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  • Question 1 - A 7-year-old girl presents with diffuse lower limb bone pain and tenderness. Her...

    Incorrect

    • A 7-year-old girl presents with diffuse lower limb bone pain and tenderness. Her past medical history and family history are mostly unknown, but she is known to have been malnourished and is currently under the care of social services.

      During examination, she appears malnourished and pale, with bossing of her forehead, bowing of her legs, and prominent kyphoscoliosis of her spine. She has a waddling gait when walking, and her weight is below the 2nd centile according to a growth chart.

      What radiological feature may be observed given the probable diagnosis?

      Your Answer: Osteolysis

      Correct Answer: Joint widening

      Explanation:

      Rickets can cause joint widening due to an excess of non-mineralized osteoid at the growth plate. This is consistent with the patient’s symptoms of forehead bossing, bowing of the legs, waddling gait, bone pain, and kyphoscoliosis of the spine. The patient’s malnourishment and pale appearance suggest a possible dietary deficiency of vitamin D, which can lead to inadequate mineralization of developing bones. Ballooning, joint space narrowing, and osteolysis are not associated with rickets and do not explain the patient’s symptoms.

      Understanding Rickets: Causes, Symptoms, and Treatment

      Rickets is a condition that occurs when bones in developing and growing bodies are inadequately mineralized, resulting in soft and easily deformed bones. This condition is usually caused by a deficiency in vitamin D. In adults, a similar condition called osteomalacia can occur.

      There are several factors that can predispose individuals to rickets, including a dietary deficiency of calcium, prolonged breastfeeding, unsupplemented cow’s milk formula, and lack of sunlight. Symptoms of rickets include aching bones and joints, lower limb abnormalities such as bow legs or knock knees, swelling at the costochondral junction (known as the rickety rosary), kyphoscoliosis, and soft skull bones in early life (known as craniotabes).

      To diagnose rickets, doctors may perform tests to measure vitamin D levels, serum calcium levels, and alkaline phosphatase levels. Treatment for rickets typically involves oral vitamin D supplementation.

      In summary, rickets is a condition that affects bone development and can lead to soft and easily deformed bones. It is caused by a deficiency in vitamin D and can be predisposed by several factors. Symptoms include bone and joint pain, limb abnormalities, and swelling at the costochondral junction. Treatment involves oral vitamin D supplementation.

    • This question is part of the following fields:

      • Paediatrics
      68.2
      Seconds
  • Question 2 - A 50-year old man has significant tics, but his language, memory and insight...

    Correct

    • A 50-year old man has significant tics, but his language, memory and insight are only mildly to moderately impaired. He also has prominent depression and a butterfly pattern in the caudate nucleus on computed tomography (CT) scan.
      Which is the most likely form of dementia in this patient?

      Your Answer: Dementia due to Huntington’s disease

      Explanation:

      Types of Dementia and their Characteristics

      Dementia is a broad term used to describe a decline in cognitive function that affects daily activities. There are several types of dementia, each with its own unique characteristics.

      Dementia due to Huntington’s disease is an autosomal dominant triplet repeat disease affecting chromosome 4. It usually presents in middle-aged patients with movement disorders (chorea) and progresses to seizures, dementia and death.

      Vascular dementia occurs in a stepwise fashion, with occlusive events leading to sudden new losses of function. Patients develop frontal release and localising neurologic signs relatively early.

      Dementia due to Parkinson’s disease is characterised by loss of dopaminergic cells in the substantia nigra. It also presents with bradykinesia, rigidity, cogwheeling and shuffling gait.

      Alzheimer’s disease has an insidious onset with gradual, continuous progression. Cognitive and language dysfunction occur early, with motor dysfunction and cortical release signs only appearing after diffuse cortical damage has occurred.

      Dementia due to normal pressure hydrocephalus is characterised by the classical triad of dementia, shuffling gait and incontinence. This condition results from blockage of the normal drainage of the cerebrospinal fluid.

      Early recognition and aggressive treatment for cardiovascular disease may slow progression of vascular dementia. Although the changes of vascular dementia are irreversible, the other types of dementia have no cure.

    • This question is part of the following fields:

      • Neurology
      45
      Seconds
  • Question 3 - A 65-year-old male with a nine year history of type 2 diabetes is...

    Incorrect

    • A 65-year-old male with a nine year history of type 2 diabetes is currently taking metformin 1 g twice daily and gliclazide 160 mg twice daily. He has gained weight over the past year and his HbA1c has worsened from 59 to 64 mmol/mol (20-42). The doctor is considering treating him with either insulin or pioglitazone. The patient is curious about the potential side effects of pioglitazone.

