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Question 1
Correct
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A 62-year-old woman comes to the clinic with a complaint of postmenopausal bleeding that has been going on for a month. She takes aspirin 75 mg once daily as her only medication. An ultrasound scan of the uterus reveals an endometrial lining thickness of 4.1 mm. Although an endometrial pipelle biopsy was performed, it was inconclusive. What should be the next course of action?
Your Answer: Hysteroscopy with biopsy
Explanation:Investigation is necessary for any postmenopausal bleeding. The first step is to conduct a transvaginal ultrasound scan to examine the thickness of the endometrium. To diagnose endometrial cancer, a Pipelle biopsy is used to sample the endometrium, which is effective in most cases. Hysteroscopy with directed sampling (dilation and curettage) can be used to detect lesions or when Pipelle has been inconclusive. CT scan is not required as a pre-operative imaging test nor is it used to diagnose endometrial cancer.
Reference: Colombo N, Preti E, Landoni F, Carinelli S, Colombo A, et al. Endometrial cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2013; 24 (6): vi33-vi38.Endometrial cancer is a type of cancer that is commonly found in women who have gone through menopause, but it can also occur in around 25% of cases before menopause. The prognosis for this type of cancer is usually good due to early detection. There are several risk factors associated with endometrial cancer, including obesity, nulliparity, early menarche, late menopause, unopposed estrogen, diabetes mellitus, tamoxifen, polycystic ovarian syndrome, and hereditary non-polyposis colorectal carcinoma. Postmenopausal bleeding is the most common symptom of endometrial cancer, which is usually slight and intermittent initially before becoming more heavy. Pain is not common and typically signifies extensive disease, while vaginal discharge is unusual.
When investigating endometrial cancer, women who are 55 years or older and present with postmenopausal bleeding should be referred using the suspected cancer pathway. The first-line investigation is trans-vaginal ultrasound, which has a high negative predictive value for a normal endometrial thickness (< 4 mm). Hysteroscopy with endometrial biopsy is also commonly used for investigation. The management of localized disease involves total abdominal hysterectomy with bilateral salpingo-oophorectomy, while patients with high-risk disease may have postoperative radiotherapy. progesterone therapy is sometimes used in frail elderly women who are not considered suitable for surgery. It is important to note that the combined oral contraceptive pill and smoking are protective against endometrial cancer.
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This question is part of the following fields:
- Gynaecology
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Question 2
Incorrect
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A 29-year-old woman with a history of depression arrives at the Emergency Department after ingesting 50 paracetamol tablets the previous day. Upon admission, blood tests are conducted. What result would suggest the highest need for a liver transplant?
Your Answer: ALT 2364 iu/l
Correct Answer: Arterial pH 7.27
Explanation:The King’s College Hospital criteria for liver transplantation states that a pH level below 7.3, which persists for more than 24 hours after paracetamol overdose, is a crucial factor.
Paracetamol overdose management guidelines were reviewed by the Commission on Human Medicines in 2012. The new guidelines removed the ‘high-risk’ treatment line on the normogram, meaning that all patients are treated the same regardless of their risk factors for hepatotoxicity. However, for situations outside of the normal parameters, it is recommended to consult the National Poisons Information Service/TOXBASE. Patients who present within an hour of overdose may benefit from activated charcoal to reduce drug absorption. Acetylcysteine should be given if the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity. Acetylcysteine is now infused over 1 hour to reduce adverse effects. Anaphylactoid reactions to IV acetylcysteine are generally treated by stopping the infusion, then restarting at a slower rate. The King’s College Hospital criteria for liver transplantation in paracetamol liver failure include arterial pH < 7.3, prothrombin time > 100 seconds, creatinine > 300 µmol/l, and grade III or IV encephalopathy.
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This question is part of the following fields:
- Pharmacology
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Question 3
Incorrect
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You are a medical senior house officer seeing a patient called Edith with your consultant. Edith is a very frail 88-year-old lady with urinary sepsis and a history of metastatic bladder carcinoma. Your consultant completes her ward round and is of the opinion that cardiopulmonary resuscitation (CPR) would be unsuccessful if Edith were to have a cardiac arrest. After the round, a nurse asks you to complete a Do Not Attempt Resuscitation order (DNAR), which will mean that Edith would not undergo CPR in the event of a cardiac arrest. Edith does not currently have mental capacity to make decisions about her care. You have not discussed resuscitation with Edith or her family and do not have any more information available to you at this time. Her son has been appointed Power of Attorney, which includes provision for him to make decisions about Edith’s welfare and medical care.
