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Question 1
Incorrect
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You assess a patient in the Emergency Department who was admitted after a motorcycle accident. He is a diabetic patient, with multiple recent hospitalizations due to non-adherence to insulin therapy. Both of his pupils are small, responsive to accommodation, but unresponsive to light.
What is the most appropriate description of this situation?Your Answer: Horner's syndrome
Correct Answer: Argyll-Robertson pupil
Explanation:– Adie pupil: A condition where the pupil is constantly dilated and reacts slowly to light, but responds better to accommodation. It is caused by damage to the parasympathetic innervation of the eye due to viral or bacterial infection. It is more commonly seen in females and is often accompanied by absent knee or ankle jerks.
– Marcus-Gunn pupil: A relative afferent pupillary defect that is observed during the swinging light examination of pupil response. The pupils constrict less and appear to dilate when a light is swung from the unaffected to the affected eye. This condition is most commonly caused by damage to the optic nerve or severe retinal disease.
– Horner’s syndrome: A condition characterized by miosis (pupillary constriction), ptosis (droopy eyelid), apparent enophthalmos (inset eyeball), with or without anhidrosis (decreased sweating) occurring on one side. It is caused by damage to the sympathetic trunk on the same side as the symptoms, due to trauma, compression, infection, ischaemia, or other causes.
– Hutchinson’s pupil: A condition where the pupil on one side is unilaterally dilated and unresponsive to light. It is caused by compression of the occulomotor nerve on the same side, usually by an intracranial mass such as a tumor or hematoma.Argyll-Robertson Pupil: A Classic Pupillary Syndrome
The Argyll-Robertson Pupil (ARP) is a classic pupillary syndrome that is sometimes observed in neurosyphilis. It is characterized by small, irregular pupils that do not respond to light but do respond to accommodation. A useful mnemonic for remembering this syndrome is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA).
The ARP can be caused by various factors, including diabetes mellitus and syphilis. It is important to note that the presence of an ARP may indicate underlying neurological or systemic disease and should prompt further evaluation and management. Proper diagnosis and treatment of the underlying condition can help prevent further complications and improve patient outcomes.
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This question is part of the following fields:
- Ophthalmology
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Question 2
Incorrect
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A 35-year-old expectant mother seeks guidance regarding the likelihood of her child inheriting polycystic kidney disease. Despite her diagnosis, she is presently in good health. Her father, who also has the condition, is currently undergoing dialysis. What is the probability that her offspring will develop the disease?
Your Answer:
Correct Answer: 50%
Explanation:Autosomal dominant polycystic kidney disease (ADPKD) is a prevalent genetic condition that affects approximately 1 in 1,000 Caucasians. The disease is caused by mutations in two genes, PKD1 and PKD2, which produce polycystin-1 and polycystin-2, respectively. ADPKD type 1 accounts for 85% of cases, while ADPKD type 2 accounts for the remaining 15%. Individuals with ADPKD develop multiple fluid-filled cysts in their kidneys, which can lead to renal failure.
To diagnose ADPKD in individuals with a positive family history, an abdominal ultrasound is typically performed. The diagnostic criteria for ultrasound include the presence of two cysts, either unilateral or bilateral, in individuals under 30 years of age, two cysts in both kidneys for those aged 30-59 years, and four cysts in both kidneys for those over 60 years of age.
Management of ADPKD may involve the use of tolvaptan, a vasopressin receptor 2 antagonist, for select patients. Tolvaptan has been recommended by NICE as an option for treating ADPKD in adults with chronic kidney disease stage 2 or 3 at the start of treatment, evidence of rapidly progressing disease, and if the company provides it with the agreed discount in the patient access scheme. The goal of treatment is to slow the progression of cyst development and renal insufficiency. An enlarged kidney with extensive cysts is a common finding in individuals with ADPKD.
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This question is part of the following fields:
- Genetics
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Question 3
Incorrect
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A 14-year-old girl arrives at the clinic with her mother. She is asking for the combined oral contraceptive (COC) pill as she has recently started a relationship with a 19-year-old man whom she met at a local coffee shop, but they have not yet engaged in sexual activity. During the consultation, you discuss the age difference, but the mother assures you that she has met the boyfriend and believes he treats her daughter well. Both the girl and her mother insist that they do not want anyone else involved. What is the most appropriate course of action?
