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Question 1
Incorrect
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A 60-year-old man visits his GP complaining of hand pain that worsens with activity and towards the end of the day. He has a medical history of psoriasis and is not currently taking any medications. During the examination, the doctor notes tender bony swellings in three DIP joints on both hands. What is the probable diagnosis?
Your Answer: Psoriatic arthritis
Correct Answer: Osteoarthritis
Explanation:The presence of Heberden’s nodes, which are bony swellings at the DIP joints, is a characteristic feature of osteoarthritis in the hand. Pain that worsens with activity, rather than rest, is also more indicative of OA than inflammatory arthritis. Psoriatic arthritis can cause swelling of the DIP joints, but the swelling is typically boggy rather than bony, and the pain tends to be worse in the morning and improve with activity. Reactive arthritis is unlikely to cause a DIP predominant arthritis, as it typically presents as a large joint lower limb oligoarthritis, and there is no recent history of infection. Rheumatoid arthritis does not typically affect the DIP joints.
Understanding Osteoarthritis of the Hand
Osteoarthritis of the hand, also known as nodal arthritis, is a condition that occurs when the cartilage at synovial joints is lost, leading to the degeneration of underlying bone. It is more common in women, usually presenting after the age of 55, and may have a genetic component. Risk factors include previous joint trauma, obesity, hypermobility, and certain occupations. Interestingly, osteoporosis may actually reduce the risk of developing hand OA.
Symptoms of hand OA include episodic joint pain, stiffness that worsens after periods of inactivity, and the development of painless bony swellings known as Heberden’s and Bouchard’s nodes. These nodes are the result of osteophyte formation and are typically found at the distal and proximal interphalangeal joints, respectively. In severe cases, there may be reduced grip strength and deformity of the carpometacarpal joint of the thumb, resulting in fixed adduction.
Diagnosis is typically made through X-ray, which may show signs of osteophyte formation and joint space narrowing before symptoms develop. While hand OA may not significantly impact a patient’s daily function, it is important to manage symptoms through pain relief and joint protection strategies. Additionally, the presence of hand OA may increase the risk of future hip and knee OA, particularly for hip OA.
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This question is part of the following fields:
- Musculoskeletal
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Question 2
Incorrect
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The hypothalamus is responsible for producing which hormones?
Your Answer: Prolactin
Correct Answer: Corticotrophin-releasing hormone
Explanation:Hormones of the Hypothalamus
The hypothalamus produces several hormones that regulate various bodily functions. These hormones include thyrotrophic-releasing hormone (TRH), gonadotrophin-releasing hormone (GnRH), growth hormone-releasing hormone (GHRH), corticotrophin-releasing hormone (CRH), antidiuretic hormone (also known as vasopressin), dopamine (prolactin-inhibiting hormone), somatostatin (growth hormone-inhibiting hormone), and oxytocin.
CRH is responsible for regulating the release of adrenocorticotrophic hormone (ACTH) from the anterior pituitary. Oxytocin is produced by the cells in the paraventricular nucleus and secreted from the posterior pituitary. These hormones play a crucial role in maintaining homeostasis in the body. By regulating the release of other hormones, they help to control various bodily functions such as growth, metabolism, and reproduction.
In summary, the hormones of the hypothalamus are essential for maintaining the proper functioning of the body. They work together to regulate the release of other hormones and ensure that bodily functions are kept in balance.
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This question is part of the following fields:
- Endocrinology
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Question 3
Correct
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A 68-year-old man visits his GP with a complaint of a droopy eyelid that started yesterday and has not improved. He has a medical history of poorly controlled type two diabetes mellitus and hypertension, which cause him recurrent foot ulcers. Additionally, he has been a smoker for his entire life.
During the eye examination, the doctor observes ptosis of the left palpebra with a constricted pupil. However, the patient's visual acuity is 6/6 in both eyes, and he has normal colour vision, intact central and peripheral fields. The patient had a similar episode after a motorbike accident, which was diagnosed as a nerve palsy and later resolved.
What is the most probable diagnosis?Your Answer: Horner's syndrome
Explanation:The correct diagnosis is Horner’s syndrome, which is characterized by ptosis and a constricted pupil. This syndrome is caused by a loss of sympathetic innervation and is likely due to a Pancoast tumor in this patient, who has a history of smoking. Other features of Horner’s syndrome include anhidrosis.
An abducens nerve palsy would cause horizontal diplopia and defective eye abduction. Lateral medullary syndrome, caused by a stroke, can also cause Horner’s syndrome but would present with additional symptoms such as ataxia and dysphagia.
An oculomotor nerve palsy would cause ptosis, a ‘down and out’ eye, and a dilated pupil. This patient only has ptosis and a constricted pupil, making oculomotor nerve palsy an incorrect diagnosis. A trochlear nerve palsy would cause vertical diplopia and limitations in eye movement.
Horner’s syndrome is a medical condition that is characterized by a set of symptoms including a small pupil (miosis), drooping of the upper eyelid (ptosis), sunken eye (enophthalmos), and loss of sweating on one side of the face (anhidrosis). The presence of heterochromia, or a difference in iris color, is often seen in cases of congenital Horner’s syndrome. Anhidrosis is also a distinguishing feature that can help differentiate between central, Preganglionic, and postganglionic lesions. Pharmacologic tests, such as the use of apraclonidine drops, can be helpful in confirming the diagnosis of Horner’s syndrome and localizing the lesion.
Central lesions, Preganglionic lesions, and postganglionic lesions can all cause Horner’s syndrome, with each type of lesion presenting with different symptoms. Central lesions can result in anhidrosis of the face, arm, and trunk, while Preganglionic lesions can cause anhidrosis of the face only. postganglionic lesions, on the other hand, do not typically result in anhidrosis.
There are many potential causes of Horner’s syndrome, including stroke, syringomyelia, multiple sclerosis, tumors, encephalitis, thyroidectomy, trauma, cervical rib, carotid artery dissection, carotid aneurysm, cavernous sinus thrombosis, and cluster headache. It is important to identify the underlying cause of Horner’s syndrome in order to determine the appropriate treatment plan.
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This question is part of the following fields:
- Ophthalmology
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Question 4
Incorrect
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A 42-year-old obese woman, with a history of type II diabetes mellitus, complains of weight gain during the past 3 years, despite her adherence to a balanced diet. She has diffuse skeletal pain. She is not married and does not have a sexual partner. Her family history is unremarkable. Her blood pressure is 160/105 mmHg. Her face is plethoric and round and she has hypertrichosis of the upper lip (hirsutism). There are purple striae on the abdomen and thigh, and mild wasting of the upper and lower limb muscles. Her full blood count shows a slight increase in the polymorphonuclear leukocyte count, without a left shift. Her haemoglobin is 180 (115–155 g/l).