Select the most appropriate action to take in this case.Your Answer: Complete the DNAR form only if you obtain consent from Edith’s Power of Attorney
Correct Answer: Attempt to contact Edith’s son to discuss the DNACPR order first and then complete the DNAR form
Explanation:Making Decisions about DNACPR and DNAR Orders for Patients without Capacity
When a patient lacks capacity, decisions about their care must be made by their appointed Lasting Power of Attorney (LPA) for health and welfare. In the case of Edith, a decision has been made by the consultant that CPR would not be successful, and a DNACPR order must be put in place to avoid futile attempts at resuscitation. It is good practice to discuss this decision with Edith’s son, who has been assigned as her LPA. However, if he cannot be reached, the order must still be put in place, with continued attempts to contact him for discussion.
It is important to note that a DNAR form should only be completed when the patient has regained mental capacity and can consent to the decision. In Edith’s case, a senior clinician has already determined that attempts at resuscitation would be unsuccessful, and waiting for the consultant to sign the DNAR form may cause harm to Edith if she suffers a cardiac arrest before it is completed.
While it is important to involve the LPA in discussions about the patient’s care, the decision on whether to attempt CPR is ultimately a clinical decision made by the multidisciplinary team. If there is disagreement between the healthcare team and the LPA, a second opinion can be sought, and if necessary, the Court of Protection may be asked to make a declaration. However, the priority should always be the patient’s best interest and avoiding unnecessary distress or harm.
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This question is part of the following fields:
- Ethics And Legal
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Question 4
Correct
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A 65-year-old man visits his General Practitioner (GP) complaining of a swollen and painful first metatarsophalangeal joint that has been bothering him for a week. He reports that the pain became unbearable last night. The patient denies any fever or toe injuries. Upon examination, the joint appears red, swollen, and warm to touch. The patient has a history of gout, peptic ulcer, and is currently taking allopurinol 300 mg once a day for gout prophylaxis. What is the most appropriate next step in management?
Your Answer: Continue allopurinol and start oral colchicine
Explanation:Managing Gout Attacks in Patients on Allopurinol: Options and Considerations
When a patient on allopurinol develops a gout attack, it is important to manage the acute inflammation while continuing the prophylactic treatment. Here are some options and considerations:
– Continue allopurinol and start oral colchicine: Colchicine can be used for acute treatment, but allopurinol should not be stopped.
– Increase allopurinol dose: The dose may need to be increased up to 600 mg for better prophylaxis, but not during an acute attack.
– Stop allopurinol and recommence two weeks after acute inflammation settled: Allopurinol should not be stopped during an attack. It should be continued at the same dose.
– Stop allopurinol and start non-steroidal anti-inflammatory drugs (NSAIDs): NSAIDs can control acute pain, but not appropriate for patients with a history of peptic ulcer.
– Stop allopurinol and recommence at a higher dose after acute inflammation has settled: Allopurinol should not be stopped during an attack. The dose can be reviewed and increased after the attack has settled down.In summary, managing gout attacks in patients on allopurinol requires a careful balance between acute treatment and prophylaxis. Each option should be considered based on the patient’s individual circumstances and medical history.
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This question is part of the following fields:
- Rheumatology
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Question 5
Correct
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A 83-year-old woman presents with urinary frequency and dysuria. She reports that her urine appears bubbly. Over the past year, she has been treated for UTI five times. Her medical history includes hypertension, which is managed with amlodipine. On examination, she has mild suprapubic tenderness but no other significant findings. Her vital signs are heart rate 88/min, blood pressure 128/84 mmHg, respiratory rate 22/min, temperature 37.3ºC, and saturation 93%. A urine dipstick reveals the following: Blood +, Protein +, Leucocytes ++, Nitrites ++. What is the most likely diagnosis?