Your Answer:
Correct Answer: Immediately phone local child protection lead and refer to social services
Explanation:According to the GMC guidelines, sexual intercourse with children below the age of 13 cannot be considered consensual, and therefore, any sexual activity would be classified as rape. In such cases, breaking confidentiality is mandatory.
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 4
Incorrect
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Which of the following characteristics does not match bacterial vaginosis in a 33-year-old female with vaginal discharge?
Your Answer:
Correct Answer: Strawberry cervix
Explanation:Trichomonas vaginalis is linked to a strawberry cervix, which can have symptoms resembling those of bacterial vaginosis.
Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.
Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimes. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.
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This question is part of the following fields:
- Reproductive Medicine
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Question 5
Incorrect
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A 60-year-old woman has blood tests done by her primary care physician during a routine check-up. The results show a decline in her renal function. Upon further examination, she reports experiencing ankle swelling and increased fatigue. The renal team suspects she may have amyloidosis. What diagnostic test could be used to confirm this diagnosis?
Your Answer:
Correct Answer: Renal biopsy
Explanation:Diagnostic Methods for Renal Amyloidosis
Renal amyloidosis is a condition that can be challenging to diagnose. It is caused by the accumulation of proteinaceous material in tissues, which can be identified through a biopsy. Congo-red staining extracellular fibrillar material is a characteristic feature of amyloid protein in the kidney. While a urine dip may show proteinuria, a renal biopsy is necessary for a definitive diagnosis as proteinuria can be caused by other conditions. A bone marrow biopsy can confirm amyloidosis if there is suspicion of bone marrow infiltration. CT scans of the abdomen may reveal abnormalities in the kidneys or lymph nodes, but a renal biopsy is still required for a definitive diagnosis. As amyloidosis can affect other organs, a lung biopsy may not be the most targeted approach for diagnosing renal amyloidosis. Overall, a renal biopsy is the most reliable method for diagnosing renal amyloidosis.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 6
Incorrect
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A 42-year-old woman presents to her General Practitioner with polyuria, weight loss and tiredness for six months. Full blood count, urea and electrolytes (U&Es), liver function tests, thyroid function test and calcium are all normal. Glycosylated haemoglobin (HbA1c) is 48 mmol/mol and repeat sample is 50 mmol/mol. On examination, her body mass index is 35 kg/m2, she is normotensive and urinalysis is normal.
Which of the following investigations should be arranged urgently?
Select ONE investigation from the list below.Your Answer:
Correct Answer: Computed tomography (CT) abdomen
Explanation:Diagnostic Tests for a Patient with Suspected Type II Diabetes Mellitus
Computed Tomography (CT) Abdomen:
A CT abdomen is recommended for any patient over the age of 60 with weight loss combined with a new onset of diabetes or abdominal or back pain, nausea, vomiting or change in bowel habit. This is because new-onset type II diabetes can be a presenting feature of pancreatic cancer in patients over the age of 60, especially those who have also experienced weight loss.Pancreatic Autoantibodies:
Pancreatic autoantibodies include anti-glutamic acid decarboxylase, insulin autoantibodies and islet-cell antibodies, the presence of which would support a diagnosis of type I diabetes. These tests are usually carried out in secondary care for atypical presentations such as suspected type II diabetes in a child or a non-overweight person.Glucose Tolerance Test:
Glucose tolerance test has a limited role in diagnosing type II diabetes now that HbA1c is an accepted diagnostic investigation. It is still used routinely to investigate pregnant women at risk of gestational diabetes.Short Synacthen Test:
A short synacthen test is used to diagnose adrenal insufficiency. The history and investigation results do not suggest this as a likely diagnosis, so this test would not be indicated.Ultrasound of the Urinary Tract:
Ultrasound is not indicated unless a structural problem is suspected. Although this man is experiencing polyuria, his urinalysis and PSA are both normal, which makes a urological cause for his symptoms less likely than the newly diagnosed diabetes. Diabetes can cause renal impairment, but this should be monitored with annual urine albumin : creatinine measurement and regular U&Es blood test. -
This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 7
Incorrect
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ACE inhibitors can cause cough as a side effect. Which of the following statements is true about the cause of this cough? Please select one option.
