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  • Question 1 - A new screening tool for lower gastrointestinal malignancies has been developed known as...

    Incorrect

    • A new screening tool for lower gastrointestinal malignancies has been developed known as the Faecal Immunochemical Test (FIT). The test is hoped to be an improvement on the previous stool tests as the FIT targets human haemoglobin.

      The researchers would like to determine the specificity of the FIT test for colorectal cancer in a study involving 3000 participants aged 50 and above. All participants undergo a FIT and are subsequently evaluated with colonoscopy, which is considered the gold standard test.

      Out of the 1200 participants who tested positive on the FIT, 800 were later confirmed to have colorectal cancer on colonoscopy.

      On the other hand, out of the 1800 participants who tested negative on the FIT, 100 were later found to have colorectal cancer on colonoscopy.

      What is the specificity of the FIT test for colorectal cancer in this study?

      Your Answer: 25%

      Correct Answer: 95%

      Explanation:

      The specificity of the test is 0.95 or 95%.

      Precision refers to the consistency of a test in producing the same results when repeated multiple times. It is an important aspect of test reliability and can impact the accuracy of the results. In order to assess precision, multiple tests are performed on the same sample and the results are compared. A test with high precision will produce similar results each time it is performed, while a test with low precision will produce inconsistent results. It is important to consider precision when interpreting test results and making clinical decisions.

    • This question is part of the following fields:

      • Evidence Based Practice, Research And Sharing Knowledge
      94.5
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  • Question 2 - A 15-year-old girl, with Down's syndrome, has complained of neck pain. The pain...

    Incorrect

    • A 15-year-old girl, with Down's syndrome, has complained of neck pain. The pain began after she fell while playing basketball. Her parents have noticed that she has been experiencing more falls lately.
      During the examination, she displays tenderness throughout her neck muscles and limited neck mobility.

      What is the MOST SUITABLE course of action to take next?

      Your Answer: Out patient cervical spine x ray

      Correct Answer: Refer to on-call orthopaedic spinal team

      Explanation:

      Warning Signs of Craniovertebral Instability in Down’s Syndrome

      Warning signs of craniovertebral instability or myelopathy in individuals with Down’s syndrome include neck pain, abnormal head posture, reduced neck movements, deterioration of gait, increased frequency of falls, and deterioration of manipulative skills. While the term atlantoaxial instability is sometimes used, occipitoatlantal subluxation is also a concern, making craniovertebral instability the preferred term.

      Cervical spine x-rays are often unreliable, and primary care referrals can result in delays in reporting. Therefore, any clinical abnormality should be enough to warrant a referral to a specialist team. While neck exercises, simple analgesia, and physiotherapy may be helpful in cases of muscular neck pain, it is important to rule out craniovertebral instability first. Early detection and intervention can prevent further complications and improve outcomes for individuals with Down’s syndrome.

    • This question is part of the following fields:

      • Musculoskeletal Health
      75.2
      Seconds
  • Question 3 - A 23-year-old male patient complains of experiencing tinnitus in his left ear for...

    Incorrect

    • A 23-year-old male patient complains of experiencing tinnitus in his left ear for the past two weeks. He describes the sound as a buzz but denies any other accompanying ear symptoms. Upon examination, Otoscopy, Rinne, and Weber tests are all normal. What is the recommended course of action for management?

      Your Answer: Routine referral to ENT

      Correct Answer: Urgent referral to ENT

      Explanation:

      An urgent referral to ENT is necessary for a patient experiencing unilateral tinnitus, even if their examination appears normal. This is because it could be a sign of an acoustic neuroma and requires further investigation.

      While an audiogram could provide additional information, it would not alter the management plan for a GP, which would still involve an urgent referral.

      CBT, reassurance, and white noise may be appropriate for chronic bilateral tinnitus, but not for this patient with unilateral tinnitus.

      Tinnitus is a condition where a person perceives sounds in their ears or head that do not come from an external source. It affects approximately 1 in 10 people at some point in their lives and can be distressing for patients. While it is sometimes considered a minor symptom, it can also be a sign of a serious underlying condition. The causes of tinnitus can vary, with some patients having no identifiable underlying cause. Other causes may include Meniere’s disease, otosclerosis, conductive deafness, positive family history, sudden onset sensorineural hearing loss, acoustic neuroma, hearing loss, drugs, and impacted earwax.

      To assess tinnitus, an audiologist may perform an audiological assessment to detect any underlying hearing loss. Imaging may also be necessary, with non-pulsatile tinnitus generally not requiring imaging unless it is unilateral or there are other neurological or ontological signs. Pulsatile tinnitus, on the other hand, often requires imaging as there may be an underlying vascular cause. Management of tinnitus may involve investigating and treating any underlying cause, using amplification devices if associated with hearing loss, and psychological therapy such as cognitive behavioural therapy or joining tinnitus support groups.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
      32.9
      Seconds
  • Question 4 - You are the GP trainee doing your morning clinic. You see a 35-year-old...