Your Answer: Enterovesical fistula
Explanation:The presence of bubbly urine in a woman with recurrent UTIs may indicate an enterovesical fistula, which is a connection between the bowel and bladder. This condition is often associated with colorectal cancer, as suggested by the patient’s tissue wasting. It is important to investigate this possibility. There are no symptoms of pyelonephritis or bladder stones, which would not cause gas in the urine. While the patient’s wasting could be a sign of malignancy, there is no indication that it is endometrial cancer, which typically presents with postmenopausal bleeding. The most common organism in UTIs is E. coli, which is a facultative anaerobe and does not produce large amounts of gas.
Fistulas are abnormal connections between two epithelial surfaces, with the majority arising from diverticular disease and Crohn’s in the abdominal cavity. They can be enterocutaneous, enteroenteric or enterocolic, enterovaginal, or enterovesicular. Conservative measures may be the best option for management, but high output fistulas may require octreotide and TPN for nutritional support. Surgeons should avoid probing perianal fistulae with acute inflammation and use setons for those secondary to Crohn’s disease. It is important to delineate the fistula anatomy using barium and CT studies for intraabdominal sources and recalling Goodsall’s rule for perianal fistulae.
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This question is part of the following fields:
- Surgery
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Question 6
Incorrect
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An older man comes in with a severe headache, nausea, vomiting and a painful, red right eye. He has reduced visual acuity in the right eye and normal visual acuity in the left eye. During the examination, he had a stony hard eye with marked pericorneal reddening and a hazy corneal reflex. Tonometry revealed a raised intraocular pressure. The patient reports that he has recently been prescribed a new medication by his general practitioner.
What medication could be responsible for this sudden onset of symptoms?Your Answer: Topical pilocarpine
Correct Answer: Ipratropium nebuliser
Explanation:Understanding Acute Closed Angle Glaucoma and its Treatment Options
Acute closed angle glaucoma is a serious eye condition that can cause sudden vision loss, severe eye pain, and nausea. It occurs when the angle between the iris and cornea is reduced, leading to a blockage of the aqueous humour flow and increased intraocular pressure. Risk factors include female sex, Asian ethnicity, and hypermetropia.
Certain drugs, such as nebulised ipratropium and tricyclic antidepressants, can induce angle closure due to their antimuscarinic effects. Other antimuscarinic drug side-effects include dry eyes, xerostomia, bronchodilation, decreased gut motility, urinary outflow obstruction, and hallucinations.
Acetazolamide is a carbonic anhydrase inhibitor that is given intravenously to treat acute closed angle glaucoma. It helps to reduce intraocular pressure and prevent damage to the optic nerve. Bisoprolol is a β-blocker that does not precipitate an episode of acute closed angle glaucoma, while montelukast is used in the long-term management of asthma and does not increase the risk of acute closed angle glaucoma.
Topical pilocarpine is a miotic that is used to treat acute angle closure glaucoma by constricting the pupil and promoting aqueous humour flow. It is important to understand the causes and treatment options for acute closed angle glaucoma to prevent vision loss and other serious complications.
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This question is part of the following fields:
- Ophthalmology
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Question 7
Incorrect
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What is the most frequent kind of kidney stone?
Your Answer: Calcium phosphate
Correct Answer: Calcium oxalate
Explanation:Types of Renal Stones and their Appearance on X-ray
Renal stones, also known as kidney stones, are solid masses that form in the kidneys due to the accumulation of certain substances. There are different types of renal stones, each with a unique appearance on x-ray. Calcium oxalate stones are the most common, accounting for 40% of cases, and appear opaque on x-ray. Mixed calcium oxalate/phosphate stones and calcium phosphate stones also appear opaque and make up 25% and 10% of cases, respectively. Triple phosphate stones, which develop in alkaline urine and are composed of struvite, account for 10% of cases and appear opaque as well. Urate stones, which are radiolucent, make up 5-10% of cases. Cystine stones, which have a semi-opaque, ‘ground-glass’ appearance, are rare and only account for 1% of cases. Xanthine stones are the least common, accounting for less than 1% of cases, and are also radiolucent. Stag-horn calculi, which involve the renal pelvis and extend into at least 2 calyces, are composed of triple phosphate and are more likely to develop in alkaline urine. Infections with Ureaplasma urealyticum and Proteus can increase the risk of their formation.