Your Answer:
Correct Answer: They affect the breakdown of bradykinin within the lungs
Explanation:The Effects of ACE Inhibitors on the Lungs
ACE inhibitors are a class of medications commonly used to treat hypertension and heart failure. While they are generally well-tolerated, they can have some effects on the lungs. Here are some key points to keep in mind:
– ACE inhibitors can increase the concentration of bradykinin within the lungs, which can lead to a persistent dry cough in some patients.
– Unlike beta blockers, ACE inhibitors do not cause bronchospasm. In fact, they may be a good choice for patients with asthma or other respiratory conditions.
– Dysgeusia, or a metallic taste in the mouth, is a possible side effect of ACE inhibitors. This is more common with captopril than with other drugs in this class.
– ACE inhibitors do not increase bronchial mucus secretion.
– While ACE inhibitors do cause vasodilation, which can lower blood pressure, they are not associated with pulmonary congestion.Overall, ACE inhibitors are generally safe and effective medications for treating hypertension and heart failure. However, patients should be aware of these potential effects on the lungs and discuss any concerns with their healthcare provider.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 8
Incorrect
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Which one of the following is not a first-rank symptom of schizophrenia for individuals?
Your Answer:
Correct Answer: Catatonia
Explanation:Schizophrenia is a mental disorder that is characterized by various symptoms. Schneider’s first rank symptoms are divided into four categories: auditory hallucinations, thought disorders, passivity phenomena, and delusional perceptions. Auditory hallucinations can include hearing two or more voices discussing the patient in the third person, thought echo, or voices commenting on the patient’s behavior. Thought disorders can involve thought insertion, thought withdrawal, or thought broadcasting. Passivity phenomena can include bodily sensations being controlled by external influence or actions/impulses/feelings that are imposed on the individual or influenced by others. Delusional perceptions involve a two-stage process where a normal object is perceived, and then there is a sudden intense delusional insight into the object’s meaning for the patient.
Other features of schizophrenia include impaired insight, incongruity/blunting of affect (inappropriate emotion for circumstances), decreased speech, neologisms (made-up words), catatonia, and negative symptoms such as incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), and avolition (poor motivation). It is important to note that schizophrenia can manifest differently in each individual, and not all symptoms may be present.
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This question is part of the following fields:
- Psychiatry
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Question 9
Incorrect
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A 26-year-old woman presents with swelling and pain in one calf. Upon Doppler ultrasound scan, an unprovoked DVT is discovered. She expresses a strong desire to start a family with her partner within the next year. Which medication would be the most appropriate choice?
Your Answer:
Correct Answer: Low molecular weight heparin
Explanation:Warfarin is not recommended for treating VTE in pregnancy due to its teratogenic effects. LMWH is the first-line treatment with below-knee compression stockings as an adjunct. Aspirin is not a suitable treatment for VTE.
Warfarin is an oral anticoagulant used to manage venous thromboembolism and reduce stroke risk in patients with atrial fibrillation. It inhibits epoxide reductase, preventing the reduction of vitamin K and the carboxylation of clotting factors. Warfarin is monitored using the INR and may take several days to achieve a stable level. Factors that may potentiate warfarin include liver disease, P450 enzyme inhibitors, cranberry juice, and NSAIDs. Side effects include haemorrhage, teratogenicity, skin necrosis, and purple toes.
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This question is part of the following fields:
- Haematology/Oncology
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Question 10
Incorrect
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A 27-year-old woman who has never given birth presents to your clinic seeking contraception. She complains of experiencing extremely heavy menstrual periods and desires a long-term contraceptive option that can alleviate her heavy bleeding. What is the most appropriate contraceptive method for this patient?
Your Answer:
Correct Answer: Intrauterine system
Explanation:The Mirena coil is a contraceptive method that reduces the duration and intensity of periods and can be used for an extended period.
