in children. It is important to seek medical advice if headaches are frequent or severe, or if there are any concerning symptoms such as neurological deficits or changes in behavior.
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This question is part of the following fields:
- Paediatrics
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Question 17
Correct
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A woman who is 32 weeks pregnant has been diagnosed with syphilis during her routine booking visit bloods. What is the best course of action for management?
Your Answer: IM benzathine penicillin G
Explanation:Management of Syphilis
Syphilis can be effectively managed with intramuscular benzathine penicillin as the first-line treatment. In cases where penicillin cannot be used, doxycycline may be used as an alternative. After treatment, nontreponemal titres such as rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) should be monitored to assess the response. A fourfold decline in titres is often considered an adequate response to treatment.
It is important to note that the Jarisch-Herxheimer reaction may occur following treatment. This reaction is characterized by fever, rash, and tachycardia after the first dose of antibiotic. Unlike anaphylaxis, there is no wheezing or hypotension. The reaction is thought to be due to the release of endotoxins following bacterial death and typically occurs within a few hours of treatment. However, no treatment is needed other than antipyretics if required.
In summary, the management of syphilis involves the use of intramuscular benzathine penicillin or doxycycline as an alternative. Nontreponemal titres should be monitored after treatment, and the Jarisch-Herxheimer reaction may occur but does not require treatment unless symptomatic.
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This question is part of the following fields:
- Reproductive Medicine
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Question 18
Correct
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A 42-year-old woman visits her doctor with complaints of a persistent blocked nose and reduced sense of smell for the past few months. During examination, the doctor observes pale grey mucosal sacs in both nostrils. The patient has a history of allergies but is otherwise healthy. What is the most likely condition she is suffering from?
Your Answer: Aspirin usage
Explanation:Medical Conditions and Medication Usage: A Brief Overview
Aspirin Usage and Nasal Polyps
Nasal polyps, asthma, and rhinosinusitis are all symptoms of aspirin-exacerbated respiratory disease. This condition is caused by hypersensitivity to aspirin or other cyclooxygenase 1 inhibitors and typically develops in individuals aged 30-40 years. Treatment involves avoiding non-steroidal anti-inflammatory drugs, and in some cases, aspirin desensitization may be performed.COPD and Nasal Polyps
While nasal polyps can be associated with asthma, there is no known association with chronic obstructive pulmonary disease (COPD). Smokers with nosebleeds or unilateral nasal polyps should be referred for urgent ENT assessment to rule out malignancy.Infective Endocarditis and Nasal Polyps
Infective endocarditis occurs when bacteria enters the bloodstream, usually via poor dentition, an open wound, or mechanical device placed in the heart. There is no known association between nasal polyps and infective endocarditis.Paracetamol Usage and Nasal Polyps
Nasal polyps are associated with aspirin sensitivity, not sensitivity to paracetamol. According to the British National Formulary, the only side effect of oral paracetamol is thrombocytopenia, which is considered very rare.Simvastatin Usage and Nasal Polyps
Nasal polyps are not a recognized side effect of statins, which can cause muscle aches, headaches, diarrhea, and sleep disturbances.Understanding Medical Conditions and Medication Usage
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This question is part of the following fields:
- ENT
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Question 19
Correct
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A 65-year-old woman is diagnosed with a DVT 2 weeks after undergoing a hip replacement surgery, despite being on prophylactic dose LMWH. She has a history of osteoarthritis but no other significant medical history. The treatment for her DVT is started with LMWH. What is the best anticoagulation plan for her?
Your Answer: Switch to direct oral anticoagulant for 3 months
Explanation:For cases of venous thromboembolism that are provoked, such as those resulting from recent surgery, a standard length of warfarin treatment is 3 months. However, for unprovoked cases, the recommended length of treatment is 6 months.
NICE updated their guidelines on the investigation and management of venous thromboembolism (VTE) in 2020. The use of direct oral anticoagulants (DOACs) is recommended as first-line treatment for most people with VTE, including as interim anticoagulants before a definite diagnosis is made. Routine cancer screening is no longer recommended following a VTE diagnosis. The cornerstone of VTE management is anticoagulant therapy, with DOACs being the preferred choice. All patients should have anticoagulation for at least 3 months, with the length of anticoagulation being determined by whether the VTE was provoked or unprovoked.
