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  • Question 1 - A 29-year-old man presents to you with a history of intermittent 'stabbing' headaches....

    Incorrect

    • A 29-year-old man presents to you with a history of intermittent 'stabbing' headaches.

      He reports experiencing excruciating unilateral headache around his right eye and over the right temporal area. The headaches last anywhere from a couple of minutes to half an hour. He also experiences lacrimation, nasal epiphora, and a slightly red eye on the affected side during a headache episode.

      He reports having about 20 attacks of the headache a day, which tend to occur during the daytime rather than the night. During attacks, he tends to go and 'curl up in bed' to try and let things settle.

      What is the most appropriate treatment for this headache?

      Your Answer: High flow oxygen

      Correct Answer: Amitriptyline orally

      Explanation:

      Differentiating Episodic Paroxysmal Hemicrania from Cluster Headache

      Episodic paroxysmal hemicrania (EPH) and cluster headache (CH) share similar characteristics, making it difficult to differentiate between the two. However, there are key elements in their history that can help clinicians make an accurate diagnosis. EPH is characterized by frequent attacks of unilateral pain focused around the eye or temporal region, lasting from 2-30 minutes and occurring during the day. In contrast, CH attacks typically last between 15 and 180 minutes, start one to two hours after falling asleep, and occur in clusters ranging from one every other day to eight a day.

      Furthermore, EPH is associated with autonomic symptoms and responds well to treatment with indomethacin (25-75 mg TDS), while CH doesn’t. Indomethacin is a useful differentiator, as it is not commonly prescribed in practice but can have a significant impact on the patient’s symptoms if the diagnosis is correct. By understanding the duration, frequency, and timing of the headaches, clinicians can accurately differentiate between EPH and CH and provide appropriate treatment.

    • This question is part of the following fields:

      • Neurology
      49.5
      Seconds
  • Question 2 - You are assessing a 16-month-old boy with croup. What sign should indicate the...

    Incorrect

    • You are assessing a 16-month-old boy with croup. What sign should indicate the need for referral to a hospital for further evaluation?

      Your Answer:

      Correct Answer: Audible stridor at rest

      Explanation:

      Admission is recommended for patients with croup who exhibit audible stridor at rest. For further information, please refer to the guidelines provided by Clinical Knowledge Summaries.

      Croup is a respiratory infection that affects young children, typically those between 6 months and 3 years old. It is most common in the autumn and is caused by parainfluenza viruses. The main symptom is stridor, which is caused by swelling and secretions in the larynx. Other symptoms include a barking cough, fever, and cold-like symptoms. The severity of croup can be graded based on the child’s symptoms, with mild cases having occasional coughing and no audible stridor at rest, and severe cases having frequent coughing, prominent stridor, and significant distress or lethargy. Children with moderate or severe croup should be admitted to the hospital, especially if they are under 6 months old or have other airway abnormalities. Diagnosis is usually made based on clinical symptoms, but a chest x-ray can show subglottic narrowing. Treatment typically involves a single dose of oral dexamethasone or prednisolone, and emergency treatment may include high-flow oxygen or nebulized adrenaline.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 3 - A 29 year old woman with no pre-existing medical conditions has discovered that...

    Incorrect

    • A 29 year old woman with no pre-existing medical conditions has discovered that she is expecting her first child. She has been purchasing pricey pregnancy supplements from the pharmacy and wonders if they are truly essential. What are the daily supplements recommended by the NHS for all pregnant women (without any additional risk factors)?

      Your Answer:

      Correct Answer: Folic acid 400mcg for first 12 weeks and vitamin D 10mcg throughout pregnancy

      Explanation:

      To reduce the risk of neural tube defects, women who are trying to conceive and up to 12 weeks into their pregnancy are recommended to take 400 mcg of folic acid. If there are additional risk factors, such as diabetes or a personal or family history of neural tube defects, a higher dose of 5mg is recommended. For bone health, a daily supplement of 10mcg of vitamin D is advised throughout pregnancy and breastfeeding. If a woman chooses to take a multivitamin during pregnancy, she should ensure that it doesn’t contain high doses of vitamin A (retinol) as it can cause birth defects.

      Folic Acid: Importance, Deficiency, and Prevention

      Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. THF plays a crucial role in transferring 1-carbon units to essential substrates involved in DNA and RNA synthesis. Green, leafy vegetables are a good source of folic acid. However, certain medications like phenytoin and methotrexate, pregnancy, and alcohol excess can cause folic acid deficiency. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

      To prevent neural tube defects during pregnancy, all women should take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if either partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with antiepileptic drugs or coeliac disease, diabetes, or thalassaemia trait, and those who are obese (BMI of 30 kg/m2 or more) are also at higher risk and should take the higher dose of folic acid.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
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  • Question 4 - Primary biliary cirrhosis is most characteristically associated with: ...

    Incorrect

    • Primary biliary cirrhosis is most characteristically associated with:

      Your Answer:

      Correct Answer: Anti-mitochondrial antibodies

      Explanation:

      The M rule for primary biliary cholangitis includes the presence of IgM and anti-Mitochondrial antibodies, specifically the M2 subtype, in middle-aged women.

      Primary biliary cholangitis is a chronic liver disorder that affects middle-aged women. It is thought to be an autoimmune condition that damages interlobular bile ducts, causing progressive cholestasis and potentially leading to cirrhosis. The classic presentation is itching in a middle-aged woman. It is associated with Sjogren’s syndrome, rheumatoid arthritis, systemic sclerosis, and thyroid disease. Diagnosis involves immunology and imaging tests. Management includes ursodeoxycholic acid, cholestyramine for pruritus, and liver transplantation in severe cases. Complications include cirrhosis, osteomalacia and osteoporosis, and an increased risk of hepatocellular carcinoma.