Intrauterine contraceptive devices include copper IUDs and levonorgestrel-releasing IUS. Both are over 99% effective. The IUD prevents fertilization by decreasing sperm motility, while the IUS prevents endometrial proliferation and thickens cervical mucus. Potential problems include heavier periods with IUDs and initial bleeding with the IUS. There is a small risk of uterine perforation, ectopic pregnancy, and infection. New IUS systems, such as Jaydess® and Kyleena®, have smaller frames and less levonorgestrel, resulting in lower serum levels and different rates of amenorrhea.
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This question is part of the following fields:
- Reproductive Medicine
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Question 11
Incorrect
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What is the frequency of the cervical cancer screening program in England for women over 50 years old?
Your Answer:
Correct Answer: 25-49 years - 3-yearly screening; 50-64 years - 5-yearly screening
Explanation:In England, cervical cancer screening is recommended every 3 years for women aged 25-49 and every 5 years for women aged 50-64.
Cervical Cancer Screening in the UK
Cervical cancer screening is a well-established program in the UK that aims to detect pre-malignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that around 15% of cervical adenocarcinomas are frequently undetected by screening.
The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification, and the NHS has now moved to an HPV first system. This means that a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.
All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. However, cervical screening cannot be offered to women over 64. In Scotland, screening is offered from 25-64 every five years.
In special situations, cervical screening in pregnancy is usually delayed until three months post-partum, unless there are missed screenings or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.
It is recommended to take a cervical smear around mid-cycle, although there is limited evidence to support this advice. Overall, the UK’s cervical cancer screening program is an essential tool in preventing cervical cancer and promoting women’s health.
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This question is part of the following fields:
- Haematology/Oncology
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Question 12
Incorrect
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A 67-year-old male with type 2 diabetes presents for a check-up. He is currently on metformin 1g twice daily and gliclazide 160 mg twice daily. His BMI is 29 kg/m². Blood tests are taken.
Sodium 140 mmol/L
Potassium 4.0mmol/L
Urea 5.8mmol/L
Creatinine 135 umol/L
eGFR 44 ml/min/1.73m²
HbA1c 7.5% (58 mmol/mol)
What modification to his current treatment plan is recommended based on the provided information?Your Answer:
Correct Answer: No change to medication
Explanation:Metformin is typically the first choice for diabetes treatment due to its positive impact on weight. Sulphonylureas are usually the second option, unless they cause hypoglycaemia or are not well-tolerated. If sulphonylureas are not an option, alternatives like DPP4 inhibitors or thiazolidinediones may be considered. Insulin is the next line of treatment after metformin and sulphonylureas, but DPP4 inhibitors may be preferred if insulin is not suitable or if the patient wants to avoid injections or weight gain. However, DPP4 inhibitors should only be continued if they are effective, as they can be expensive.
When it comes to metformin and renal function, it is recommended to stop using it if creatinine levels exceed 150mmol/L or eGFR is below 30ml/min/1.73m². Caution is advised when eGFR is between 30-45ml/min/1.73m², taking into account the rate of deterioration in renal function. For example, if eGFR has remained stable at 33ml/min/1.73m² for six months, it may be reasonable to continue using metformin. However, if eGFR has decreased from 50 to 38ml/min/1.73m², it is likely that metformin should be discontinued due to the risk of lactic acidosis.
NICE updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022, reflecting advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. The first-line drug of choice remains metformin, which should be titrated up slowly to minimize gastrointestinal upset. HbA1c targets should be agreed upon with patients and checked every 3-6 months until stable, with consideration for relaxing targets on a case-by-case basis. Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates and controlling intake of foods containing saturated fats and trans fatty acids. Blood pressure targets are the same as for patients without type 2 diabetes, and antiplatelets should not be offered unless a patient has existing cardiovascular disease. Only patients with a 10-year cardiovascular risk > 10% should be offered a statin, with atorvastatin 20mg as the first-line choice.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 13
Incorrect
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A 55-year-old man arrives at the emergency department with complaints of abdominal pain, nausea, and vomiting. His urine and serum tests reveal elevated ketone levels, and his serum glucose level is 3 mmol/L. An ABG is conducted, and the results are as follows:
pH 7.24
PaO2 14.7 kPa
PCO2 3.5 kPa
HCO3 13 mEq/L
What is the most probable cause of these findings?Your Answer:
Correct Answer: Alcoholic ketoacidosis
Explanation:If a patient is experiencing metabolic ketoacidosis with normal or low glucose levels, alcohol consumption should be considered as a possible cause. This condition is characterized by partial respiratory compensation. While diabetic ketoacidosis could also be a potential cause, a serum glucose level of 3mmol/L makes it less likely. Therefore, the patient is more likely to be suffering from alcoholic ketoacidosis. It is important to note that a hyperosmolar hyperglycemic state would present with high serum glucose levels and normal ketone levels, while a diabetic hypoglycemic episode would not typically result in elevated ketone levels or metabolic acidosis.