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This question is part of the following fields:
- Haematology/Oncology
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Question 20
Correct
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A 50-year-old obese man with a history of type 2 diabetes mellitus presents at the clinic for a review. He is currently asymptomatic but his recent annual blood tests have shown slightly abnormal liver function tests. The results are as follows:
- Bilirubin: 20 µmol/L (3 - 17)
- ALP: 104 u/L (30 - 100)
- ALT: 53 u/L (3 - 40)
- γGT: 58 u/L (8 - 60)
- Albumin: 38 g/L (35 - 50)
A liver ultrasound was conducted and reported fatty changes. All other standard liver screen bloods, including viral serology, are normal. The patient's alcoholic intake is within recommended limits. What is the most appropriate next test to perform?Your Answer: Enhanced liver fibrosis blood test
Explanation:For patients with non-alcoholic fatty liver disease who exhibit characteristics such as obesity and type 2 diabetes mellitus, it is recommended to conduct an enhanced liver fibrosis (ELF) test to aid in the diagnosis of liver fibrosis. According to NICE guidelines, if NAFLD is discovered incidentally, an ELF blood test should be conducted to evaluate for the presence of more advanced liver disease.
Non-Alcoholic Fatty Liver Disease: Causes, Features, and Management
Non-alcoholic fatty liver disease (NAFLD) is a prevalent liver disease in developed countries, primarily caused by obesity. It encompasses a range of conditions, from simple steatosis (fat accumulation in the liver) to steatohepatitis (fat with inflammation) and may progress to fibrosis and liver cirrhosis. Insulin resistance is believed to be the primary mechanism leading to steatosis, making NAFLD a hepatic manifestation of metabolic syndrome. Non-alcoholic steatohepatitis (NASH) is a type of liver damage similar to alcoholic hepatitis but occurs in the absence of alcohol abuse. It affects around 3-4% of the general population and may be responsible for some cases of cryptogenic cirrhosis.
NAFLD is usually asymptomatic, but hepatomegaly, increased echogenicity on ultrasound, and elevated ALT levels are common features. The enhanced liver fibrosis (ELF) blood test is recommended by NICE to check for advanced fibrosis in patients with incidental NAFLD. If the ELF blood test is not available, non-invasive tests such as the FIB4 score or NAFLD fibrosis score, in combination with a FibroScan, may be used to assess the severity of fibrosis. Patients with advanced fibrosis should be referred to a liver specialist for further evaluation, which may include a liver biopsy to stage the disease more accurately.
The mainstay of NAFLD treatment is lifestyle changes, particularly weight loss, and monitoring. Research is ongoing into the role of gastric banding and insulin-sensitizing drugs such as metformin and pioglitazone. While there is no evidence to support screening for NAFLD in adults, NICE guidelines recommend the management of incidental NAFLD findings.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 21
Correct
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During a routine General Practitioner (GP) clinic, a mother attends with her 8-year-old daughter who has worsening dry, itchy skin, mainly affecting the flexor surfaces, particularly on the legs. She has tried regular liberal use emollient cream with limited success.
What would be the most appropriate next step in the management of the child’s eczema?Your Answer: Prescribe hydrocortisone cream 1%
Explanation:Managing Eczema in Children: Treatment Options and Considerations
Eczema is a common condition in children that can be effectively managed with the right treatment approach. When a child presents with eczema symptoms, the first step is often to use emollient cream to moisturize the affected area. However, if the symptoms persist or worsen, a topical corticosteroid cream may be prescribed to help manage the flare-up. It is important to use this medication sparingly and in conjunction with emollients.
If the eczema symptoms continue to be troublesome despite these measures, it may be appropriate to refer the child to a dermatology clinic. However, it is important to note that oral corticosteroids should be used with caution in children and only under the direction of a dermatologist.
While emollient creams are often effective, in some cases, an emollient ointment may be more moisturizing and helpful. However, if the eczema flare-up is not resolving with emollients alone, a short course of topical corticosteroid is likely necessary.
Watchful waiting is not appropriate in this situation, as the child has already presented to the GP and symptoms are worsening despite reasonable management by the mother. By understanding the various treatment options and considerations for managing eczema in children, healthcare providers can help ensure the best possible outcomes for their patients.
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This question is part of the following fields:
- Dermatology
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Question 22
Correct
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An 80-year-old woman is under palliative care for glioblastoma and is currently managing her pain with regular paracetamol. However, she has been experiencing nausea. What would be the most suitable initial anti-emetic medication to prescribe for her?