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 5 - A 50-year-old male construction worker had recently noticed a decline in his hearing...

    Incorrect

    • A 50-year-old male construction worker had recently noticed a decline in his hearing ability in both ears. As a child, he had experienced several ear infections, including a severe one during a bout of measles that impacted his education. There was no history of deafness in his family. During examination, his tympanic membranes appeared intact, but there were calcified scars anterior to the handle of the malleus in both ears. The Rinne test was positive in both ears, and the Weber test was central in both anterior and posterior positions. Striking the 256 cps tuning fork firmly was necessary to achieve the desired volume. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Chronic acoustic trauma

      Explanation:

      Possible Causes of Deafness in Middle Age

      The patient’s medical history indicates a likelihood of tubotympanic problems associated with serous otitis during childhood, as evidenced by scarred tympanic membranes. However, it is unlikely that these issues would cause recent deafness in middle age. The results of the Rinne and Weber tests, using a more accurate tuning frequency of 512, suggest bilateral sensorineural deafness. With no family history, idiopathic premature deafness is less likely.

      Ossicular chain disruption is typically a result of direct trauma and is more likely to be unilateral. Given that building workers are often unregulated when it comes to hearing protection, the probable diagnosis is chronic acoustic trauma.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      0
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  • Question 6 - You are reviewing routine blood test results for Maria, who is a 68-year-old...

    Incorrect

    • You are reviewing routine blood test results for Maria, who is a 68-year-old Hispanic female. Her HbA1c has come back as 56mmol/mol. Her previous result for HbA1c was 44 mmol/mol. Maria has a past medical history of hypertension and hypercholesterolaemia and her body mass index is 32kg/m².

      You have a telephone consultation with Maria. She tells you that she feels well in herself and has no symptoms of thirst, weight loss or recurrent infection.

      What is the most appropriate information to give to Maria?

      Your Answer:

      Correct Answer: He requires a repeat blood test to re-check HbA1c level

      Explanation:

      If HbA1c cannot be used, such as in individuals with end-stage chronic kidney disease, the diagnosis of type 2 diabetes is made based on a fasting plasma glucose level of 7.0 mmol/L or higher. For asymptomatic patients, two abnormal readings are necessary for a diagnosis.

      The diagnosis of type 2 diabetes mellitus can be made through a plasma glucose or HbA1c sample. Diagnostic criteria vary depending on whether the patient is symptomatic or not. WHO released guidance on the use of HbA1c for diagnosis, with a value of 48 mmol/mol or higher being diagnostic of diabetes. Impaired fasting glucose and impaired glucose tolerance are also defined. People with IFG should be offered an oral glucose tolerance test to rule out a diagnosis of diabetes.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
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  • Question 7 - A 70-year-old male patient of yours is confused. He has had nausea and...

    Incorrect

    • A 70-year-old male patient of yours is confused. He has had nausea and vomiting for two days and is now complaining of yellow vision.

      Which of the following is the most likely cause?

      Your Answer:

      Correct Answer: Digoxin

      Explanation:

      Xanthopsia and Digoxin Toxicity

      Confusion, nausea, vomiting, and yellow discoloration of vision are all symptoms that suggest digoxin toxicity. Xanthopsia, or yellow vision, is a rare but possible side effect of digoxin toxicity, particularly in the elderly. Amiodarone can cause corneal deposits and impaired vision, but it doesn’t result in xanthopsia.

      While rotavirus and viral labyrinthitis may cause nausea and vomiting, they do not result in xanthopsia. It is important to note that the elderly are often more susceptible to side effects from medications due to various factors such as declining renal function and rates of gastric emptying.

      If a patient presents with xanthopsia and other symptoms of digoxin toxicity, it is crucial to consider the possibility of digoxin toxicity and take appropriate action. The British National Formulary provides information on digoxin and its potential side effects.

    • This question is part of the following fields:

      • Eyes And Vision
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  • Question 8 - A 10-year-old girl is brought in for a follow-up appointment regarding her asthma...

    Incorrect

    • A 10-year-old girl is brought in for a follow-up appointment regarding her asthma treatment. She is currently using salbutamol inhaler as needed and Symbicort 100/6 (budesonide 100 micrograms/formoterol 6 micrograms) two puffs twice a day. She has been using these inhalers for the past six months. Before that, she was using salbutamol as needed and budesonide 200 micrograms twice a day. The Symbicort was added to her regimen to include a long-acting beta2 agonist as she was using her salbutamol once or twice a day. Despite the addition of the long-acting beta2 agonist, she still experiences occasional tightness in her chest and nighttime coughing. She uses her salbutamol inhaler an average of three to four times a week. Her parents confirm that she is compliant with her inhalers and her inhaler technique is good. What is the most appropriate management plan for her current asthma treatment?

      Your Answer:

      Correct Answer: Add in a leukotriene receptor antagonist to her current treatment

      Explanation:

      Treatment Ladder for Asthma in a 9-Year-Old Child

      Here we have a 9-year-old child with asthma who is currently on a regular inhaled corticosteroid (ICS) + long acting beta2 agonist (LABA) combination inhaler and salbutamol as needed. Despite some improvement with the regular inhaled ICS+LABA, the child is still requiring salbutamol quite frequently.

      To guide treatment titration, the British Thoracic Society treatment ladder is the best recognized guideline in the UK. Based on this, the next step would be to trial a leukotriene receptor antagonist. If the addition of the LABA had not yielded any clinical benefit, then it should be stopped. However, since it has proved to be somewhat helpful, it should be continued.

      In summary, the treatment ladder for asthma in a 9-year-old child involves gradually increasing the level of medication until symptoms are controlled. The addition of a leukotriene receptor antagonist may be the next step in this process.

    • This question is part of the following fields:

      • Children And Young People
      0
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  • Question 9 - Of the given eye injuries, which one would require hospital referral for management?...