    Correct

    • You are the GP trainee doing your morning clinic. You see a 35-year-old woman with coeliac disease.

      Which of the following is indicated as part of her management?

      Your Answer: Administration of the pneumococcal vaccine

      Explanation:

      To prevent overwhelming pneumococcal sepsis due to hyposplenism, Coeliac UK advises that individuals with coeliac disease receive a pneumococcal infection vaccine and a booster every five years. Pertussis vaccines beyond those in the vaccination schedule are unnecessary. According to NICE CKS guidelines, annual blood tests for FBC, ferritin, thyroid function tests, liver function tests, B12, and folate are recommended. Calprotectin is utilized to assess gut inflammation, often as part of the diagnostic process for inflammatory bowel disease. Faecal occult blood testing is typically conducted if there are concerns about bowel cancer.

      Managing Coeliac Disease with a Gluten-Free Diet

      Coeliac disease is a condition that requires the management of a gluten-free diet. Gluten-containing cereals such as wheat, barley, rye, and oats must be avoided. However, some patients with coeliac disease can tolerate oats. Gluten-free foods include rice, potatoes, and corn. Compliance with a gluten-free diet can be checked by testing for tissue transglutaminase antibodies.

      Patients with coeliac disease often have functional hyposplenism, which is why they are offered the pneumococcal vaccine. Coeliac UK recommends that patients with coeliac disease receive the pneumococcal vaccine and have a booster every five years. influenza vaccine is given on an individual basis according to current guidelines.

      Overall, managing coeliac disease requires strict adherence to a gluten-free diet and regular immunisation to prevent infections.

    • This question is part of the following fields:

      • Gastroenterology
      41.5
      Seconds
  • Question 5 - A 50-year-old man with type 2 diabetes presents for review. He reports feeling...

    Incorrect

    • A 50-year-old man with type 2 diabetes presents for review. He reports feeling well and having recently undergone foot and optometrist checks. He enjoys drinking alcohol on the weekends, limiting himself to 4-5 standard drinks each Saturday. His HbA1c remains stable at 48 mmol/L while taking metformin. However, his liver function tests reveal the following results:

      Bilirubin: 18 µmol/L (3 - 17)
      ALP: 95 u/L (30 - 100)
      ALT: 157 u/L (3 - 40)
      γGT: 40 u/L (8 - 60)
      AST: 74 u/L (3 - 40)
      Albumin: 37 g/L (35 - 50)

      What is the most likely cause of these findings?

      Your Answer: Viral hepatitis

      Correct Answer: Non-alcoholic fatty liver disease

      Explanation:

      Non-alcoholic fatty liver disease is the most common cause of abnormal liver function tests (LFT) in patients with type 2 diabetes. This condition is prevalent in developed countries and should be assessed through a reassessment of the patient’s LFTs and an ultrasound if necessary. The patient’s weekend drinking habits are not significant enough to suggest alcoholic liver disease as the cause of the LFT derangement. Drug-induced liver injuries (DILI) are not predictable and can present with various LFT changes, including cholestatic and mixed patterns. Gallstone disease is more common in overweight fertile females and presents with a cholestatic pattern of LFT derangement. Viral hepatitis is a possible cause but not the most likely answer in this case. A liver screen may be necessary if the LFT derangement persists without explanation from an ultrasound.

      Non-Alcoholic Fatty Liver Disease: Causes, Features, and Management

      Non-alcoholic fatty liver disease (NAFLD) is a prevalent liver disease in developed countries, primarily caused by obesity. It is a spectrum of disease that ranges from simple steatosis (fat in the liver) to steatohepatitis (fat with inflammation) and may progress to fibrosis and liver cirrhosis. NAFLD is believed to be the hepatic manifestation of the metabolic syndrome, with insulin resistance as the key mechanism leading to steatosis. Non-alcoholic steatohepatitis (NASH) is a term used to describe liver changes similar to those seen in alcoholic hepatitis but without a history of alcohol abuse.

      NAFLD is usually asymptomatic, but patients may present with hepatomegaly, increased echogenicity on ultrasound, and elevated ALT levels. The enhanced liver fibrosis (ELF) blood test is recommended by NICE to check for advanced fibrosis in patients with incidental findings of NAFLD. If the ELF blood test is not available, non-invasive tests such as the FIB4 score or NAFLD fibrosis score may be used in combination with a FibroScan to assess the severity of fibrosis. Patients with advanced fibrosis should be referred to a liver specialist for further evaluation, which may include a liver biopsy to stage the disease more accurately.