Which of the following changes in serum calcium, phosphate and parathyroid hormone concentrations would you expect to find in this patient?Your Answer: Calcium, phosphate and parathyroid normal
Correct Answer: Calcium - decreased; phosphate - decreased; parathyroid hormone - increased
Explanation:Interpreting Calcium, Phosphate, and Parathyroid Hormone Levels in a Patient with Prolonged Hypercortisolism
A patient presents with diffuse bone pain and laboratory results show decreased calcium and phosphate levels, along with increased parathyroid hormone levels. This is indicative of secondary hyperparathyroidism, which is a common complication of hypercortisolism. Elevated serum cortisol levels can lead to hypocalcaemia and secondary hyperparathyroidism, causing increased osteoclast activity and osteoblast dysfunction, ultimately resulting in osteoporosis and pathological fractures.
If the patient had increased phosphate levels instead of decreased levels, it would suggest renal impairment. If the patient had increased calcium levels and decreased phosphate levels, it would suggest primary hyperparathyroidism. If the patient had decreased calcium levels and increased phosphate levels, it would suggest hypoparathyroidism. If all levels were normal, it may be too early in the course of hypercortisolism to see changes in these markers.
In summary, interpreting calcium, phosphate, and parathyroid hormone levels can provide valuable information in diagnosing and managing complications of hypercortisolism.
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This question is part of the following fields:
- Endocrinology
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Question 5
Incorrect
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Sophie is a 15-year-old who has visited her GP seeking advice on contraception. She discloses that she has been sexually active with a 15-year-old male partner for the past 3 months. Sophie has done her research on various contraceptive methods and expresses her interest in trying the combined oral contraceptive pill (COCP). She has a history of depression due to childhood abuse and is currently receiving treatment from the Child and Adolescent Mental Health Services. However, she reports feeling much better since starting her relationship with her partner. Sophie's parents are unaware of the situation, and she is unwilling to inform them. What is the appropriate course of action?
Your Answer: Prescribe the COCP, only after a full STI screen and pregnancy test
Correct Answer: Prescribe the COCP, providing there are no contraindications
Explanation:The Fraser guidelines state that if a child meets the criteria, they can be prescribed the combined oral contraceptive pill (COCP) without parental knowledge or consent. It is important to maintain confidentiality and not breach it by discussing with the child’s parents. The child’s age or lack of consent for sexual intercourse should not affect their entitlement to contraception. While a full STI screen and pregnancy test are important aspects of holistic care, they are not necessary to prescribe the COCP. The GMC’s guidance on contraception, abortion, and STIs for those aged 0-18 also allows for providing such advice and treatment to young people under 16 without parental knowledge or consent if certain criteria are met.
Guidelines for Obtaining Consent in Children
The General Medical Council has provided guidelines for obtaining consent in children. According to these guidelines, young people who are 16 years or older can be treated as adults and are presumed to have the capacity to make decisions. However, for children under the age of 16, their ability to understand what is involved determines whether they have the capacity to decide. If a competent child refuses treatment, a person with parental responsibility or the court may authorize investigation or treatment that is in the child’s best interests.
When it comes to providing contraceptives to patients under 16 years of age, the Fraser Guidelines must be followed. These guidelines state that the young person must understand the professional’s advice, cannot be persuaded to inform their parents, is likely to begin or continue having sexual intercourse with or without contraceptive treatment, and will suffer physical or mental health consequences without contraceptive treatment. Additionally, the young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent.
Some doctors use the term Fraser competency when referring to contraception and Gillick competency when referring to general issues of consent in children. However, rumors that Victoria Gillick removed her permission to use her name or applied copyright have been debunked. It is important to note that in Scotland, those with parental responsibility cannot authorize procedures that a competent child has refused.
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This question is part of the following fields:
- Paediatrics
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Question 6
Correct
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A 21-year-old student presents to the University Health Service with jaundice. He had been to a party three nights earlier and since then has been laid up in bed with flu-like symptoms. On examination, he has mild jaundice, but otherwise the examination is normal.
Bloods:
Investigation Result Normal value
Bilirubin 62 μmol/l 2–17 µmol/l
Alanine aminotransferase (ALT) 21 IU/l 5–30 IU/l
Aspartate aminotransferase (AST) 15 IU/l 10–40 IU/l
Haemoglobin 131 g/l 135–175 g/l
White cell count (WCC) 4.2 × 109/l 4–11 × 109/l
Platelets 320 × 109/l 150–400 × 109/l
Which of the following is the most likely diagnosis in this case?Your Answer: Gilbert's syndrome
Explanation:Understanding Gilbert’s Syndrome and Its Differential Diagnosis
Gilbert’s syndrome is a genetic condition that affects the conjugation of bilirubin due to a defect in the bilirubin-uridine diphosphate (UDP) glucuronyl transferase enzyme. This results in an isolated rise in bilirubin levels during times of stress, fatigue, or viral illness. A 48-hour fast can confirm the diagnosis if it is unclear. The condition is benign and does not require specific treatment.
Crigler-Najjar syndrome is another condition that affects UDP glucuronyl transferase, but it presents with jaundice and typically results in death during the neonatal period.
Cholecystitis causes right upper quadrant abdominal pain and fever but does not typically result in jaundice. Acute ethanol poisoning can lead to alcoholic hepatitis, but the mild jaundice and overall well-being of the patient are more consistent with Gilbert’s syndrome.
Viral hepatitis can also cause jaundice, but the clinical picture is more in line with Gilbert’s syndrome. Understanding the differential diagnosis is crucial in determining the appropriate treatment and management for patients.
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This question is part of the following fields:
- Gastroenterology
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Question 7
Incorrect
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A 42-year-old West Indian diplomat, while on secondment in the United Kingdom, develops an uncomfortable raised rash on the anterior aspects of both her lower legs. She has prided herself with her remarkably good health over the years. She has recently visited Nigeria, Guyana and Vietnam for her work.
What would be the most appropriate initial investigation to conduct?Your Answer: Stool microbiology
Correct Answer: Chest X-ray
Explanation:The patient is presenting with erythema nodosum, which may have an unknown cause or could be related to their extensive travel history. While a skin biopsy may provide a definitive diagnosis, the best initial investigation is a chest X-ray to rule out tuberculosis and sarcoidosis. A blood film is not necessary as there is no indication of malaria. An ultrasound of the abdomen is not useful in this case, as the skin lesions are the primary concern. Stool microbiology is not necessary as there is no mention of diarrhea. While a skin biopsy may provide information on the lesions themselves, it does not aid in identifying the underlying cause.
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This question is part of the following fields:
- Dermatology
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Question 8
Correct
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A 76-year-old woman, who was previously in good health, presents for review. For the past 2–3 months, she has suffered from increasing pain and stiffness, particularly in the early part of the day, affecting her shoulders and, most recently, her hips. There has also been low-grade fever and she has lost 4 kg in weight. Examination reveals normal proximal muscle strength.