    Incorrect

    • Of the given eye injuries, which one would require hospital referral for management?

      Your Answer:

      Correct Answer: Deep corneal foreign body

      Explanation:

      Managing Ocular Trauma: Understanding Different Types of Injuries

      Ocular trauma can be challenging to manage, and it is important to understand the different types of injuries and when to refer to specialists. Deep corneal foreign bodies and large hyphaemas should be managed in centers with slit lamp examinations and intraocular pressure measurements. Urgent referral to secondary care is necessary for open globe injuries, lid lacerations involving the lid margin or canaliculi, blowout orbital fractures with diplopia in the primary position, iris abnormalities, vitreous hemorrhage, and potentially intraocular foreign bodies.

      The most common pitfalls in dealing with ocular trauma are missing tarsal foreign bodies, intraocular foreign bodies, corneal ulcers, scleral lacerations and ruptures, and cranial injuries in sharp orbital trauma.

      Superficial corneal abrasions can usually be managed by a general practitioner or nurse, while corneal foreign bodies can be removed under topical anesthesia. Eyelid lacerations not involving the margin may not require referral, but specialists such as plastic surgeons or ophthalmic surgeons should be consulted for most eyelid lacerations, especially if the lid margin is involved.

      It is crucial to understand the appropriate management and referral for different types of ocular trauma to ensure the best possible outcomes for patients.

    • This question is part of the following fields:

      • Eyes And Vision
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  • Question 10 - A 65-year-old patient presents at the local walk-in centre with central crushing chest...

    Incorrect

    • A 65-year-old patient presents at the local walk-in centre with central crushing chest pain. The nurse immediately calls 999 and performs an ECG which reveals ST elevation in leads II, III and aVF. The patient's blood pressure is 130/70 mmHg, pulse rate is 90 beats per minute, and oxygen saturation is 96%. What is the most suitable course of action to take while waiting for the ambulance to arrive?

      Your Answer:

      Correct Answer: Aspirin 300 mg + sublingual glyceryl trinitrate

      Explanation:

      Assessment of Patients with Suspected Cardiac Chest Pain

      Patients presenting with acute chest pain should receive immediate management for suspected acute coronary syndrome (ACS), including glyceryl trinitrate and aspirin 300 mg. Oxygen should only be given if sats are less than 94%. A normal ECG doesn’t exclude ACS, so referral should be made based on the timing of chest pain and ECG results. Patients with current chest pain or chest pain in the last 12 hours with an abnormal ECG should be emergency admitted. Those with chest pain 12-72 hours ago should be referred to the hospital the same day for assessment. Chest pain more than 72 hours ago should undergo a full assessment with ECG and troponin measurement before deciding upon further action.

      For patients presenting with stable chest pain, NICE defines anginal pain as constricting discomfort in the front of the chest, neck, shoulders, jaw, or arms, precipitated by physical exertion, and relieved by rest or GTN in about 5 minutes. Patients with all three features have typical angina, those with two have atypical angina, and those with one or none have non-anginal chest pain. If stable angina cannot be excluded by clinical assessment alone, NICE recommends CT coronary angiography as the first line of investigation, followed by non-invasive functional imaging and invasive coronary angiography as second and third lines, respectively. Non-invasive functional imaging options include myocardial perfusion scintigraphy with single photon emission computed tomography, stress echocardiography, first-pass contrast-enhanced magnetic resonance perfusion, and MR imaging for stress-induced wall motion abnormalities.

    • This question is part of the following fields:

      • Cardiovascular Health
      0
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  • Question 11 - An 80-year-old man presents to the emergency department with worsening pain and fever...

    Incorrect

    • An 80-year-old man presents to the emergency department with worsening pain and fever following a dental extraction 5 days ago. He is usually in good health. On examination, he has a tender swelling in the left submandibular region and mild trismus. His tongue is slightly displaced upwards and he is unable to protrude it. There is no respiratory distress or stridor. What is the best course of action for management?

      Your Answer:

      Correct Answer: Arrange a 999 ambulance for immediate transfer to hospital

      Explanation:

      Ludwig’s Angina is a medical emergency that falls under the domain of ENT. The patient in question is displaying symptoms and indications that suggest the presence of this rare infection, which affects the soft tissues of the neck and the floor of the mouth. While it is typically caused by dental issues, it can also arise from other types of soft tissue infections in the neck. Due to the effectiveness of modern antibiotics and dental hygiene, Ludwig’s Angina is now quite uncommon, and many physicians may not be familiar with its presentation. However, it can lead to rapid deterioration and airway obstruction within a matter of minutes, necessitating immediate airway management and aggressive surgical intervention. If there is any suspicion of Ludwig’s Angina, it is crucial to transfer the patient to the emergency department without delay.

      Understanding Ludwig’s Angina

      Ludwig’s angina is a serious form of cellulitis that affects the soft tissues of the neck and the floor of the mouth. It is usually caused by an infection that originates from the teeth and spreads to the submandibular space. The condition is characterized by symptoms such as neck swelling, fever, and difficulty swallowing.

      Ludwig’s angina is a medical emergency that requires immediate attention as it can lead to airway obstruction, which can be life-threatening. The management of this condition involves airway management and the administration of intravenous antibiotics.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      0
      Seconds
  • Question 12 - What plasma glucose level is considered diagnostic for diabetes mellitus in a patient...

    Incorrect

    • What plasma glucose level is considered diagnostic for diabetes mellitus in a patient with symptoms?

      Your Answer:

      Correct Answer: Random plasma glucose 10.1 mmol/L

      Explanation:

      Diagnosis of Diabetes: Interpreting Plasma Glucose Concentrations

      The diagnosis of diabetes is based on interpreting plasma glucose concentrations. To diagnose diabetes mellitus, a fasting plasma glucose above 7 mmol/L or a random glucose above 11.1 mmol/L is required. However, it is important to note that two plasma glucose readings are needed according to these parameters in an asymptomatic patient to make the diagnosis. In a symptomatic patient, only one reading is needed.