Your Answer: Cyclizine
Explanation:Cyclizine is a recommended first choice anti-emetic for nausea and vomiting caused by intracranial or intra-vestibular issues. It is also useful in palliative care for managing gastrointestinal obstruction and vagally-mediated nausea or vomiting caused by mechanical bowel obstruction, movement disorders, or raised intracranial pressure. Domperidone is effective for gastro-intestinal pain in palliative care, while metoclopramide is used for acute migraine, chemotherapy or radiotherapy-induced nausea and vomiting. Ondansetron is indicated for chemotherapy-related nausea and vomiting. Dexamethasone is a steroid that may be used in palliative care for treating nausea, anorexia, spinal cord compression, and liver capsule pain. If the cause of nausea is suspected to be raised intracranial pressure, cyclizine should be the first-line option, and dexamethasone may be considered as an additional treatment.
Managing Nausea and Vomiting in Palliative Care: A Mechanistic Approach
Nausea and vomiting are common symptoms in palliative care, often caused by multiple factors. Identifying the primary cause is crucial in selecting the appropriate anti-emetic therapy. Six broad syndromes have been identified, with gastric stasis and chemical disturbance being the most common. In palliative care, pharmacological therapy is the first-line method for treating nausea and vomiting. Two approaches can be used in selecting drug therapy: empirical or mechanistic. The mechanistic approach matches the choice of anti-emetic drug to the likely cause of the patient’s symptoms.
The mechanistic approach involves selecting medication based on the underlying cause of the nausea and vomiting. For example, pro-kinetic agents are useful in scenarios where reduced gastric motility is the primary cause. First-line medications for this syndrome include metoclopramide and domperidone. However, metoclopramide should not be used in certain situations, such as complete bowel obstruction or gastrointestinal perforation. If the cause is chemically mediated, correcting the chemical disturbance should be the first step. Key treatment options include ondansetron, haloperidol, and levomepromazine. Cyclizine and levomepromazine are first-line for visceral/serosal causes, while cyclizine is recommended for nausea and vomiting due to intracranial disease. If the oral route is not possible, the parenteral route of administration is preferred, with the intravenous route used if access is already established.
In summary, a mechanistic approach to managing nausea and vomiting in palliative care involves selecting medication based on the underlying cause of the symptoms. This approach can improve the effectiveness of anti-emetic therapy and reduce the risk of adverse effects.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 23
Incorrect
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A primigravid 44 year-old woman, who is at 28 weeks gestation, arrives at the maternity unit with regular weak contractions. Upon examination, her cervix is found to be 3 cm dilated and her membranes are intact. What is the most suitable course of action?
Your Answer: Admit and administer tocolytics and antibiotics
Correct Answer: Admit and administer tocolytics and steroids
Explanation:At present, the woman is experiencing premature labour, but it is still in its early stages as she is only 3 cm dilated. As a result, tocolytic medication may be used to halt the labour. However, if the labour persists and delivery becomes necessary, steroids will be administered beforehand to aid in the development of the foetal lungs. Antibiotics are unnecessary since there is no evidence of an infection. The Syntocinon injection contains oxytocin, which increases the strength of uterine contractions.
Risks Associated with Prematurity
Prematurity is a condition that poses several risks to the health of newborns. The risk of mortality increases with decreasing gestational age. Premature babies are at risk of developing respiratory distress syndrome, intraventricular haemorrhage, necrotizing enterocolitis, chronic lung disease, hypothermia, feeding problems, infection, jaundice, and retinopathy of prematurity. Retinopathy of prematurity is a significant cause of visual impairment in babies born before 32 weeks of gestation. The cause of this condition is not fully understood, but it is believed that over oxygenation during ventilation can lead to the proliferation of retinal blood vessels, resulting in neovascularization. Screening for retinopathy of prematurity is done in at-risk groups. Premature babies are also at risk of hearing problems.
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This question is part of the following fields:
- Reproductive Medicine
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Question 24
Correct
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A 78-year-old man with known metastatic prostate cancer presents to his General Practitioner with generalised pain. He states that he has always had aches and pains from old age, but that this is different: he can feel the pain particularly in his back at night.
What is the most likely site to be involved in bone metastasis in this patient?Your Answer: Spine
Explanation:Common Sites of Metastatic Spread in Bone
Metastatic spread to the bone is a common occurrence in many types of cancer. The following are some of the most common sites of metastases in bone:
Spine: The spine is the most common site for bony metastases, with spread often found from a range of solid and haematological cancers, as well as infectious diseases such as tuberculosis.