Investigations:
Investigation Result Normal value
Haemoglobin 111 g/l 115–155 g/l
Mean corpuscular volume (MCV) 96 fl 76–98 fl
White cell count (WCC) 6.1 × 109/l 4–11 × 109/l
Platelets 345 × 109/l 150–400 × 109/l
Erythrocyte sedimentation rate (ESR) 75 mm/h 0–10mm in the 1st hour
Sodium (Na+) 140 mmol/l 135–145 mmol/l
Potassium (K+) 5.0 mmol/l 3.5–5.0 mmol/l
Creatinine 130 μmol/l 50–120 µmol/l
Creatine kinase 31 IU/l 23–175 IU/l
Alanine aminotransferase (ALT) 45 IU/l 5–30 IU/l
Chest X-ray (CXR) Slight cardiomegaly, otherwise normal
Which of the following is the most likely diagnosis?Your Answer: Polymyalgia rheumatica (PMR)
Explanation:Differential Diagnosis for a Patient with Shoulder and Pelvic Girdle Pain
Polymyalgia rheumatica (PMR) is a likely diagnosis for a patient presenting with shoulder and pelvic girdle pain without muscle weakness and a markedly raised ESR. Rapid improvement of symptoms with corticosteroids and a subsequent fall in ESR confirms the diagnosis. Temporal arthritis, a vasculitis associated with PMR, should also be considered in patients over 50 presenting with headache, vision loss, and jaw claudication. Myositis and dermatomyositis are less likely diagnoses due to the patient’s normal CK and lack of muscle weakness. Rheumatoid arthritis is unlikely given the patient’s age and the classic joint involvement pattern.
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This question is part of the following fields:
- Rheumatology
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Question 9
Incorrect
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You review a 62-year-old man who presents with a gradual history of worsening fatigue and denies any other symptoms. He has no medical history and takes no medication. Routine observations are within normal limits and there are no abnormalities on thorough examination.
You perform a set of blood tests which come back as below:
Hb 118 g/L Male: (135-180) Female: (115 - 160)
Platelets 395* 109/L (150 - 400)
WBC 10.9* 109/L (4.0 - 11.0)
Na+ 140 mmol/L (135 - 145)
K+ 3.7 mmol/L (3.5 - 5.0)
Urea 6.9 mmol/L (2.0 - 7.0)
Creatinine 110 µmol/L (55 - 120)
Ferritin 17 ng/mL (20 - 230)
Vitamin B12 450 ng/L (200 - 900)
Folate 5 nmol/L (> 3.0)
What would be your next steps in managing this patient?Your Answer: Prescribe oral iron supplements and re-check bloods in 4 weeks
Correct Answer: Prescribe oral iron supplements and refer the patient urgently under the suspected colorectal cancer pathway
Explanation:If a patient over 60 years old presents with new iron-deficiency anaemia, urgent referral under the colorectal cancer pathway is necessary. The blood test results indicate low haemoglobin and ferritin levels, confirming anaemia due to iron deficiency. Even if the patient does not exhibit other symptoms of malignancy, this is a red flag symptom for colorectal cancer. Therefore, an urgent colonoscopy is required to assess for malignancy, and oral iron replacement should be started immediately, as per NICE guidelines. Referring the patient to gastroenterology routinely would be inappropriate, as they meet the criteria for a 2-week wait referral. While prescribing oral iron supplements and monitoring their efficacy is important, it should not be done without investigating the cause of anaemia. Intravenous iron replacement is not necessary for this patient, as their ferritin level is not critically low. Poor diet is not a likely cause of this deficiency, and it would be inappropriate to not treat the anaemia or investigate its cause.
Referral Guidelines for Colorectal Cancer
Colorectal cancer is a serious condition that requires prompt diagnosis and treatment. In 2015, the National Institute for Health and Care Excellence (NICE) updated their referral guidelines for patients suspected of having colorectal cancer. According to these guidelines, patients who are 40 years or older with unexplained weight loss and abdominal pain, 50 years or older with unexplained rectal bleeding, or 60 years or older with iron deficiency anemia or change in bowel habit should be referred urgently to colorectal services for investigation. Additionally, patients who test positive for occult blood in their feces should also be referred urgently.
An urgent referral should also be considered for patients who have a rectal or abdominal mass, unexplained anal mass or anal ulceration, or are under 50 years old with rectal bleeding and any of the following unexplained symptoms/findings: abdominal pain, change in bowel habit, weight loss, or iron deficiency anemia.
The NHS offers a national screening program for colorectal cancer, which involves sending eligible patients aged 60 to 74 years in England and 50 to 74 years in Scotland FIT tests through the post. FIT is a type of fecal occult blood test that uses antibodies to detect and quantify the amount of human blood in a single stool sample. Patients with abnormal results are offered a colonoscopy.
The FIT test is also recommended for patients with new symptoms who do not meet the 2-week criteria listed above. For example, patients who are 50 years or older with unexplained abdominal pain or weight loss, under 60 years old with changes in their bowel habit or iron deficiency anemia, or 60 years or older who have anemia even in the absence of iron deficiency. Early detection and treatment of colorectal cancer can significantly improve patient outcomes, making it important to follow these referral guidelines.
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This question is part of the following fields:
- Surgery
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Question 10
Correct
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A 35-year-old man visits his doctor with a complaint about his penis. He explains that he experiences a noticeable curvature during erection, which has become more severe in recent years. He feels ashamed and worried that it could be cancerous.
What is the probable diagnosis?Your Answer: Peyronie’s disease
Explanation:The patient is exhibiting symptoms of Peyronie’s disease, a condition where fibrous tissue accumulates in the penis, causing it to curve or bend in a particular direction. This is a non-malignant connective tissue disorder that affects approximately 5% of men. The condition results in scar tissue forming in the tunica albuginea, the thick sheath of tissue surrounding the corpora cavernosa, leading to pain, abnormal curvature, erectile dysfunction, indentation, loss of girth, and shortening.
Bowenoid papulosis, on the other hand, is a rare pre-cancerous skin condition that causes the accumulation of red or dark papules on the penis, but does not cause curvature. It is linked to human papillomavirus (HPV) and can transform into invasive squamous cell carcinoma in a small percentage of cases.
Bowen’s disease is a neoplastic skin disease that causes a grey plaque to form on the penis or scrotum, usually affecting older men. It is an early stage or intraepidermal form of squamous cell carcinoma.
Penile lymphoma is unlikely in a young man without associated systemic symptoms, and a history of progressive curvature of the penis is more suggestive of Peyronie’s disease. Erythroplasia of Queyrat is another in situ squamous cell carcinoma of the penis that causes red patches to form.
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This question is part of the following fields:
- Genitourinary
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Question 11
Incorrect
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You have been referred a 14-year-old girl who appears very upset by her parents’ ongoing divorce. She has begun to engage in self-injurious behaviour by banging her head against walls at times of stress. Her intelligence quotient (IQ) has been assessed by her school as 62.