      It is crucial to pay attention to the details of the question and not misinterpret any of the options. For instance, candidates may misread or misinterpret the threshold of 7.0 mmol/L and argue that 7.1 mmol/L cannot be the correct answer. Therefore, using good examination technique, it is recommended to go over the options again to ensure that the question has been read correctly.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
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  • Question 13 - A child is being monitored for body weight at a routine 12-week check....

    Incorrect

    • A child is being monitored for body weight at a routine 12-week check. The child’s weight is taken and plotted on a centile chart. It is determined that the child's current weight is on the 40th centile.
      What does this indicate about this child’s weight compared with other children of his age in the population?

      Your Answer:

      Correct Answer: This child is heavier than 40% of the children in his age group

      Explanation:

      Understanding Centile Ranks: Interpreting an Individual Score in Relation to a Population

      Centile ranks provide a way of understanding an individual score in relation to all the other scores in a population. The 40th centile, for example, is the value at which 40% of observations would be less than that value. This means that if fewer than 40% of the children in the child’s age group weighed less than the child, the child would be below the 40th centile. On the other hand, if the child were heavier than 60% of the children in his age group, the child would be on the 60th centile. It’s important to note that centiles do not relate an individual score to the average score of a population, but rather to where it would fall if all the scores of a population were arranged in order. By understanding centile ranks, we can better interpret an individual score in relation to a larger population.

    • This question is part of the following fields:

      • Population Health
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  • Question 14 - A 45-year-old man comes to the clinic complaining of a severe headache on...

    Incorrect

    • A 45-year-old man comes to the clinic complaining of a severe headache on the right side of his head that has been ongoing for the past hour. He also reports excessive watering of his right eye and a blocked nose.

      Over the past two weeks, he has experienced five similar episodes, each lasting around two hours. He has been feeling well in between each episode. He is a heavy smoker, consuming 20 cigarettes a day.

      During the examination, he appears restless and agitated, making it difficult to perform a neurological assessment. However, you observe that his right pupil is more constricted than the left, and his blood pressure is 145/90 mmHg. He is apyrexial.

      Apart from referring him to a neurologist for a confirmed diagnosis, what immediate treatment options are available to alleviate his symptoms?

      Your Answer:

      Correct Answer: Subcutaneous sumatriptan

      Explanation:

      This individual is displaying classic symptoms of a cluster headache, including severe unilateral headache lasting between 15-180 minutes, accompanied by lacrimation, nasal congestion, and miosis on the same side.

      Subcutaneous triptans are an effective treatment for managing acute bouts of cluster headache. While intranasal triptans can also provide rapid relief, subcutaneous use has been shown to be more effective.

      There is no evidence to support the use of opioids, nonsteroidal anti-inflammatories, paracetamol, or oral triptans in this situation, and they should not be used.

      Short-burst oxygen therapy can also be used for rapid relief, but the individual’s current smoking status would make the use of home oxygen unsafe.

      Cluster headaches are a type of headache that is known to be extremely painful. They are called cluster headaches because they tend to occur in clusters that last for several weeks, usually once a year. These headaches are more common in men and smokers, and alcohol and sleep patterns may trigger an attack. The pain is typically sharp and stabbing, and it occurs around one eye. Patients may experience redness, lacrimation, lid swelling, nasal stuffiness, and miosis and ptosis in some cases.

      To manage cluster headaches, acute treatment options include 100% oxygen or subcutaneous triptan. Prophylaxis involves using verapamil as the drug of choice, and a tapering dose of prednisolone may also be effective. It is recommended to seek specialist advice from a neurologist if a patient develops cluster headaches with respect to neuroimaging. Some neurologists use the term trigeminal autonomic cephalgia to group a number of conditions including cluster headache, paroxysmal hemicrania, and short-lived unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). Patients with these conditions should be referred for specialist assessment as specific treatment may be required, such as indomethacin for paroxysmal hemicrania.

    • This question is part of the following fields:

      • Neurology
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  • Question 15 - What is the primary purpose of checking the urea and electrolytes before initiating...

    Incorrect

    • What is the primary purpose of checking the urea and electrolytes before initiating amiodarone therapy in a patient?

      Your Answer:

      Correct Answer: To detect hypokalaemia

      Explanation:

      The risk of arrhythmias can be increased by all antiarrhythmic drugs, especially when hypokalaemia is present.

      Amiodarone is a medication used to treat various types of abnormal heart rhythms. It works by blocking potassium channels, which prolongs the action potential and helps to regulate the heartbeat. However, it also has other effects, such as blocking sodium channels. Amiodarone has a very long half-life, which means that loading doses are often necessary. It should ideally be given into central veins to avoid thrombophlebitis. Amiodarone can cause proarrhythmic effects due to lengthening of the QT interval and can interact with other drugs commonly used at the same time. Long-term use of amiodarone can lead to various adverse effects, including thyroid dysfunction, corneal deposits, pulmonary fibrosis/pneumonitis, liver fibrosis/hepatitis, peripheral neuropathy, myopathy, photosensitivity, a ‘slate-grey’ appearance, thrombophlebitis, injection site reactions, and bradycardia. Patients taking amiodarone should be monitored regularly with tests such as TFT, LFT, U&E, and CXR.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 16 - A 50-year-old obese man has hyperpigmented, thickened, velvety skin, with surrounding skin tags...