Ribs: While breast cancer is known to spread to the ribs, this is not the case for many other cancers.
Pelvis: The pelvis is a prevalent site of metastatic spread occurring mostly from the prostate, breast, kidney, lung, and thyroid cancer.
Skull: Skull metastases are seen in 15-25% of all cancer patients and tend to include those from the breast, lungs, prostate, and thyroid, as well as melanoma.
Long bones: Localised bone pain is a red flag for metastatic spread to any of the long bones such as the femur and humerus. Breast, prostate, renal, thyroid, and lung cancers frequently metastasize to these areas.
Overall, understanding the common sites of metastatic spread in bone can help with early detection and treatment of cancer.
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This question is part of the following fields:
- Haematology/Oncology
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Question 25
Incorrect
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A 48-year-old male patient comes to the GP clinic complaining of pain and redness on his left upper eyelid. Upon examination, a tender papule with erythema is found at the left eyelid margin, with a small area of pus discharge. Additionally, there is slight redness of the conjunctiva. What is the probable diagnosis?
Your Answer: Chalazion
Correct Answer: Hordeolum externum
Explanation:The individual is experiencing an infection in the glands of their external eyelid, which is classified as a type of stye known as hordeolum externum. It should be noted that a chalazion, also referred to as a meibomian cyst, typically occurs on the internal eyelid. Blepharitis, on the other hand, is characterized by inflammation of the eyelid margins and does not typically result in a lump. Ectropion refers to the outward turning of the eyelids, while acne vulgaris does not typically impact the eyelids.
Eyelid problems are quite common and can include a variety of issues. One such issue is blepharitis, which is inflammation of the eyelid margins that can cause redness in the eye. Another problem is a stye, which is an infection of the glands in the eyelids. Chalazion, also known as Meibomian cyst, is another eyelid problem that can occur. Entropion is when the eyelids turn inward, while ectropion is when they turn outward.
Styes can come in different forms, such as external or internal. An external stye is an infection of the glands that produce sebum or sweat, while an internal stye is an infection of the Meibomian glands. Treatment for styes typically involves hot compresses and pain relief, with topical antibiotics only being recommended if there is also conjunctivitis present. A chalazion, on the other hand, is a painless lump that can form in the eyelid due to a retention cyst of the Meibomian gland. While most cases will resolve on their own, some may require surgical drainage.
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This question is part of the following fields:
- Ophthalmology
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Question 26
Incorrect
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A 26-year-old patient visits the GP clinic seeking a sexual health examination. He engages in sexual activity with men and practices unprotected anal intercourse as both the insertive and receptive partner. He has never undergone any HIV testing and desires a prompt result. What is the most suitable test to request for this patient?
Your Answer: HIV p24 antigen test
Correct Answer: HIV p24 antigen and HIV antibody test
Explanation:The current standard for HIV diagnosis and screening involves a combination of p24 antigen and HIV antibody tests. This is because the HIV antibody may not be detectable until 4-6 weeks after infection, while the p24 antigen can show up as early as 1 week after infection. By using both tests, a more accurate assessment of infectious status can be made, allowing for discussions about pre-exposure prophylaxis and safe sexual practices. HIV viral load levels are not used for diagnosis, but can be helpful in assessing treatment efficacy after diagnosis has been confirmed. It is important to note that viral load testing should not be used alone, but rather in conjunction with the antibody and antigen tests.
Understanding HIV Seroconversion and Diagnosis
HIV seroconversion is a process where the body develops antibodies to the HIV virus after being infected. This process is symptomatic in 60-80% of patients and usually presents as a glandular fever type illness. Symptoms may include sore throat, lymphadenopathy, malaise, myalgia, arthralgia, diarrhea, maculopapular rash, mouth ulcers, and rarely meningoencephalitis. The severity of symptoms is associated with a poorer long-term prognosis and typically occurs 3-12 weeks after infection.
Diagnosing HIV involves testing for HIV antibodies, which may not be present in early infection. However, most people develop antibodies to HIV at 4-6 weeks, and 99% do so by 3 months. The diagnosis usually consists of both a screening ELISA test and a confirmatory Western Blot Assay. Additionally, a p24 antigen test may be used to detect a viral core protein that appears early in the blood as the viral RNA levels rise. Combination tests that test for both HIV p24 antigen and HIV antibody are now standard for the diagnosis and screening of HIV. If the combined test is positive, it should be repeated to confirm the diagnosis. Testing for HIV in asymptomatic patients should be done at 4 weeks after possible exposure, and after an initial negative result, a repeat test should be offered at 12 weeks.