With which of the following is this score most consistent?Your Answer: Moderate learning disability
Correct Answer: Mild learning disability
Explanation:Understanding Learning Disabilities: Levels of Intelligence Quotient (IQ)
Learning disabilities are diagnosed through a combination of intelligence testing and functional assessments. The intelligence quotient (IQ) level is used to determine the severity of the learning disability. A score of 70 is considered within the normal range, while a score between 50-69 indicates a mild learning disability. A score of 35-49 is classified as a moderate learning disability, and a score of 20-34 is considered a severe learning disability. Scores below 20 indicate a profound learning disability. It’s important to note that a score of 60 falls within the mild learning difficulty range, which is still considered a learning disability. Understanding IQ levels can help individuals and their families better understand and manage their learning disabilities.
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This question is part of the following fields:
- Psychiatry
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Question 12
Correct
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A 62-year-old woman is being evaluated on the medical ward due to increasing episodes of dyspnoea, mainly on exertion. She has been experiencing fatigue more frequently over the past few months. Upon examination, she exhibits slight wheezing and bilateral pitting ankle oedema. Her medical history includes type I diabetes, rheumatoid arthritis, hypertension, recurrent UTIs, and hypothyroidism. Her current medications consist of insulin, methotrexate, nitrofurantoin, and amlodipine. She has never smoked, drinks two units of alcohol per week, and does not use recreational drugs. Blood tests reveal a haemoglobin level of 152 g/l, a white cell count of 4.7 × 109/l, a sodium level of 142 mmol/l, a potassium level of 4.6 mmol/l, a urea level of 5.4 mmol/l, and a creatinine level of 69 µmol/l. Additionally, her N-terminal pro-B-type natriuretic peptide (NT-proBNP) level is 350 pg/ml, which is higher than the normal value of < 100 pg/ml. What is the most probable diagnosis?
Your Answer: Cor pulmonale
Explanation:Differential Diagnosis: Cor Pulmonale vs. Other Conditions
Cor pulmonale, or right ventricular failure due to pulmonary heart disease, is the most likely diagnosis for a patient presenting with symptoms such as wheeze, increasing fatigue, and pitting edema. The patient’s history of taking drugs known to cause pulmonary fibrosis, such as methotrexate and nitrofurantoin, supports this diagnosis. Aortic stenosis, asthma, COPD, and left ventricular failure are all possible differential diagnoses, but each has distinguishing factors that make them less likely. Aortic stenosis would not typically present with peripheral edema, while asthma and COPD do not fit with the patient’s lack of risk factors and absence of certain symptoms. Left ventricular failure is also less likely due to the absence of signs such as decreased breath sounds and S3 gallop on heart auscultation. Overall, cor pulmonale is the most likely diagnosis for this patient.
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This question is part of the following fields:
- Cardiology
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Question 13
Incorrect
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A Cardiotocogram (CTG) is performed on a 29-year-old female at 37 weeks gestation who has arrived at labour ward in spontaneous labour. The CTG shows a foetal heart rate of 120 bpm and variable decelerations and accelerations are present. There are no late decelerations. However, the midwife notices a 15 minute period where the foetal heart rate only varies by 2-3bpm. The mum is worried as she has not felt her baby move much for about 15 mins and would like to know what the likely cause is. She starts crying when she tells you that she took some paracetamol earlier as she was in so much pain from the contractions and is concerned this has harmed her baby. What is the most probable reason for this reduced variability?
Your Answer:
Correct Answer: Foetus is sleeping
Explanation:Episodes of decreased variability on CTG that last less than 40 minutes are often attributed to the foetus being asleep. However, if the decreased variability persists for more than 40 minutes, it can be a cause for concern. Other factors that can lead to decreased variability in foetal heart rate on CTG include maternal drug use (such as benzodiazepines, opioids or methyldopa – but not paracetamol), foetal acidosis (usually due to hypoxia), prematurity (which is not applicable in this case), foetal tachycardia (heart rate above 140 bpm, which is also not the case here), and congenital heart abnormalities.
Cardiotocography (CTG) is a medical procedure that measures pressure changes in the uterus using either internal or external pressure transducers. It is used to monitor the fetal heart rate, which normally ranges between 100-160 beats per minute. There are several features that can be observed during a CTG, including baseline bradycardia (heart rate below 100 beats per minute), which can be caused by increased fetal vagal tone or maternal beta-blocker use. Baseline tachycardia (heart rate above 160 beats per minute) can be caused by maternal pyrexia, chorioamnionitis, hypoxia, or prematurity. Loss of baseline variability (less than 5 beats per minute) can be caused by prematurity or hypoxia. Early deceleration, which is a decrease in heart rate that starts with the onset of a contraction and returns to normal after the contraction, is usually harmless and indicates head compression. Late deceleration, on the other hand, is a decrease in heart rate that lags behind the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction. This can indicate fetal distress, such as asphyxia or placental insufficiency. Variable decelerations, which are independent of contractions, may indicate cord compression.
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This question is part of the following fields:
- Obstetrics
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Question 14
Incorrect
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A 55-year-old woman visits her GP and mentions her diagnosis of heart failure. She expresses interest in learning about medications that can potentially decrease mortality in heart failure. Which drug has been proven to have this effect?
Your Answer:
Correct Answer: Spironolactone
Explanation:Common Medications for Heart Failure: Benefits and Limitations
Heart failure is a chronic condition that affects millions of people worldwide. While there is no cure for heart failure, medications can help manage symptoms and improve quality of life. Here are some common medications used in the treatment of heart failure, along with their benefits and limitations.
Spironolactone: Recent trials have shown that spironolactone can reduce mortality in severe heart failure. This drug works by antagonizing the deleterious effects of aldosterone on cardiac remodeling, rather than its diuretic effect.
Simvastatin: While statins are effective in reducing morbidity and mortality in patients with coronary artery disease, their beneficial effects in heart failure remain inconclusive.
Atenolol: Atenolol has not been shown to be effective in reducing mortality in heart failure and is not used as part of the condition’s management. However, certain beta-blockers like carvedilol, metoprolol, or bisoprolol are recommended in patients who have been stabilized on diuretic and angiotensin-converting enzyme (ACE-I) therapy.
Furosemide: Furosemide is a mainstay in the treatment of both acute and long-term heart failure, particularly for relieving symptoms of fluid overload. However, there is little data to prove that it improves long-term mortality in patients with chronic congestive cardiac failure (CCF).
Digoxin: Digoxin does not decrease mortality in heart failure. Its use is reserved for patients in atrial fibrillation and those who cannot be controlled on an ACE-I, beta-blocker, and loop diuretic. Some studies suggest a decreased rate in CHF-related hospital admissions.
In conclusion, while these medications can help manage symptoms and improve quality of life in heart failure patients, their limitations should also be considered. It is important to work closely with a healthcare provider to determine the best treatment plan for each individual.