      The mainstay of treatment for NAFLD is lifestyle changes, particularly weight loss, and monitoring. There is ongoing research into the role of gastric banding and insulin-sensitizing drugs such as metformin and pioglitazone in the management of NAFLD. While there is no evidence to support screening for NAFLD in adults, it is essential to identify and manage incidental findings of NAFLD to prevent disease progression and complications.

    • This question is part of the following fields:

      • Gastroenterology
      123.6
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  • Question 6 - You see a 10-week-old baby boy with his father. He was born at...

    Correct

    • You see a 10-week-old baby boy with his father. He was born at 40+5 without complication. He is breastfeeding well but his father is concerned as he vomits small amounts of milk after most feeds, approximately a tablespoon full. He doesn't seem distressed by the vomiting and is growing along the 75th centile. He has wet and full nappies. He would like some treatment for the regurgitation.

      What would be your initial recommendation for managing this infant's regurgitation?

      Your Answer: This infant requires observation but no treatment initially, and review if worsening or weight loss

      Explanation:

      Gastro-oesophageal reflux (GOR) is a common condition in infants that usually resolves by the age of one. If the infant is not bothered by the GOR and doesn’t experience any complications, observation is sufficient. However, parents should monitor for worsening symptoms, weight loss, or complications. If the infant is distressed or has complications, they may have gastro-oesophageal reflux disease (GORD) and require treatment. Alginate therapy, such as Gaviscon® Infant, is the first-line treatment for breastfed infants with GORD.

      Gastro-oesophageal reflux is a common cause of vomiting in infants, with around 40% of babies experiencing some degree of regurgitation. However, certain risk factors such as preterm delivery and neurological disorders can increase the likelihood of developing this condition. Symptoms typically appear before 8 weeks of age and include vomiting or regurgitation, milky vomits after feeds, and excessive crying during feeding. Diagnosis is usually made based on clinical observation.

      Management of gastro-oesophageal reflux in infants involves advising parents on proper feeding positions, ensuring the infant is not overfed, and considering a trial of thickened formula or alginate therapy. However, proton pump inhibitors (PPIs) are not recommended as a first-line treatment for isolated symptoms of regurgitation. PPIs may be considered if the infant experiences unexplained feeding difficulties, distressed behavior, or faltering growth. Metoclopramide, a prokinetic agent, should only be used with specialist advice.

      Complications of gastro-oesophageal reflux can include distress, failure to thrive, aspiration, frequent otitis media, and dental erosion in older children. If medical treatment is ineffective and severe complications arise, fundoplication may be considered. It is important for healthcare professionals to be aware of the risk factors, symptoms, and management options for gastro-oesophageal reflux in infants.

    • This question is part of the following fields:

      • Children And Young People
      86.2
      Seconds
  • Question 7 - A 35-year-old woman with a significant family history of diabetes is currently 30...

    Incorrect

    • A 35-year-old woman with a significant family history of diabetes is currently 30 weeks pregnant in her first pregnancy.

      Upon completing the oral glucose tolerance test, she has been diagnosed with gestational diabetes, with a fasting glucose level of 7.3mmol/L and a 2-hour glucose level of 9.2mmol/L.

      What would be the most suitable course of action for managing this situation?

      Your Answer: Lifestyle measures only

      Correct Answer: Insulin

      Explanation:

      Immediate insulin (with or without metformin) should be initiated if the fasting glucose level is equal to or greater than 7 mmol/L at the time of gestational diabetes diagnosis. Glibenclamide may be considered for women who cannot tolerate metformin or do not achieve glucose targets with metformin but decline insulin therapy. If the fasting plasma glucose level is less than 7 mmol/L, lifestyle interventions such as a low glycemic index diet and exercise should be attempted first. If glucose targets are not achieved within 1-2 weeks of lifestyle measures, metformin may be initiated.

      Gestational diabetes is a common medical disorder that affects around 4% of pregnancies. It can develop during pregnancy or be a pre-existing condition. According to NICE, 87.5% of cases are gestational diabetes, 7.5% are type 1 diabetes, and 5% are type 2 diabetes. Risk factors for gestational diabetes include a BMI of > 30 kg/m², previous gestational diabetes, a family history of diabetes, and family origin with a high prevalence of diabetes. Screening for gestational diabetes involves an oral glucose tolerance test (OGTT), which should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal.

      To diagnose gestational diabetes, NICE recommends using the following thresholds: fasting glucose is >= 5.6 mmol/L or 2-hour glucose is >= 7.8 mmol/L. Newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week and taught about self-monitoring of blood glucose. Advice about diet and exercise should be given, and if glucose targets are not met within 1-2 weeks of altering diet/exercise, metformin should be started. If glucose targets are still not met, insulin should be added to the treatment plan.