    Incorrect

    • A 50-year-old obese man has hyperpigmented, thickened, velvety skin, with surrounding skin tags in both axillae.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Acanthosis nigricans

      Explanation:

      Differential Diagnosis for Hyperpigmented Skin: Acanthosis Nigricans, Erythrasma, Melasma, Necrobiosis Lipoidica Diabeticorum, and Post-Inflammatory Hyperpigmentation

      Hyperpigmented skin can be caused by a variety of conditions. One possible cause is acanthosis nigricans, which presents with thick, velvety skin in the neck and flexures, often accompanied by skin tags. This condition is commonly associated with obesity and hereditary factors. However, it can also be a sign of an internal malignancy, particularly gastric cancer.

      Another possible cause of hyperpigmented skin is erythrasma, a bacterial infection that causes pink-red macules that turn brown, typically in the groin and axilla. However, the bilateral distribution of the pigmentation in this case makes erythrasma less likely.

      Melasma is another condition that can cause hyperpigmentation, but it typically presents with symmetrical blotchy brown pigmentation on the face. The distribution described in the scenario makes melasma less likely.

      Necrobiosis lipoidica diabeticorum is a rare condition that affects the shins of people with diabetes. However, the distribution of the pigmentation in this case rules out this condition as a cause.

      Finally, post-inflammatory hyperpigmentation can occur after trauma such as burns, causing flat macules. However, it doesn’t cause skin thickening, as described in this case.

      In summary, the differential diagnosis for hyperpigmented skin includes acanthosis nigricans, erythrasma, melasma, necrobiosis lipoidica diabeticorum, and post-inflammatory hyperpigmentation. A thorough evaluation is necessary to determine the underlying cause and appropriate treatment.

    • This question is part of the following fields:

      • Dermatology
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  • Question 17 - You see a 65-year-old man in a 'hypertension review' appointment. You have been...

    Incorrect

    • You see a 65-year-old man in a 'hypertension review' appointment. You have been struggling to control his blood pressure. He is now taking valsartan 320 mg (his initial ACE inhibitor, Perindopril, was stopped due to persistent coughing), amlodipine 10 mg and chlorthalidone 12.5 mg. He is also taking aspirin and simvastatin for primary prevention. His blood pressure today is 158/91. His recent renal function (done for annual hypertension) showed a sodium of 138, a potassium of 4.7, a urea of 4.2 and a creatinine of 80. His eGFR is 67. He is otherwise well in himself.

      Which of the following options would be appropriate for him?

      Your Answer:

      Correct Answer: Try ramipril

      Explanation:

      Managing Resistant Hypertension

      Resistant hypertension can be a challenging condition to manage, often requiring up to four different Antihypertensive agents. If a person is already taking three Antihypertensive drugs and their blood pressure is still not controlled, increasing chlorthalidone to a maximum of 50 mg may be considered, provided that blood potassium levels are higher than 4.5mmol/L. However, caution should be exercised when using co-amilofruse, a potassium-sparing diuretic, in conjunction with valsartan, especially if the patient has a recent history of having a potassium level of 4.5 or higher.

      If a patient has previously developed a cough with an ACE inhibitor, switching to a different ACE inhibitor is unlikely to make any difference. In such cases, bisoprolol may be added if further diuretic treatment is not tolerated, is contraindicated, or is ineffective. It is important to seek specialist advice if secondary causes for hypertension are likely or if a patient’s blood pressure is not controlled on the optimal or maximum tolerated doses of four Antihypertensive drugs.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 18 - A 28-year-old nurse had a needlestick injury six months ago. She did not...

    Incorrect

    • A 28-year-old nurse had a needlestick injury six months ago. She did not present immediately to Occupational Health but eventually came because she began to feel tired and lethargic. She has a raised alanine aminotransferase (ALT) level, anti-hepatitis B surface antibodies and anti-hepatitis C virus (HCV) antibodies. Low levels of HCV ribonucleic acid (RNA) are detected. A liver biopsy reveals early inflammatory changes.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Chronic hepatitis C infection

      Explanation:

      Explanation of Hepatitis C Infection and Differential Diagnosis

      Hepatitis C virus (HCV) ribonucleic acid (RNA) is detected in a patient, indicating active hepatitis C infection. The presence of anti-HCV antibodies and an 8-month history since exposure confirms that the infection is now chronic. Liver biopsy may show varying degrees of inflammation, fibrosis, and cirrhosis, with this patient exhibiting early inflammatory changes.

      Autoimmune hepatitis, which is associated with antinuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA), is not consistent with the presence of anti-HCV antibodies and HCV RNA. Chronic hepatitis B infection is also ruled out, as the patient’s anti-hepatitis B antibodies are likely due to vaccination. Functional symptoms may cause tiredness and lethargy, but the patient’s deranged liver function tests and positive hepatitis C antibodies indicate an underlying diagnosis of hepatitis C.

      Understanding Hepatitis C Infection and Differential Diagnosis

    • This question is part of the following fields:

      • Gastroenterology
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  • Question 19 - A 55-year-old woman comes to your clinic after noticing that a mole on...

    Incorrect

    • A 55-year-old woman comes to your clinic after noticing that a mole on the side of her neck has recently grown. Upon examination, you observe an irregularly shaped lesion with variable pigmentation and a diameter of 7 mm.

      What would be the best course of action for this patient?

      Your Answer:

      Correct Answer: Reassess in two weeks

      Explanation:

      Urgent Referral Needed for Suspicious Lesion

      This patient’s lesion is highly suspicious of a melanoma and requires immediate referral to a dermatologist. Any delay in monitoring in primary care could result in delayed treatment and potentially worse outcomes. The lesion’s recent increase in size, irregular pigmentation, and margin are all factors that raise suspicions. To aid in decision-making, the 7-point weighted checklist can be used, which includes major features such as change in size, irregular shape, and irregular color, as well as minor features like inflammation, oozing, change in sensation, and largest diameter 7 mm or more. Lesions scoring 3 or more points are considered suspicious and should be referred, even if the score is less than 3. If the lesion were low risk, it would be reasonable to monitor over an eight-week period using the 7-point checklist, photographs, and a marker scale and/or ruler. However, it is not appropriate to excise or biopsy suspicious pigmented lesions in primary care.