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This question is part of the following fields:
- Cardiology
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Question 15
Incorrect
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A 28-year-old woman has been diagnosed with HIV and started on antiretroviral medication. She initially responded well to treatment, but now presents with fatigue and abdominal discomfort after 8 months. Upon conducting blood tests, the following results were obtained:
- Haemoglobin: 92 g/L (115-165)
- Urea: 6 mmol/L (2.5-7.5)
- Bilirubin: 3 mg/dL; direct: 0.2 mg/dL (0.3-1.9)
- AST: 39 IU/L (<35)
- ALP: 150 IU/L (44-140)
Which specific antiretroviral drug is this patient currently taking?Your Answer:
Correct Answer: Atazanavir
Explanation:Drug Reaction with Atazanavir and Indinavir
The use of protease inhibitors such as atazanavir and indinavir can lead to unconjugated hyperbilirubinemia, which is characterized by elevated levels of bilirubin in the blood. This condition was observed in a patient who had normal renal function and mildly raised liver enzymes. The reaction is usually benign and reversible upon discontinuation of the drug. The mechanism of this drug reaction is competitive inhibition of the UGT1A1 enzyme. Individuals with Gilbert’s syndrome are more susceptible to this reaction.
Other drugs used in the treatment of HIV/AIDS have different side effect profiles. Nevirapine can cause hepatitis, which is characterized by elevated liver enzymes. Stavudine can cause peripheral neuropathy and pancreatitis, but it is being phased out of treatment regimens. Tenofovir can lead to renal dysfunction, which was not observed in this patient. Zidovudine can cause anemia, hepatitis, and myopathy, among other side effects.
In conclusion, the patient’s presentation of unconjugated hyperbilirubinemia is most likely due to the use of atazanavir or indinavir. Discontinuation of the drug is usually sufficient to reverse the condition. Other drugs used in the treatment of HIV/AIDS have different side effect profiles and should be considered when evaluating patients for drug reactions.
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This question is part of the following fields:
- Infectious Diseases
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Question 16
Incorrect
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A 52-year-old man is shot in the abdomen and suffers a significant intra-abdominal injury. He undergoes a laparotomy, bowel resection, and end colostomy, and requires a 6-unit blood transfusion due to an associated vascular injury. After a prolonged recovery, he is paralyzed and ventilated for 2 weeks in the intensive care unit. He is given total parenteral nutrition and eventually weaned off the ventilator and transferred to the ward. During a routine blood test, the following results are observed:
Full blood count
Hb 11.3 g/dl
Platelets 267 x 109/l
WBC 10.1 x109/l
Urea and electrolytes
Na+ 131 mmol/l
K+ 4.6 mmol/l
Urea 2.3 mmol/l
Creatinine 78 µmol/l
Liver function tests
Bilirubin 25 µmol/l
ALP 445 u/l
ALT 89 u/l
γGT 103 u/l
What is the most probable underlying cause for the noted abnormalities?Your Answer:
Correct Answer: Total parenteral nutrition
Explanation:Liver function tests are often affected by TPN, which can cause cholestasis but it is unlikely to lead to the formation of gallstones as seen in the image. While blood transfusion reactions may cause hepatitis, they usually present earlier and with changes in haemoglobin, which is rare in modern times.
Understanding Total Parenteral Nutrition
Total parenteral nutrition is a commonly used method of providing nutrition to surgical patients who are nutritionally compromised. The bags used in this method contain a combination of glucose, lipids, and essential electrolytes, with the exact composition being determined by the patient’s nutritional requirements. While it is possible to infuse this nutrition peripherally, doing so may result in thrombophlebitis. As such, longer-term infusions should be administered into a central vein, preferably via a PICC line.
Complications associated with total parenteral nutrition are related to sepsis, refeeding syndromes, and hepatic dysfunction. It is important to monitor patients closely for any signs of these complications and adjust the nutrition accordingly. By understanding the basics of total parenteral nutrition, healthcare professionals can provide optimal care to their patients and ensure their nutritional needs are being met.
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This question is part of the following fields:
- Surgery
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Question 17
Incorrect
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A 32-year-old man visits his General Practitioner (GP) for an annual mental health review. He was diagnosed with schizophrenia eight years ago. He has been on medication since diagnosis and takes this daily without any side-effects. He has regular contact with the community mental health team. He is working part-time as a shop assistant, which he enjoys. He has a good appetite, sleeps well and exercises regularly.
What is true regarding the treatment of schizophrenia in a 32-year-old man who has been diagnosed with the condition for eight years and is currently on medication without any side-effects, has regular contact with the community mental health team, works part-time, and has good appetite, sleep, and exercise habits?Your Answer:
Correct Answer: People with a first episode of psychosis should be offered oral antipsychotic treatment, along with psychological interventions
Explanation:Mythbusting: Common Misconceptions About Schizophrenia Treatment
1. Oral antipsychotic treatment and psychological interventions should be offered to those with a first episode of psychosis.
2. Patients with schizophrenia should remain under the care of a psychiatrist lifelong, but can be eligible for shared care with a GP after 12 months of stability.
3. An ECG is only necessary before starting antipsychotic medication in certain circumstances.
4. Before starting any oral antipsychotic medication, various health factors need to be checked in all patients.
5. The choice of antipsychotic medication should be made on an individual basis, taking into account potential side-effects.
6. Early intervention in psychosis services should be accessed urgently for anyone presenting with a first episode of psychosis. Antipsychotic medication should not be initiated in primary care without the advice of a psychiatrist. -
This question is part of the following fields:
- Psychiatry
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Question 18
Incorrect
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A 25-year-old man presents with a complaint of painful hands. He reports that his fingers turn white and become numb when exposed to cold, and then turn blue upon rewarming. His medical history is unremarkable, and he works in construction. On examination, there is no evidence of digital ulcers, calcinosis, chilblains, rash, or arthralgia. His blood results show a hemoglobin level of 145 g/L, platelet count of 260 * 109/L, WBC count of 6.2 * 109/L, and ESR of 10mm/hr. What is the most likely cause of his symptoms?
Your Answer:
Correct Answer: Use of vibrating tools
Explanation:Understanding Raynaud’s Phenomenon
Raynaud’s phenomenon is a condition where the digital arteries and cutaneous arteriole overreact to cold or emotional stress, causing an exaggerated vasoconstrictive response. It can be classified as primary or secondary. Primary Raynaud’s disease is more common in young women and presents with bilateral symptoms. On the other hand, secondary Raynaud’s phenomenon is associated with underlying connective tissue disorders such as scleroderma, rheumatoid arthritis, and systemic lupus erythematosus, among others.
Factors that suggest an underlying connective tissue disease include onset after 40 years, unilateral symptoms, rashes, presence of autoantibodies, and digital ulcers. Management of Raynaud’s phenomenon involves referral to secondary care for patients with suspected secondary Raynaud’s phenomenon. First-line treatment includes calcium channel blockers such as nifedipine. In severe cases, IV prostacyclin (epoprostenol) infusions may be used, and their effects may last for several weeks or months.
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This question is part of the following fields:
- Musculoskeletal
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Question 19
Incorrect
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A 67-year-old woman was admitted 3 days ago with small bowel obstruction. A nasogastric (NG) tube was inserted, and she began 2 litres of intravenous (IV) fluids daily. She reports feeling short of breath and, on examination has widespread fine crackles on auscultation of her chest and pitting sacral oedema. Her notes show that she weighs 48 kg. You're-calculate her daily fluid intake.