Alcoholic ketoacidosis is a type of ketoacidosis that occurs in individuals who consume large amounts of alcohol regularly. This condition is not related to diabetes and is characterized by normal blood sugar levels. Alcoholics often suffer from malnutrition due to their irregular eating habits and may vomit the food they consume, leading to starvation. When the body becomes malnourished, it starts breaking down body fat, which produces ketones and leads to ketoacidosis.
The typical symptoms of alcoholic ketoacidosis include metabolic acidosis, elevated anion gap, elevated serum ketone levels, and normal or low glucose concentration. The most effective treatment for this condition is an infusion of saline and thiamine. Thiamine is essential to prevent the development of Wernicke encephalopathy or Korsakoff psychosis. Therefore, it is crucial to provide timely and appropriate treatment to individuals suffering from alcoholic ketoacidosis to prevent further complications.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 14
Incorrect
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A 36-year-old woman visits her General Practitioner complaining of a 3 kg weight gain, fatigue, dry hair and skin, and a small diffuse goitre. She always feels cold and has a family history of thyroid disease.
Investigation Result Normal value
Thyroid-stimulating hormone (TSH) 18.0 mU/l 0.25–4.0 mU/l
Free T4 6 pmol/l 12–22 pmol/l
Thyroid peroxidase antibody Positive at high titres
What is the most probable diagnosis?Your Answer:
Correct Answer: Hashimoto’s thyroiditis
Explanation:The patient’s symptoms and blood test results suggest hypothyroidism, which is commonly caused by Hashimoto’s thyroiditis, an autoimmune disorder affecting the thyroid gland. Risk factors for this condition include a family history of autoimmune disease, being female, and having another autoimmune disorder. Positive thyroid antibodies and a diffuse goitre may also be present. De Quervain’s thyroiditis, on the other hand, typically presents with hyperthyroidism after a viral infection and is associated with neck pain and fever. Follicular thyroid carcinoma is characterized by a painless thyroid nodule and possible hoarseness or stridor if the recurrent laryngeal nerve is affected. Graves’ disease, the most common cause of hyperthyroidism, presents with symptoms such as sweating, anxiety, and weight loss, as well as eye signs in some cases. Multinodular goitre, which involves multiple autonomously functioning thyroid nodules, typically presents as hyperthyroidism with a multinodular goitre, but the patient in this scenario is hypothyroid.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 15
Incorrect
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A 67-year-old man presents to his General Practitioner reporting a feeling of weakness in his right arm that occurred about 10 hours ago. He states that the weakness lasted for around one hour and has since disappeared. He has a history of hypertension and takes amlodipine, but is typically healthy.
What is the most suitable course of action for management?Your Answer:
Correct Answer: Give aspirin 300 mg and refer immediately to be seen in the Stroke Clinic within 24 hours
Explanation:Management of Transient Ischaemic Attack (TIA)
Transient ischaemic attack (TIA) is a medical emergency that requires prompt management to prevent a subsequent stroke. Here are some management strategies for TIA:
Immediate administration of aspirin 300 mg and referral to the Stroke Clinic within 24 hours is recommended, unless contraindicated. Clopidogrel 75 mg once daily is the preferred secondary prevention following a stroke or TIA.
An outpatient magnetic resonance imaging (MRI) head scan may be considered to determine the territory of ischaemia, but only after assessment by a specialist at a TIA clinic.