    • This question is part of the following fields:

      • Dermatology
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  • Question 20 - A patient with a history of heart failure experiences mild physical activity limitations....

    Incorrect

    • A patient with a history of heart failure experiences mild physical activity limitations. While at rest, she is comfortable, but everyday tasks like walking to nearby stores cause fatigue, palpitations, or dyspnea. Which New York Heart Association class accurately characterizes the extent of her condition?

      Your Answer:

      Correct Answer: NYHA Class II

      Explanation:

      NYHA Classification for Chronic Heart Failure

      Chronic heart failure is a condition that affects the heart’s ability to pump blood effectively. The New York Heart Association (NYHA) classification is a widely used system to categorize the severity of heart failure. The NYHA classification has four classes, each with a different level of symptoms and limitations.

      NYHA Class I refers to patients who have no symptoms and no limitations in their physical activity. They can perform ordinary physical exercise without experiencing fatigue, dyspnea, or palpitations.

      NYHA Class II patients have mild symptoms and slight limitations in their physical activity. They are comfortable at rest, but ordinary activity can cause fatigue, palpitations, or dyspnea.

      NYHA Class III patients have moderate symptoms and marked limitations in their physical activity. They are comfortable at rest, but less than ordinary activity can result in symptoms.

      NYHA Class IV patients have severe symptoms and are unable to carry out any physical activity without discomfort. Symptoms of heart failure are present even at rest, and any physical activity increases discomfort.

      In summary, the NYHA classification is a useful tool for healthcare professionals to assess the severity of chronic heart failure and determine appropriate treatment plans.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 21 - A father brings his eight-year-old daughter to an emergency appointment at the Duty...

    Incorrect

    • A father brings his eight-year-old daughter to an emergency appointment at the Duty Doctor Clinic after she sustained a needlestick injury that day on her way home from school. He explains that he picked her up from school by car, and he then parked in the underground car park where they have an allocated space next to their flat.
      Unfortunately, rough sleepers have been using the car park as shelter, and on getting out of the car his daughter found a needle on the floor which she picked up but accidentally pricked her finger in doing so. His dad is very concerned about her risk of human immunodeficiency virus (HIV) and wants to know if she should be tested.
      What is the most appropriate advice to give him, regarding immediate management of this needlestick injury?

      Your Answer:

      Correct Answer: The risk of hepatitis from a contaminated needle is greater than the risk of HIV

      Explanation:

      Managing a Needlestick Injury: Important Considerations

      A needlestick injury can be a stressful and potentially dangerous situation. Here are some important considerations to keep in mind when managing such an injury:

      – The risk of hepatitis from a contaminated needle is greater than the risk of HIV. However, post-exposure prophylaxis (PEP) should still be considered for HIV prevention.
      – If the individual has not been vaccinated against hepatitis B, an accelerated course of hepatitis B should be offered following the injury.
      – Blood tests should be arranged as soon as possible for baseline virology and liver function tests. These should be repeated at three and six months.
      – First aid for a needlestick injury includes encouraging bleeding and washing with soap and running water. However, there is no need to re-open the wound to encourage further bleeding.
      – HIV self-test kits are available through online request platforms, but they are generally not appropriate for individuals who do not belong to a high-risk group and have had a single needlestick injury in the community.

      By keeping these considerations in mind, individuals can take appropriate steps to manage a needlestick injury and reduce the risk of infection.

    • This question is part of the following fields:

      • Allergy And Immunology
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  • Question 22 - A study found that of 100 people over the age of 60 treated...

    Incorrect

    • A study found that of 100 people over the age of 60 treated with a certain medication, 80 had improvement in their symptoms, whereas of 100 people over the age of 60 not treated, only 50 had improvement. What is the number needed to treat (NNT)?

      Your Answer:

      Correct Answer: 4

      Explanation:

      Calculating the Number Needed to Treat (NNT) for Vertigo Treatment

      To determine the effectiveness of a vertigo treatment, we can calculate the Number Needed to Treat (NNT). This is done by first calculating the Absolute Risk Reduction (ARR), which is the difference between the Control Event Rate (CER) and the Experimental Event Rate (EER). For example, if 55 out of 100 control patients failed to have a resolution of vertigo, and 30 out of 100 treatment patients failed to improve, the ARR would be 0.55 – 0.30 = 0.25. To find the NNT, we simply take the reciprocal of the ARR, which in this case would be 1/0.25 = 4. This means that for every 4 patients treated with the vertigo treatment, one patient will have a resolution of their vertigo.

    • This question is part of the following fields:

      • Population Health
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  • Question 23 - A physician needs a Home Office license to prescribe which of the following...

    Incorrect

    • A physician needs a Home Office license to prescribe which of the following controlled substances to a minor drug addict?

      Your Answer:

      Correct Answer: Pethidine

      Explanation:

      Prescribing Controlled Drugs to Addicts

      A doctor must obtain a Home Office licence to prescribe diamorphine, dipipanone, and cocaine to addicts. These drugs are classified as class A drugs under the Misuse of Drugs Act 1971, which means they are highly addictive and subject to strict control to prevent illegal misuse. However, non-addicts can receive these drugs without a licence if it is clinically appropriate.

      The Misuse of Drugs Regulations 2001 outlines the authorised individuals who can supply and possess controlled drugs. It is important to note that prescribing these drugs to addicts requires a special licence due to the potential for misuse and addiction.

    • This question is part of the following fields:

      • Improving Quality, Safety And Prescribing
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  • Question 24 - A 10-year-old girl presents for an urgent review. She has been experiencing wheezing...