      What is a common side effect of pioglitazone therapy?

      Your Answer: Acanthosis nigricans

      Correct Answer: Fluid retention

      Explanation:

      Common Side Effects of Diabetes Medications

      Pioglitazone, a medication used to treat diabetes, can lead to fluid retention in approximately 10% of patients. This side effect can be worsened when taken with other drugs that also cause fluid retention, such as NSAIDs and calcium antagonists. Additionally, weight gain associated with pioglitazone is due to both fat accumulation and fluid retention. It is important to note that pioglitazone is not recommended for patients with cardiac failure.

      Metformin, another commonly prescribed diabetes medication, can cause lactic acidosis as a side effect. This is a known risk and should be monitored closely by healthcare providers.

      Sulphonylureas, a class of medications used to stimulate insulin production, may cause a rash that is sensitive to sunlight.

      Finally, statins and fibrates, medications used to lower cholesterol levels, have been associated with myositis, a condition that causes muscle inflammation and weakness. It is important for patients to be aware of these potential side effects and to discuss any concerns with their healthcare provider.

    • This question is part of the following fields:

      • Cardiology
      52.7
      Seconds
  • Question 4 - A 27-year-old woman visits her GP with complaints of itchy eyes. She reports...

    Correct

    • A 27-year-old woman visits her GP with complaints of itchy eyes. She reports a sensation of grittiness in both eyes and observes that they stick together in the morning. The grittiness is most severe upon waking up. She denies experiencing any other symptoms.
      What is the probable diagnosis based on her presentation?

      Your Answer: Blepharitis

      Explanation:

      The patient is experiencing bilateral grittiness that is worse in the mornings and sticking eyelids, which is a classic symptom of blepharitis. Dry eye syndrome, which is more common in the elderly, can also cause a bilateral gritty feeling, but symptoms are typically worse at the end of the day and may be associated with pain. Cellulitis, on the other hand, would present with redness, inflammation, tenderness, and signs of infection such as fever or discharge. A basal cell carcinoma (BCC) of the eyelid may cause a gritty feeling in the eye, but it would be unilateral, not bilateral. Allergic rhinitis (hay fever) may also cause itchy eyes, but other symptoms such as sneezing, a runny nose, and an itchy nose are typically present.

      Blepharitis is a condition where the eyelid margins become inflamed. This can be caused by dysfunction of the meibomian glands (posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (anterior blepharitis). It is more common in patients with rosacea. The meibomian glands secrete oil to prevent rapid evaporation of the tear film, so any problem affecting these glands can cause dryness and irritation of the eyes. Symptoms of blepharitis are usually bilateral and include grittiness, discomfort around the eyelid margins, sticky eyes in the morning, and redness of the eyelid margins. Styes and chalazions are also more common in patients with blepharitis, and secondary conjunctivitis may occur.

      Management of blepharitis involves softening the lid margin with hot compresses twice a day and practicing lid hygiene to remove debris from the lid margins. This can be done using cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo or sodium bicarbonate in cooled boiled water. Artificial tears may also be given for symptom relief in people with dry eyes or an abnormal tear film.

    • This question is part of the following fields:

      • Ophthalmology
      19.1
      Seconds
  • Question 5 - A 42-year-old mechanic visits his GP complaining of intermittent jaundice that has been...

    Incorrect

    • A 42-year-old mechanic visits his GP complaining of intermittent jaundice that has been occurring for the past 5 months. He has been feeling fatigued lately and occasionally experiences mild itching on his arms. He denies any pain or weight loss. The patient has a history of ulcerative colitis, which was diagnosed 13 years ago and has been managed with mesalazine, anti-diarrhoeals, and steroids. The GP orders liver function tests, which reveal the following results:
      total bilirubin 38 mmol/l
      aspartate aminotransferase (AST) 32 iu/l
      alanine aminotransferase (ALT) 34 iu/l
      alkaline phosphatase 310 u/l.
      What is the most probable diagnosis?

      Your Answer: Primary biliary cholangitis

      Correct Answer: Primary sclerosing cholangitis (PSC)

      Explanation:

      Differential Diagnosis for Cholestatic Jaundice in a Patient with UC

      Primary sclerosing cholangitis (PSC) is a condition that should be considered in a patient with UC who presents with a raised alkaline phosphatase level. This is because approximately two-thirds of patients with PSC also have coexisting UC, and between 3% and 8% of UC sufferers will develop PSC. Chronic cholecystitis would present with pain, which is not present in this patient, making PSC the more likely diagnosis. Acute cholecystitis would present with right upper quadrant pain and obstructive liver function tests, which are not present in this case. Primary biliary cholangitis is more likely to affect women aged 30-60, and given the patient’s history of UC, PSC is more likely. Pancreatic carcinoma would be associated with weight loss and obstructive liver function tests. Therefore, in a patient with UC presenting with cholestatic jaundice, PSC should be considered as a possible diagnosis.