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This question is part of the following fields:
- Surgery
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Question 8
Incorrect
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An 80-year-old man has been experiencing severe, throbbing headaches for a few months, focused on the right side. A tender cord-like area can be felt over his right temple. Upon examination, his heart rate is regular without murmurs, gallops, or rubs. His pulses are equal and full in all extremities, and his blood pressure is 110/85 mmHg. A biopsy of the lesion is taken, revealing a muscular artery with luminal narrowing and medial inflammation with lymphocytes, macrophages, and occasional giant cells. The patient responds well to high-dose corticosteroid therapy. What laboratory test finding is most likely to be present with this disease?
Your Answer: pANCA titre of 1:160
Correct Answer: Erythrocyte sedimentation rate of 50 mm/hr
Explanation:Temporal arthritis and its Consequences
Temporal arthritis, also known as giant cell arthritis, is a condition that commonly affects the temporal artery. Its classic symptoms include headache, scalp tenderness, and jaw claudication. If left untreated, it can lead to involvement of other branches of the external carotid artery, with the ophthalmic branch being the worst affected. This can cause blindness due to ischaemic optic neuropathy, central retinal artery occlusion, or cortical infarction. Although corticosteroid therapy can reduce symptoms, established blindness is irreversible. Therefore, it is crucial to diagnose and treat temporal arthritis promptly to prevent severe consequences.
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This question is part of the following fields:
- Miscellaneous
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Question 9
Incorrect
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A 48-year-old woman presents with sudden-onset severe headache. She complains of pain behind the eyes and photophobia. She has vomited twice since the headache came on. She says it is the worst headache she has ever had by far. There is no past history of migraine. Examination reveals no neurological deficit.
What is the most appropriate initial investigation?Your Answer: Lumbar puncture
Correct Answer: Computerised tomography (CT) scan of the head
Explanation:Diagnostic Tests for Headache: CT Scan, Lumbar Puncture, Plasma Viscosity, MRI, and Angiography
Headaches can have various causes, and it is important to determine the underlying condition to provide appropriate treatment. Here are some diagnostic tests that can help identify the cause of a headache:
1. CT Scan of the Head: This imaging test is the initial investigation of choice when subarachnoid haemorrhage is suspected. It can show the presence of blood in the subarachnoid or intraventricular spaces.
2. Lumbar Puncture: If there is doubt about the presence of subarachnoid haemorrhage, a lumbar puncture may be considered 12 hours after the onset of symptoms. Multiple cerebrospinal fluid samples should be sent for microscopy to look for the persistent presence of red blood cells and xanthochromia.
3. Plasma Viscosity: This test is useful when temporal arthritis is suspected as a cause of headache. It will typically be highly elevated. However, it is not useful in the diagnosis of subarachnoid haemorrhage.
4. MRI of the Head: This imaging test may be considered later in the diagnostic process if other diagnoses are being considered. However, CT scan is a more appropriate first-line test.
5. Angiography: This test is usually performed to identify an aneurysm that may be amenable to intervention, either with open surgery or commonly interventional radiology.
In conclusion, the appropriate diagnostic test for a headache depends on the suspected underlying condition. A thorough evaluation by a healthcare professional is necessary to determine the most appropriate course of action.
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This question is part of the following fields:
- Neurology
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Question 10
Correct
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A 42-year-old woman presented to the Emergency Department with a swollen and tender left leg. She had been diagnosed with a deep vein thrombosis (DVT) on her right leg 3 months ago and was prescribed warfarin, which has maintained her INR at 2.0–3.0. The Doppler scan confirmed a positive DVT on her left leg this time, and she has been referred to haematology for further investigations. What is the most appropriate plan for her anticoagulation?
Your Answer: Continue warfarin, aim INR target 3.5
Explanation:Choosing the Right INR Target for Recurrent DVT: A Guide
When it comes to treating recurrent deep vein thrombosis (DVT), determining the appropriate international normalized ratio (INR) target is crucial. While a target of 2.5 (2.0-3.0) is recommended for first presentations of DVT, the target should be increased to 3.5 for recurrent cases. However, if the patient’s INR has been stable within the target range, there is no need to switch to low-molecular-weight heparin. Additionally, antiplatelet agents like clopidogrel have limited use in venous thromboembolism. By following these guidelines, healthcare providers can ensure that their patients receive the most effective treatment for recurrent DVT.
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This question is part of the following fields:
- Pharmacology
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