    Incorrect

    • A 10-year-old girl presents for an urgent review. She has been experiencing wheezing and coughing for the past 24 hours despite regular use of a salbutamol inhaler. She is otherwise healthy. The patient was diagnosed with asthma two years ago and has been managing it well with occasional reliever therapy.

      Upon examination, the patient appears well and is able to communicate without difficulty. There are no signs of respiratory distress. Mild wheezing is present throughout the chest with no crackles. Vital signs are as follows: respiratory rate 20, pulse 100 bpm, blood pressure 110/60mmHg, oxygen saturation 96%, and temperature 37°C. Peak flow is measured at 290L/min (315L/min expected).

      What is the most appropriate course of action?

      Your Answer:

      Correct Answer: 10 puffs of salbutamol with spacer (repeat as required) + prednisolone

      Explanation:

      Corticosteroid therapy should be administered to all children experiencing an asthma exacerbation. The appropriate treatment for this child, who is presenting with a mild exacerbation of asthma without signs of infection, is 10 puffs of salbutamol with spacer (to be repeated as necessary) and prednisolone. Antibiotics are not necessary in this case. It is important to increase the short-acting beta agonist dose and deliver it through a spacer to ensure effective medication delivery. Two puffs of salbutamol with spacer (to be repeated as necessary) is not sufficient for treating an asthma exacerbation.

      The management of acute asthma attacks in children depends on the severity of the attack. Children with severe or life-threatening asthma should be immediately transferred to the hospital. For children with mild to moderate acute asthma, bronchodilator therapy and steroid therapy should be given. The dosage of prednisolone depends on the age of the child. It is important to monitor SpO2, PEF, heart rate, respiratory rate, use of accessory neck muscles, and other clinical features to determine the severity of the attack.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 25 - A 65-year-old woman presents for her medication review. She was prescribed alendronate three...

    Incorrect

    • A 65-year-old woman presents for her medication review. She was prescribed alendronate three years ago after being diagnosed with osteoporosis following a wrist fracture. The patient inquires about the duration of bone protection therapy.

      When is the optimal time to evaluate her risk and determine if ongoing treatment is necessary?

      Your Answer:

      Correct Answer: At 5 years

      Explanation:

      Monitoring Osteoporosis Treatment: What Patients Need to Know

      After starting bone protection treatment, patients often wonder how they can tell if the treatment is working and if they need to repeat the DEXA scan. Unfortunately, there is little clear guidance from major guidelines on these issues. However, the general consensus is that patients do not need to assess their bone mineral density once bone protection has been started. This is because there is limited evidence of any link between improvement in bone mineral density and reduction in fracture risk.

      As for the length of treatment, the National Osteoporosis Guideline Group (NOGG) recommends a treatment review after 5 years of treatment for alendronate, risedronate, or ibandronate, and after 3 years for zoledronic acid. This review will likely involve a recalculation of the patient’s fracture risk and a DEXA scan. It is important for patients to follow their healthcare provider’s recommendations and attend regular check-ups to ensure the best possible outcomes for their osteoporosis treatment.

    • This question is part of the following fields:

      • Musculoskeletal Health
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  • Question 26 - You see a 70-year-old patient with diabetes, hypertension, and chronic kidney disease (CKD)....

    Incorrect

    • You see a 70-year-old patient with diabetes, hypertension, and chronic kidney disease (CKD). He had an anterior myocardial infarction (MI) 2 months ago for which he had a stent. He is having his annual review when he mentions that he has suffered from erectile dysfunction for the last 2 years. He says that it came on gradually and that he now never has erections anymore, in any situation. He has been married for 45 years and this is having an effect on his relationship with his wife.

      His blood pressure today is 135/85 mmHg. Recent blood tests reveal that his blood glucose levels are well controlled on oral medications and his CKD is stable. He takes regular exercise.

      What is the recommended first-line treatment for this patient's erectile dysfunction?

      Your Answer:

      Correct Answer: A vacuum erection device along with lifestyle advice

      Explanation:

      The NICE clinical knowledge summary (CKS) guidelines recommend phosphodiesterase (PDE-5) inhibitors, such as sildenafil and tadalafil, as the first-line treatment for erectile dysfunction (ED) unless there are contraindications. However, those who cannot or will not take PDE-5 inhibitors may benefit from vacuum erection devices, which are recommended as the first-line treatment for well-informed older men with infrequent sexual intercourse and comorbidity requiring non-invasive, drug-free management of ED. Lifestyle changes and risk factor modification should also be considered, but this patient already has good control of his risk factors and regularly exercises. Intracavernous injections may be a second-line option for men with pelvic trauma or spinal cord injury. Vasculogenic causes, such as cardiovascular disease, are the most common organic cause of ED, and lifestyle changes and drug treatment can be effective in managing this condition.

      Erectile dysfunction (ED) is a condition where a man is unable to achieve or maintain an erection that is sufficient for sexual performance. It is not a disease but a symptom that can be caused by organic, psychogenic, or mixed factors. It is important to differentiate between the causes of ED, with factors such as a gradual onset of symptoms and lack of tumescence favoring an organic cause, while sudden onset of symptoms and decreased libido favoring a psychogenic cause. Risk factors for ED include cardiovascular disease, alcohol use, and certain medications.

      To assess for ED, it is recommended to measure lipid and fasting glucose serum levels to calculate cardiovascular risk. Free testosterone should also be measured in the morning, and if low or borderline, further assessment may be needed. PDE-5 inhibitors, such as sildenafil, are the first-line treatment for ED and should be prescribed to all patients regardless of the cause. Vacuum erection devices can be used as an alternative for those who cannot or will not take PDE-5 inhibitors. Referral to urology may be appropriate for young men who have always had difficulty achieving an erection, and those who cycle for more than three hours per week should be advised to stop.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 27 - A 36-year-old man presents with sudden onset pain in the left flank radiating...