    • This question is part of the following fields:

      • Gastroenterology
      42.9
      Seconds
  • Question 6 - Which statement about leptin is accurate? ...

    Correct

    • Which statement about leptin is accurate?

      Your Answer: Produces satiety

      Explanation:

      The Role of Leptin in Regulating Appetite and Body Weight

      Leptin is a hormone that is produced by adipocytes, or fat cells, and its concentration in the bloodstream is directly related to the amount of fat in the body. When leptin levels are high, it acts on receptors in the hypothalamus to produce feelings of satiety, or fullness, which can help to reduce food intake. This makes leptin an important regulator of appetite and body weight.

      However, in some cases, patients may develop leptin resistance, which means that their bodies are no longer able to respond to the hormone in the same way. This can lead to continued weight gain and difficulty in controlling food intake, even when leptin levels are high. Despite this, researchers continue to study the role of leptin in the body and explore potential treatments for obesity and other related conditions.

      Overall, the physiology of leptin and its effects on appetite and body weight is an important area of research that has the potential to improve the health and well-being of millions of people around the world. By developing new treatments and interventions that target leptin and other related hormones, we may be able to help patients achieve and maintain a healthy weight and reduce their risk of developing chronic diseases such as diabetes, heart disease, and cancer.

    • This question is part of the following fields:

      • Endocrinology
      15.1
      Seconds
  • Question 7 - A 47-year-old man presents to his GP complaining of facial swelling and pain...

    Incorrect

    • A 47-year-old man presents to his GP complaining of facial swelling and pain following a recent upper respiratory tract infection. Upon examination, the right eye is surrounded by erythema and swelling, and there is discomfort when moving the eye. The patient's left eye has a visual acuity of 6/6, while the right eye has a visual acuity of 6/24.

      What would be the best course of action in this case?

      Your Answer: Prescribe high-dose oral steroids and refer urgently to Rheumatology

      Correct Answer: Admit to hospital for IV antibiotics

      Explanation:

      Patients who exhibit symptoms of orbital cellulitis should be admitted to the hospital for IV antibiotics due to the potential risks of cavernous sinus thrombosis and intracranial spread. Prescribing high-dose oral steroids and checking thyroid function is not the appropriate course of action, as these symptoms are more indicative of orbital cellulitis resulting from the spread of infection from the upper respiratory tract. Referring to Rheumatology and prescribing high-dose oral steroids is also not recommended, as this would be more appropriate for suspected giant cell arthritis, which is rare in patients under 65 years old. Supportive management and nasal decongestants are not recommended at this stage, as the facial pain and swelling with painful eye movements suggest that the condition has progressed to orbital cellulitis and requires IV antibiotics.

      Understanding Orbital Cellulitis: Causes, Symptoms, and Management

      Orbital cellulitis is a serious infection that affects the fat and muscles behind the orbital septum within the orbit, but not the globe. It is commonly caused by upper respiratory tract infections that spread from the sinuses and can lead to a high mortality rate. On the other hand, periorbital cellulitis is a less severe infection that occurs in the superficial tissues anterior to the orbital septum. However, it can progress to orbital cellulitis if left untreated.

      Risk factors for orbital cellulitis include childhood, previous sinus infections, lack of Haemophilus influenzae type b (Hib) vaccination, recent eyelid infections or insect bites, and ear or facial infections. Symptoms of orbital cellulitis include redness and swelling around the eye, severe ocular pain, visual disturbance, proptosis, ophthalmoplegia, eyelid edema, and ptosis. In rare cases, meningeal involvement can cause drowsiness, nausea, and vomiting.

      To differentiate between orbital and preseptal cellulitis, doctors look for reduced visual acuity, proptosis, and ophthalmoplegia, which are not consistent with preseptal cellulitis. Full blood count and clinical examination involving complete ophthalmological assessment are necessary to determine the severity of the infection. CT with contrast can also help identify inflammation of the orbital tissues deep to the septum and sinusitis. Blood culture and microbiological swab are also necessary to determine the organism causing the infection.