Patients who have had a suspected TIA within the last week should be offered aspirin 300 mg at once and be seen by a stroke specialist within 24 hours. If the suspected TIA was more than one week ago, patients should be seen by a specialist within the next seven days.
Dual antiplatelet therapy with aspirin and clopidogrel may be considered for the first three months following a TIA or ischaemic stroke if the patient has severe symptomatic intracranial stenosis or for another condition such as acute coronary syndrome.
Management Strategies for Transient Ischaemic Attack (TIA)
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This question is part of the following fields:
- Neurology
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Question 16
Incorrect
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A young lady requests for the 'morning after pill'. Within what timeframe after sexual intercourse is levonorgestrel approved for use?
Your Answer:
Correct Answer: 72 hours
Explanation:Levonorgestrel should be taken within 72 hours of unprotected sexual intercourse (UPSI). Administration of a single dose of levonorgestrel after this time is not licensed but may be considered.
Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, while ulipristal primarily inhibits ovulation. Levonorgestrel should be taken as soon as possible after unprotected sexual intercourse, within 72 hours, and is 84% effective when used within this time frame. The dose should be doubled for those with a BMI over 26 or weight over 70kg. Ulipristal should be taken within 120 hours of intercourse and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which can be inserted within 5 days of unprotected intercourse or up to 5 days after the likely ovulation date. It may inhibit fertilization or implantation and is 99% effective regardless of where it is used in the cycle. Prophylactic antibiotics may be given if the patient is at high risk of sexually transmitted infection.
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This question is part of the following fields:
- Reproductive Medicine
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Question 17
Incorrect
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A 65-year-old man has scheduled an elective inguinal hernia surgery and is a diabetic taking metformin once daily. His blood glucose levels have been well controlled. He is wondering what he should do with his medication before the surgery.
What advice would be appropriate for him?Your Answer:
Correct Answer: Continue metformin as normal the day before surgery
Explanation:Preparation for surgery varies depending on whether the patient is undergoing an elective or emergency procedure. For elective cases, it is important to address any medical issues beforehand through a pre-admission clinic. Blood tests, urine analysis, and other diagnostic tests may be necessary depending on the proposed procedure and patient fitness. Risk factors for deep vein thrombosis should also be assessed, and a plan for thromboprophylaxis formulated. Patients are advised to fast from non-clear liquids and food for at least 6 hours before surgery, and those with diabetes require special management to avoid potential complications. Emergency cases require stabilization and resuscitation as needed, and antibiotics may be necessary. Special preparation may also be required for certain procedures, such as vocal cord checks for thyroid surgery or bowel preparation for colorectal cases.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 18
Incorrect
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A 25-year-old woman presents complaining of severe itching, which is mainly affecting her groin. The problem has been worsening over the past two to three weeks and is now unbearable. She mentions having slept with a new partner a few weeks before she noticed the problem.
You notice an erythematous, papular rash affecting the web spaces on the hands. She also has erythematous papules and scratch marks around the groin in particular.
Investigations reveal the following:
Investigation Result Normal value
Haemoglobin (Hb) 131 g/l 115–155 g/l
White cell count (WCC) 4.1 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 320 × 109/l 150–400 × 109/l
Sodium (Na+) 141 mmol/l 135–145 mmol/l
Potassium (K+) 4.1 mmol/l 3.5–5.0 mmol/l
Creatinine (Cr) 80 μmol/l 50–120 μmol/l
You draw on the web spaces between her fingers with a felt-tip. Rubbing off the excess reveals several burrows.
What is the most likely diagnosis?Your Answer:
Correct Answer: Sarcoptes scabiei hominis infection
Explanation:Differential Diagnosis for a Patient with Itching and Skin Lesions: Scabies, Atopic Dermatitis, Erythema Infectiosum, Folliculitis, and Keratosis Pilaris
A patient presents with itching between the web spaces and in the groin, which has been ongoing for three to four weeks. The patient reports sexual intercourse as a possible mode of transmission. The differential diagnosis includes scabies, atopic dermatitis, erythema infectiosum, folliculitis, and keratosis pilaris.
Scabies is the most likely diagnosis, as it presents with itching after a delay of three to four weeks following skin-to-skin contact. A washable felt-tip can be used to identify the burrows of the scabies mites, and treatment involves a typical topical agent such as permethrin cream.