    Incorrect

    • A 36-year-old man presents with sudden onset pain in the left flank radiating to the left groin and testis. The pain is accompanied by vomiting. You suspect the patient may have ureteric colic.
      Select from the list the single other feature that would support this diagnosis.

      Your Answer:

      Correct Answer: Haematuria

      Explanation:

      Renal/Ureteric Colic: Symptoms and Characteristics

      Renal/ureteric colic is characterized by sudden and severe pain, often caused by stones. However, in some cases, no obvious cause is found. Unlike biliary or intestinal colic, the pain of renal colic is constant, with periods of relief or dull aches before it returns. The location of the pain changes as the stone moves. Patients with renal colic experience intense pain and may writhe around in agony, while those with peritoneal irritation lie still. Although there may be severe pain in the testis, it should not be tender. Uncomplicated renal colic doesn’t cause fever, which suggests pyelonephritis. Haematuria, often detected only on dipstick testing, is a common symptom.

    • This question is part of the following fields:

      • Kidney And Urology
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  • Question 28 - A healthy 26-year-old archaeologist has been experiencing an itchy, raised erythematous rash on...

    Incorrect

    • A healthy 26-year-old archaeologist has been experiencing an itchy, raised erythematous rash on his forearms for the past 2 weeks. Loratadine has provided some relief for the itch, and occasionally the rash disappears within a few hours. However, in the last day, the rash has spread to his back and loratadine is no longer effective. The patient has no known allergies or triggers and is feeling well otherwise. What should be the next course of action for management?

      Your Answer:

      Correct Answer: Trial of an oral corticosteroid

      Explanation:

      It is likely that the patient is experiencing a severe urticarial rash, which is a common condition that doesn’t require a dermatology appointment or further investigations at this stage. The patient is stable and not showing signs of anaphylaxis. To investigate further, a symptom diary would be sufficient, especially with exposure to different work environments as an archaeologist. The first-line treatment would be a non-sedating antihistamine such as loratadine or cetirizine. However, if the urticaria is severe, as in this case, a short course of oral corticosteroids may be necessary.

      Urticaria is a condition characterized by the swelling of the skin, either locally or generally. It is commonly caused by an allergic reaction, although non-allergic causes are also possible. The affected skin appears pale or pink and is raised, resembling hives, wheals, or nettle rash. It is also accompanied by itching or pruritus. The first-line treatment for urticaria is non-sedating antihistamines, while prednisolone is reserved for severe or resistant cases.

    • This question is part of the following fields:

      • Dermatology
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  • Question 29 - Which one of the following statements regarding hand, foot and mouth disease is...

    Incorrect

    • Which one of the following statements regarding hand, foot and mouth disease is incorrect?

      Your Answer:

      Correct Answer: Palm and sole lesions tend to occur before oral ulcers

      Explanation:

      Oral lesions typically manifest before palm and sole lesions in cases of hand, foot and mouth disease.

      Hand, Foot and Mouth Disease: A Contagious Condition in Children

      Hand, foot and mouth disease is a viral infection that commonly affects children. It is caused by intestinal viruses from the Picornaviridae family, particularly coxsackie A16 and enterovirus 71. This condition is highly contagious and often occurs in outbreaks in nurseries.

      The clinical features of hand, foot and mouth disease include mild systemic upset such as sore throat and fever, followed by the appearance of oral ulcers and vesicles on the palms and soles of the feet.

      Symptomatic treatment is the only management option available, which includes general advice on hydration and analgesia. It is important to note that there is no link between this disease and cattle, and children do not need to be excluded from school. However, the Health Protection Agency recommends that children who are unwell should stay home until they feel better. If there is a large outbreak, it is advisable to contact the agency for assistance.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 30 - Which option from the following list is currently considered the least valuable use...

    Incorrect

    • Which option from the following list is currently considered the least valuable use of the prostate specific antigen (PSA) test in clinical practice?

      Your Answer:

      Correct Answer: Screening

      Explanation:

      Understanding the Total PSA Test and Digital Rectal Examination for Prostate Cancer Diagnosis and Monitoring

      Prostate cancer is a common cancer in men, and early detection is crucial for successful treatment. The total PSA test and digital rectal examination (DRE) are commonly used to diagnose and monitor prostate cancer. These tests are ordered when a man has symptoms that could be due to prostate cancer, such as obstructive lower urinary symptoms, unexplained low back pain, pelvic pain, or bone pain.

      The PSA level at the time of diagnosis can indicate the tumor burden. A higher PSA level indicates a higher tumor burden in the body. A PSA of < 10 is favorable, while a PSA of > 20 is considered unfavorable. The stage/prognostic grouping of prostate cancer is based on the stage, PSA level, and Gleason score.

      The total PSA test may also be ordered during treatment for men who have been diagnosed with prostate cancer to verify the effectiveness of treatment and at regular intervals after treatment to monitor for cancer recurrence. It is also ordered at regular intervals when a man with cancer is participating in ‘watchful waiting’ and not currently being treated for his prostate cancer.

      Screening for prostate cancer, particularly by the PSA test, is controversial. While it can lead to early detection and treatment of prostate cancer, about 15% of men with a negative PSA test have prostate cancer, and about 65% of men with a positive PSA test have a negative prostate biopsy. A systematic review and meta-analysis of randomized controlled trials found that screening for prostate cancer increases the probability of diagnosis, but there is no statistically significant effect on death rates. The included studies provided little information about the potential harms associated with screening.

      In conclusion, understanding the total PSA test and digital rectal examination is crucial for the diagnosis and monitoring of prostate cancer. While screening for prostate cancer remains controversial, these tests are essential for men with symptoms that could be due to prostate cancer and for those who have been diagnosed with prostate cancer.

    • This question is part of the following fields:

      • Kidney And Urology
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