What is her required daily fluid intake?Your Answer:
Correct Answer: 1000–1500 ml
Explanation:Calculating Maintenance Fluids for a Patient in Fluid Overload
When a patient is in fluid overload and experiencing pulmonary edema, it is important to carefully calculate their maintenance fluid requirements to avoid worsening their condition. The recommended calculation is 25-30 ml/kg/day. For a patient weighing 48 kg, this equates to a fluid requirement of 1200-1440 ml per day.
If the patient is currently receiving 2 liters of fluid per day, it is likely that this was necessary initially to replace fluid loss. However, once this has been achieved, it is important to step down to normal maintenance levels to avoid exacerbating the fluid overload. Giving 1500-2000 ml or more would only worsen the patient’s condition.
Therefore, it is important to carefully monitor a patient’s fluid intake and adjust as necessary to maintain a safe balance and prevent complications.
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This question is part of the following fields:
- Clinical Biochemistry
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Question 20
Incorrect
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A 21-year-old male student is admitted in the second week of university after a night-out for a basketball club social.
He presents with rigidity, disorientation and a temperature of 39.5ºC. You suspect he may have serotonin syndrome.
Which of the following drugs is most likely to be responsible in this case?Your Answer:
Correct Answer: Ecstasy
Explanation:Overdosing on ecstasy can lead to serotonin syndrome, which is typically linked to SSRI and MAOI antidepressants. Symptoms can appear within a few hours and include sweating and fever. Physical signs may include increased reflexes, muscle spasms, and enlarged pupils.
Understanding Serotonin Syndrome
Serotonin syndrome is a potentially life-threatening condition caused by an excess of serotonin in the body. It can be triggered by a variety of medications and substances, including monoamine oxidase inhibitors, SSRIs, St John’s Wort, tramadol, ecstasy, and amphetamines. The condition is characterized by neuromuscular excitation, hyperreflexia, myoclonus, rigidity, autonomic nervous system excitation, hyperthermia, sweating, and altered mental state, including confusion.
Management of serotonin syndrome is primarily supportive, with IV fluids and benzodiazepines used to manage symptoms. In more severe cases, serotonin antagonists such as cyproheptadine and chlorpromazine may be used. It is important to note that serotonin syndrome can be easily confused with neuroleptic malignant syndrome, which has similar symptoms but is caused by a different mechanism. Both conditions can cause a raised creatine kinase (CK), but it tends to be more associated with NMS. Understanding the causes, features, and management of serotonin syndrome is crucial for healthcare professionals to ensure prompt and effective treatment.
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This question is part of the following fields:
- Pharmacology
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Question 21
Incorrect
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A 50-year-old woman visits the Rheumatology Clinic seeking modification of her DMARDs for the treatment of her rheumatoid arthritis. She is informed that she will require frequent liver checks and eye exams due to the potential side-effects of these medications. What is the most probable combination of treatment she will receive for her condition?
Your Answer:
Correct Answer: Methotrexate plus hydroxychloroquine
Explanation:Medication Combinations for Treating Rheumatoid Arthritis
When treating rheumatoid arthritis, the first-line medication is a DMARD monotherapy with methotrexate. Short-term steroids may also be used in combination with DMARD monotherapy to induce remission. Hydroxychloroquine is another medication that can be used, but patients should be closely monitored for visual changes as retinopathy and corneal deposits are common side effects.
Etanercept is not a first-line treatment for rheumatoid arthritis, and methotrexate should not be given in combination with a TNF-alpha inhibitor like etanercept. Methotrexate plus sulfasalazine is an appropriate medication combination for treating rheumatoid arthritis, but regular eye checks are not required as neither medication affects vision.
If a patient has failed treatment with methotrexate, sulfasalazine plus hydroxychloroquine may be a regimen to consider trialling. However, it is important to note that new-onset rheumatoid arthritis should be treated with a DMARD monotherapy first line, with the addition of another DMARD like methotrexate as the first-line option.
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This question is part of the following fields:
- Rheumatology
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Question 22
Incorrect
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A 35-year-old female patient visits your clinic with complaints of mouth and genital ulcers, accompanied by redness in her eyes. You suspect Behcet's syndrome as the possible diagnosis. What skin manifestation would provide the strongest evidence to support your diagnosis?
Your Answer:
Correct Answer: Erythema nodosum
Explanation:Behcet’s syndrome is linked to several skin symptoms, including genital ulcers, aphthous ulcers, acne-like lesions, and painful red lesions known as erythema nodosum. These lesions are caused by inflammation of the subcutaneous fat and are commonly found on the shins. In contrast, erythema marginatum is a rare rash characterized by pink rings on the extensor surfaces and is associated with rheumatic fever. Asteatotic eczema, also known as crazy paving eczema, has a unique appearance and is linked to hypothyroidism and lymphoma.
Behcet’s syndrome is a complex disorder that affects multiple systems in the body. It is believed to be caused by inflammation of the arteries and veins due to an autoimmune response, although the exact cause is not yet fully understood. The condition is more common in the eastern Mediterranean, particularly in Turkey, and tends to affect young adults between the ages of 20 and 40. Men are more commonly affected than women, although this varies depending on the country. Behcet’s syndrome is associated with a positive family history in around 30% of cases and is linked to the HLA B51 antigen.
The classic symptoms of Behcet’s syndrome include oral and genital ulcers, as well as anterior uveitis. Other features of the condition may include thrombophlebitis, deep vein thrombosis, arthritis, neurological symptoms such as aseptic meningitis, gastrointestinal problems like abdominal pain, diarrhea, and colitis, and erythema nodosum. Diagnosis of Behcet’s syndrome is based on clinical findings, as there is no definitive test for the condition. A positive pathergy test, where a small pustule forms at the site of a needle prick, can be suggestive of the condition. HLA B51 is also a split antigen that is associated with Behcet’s syndrome.
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This question is part of the following fields:
- Musculoskeletal
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Question 23
Incorrect
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A 28-year-old woman is brought to the Emergency Department after taking an overdose of paracetamol due to a recent breakup with her partner. She expresses remorse for her actions, denies any suicidal thoughts, and requests to be discharged. Her parents and a friend arrive at the hospital soon after. Paracetamol levels at 4 hours are below the treatment limit.
What should be the next course of action in managing her case?Your Answer:
Correct Answer: Arrange review by mental health liaison team prior to discharge
Explanation:Importance of Mental Health Liaison Team Review Prior to Discharge for Paracetamol Overdose Patients
Paracetamol overdose is a common presentation of self-harm in emergency departments. While medical management is crucial, patients may also require mental health support. A hospital-based mental health liaison team can provide advice on discharge and arrange follow-up if necessary. Discharging a patient without follow-up increases the risk of further self-harm. However, temporary compulsory detention under the Mental Health Act is not appropriate for low-risk patients. Prescribing N-acetyl-L-cysteine is unnecessary if the paracetamol levels are below treatment threshold. Emergency admission to an inpatient psychiatric unit is only necessary for high-risk patients. Therefore, mental health liaison team review prior to discharge is crucial for appropriate management of paracetamol overdose patients.