Atopic dermatitis is an unlikely diagnosis, as it typically presents with a rash/itch on the flexor aspects of the joints and is unrelated to sexual intercourse.
Erythema infectiosum is a doubtful diagnosis, as it primarily affects children and presents with a slapped cheek appearance and other symptoms such as fever and headache.
Folliculitis is an unlikely diagnosis, as it presents with pinpoint erythematous lesions on the chest, face, scalp, or back and is unrelated to sexual intercourse.
Keratosis pilaris is an unlikely diagnosis, as it typically affects the upper arms, buttocks, and thighs and presents with small white lesions that make the skin feel rough. It is also unrelated to sexual activity.
In conclusion, scabies is the most likely diagnosis for this patient’s symptoms, and treatment with a topical agent such as permethrin cream is recommended.
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This question is part of the following fields:
- Dermatology
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Question 19
Incorrect
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A 30-year-old woman has been diagnosed with Graves disease and has been prescribed carbimazole. What is the most severe side effect of carbimazole?
Your Answer:
Correct Answer: Reversible agranulocytosis
Explanation:Carbimazole: Side Effects and Mechanism of Action
Carbimazole is a medication used to treat hyperthyroidism by inhibiting the production of thyroid hormones. However, it can also cause several side effects that patients should be aware of.
The most serious side effect is bone marrow suppression, which can lead to neutropenia and agranulocytosis. Patients should report any symptoms of infection immediately, as routine monitoring of white cell count is not useful. Cholestatic jaundice and drug-induced hepatitis are also possible side effects, but usually reversible upon discontinuation of the drug. Hypoprothrombinaemia, a rare side effect, can increase the risk of bleeding in patients on anticoagulant therapy.
Carbimazole works by inhibiting the enzyme thyroperoxidase, which is responsible for the synthesis of thyroid hormones. However, its onset of clinical effects is slow because it takes time to deplete the large store of pre-formed thyroid hormones in the thyroid gland.
In addition to its anti-thyroid effect, carbimazole also has a modest immunosuppressive activity, reduces the serum level of thyroid-stimulating hormone antibody, and can cause a reduction in clotting factor prothrombin. However, these effects are not thought to contribute significantly to its efficacy.
Overall, patients taking carbimazole should be aware of its potential side effects and report any symptoms to their healthcare provider promptly.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 20
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A 75-year-old man presents to his GP with persistent itch that has been bothering him for several months. The itch is widespread, affecting his torso and back, and he has not noticed any changes in his skin or overall health. Despite having an extensive medical history, there have been no recent changes to his medications. Upon examination, there are no focal skin changes other than widespread excoriation marks. The GP suspects that a systemic condition may be the underlying cause of the patient's itch. Based on his medical history, which of the following conditions is most likely to be responsible for his symptoms?
Your Answer:
Correct Answer: Chronic kidney disease
Explanation:Pruritus is a symptom of chronic kidney disease, which can cause severe itching and distress for patients. Even in the early stages of the disease, hyperuricemia can lead to intense itchiness.
Causes of Pruritus and their Characteristics
Pruritus, commonly known as itching, can be caused by various underlying conditions. Liver disease, often associated with a history of alcohol excess, can present with stigmata of chronic liver disease such as spider naevi, bruising, palmar erythema, and gynaecomastia. Iron deficiency anaemia can cause pallor and other signs such as koilonychia, atrophic glossitis, post-cricoid webs, and angular stomatitis. Pruritus in polycythaemia is particularly noticeable after a warm bath and is accompanied by a ruddy complexion. Chronic kidney disease can present with lethargy, pallor, oedema, weight gain, hypertension, and fatigue. Lymphoma can cause night sweats, lymphadenopathy, splenomegaly, hepatomegaly, and fatigue. Other causes of pruritus include hyper- and hypothyroidism, diabetes, pregnancy, senile pruritus, urticaria, and skin disorders such as eczema, scabies, psoriasis, and pityriasis rosea. It is important to identify the underlying cause of pruritus to provide appropriate treatment and alleviate symptoms.
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This question is part of the following fields:
- Dermatology
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