      Management of orbital cellulitis requires hospital admission for IV antibiotics. It is a medical emergency that requires urgent senior review. Early diagnosis and treatment are crucial to prevent complications and reduce the risk of mortality.

    • This question is part of the following fields:

      • Ophthalmology
      75
      Seconds
  • Question 8 - A 6 year old boy with worsening dry, itchy skin, mainly affecting the...

    Correct

    • A 6 year old boy with worsening dry, itchy skin, mainly affecting the flexor surfaces on his arms, attends a routine GP clinic with his mother. Despite regular liberal use of emollient cream, the symptoms have not improved significantly. What would be the most suitable course of action for managing the child's eczema?

      Your Answer: Prescribe hydrocortisone cream 1%

      Explanation:

      Managing Eczema in Children: Treatment Options and Referral Considerations

      When a child presents with eczema, the first step is often to use emollient cream to manage the symptoms. However, if the eczema persists or worsens, a topical corticosteroid cream may be necessary. It is important to use this sparingly and in conjunction with emollients. While oral corticosteroids may be considered in severe cases, they should be used with caution and ideally under the guidance of a dermatologist. Emollient ointments may also be helpful, but a short course of topical corticosteroids is often more effective for managing flare-ups. If symptoms continue to worsen despite treatment, referral to a dermatology clinic may be necessary. Watchful waiting is not appropriate in this situation.

    • This question is part of the following fields:

      • Dermatology
      21.1
      Seconds
  • Question 9 - A 25-year-old woman visits her GP complaining of feeling down for the past...

    Incorrect

    • A 25-year-old woman visits her GP complaining of feeling down for the past 4 months. She reports having trouble sleeping and losing interest in activities she used to enjoy. Additionally, she has been experiencing excessive worry about the future. The patient has a history of dysmenorrhoea, which is managed with mefenamic acid. The GP recommends cognitive behavioural therapy and prescribes sertraline. What other medication should be considered given the patient's medical history?

      Your Answer: Combined oral contraceptive pill

      Correct Answer: Omeprazole

      Explanation:

      To reduce the risk of gastrointestinal bleeding when taking both an SSRI and an NSAID like mefenamic acid, it is recommended to prescribe a PPI such as omeprazole. The combined oral contraceptive pill is not appropriate in this case as the patient is already taking mefenamic acid for dysmenorrhoea. Duloxetine, an SNRI, should not be prescribed as the patient has not yet tried an SSRI. Naproxen, another NSAID, is also not recommended as the patient is already taking mefenamic acid.

      Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.

      The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.

      When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.

      When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.

    • This question is part of the following fields:

      • Psychiatry
      62.8
      Seconds
  • Question 10 - A 25-year-old man develops a wrist drop after suffering a spiral fracture of...

    Incorrect

    • A 25-year-old man develops a wrist drop after suffering a spiral fracture of the humerus while playing football. As a result, he is unable to extend his wrist and his hand hangs flaccidly. Which nerve is the most likely to have been damaged?

      Your Answer: Median

      Correct Answer: Radial

      Explanation:

      The brachial plexus is a network of nerves that originate from the spinal cord in the neck and supply the upper limb. Damage to these nerves can occur due to trauma or compression at various points along their course. The radial nerve, which carries fibres from C5 to C8 and a sensory component from T1, can be injured in the axilla, upper arm, elbow or wrist. A lesion at the spiral groove of the humerus can result in a wrist drop. The musculocutaneous nerve, which arises from the lateral cord of the brachial plexus, can be affected by damage to the shoulder and brachial plexus or compression by the biceps aponeurosis and tendon. The axillary nerve, which supplies the deltoid, teres minor and triceps brachii, can be injured in dislocations of the shoulder joint, compression of the axilla with a crutch or fracture of the surgical neck of the humerus. The median nerve, which innervates all of the flexors in the forearm except the flexor carpi ulnaris and that part of the flexor digitorum profundus that supplies the medial two digits, can be compressed in the carpal tunnel. The ulnar nerve, which supplies the little finger and the adjacent half of the ring finger, can be trapped in the cubital tunnel on the medial side of the elbow. Pinching of the ulnar nerve can cause paraesthesiae in the fourth and fifth digits.

    • This question is part of the following fields:

      • Neurology
      22
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Paediatrics (0/1) 0%
Neurology (1/2) 50%
Cardiology (0/1) 0%
Ophthalmology (1/2) 50%
Gastroenterology (0/1) 0%
Endocrinology (1/1) 100%
Dermatology (1/1) 100%
Psychiatry (0/1) 0%
Passmed