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This question is part of the following fields:
- Psychiatry
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Question 24
Incorrect
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A 28-year-old G2P1 woman is admitted to the maternity ward after experiencing regular contractions. During a vaginal examination, the midwife confirms that the mother is currently in the first stage of labor. When does this stage of labor typically end?
Your Answer:
Correct Answer: 10 cm cervical dilation
Explanation:The first stage of labour begins with the onset of true labour and ends when the cervix is fully dilated at 10cm. During this stage, regular contractions occur and the cervix gradually dilates. It is important to note that although 4 cm and 6cm cervical dilation occur during this stage, it does not end until the cervix is fully effaced at 10cm. The second stage of labour ends with the birth of the foetus, not the first.
Labour is divided into three stages, with the first stage beginning from the onset of true labour until the cervix is fully dilated. This stage is further divided into two phases: the latent phase and the active phase. The latent phase involves dilation of the cervix from 0-3 cm and typically lasts around 6 hours. The active phase involves dilation from 3-10 cm and progresses at a rate of approximately 1 cm per hour. In primigravidas, this stage can last between 10-16 hours.
During this stage, the baby’s presentation is important to note. Approximately 90% of babies present in the vertex position, with the head entering the pelvis in an occipito-lateral position. The head typically delivers in an occipito-anterior position.
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This question is part of the following fields:
- Obstetrics
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Question 25
Incorrect
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A 55-year-old woman presents to her GP complaining of worsening fatigue, generalised weakness, and pelvic pain over the past year. She has noticed difficulty climbing stairs and walking long distances. Upon examination, she has a waddling gait and reduced power in hip flexion, hip extension, and hip abduction. The patient has no significant medical history and takes no regular medications. She moved to the UK with her husband from Riyadh three years ago and is a non-smoker and non-drinker. What potential diagnosis should be considered for this patient?
Your Answer:
Correct Answer: Osteomalacia
Explanation:The patient is experiencing symptoms of osteomalacia, such as bone pain, tenderness, and proximal myopathy leading to a waddling gait. Pseudofractures may also be present. Secondary hyperparathyroidism and hypocalcemia should be ruled out, and vitamin D supplementation is the primary treatment. Duchenne muscular dystrophy, osteoclastoma, and Paget’s disease are unlikely diagnoses due to the patient’s age, symptoms, and presentation.
Understanding Osteomalacia
Osteomalacia is a condition that occurs when the bones become soft due to low levels of vitamin D, which leads to a decrease in bone mineral content. This condition is commonly seen in adults, while in growing children, it is referred to as rickets. The causes of osteomalacia include vitamin D deficiency, malabsorption, lack of sunlight, chronic kidney disease, drug-induced factors, inherited conditions, liver disease, and coeliac disease.
The symptoms of osteomalacia include bone pain, muscle tenderness, fractures, especially in the femoral neck, and proximal myopathy, which may lead to a waddling gait. To diagnose osteomalacia, blood tests are conducted to check for low vitamin D levels, low calcium and phosphate levels, and raised alkaline phosphatase levels. X-rays may also show translucent bands known as Looser’s zones or pseudofractures.
The treatment for osteomalacia involves vitamin D supplementation, with a loading dose often needed initially. Calcium supplementation may also be necessary if dietary calcium intake is inadequate. Understanding the causes, symptoms, and treatment options for osteomalacia is crucial in managing this condition effectively.
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This question is part of the following fields:
- Musculoskeletal
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Question 26
Incorrect
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A 32-year-old woman visits a fertility clinic after trying to conceive for more than two years. She is worried that she may not be ovulating despite having a regular menstrual cycle lasting 30 days. She is not using any form of birth control and her pregnancy test is negative. What is the most effective method to detect ovulation?
Your Answer:
Correct Answer: Progesterone level
Explanation:The most reliable way to confirm ovulation is through the Day 21 progesterone test. This test measures the peak level of progesterone in the serum, which occurs 7 days after ovulation. While the length of the follicular phase can vary, the luteal phase always lasts for 14 days. Therefore, if a woman has a 35-day cycle, she can expect to ovulate on Day 21 and her progesterone level will peak on Day 28. To determine when to take the test, subtract 7 days from the expected start of the next period (Day 21 for a 28-day cycle and Day 28 for a 35-day cycle). Basal body temperature charts and cervical mucous thickness are not reliable predictors of ovulation. Gonadotropins may be used to assess ovarian function in women with irregular menstrual cycles.
Infertility is a common issue that affects approximately 1 in 7 couples. It is important to note that around 84% of couples who have regular sexual intercourse will conceive within the first year, and 92% within the first two years. The causes of infertility can vary, with male factor accounting for 30%, unexplained causes accounting for 20%, ovulation failure accounting for 20%, tubal damage accounting for 15%, and other causes accounting for the remaining 15%.
When investigating infertility, there are some basic tests that can be done. These include a semen analysis and a serum progesterone test. The serum progesterone test is done 7 days prior to the expected next period, typically on day 21 for a 28-day cycle. The interpretation of the serum progesterone level is as follows: if it is less than 16 nmol/l, it should be repeated and if it remains consistently low, referral to a specialist is necessary. If the level is between 16-30 nmol/l, it should be repeated, and if it is greater than 30 nmol/l, it indicates ovulation.
It is important to counsel patients on lifestyle factors that can impact fertility. This includes taking folic acid, maintaining a healthy BMI between 20-25, and advising regular sexual intercourse every 2 to 3 days. Additionally, patients should be advised to quit smoking and limit alcohol consumption to increase their chances of conceiving.
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This question is part of the following fields:
- Gynaecology
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Question 27
Incorrect
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What are the typical vaccines administered to adolescents aged 12-19 years?
Your Answer:
Correct Answer: Tetanus/diphtheria/polio + Men ACWY
Explanation:The UK immunisation schedule recommends certain vaccines at different ages. At birth, the BCG vaccine is given if the baby is at risk of tuberculosis. At 2, 3, and 4 months, the ‘6-1 vaccine’ (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) and oral rotavirus vaccine are given, along with Men B and PCV at certain intervals. At 12-13 months, the Hib/Men C, MMR, and PCV vaccines are given, along with Men B. At 3-4 years, the ‘4-in-1 preschool booster’ (diphtheria, tetanus, whooping cough and polio) and MMR vaccines are given. At 12-13 years, the HPV vaccination is given, and at 13-18 years, the ‘3-in-1 teenage booster’ (tetanus, diphtheria and polio) and Men ACWY vaccines are given. Additionally, the flu vaccine is recommended annually for children aged 2-8 years.