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This question is part of the following fields:
- Infectious Diseases
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Question 27
Correct
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As a foundation doctor on the neonatal ward, you conduct a newborn examination on a six hour old infant. The baby was delivered vaginally at 38 weeks with no risk factors for sepsis and no maternal concerns. The baby was born in a healthy condition, with good tone. However, you observe cyanosis in the peripheries, while the rest of the examination appears normal. Pre and post ductal oxygen saturations are at 97%. What is the probable diagnosis?
Your Answer: Acrocyanosis
Explanation:Cyanosis, a bluish discoloration of the skin, is a common occurrence in newborns. Peripheral cyanosis, which affects the hands and feet, is often seen in the first 24 hours of life and can be caused by crying or illness. Central cyanosis, on the other hand, is a more serious condition that occurs when the concentration of reduced hemoglobin in the blood exceeds 5g/dl. To differentiate between cardiac and non-cardiac causes of central cyanosis, doctors may use the nitrogen washout test, which involves giving the infant 100% oxygen for ten minutes and then measuring arterial blood gases. A pO2 of less than 15 kPa indicates cyanotic congenital heart disease, which can be caused by conditions such as tetralogy of Fallot, transposition of the great arteries, and tricuspid atresia.
If cyanotic congenital heart disease is suspected, initial management involves supportive care and the use of prostaglandin E1, such as alprostadil, to maintain a patent ductus arteriosus in ductal-dependent congenital heart defects. This can serve as a temporary measure until a definitive diagnosis is made and surgical correction is performed.
Acrocyanosis, a type of peripheral cyanosis, is a benign condition that is often seen in healthy newborns. It is characterized by bluish discoloration around the mouth and extremities, such as the hands and feet, and is caused by vasomotor changes that result in peripheral vasoconstriction and increased tissue oxygen extraction. Unlike other causes of peripheral cyanosis that may indicate significant pathology, such as septic shock, acrocyanosis occurs immediately after birth in healthy infants and typically resolves within 24 to 48 hours.
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This question is part of the following fields:
- Paediatrics
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Question 28
Incorrect
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A 38-year-old homeless man presents to the emergency department after collapsing on the street. He reports feeling increasingly lethargic over the past week and has been coughing up green sputum. He has a history of alcoholic pancreatitis.
His vital signs are as follows:
- Temperature: 38.4ºC
- Heart rate: 122 bpm
- Blood pressure: 106/54 mmHg
- Respiratory rate: 22 breaths/min
- Oxygen saturations: 94% on 2L nasal cannulae
Upon examination, coarse crackles are heard in the left upper lobe. His heart sounds are normal and his abdomen is soft and nontender.
What is the most likely causative organism?Your Answer: Legionella pneumophila
Correct Answer: Klebsiella pneumoniae
Explanation:Klebsiella pneumoniae is a gram-negative rod that commonly causes a cavitating pneumonia in the upper lobes, particularly in individuals with a history of diabetes and alcoholism. The presence of upper zone crackles is a sign of Klebsiella pneumoniae infection, while a history of alcoholic pancreatitis suggests chronic alcohol use.
Legionella pneumophila causes Legionnaire’s disease, an atypical pneumonia that typically spreads through contaminated water sources, such as air conditioner vents. Symptoms include fever, cough, and myalgia, with bilateral chest symptoms being more common. Other extra-pulmonary symptoms, such as hyponatremia and hepatitis, may also be present.
Mycoplasma pneumoniae is another cause of atypical pneumonia, with symptoms including coryza and a dry cough. This form of pneumonia is associated with extra-pulmonary symptoms such as haemolytic anaemia and erythema multiforme, which are not present in this case.
Staphylococcus aureus is the most likely cause of pneumonia following influenza virus infection. However, since there is no history of preceding coryza and the patient has upper zone crackles and alcoholism, Staphylococcus aureus is less likely to be the cause of this patient’s pneumonia.
Klebsiella Pneumoniae: A Gram-Negative Rod Causing Infections in Humans
Klebsiella pneumoniae is a type of Gram-negative rod that is typically found in the gut flora of humans. Although it is a normal part of the body’s microbiome, it can also cause a variety of infections in humans, including pneumonia and urinary tract infections. This bacterium is more commonly found in individuals who have diabetes or who consume alcohol regularly. In some cases, Klebsiella pneumoniae infections can occur following aspiration.
One of the distinctive features of Klebsiella pneumoniae infections is the presence of red-currant jelly sputum. This type of sputum is often seen in patients with pneumonia caused by this bacterium. Additionally, Klebsiella pneumoniae infections tend to affect the upper lobes of the lungs.
Unfortunately, Klebsiella pneumoniae infections can be quite serious and even life-threatening. They commonly lead to the formation of lung abscesses and empyema, and the mortality rate for these infections is between 30-50%. It is important for healthcare providers to be aware of the potential for Klebsiella pneumoniae infections, particularly in patients who are at higher risk due to underlying health conditions.
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This question is part of the following fields:
- Respiratory Medicine
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Question 29
Correct
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You are a foundation doctor working in general practice. You review a sixty-five-year-old gentleman with a facial rash. On examination you note a vesicular rash extending to the tip of the nose. Observations are unremarkable.
What is your primary concern?Your Answer: Possible involvement of the cornea
Explanation:The presence of vesicles extending to the tip of the nose, known as Hutchinson’s sign, is strongly linked to shingles affecting the eyes. This is because the trigeminal nerve branch that supplies the cornea and nasal tip is affected. While pneumonia can be associated with herpes, this patient does not exhibit any respiratory symptoms. Despite the potential for post-herpetic neuralgia from the painful rash of shingles, the primary concern for this patient is the ocular involvement indicated by Hutchinson’s sign.
Herpes Zoster Ophthalmicus: Symptoms, Treatment, and Complications
Herpes zoster ophthalmicus (HZO) is a condition that occurs when the varicella-zoster virus reactivates in the area supplied by the ophthalmic division of the trigeminal nerve. It is responsible for approximately 10% of shingles cases. The main symptom of HZO is a vesicular rash around the eye, which may or may not involve the eye itself. Hutchinson’s sign, a rash on the tip or side of the nose, is a strong indicator of nasociliary involvement and increases the risk of ocular involvement.
Treatment for HZO involves oral antiviral medication for 7-10 days, ideally started within 72 hours of symptom onset. Intravenous antivirals may be necessary for severe infections or immunocompromised patients. Topical antiviral treatment is not recommended for HZO, but topical corticosteroids may be used to treat any secondary inflammation of the eye. Ocular involvement requires urgent ophthalmology review to prevent complications such as conjunctivitis, keratitis, episcleritis, anterior uveitis, ptosis, and post-herpetic neuralgia.
In summary, HZO is a condition caused by the reactivation of the varicella-zoster virus in the ophthalmic division of the trigeminal nerve. It presents with a vesicular rash around the eye and may involve the eye itself. Treatment involves oral antiviral medication and urgent ophthalmology review is necessary for ocular involvement. Complications of HZO include various eye conditions, ptosis, and post-herpetic neuralgia.
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This question is part of the following fields:
- Ophthalmology
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Question 30
Correct
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A 4-year-old boy is brought to see his General Practitioner by his mother who is concerned that he has had diarrhoea for three days. He has been experiencing 2–3 loose, watery stools every day. He has also vomited twice at the onset of the illness but not since.
On examination, he is afebrile and well hydrated. His abdomen is soft and nontender. The family recently returned from a trip to Australia. While away, the patient was admitted to hospital for two days with a lower respiratory tract infection.
Which of the patient’s features is most likely to indicate the need for a stool sample for culture and sensitivity?
Select the SINGLE factor from the list below.Your Answer: The recent hospital admission
Explanation:Assessing the Need for Stool Culture in a Child with Gastroenteritis
Gastroenteritis is a common illness characterized by diarrhea, abdominal pain, and nausea. In most cases, it is caused by a viral, bacterial, or parasitic infection and is self-limiting. However, recent hospital admission or antibiotic treatment can increase the risk of Clostridium difficile toxin as the cause, making stool culture necessary. Additionally, patients who have recently traveled to certain countries or are under the age of five and attend nursery, pre-school, or school may require stool culture. If symptoms persist beyond seven days or if there is blood or mucus in the stool, stool samples should be taken. Vomiting is not a red-flag feature unless it leads to dehydration. Parents should be given safety-net advice on when to seek further medical attention if their child’s condition worsens.
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This question is part of the following fields:
- Infectious Diseases
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