It is important to note that the meningitis ACWY vaccine has replaced meningitis C for 13-18 year-olds due to an increased incidence of meningitis W disease in recent years. The ACWY vaccine will also be offered to new students (up to the age of 25 years) at university. GP practices will automatically send letters inviting 17-and 18-year-olds in school year 13 to have the Men ACWY vaccine. Students going to university or college for the first time as freshers, including overseas and mature students up to the age of 25, should contact their GP to have the Men ACWY vaccine, ideally before the start of the academic year.
It is worth noting that the Men C vaccine used to be given at 3 months but has now been discontinued. This is because the success of the Men C vaccination programme means there are almost no cases of Men C disease in babies or young children in the UK any longer. All children will continue to be offered the Hib/Men C vaccine at one year of age, and the Men ACWY vaccine at 14 years of age to provide protection across all age groups.
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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 mother brings her 18-day old baby to the emergency department with visible jaundice and distress. The baby has been feeding poorly since yesterday. Upon examination, hepatomegaly and splenomegaly are observed. The newborn jaundice screen shows no infection, normal thyroid function tests, raised conjugated bilirubin, liver transaminases, and bile acids. Reducing substances are absent in the urine. What is the initial management option for the most probable diagnosis?
Your Answer:
Correct Answer: Surgical intervention
Explanation:Biliary atresia is diagnosed when a newborn presents with prolonged jaundice, hepatomegaly, splenomegaly, abnormal growth, and cardiac murmurs. Surgery is the preferred treatment, specifically a hepatoportoenterostomy (HPE), also known as Kasai portoenterostomy. This procedure removes the blocked bile ducts and replaces them with a segment of the small intestine, restoring bile flow from the liver to the proximal small bowel. Ursodeoxycholic acid may be given as an adjuvant after surgery to facilitate bile flow and protect the liver. However, it should not be given if the total bilirubin is >256.6 micromol/L (>15 mg/dL). Frequent monitoring is not sufficient, urgent action is required. Liver transplant is not the first-line treatment, but may be considered if HPE is unsuccessful or if there are signs of end-stage liver disease, progressive cholestasis, hepatocellular decompensation, or severe portal hypertension.
Understanding Biliary Atresia in Neonatal Children
Biliary atresia is a condition that affects the extrahepatic biliary system in neonatal children, resulting in an obstruction in the flow of bile. This condition is more common in females than males and occurs in 1 in every 10,000-15,000 live births. There are three types of biliary atresia, with type 3 being the most common. Patients typically present with jaundice, dark urine, pale stools, and abnormal growth.
To diagnose biliary atresia, doctors may perform various tests, including serum bilirubin, liver function tests, serum alpha 1-antitrypsin, sweat chloride test, and ultrasound of the biliary tree and liver. Surgical intervention is the only definitive treatment for biliary atresia, and medical intervention includes antibiotic coverage and bile acid enhancers following surgery.
Complications of biliary atresia include unsuccessful anastomosis formation, progressive liver disease, cirrhosis, and eventual hepatocellular carcinoma. However, the prognosis is good if surgery is successful. In cases where surgery fails, liver transplantation may be required in the first two years of life. Overall, understanding biliary atresia is crucial for early diagnosis and effective management in neonatal children.
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This question is part of the following fields:
- Paediatrics
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Question 29
Incorrect
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A 29-year-old woman who is 10 weeks pregnant presents to the early pregnancy assessment unit with vaginal bleeding and abdominal pain that started yesterday. She has a history of Von Willebrand disease. A trans-vaginal ultrasound scan confirms a missed miscarriage. The patient is currently stable without fever or hemodynamic instability. What is the most suitable initial approach to manage this patient's miscarriage?
Your Answer:
Correct Answer: Vaginal misoprostol
Explanation:The recommended medical management for a miscarriage is the administration of vaginal misoprostol, as stated in the 2018 NICE guidelines. This is particularly suitable for patients with a medical history of coagulopathy, such as Von Willebrand disease, as it is a safer option than expectant management. Oral methotrexate is not appropriate for a miscarriage, as it is used for the medical management of ectopic pregnancies. Salpingectomy is a surgical procedure used for tubular ectopic pregnancies, but not for miscarriages. Vacuum aspiration is a surgical option for miscarriages, but medical management is preferred as it is safer and allows the patient to have more control over the process.
Management Options for Miscarriage
Miscarriage can be a difficult and emotional experience for women. In the 2019 NICE guidelines, three types of management for miscarriage were discussed: expectant, medical, and surgical. Expectant management involves waiting for a spontaneous miscarriage and is considered the first-line option. However, if it is unsuccessful, medical or surgical management may be offered.
Medical management involves using tablets to expedite the miscarriage. Vaginal misoprostol, a prostaglandin analogue, is used to cause strong myometrial contractions leading to the expulsion of tissue. It is important to advise patients to contact their doctor if bleeding does not start within 24 hours. Antiemetics and pain relief should also be given.
Surgical management involves undergoing a surgical procedure under local or general anaesthetic. The two main options are vacuum aspiration (suction curettage) or surgical management in theatre. Vacuum aspiration is done under local anaesthetic as an outpatient, while surgical management is done in theatre under general anaesthetic. This was previously referred to as ‘Evacuation of retained products of conception’.
It is important to note that some situations are better managed with medical or surgical management, such as an increased risk of haemorrhage, being in the late first trimester, having coagulopathies or being unable to have a blood transfusion, previous adverse and/or traumatic experience associated with pregnancy, evidence of infection, and more. Ultimately, the management option chosen should be based on the individual patient’s needs and preferences.
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This question is part of the following fields:
- Obstetrics
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Question 30
Incorrect
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A 6-year-old boy spills boiling water on his hand. The lesion is wet, pink, highly tender and blistered. How would you describe this burn?
Your Answer:
Correct Answer: Superficial dermal burn
Explanation:Types of Burns and Their Characteristics
Burns are classified based on the depth of tissue damage and can help determine the severity and prognosis of the injury. Here are the different types of burns and their characteristics:
1. Superficial Dermal Burn: This type of burn damages the epidermis and part of the dermis, resulting in pale pink, painful, small blisters. It usually heals within 2-3 weeks with minimal scarring.
2. Superficial Epidermal Burn: This burn only damages the epidermis, causing redness and slight swelling without blistering. It heals within a week without scarring.
3. Deep Dermal/Partial-Thickness Burn: Both the epidermis and dermis are damaged, resulting in red, blotchy, dry or moist, swollen, blistered burns that do not blanch and have reduced sensation due to nerve damage. It takes 3-8 weeks to heal with scarring.
4. Mixed-Depth Burn: This burn is uniform without mixed features described.
5. Full-Thickness Burn: This is the most severe type of burn, where all three layers of the skin are damaged. The skin is burnt away, and the tissue underneath is pale or blackened. The remaining skin is dry and white, brown, or black without blisters, and is leathery or waxy. It requires surgical repair and grafting.
Understanding the different types of burns and their characteristics can help in proper diagnosis and treatment.
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This question is part of the following fields:
- Plastics
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