      For women with pre-existing diabetes, weight loss is recommended for those with a BMI of > 27 kg/m^2. Oral hypoglycaemic agents, apart from metformin, should be stopped, and insulin should be commenced. Folic acid 5 mg/day should be taken from preconception to 12 weeks gestation, and a detailed anomaly scan at 20 weeks, including four-chamber view of the heart and outflow tracts, should be performed. Tight glycaemic control reduces complication rates, and retinopathy should be treated as it can worsen during pregnancy.

      Targets for self-monitoring of pregnant women with diabetes include a fasting glucose level of 5.3 mmol/l and a 1-hour or 2-hour glucose level after meals of 7.8 mmol/l or 6.4 mmol/l, respectively. It is important to manage gestational diabetes and pre-existing diabetes during pregnancy to reduce the risk of complications for both the mother and baby.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
      59.7
      Seconds
  • Question 8 - A 75-year-old man who had a right cataract surgery two weeks ago comes...

    Correct

    • A 75-year-old man who had a right cataract surgery two weeks ago comes to see you to ask for help, as he has lost/mislaid the postoperative (post-op) medication given to him after the surgery, sometime in the last 24 hours. He says that he has a post-op ophthalmology clinic appointment scheduled for four weeks' after surgery.

      Which one of the following would be the best next step in managing this man's condition?

      Your Answer: Give her a new set of post-op medication (same as given before) for another two weeks and advise her to keep the ophthalmology clinic appointment

      Explanation:

      Duration of Post-Op Topical Ocular Medication after Cataract Surgery

      It is a widely accepted practice that patients who undergo cataract surgery should use post-op topical ocular medication for four weeks, which includes an antibiotic and a steroid or a combination of both. This medication helps prevent infection and inflammation, which are common complications after surgery.

      In the scenario mentioned, the patient has already completed two weeks of post-op medication. To ensure proper healing and prevent any complications, it is recommended that the patient continues using the same medication for another two weeks. It is important to note that changing post-op medications without the advice of the ophthalmologist should be avoided.

      In summary, patients who undergo cataract surgery should follow the recommended duration of post-op topical ocular medication to ensure proper healing and prevent complications.

    • This question is part of the following fields:

      • Eyes And Vision
      62.3
      Seconds
  • Question 9 - A 72-year-old man has advanced chronic kidney disease.
    Select from the list of serum...

    Incorrect

    • A 72-year-old man has advanced chronic kidney disease.
      Select from the list of serum biochemical investigations the single one that is typical for a patient with this condition.

      Your Answer: Low phosphate

      Correct Answer: Low bicarbonate

      Explanation:

      Renal Failure and its Effects on Electrolyte Balance

      Renal failure can lead to metabolic acidosis due to decreased excretion of H+ ions and reduced synthesis of urinary buffers such as phosphate and ammonia. This results in a marked decrease in urinary phosphate levels and a rise in extracellular potassium levels due to intracellular displacement. Calcium homeostasis is also affected as the kidney’s role in activating vitamin D and increasing calcium reabsorption from the kidneys is inhibited by phosphate retention. Sodium levels may be normal or decreased due to water retention outweighing the decreased excretion. Overall, renal failure has significant effects on electrolyte balance.

    • This question is part of the following fields:

      • Kidney And Urology
      40.2
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  • Question 10 - A week ago you started an elderly patient with urge incontinence on immediate...

    Correct

    • A week ago you started an elderly patient with urge incontinence on immediate release oxybutynin tablets.

      She says she had to stop taking them because of side effects.

      What side effect is commonly found in elderly women taking oxybutynin?

      Your Answer: Dry mouth

      Explanation:

      Understanding the Side Effects of Oxybutynin

      Oxybutynin is a medication that belongs to the antimuscarinic class of drugs. It is commonly used to treat urinary incontinence and overactive bladder. However, it can cause several side effects such as dry mouth, constipation, dry eyes, and decreased sweating. If the immediate release formulation of oxybutynin is not well-tolerated, a sustained release formulation may be considered.

      It is important to note that a recent clinical review published in the BMJ has highlighted the potential cognitive side effects of medications with a high anticholinergic burden, including oxybutynin. This can lead to cognitive impairment, which can worsen the symptoms of dementia or even lead to false positive diagnoses. Therefore, it is crucial to be aware of the potential side effects of oxybutynin and to discuss any concerns with your healthcare provider.

    • This question is part of the following fields:

      • Improving Quality, Safety And Prescribing
      67.2
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SESSION STATS - PERFORMANCE PER SPECIALTY

Evidence Based Practice, Research And Sharing Knowledge (0/1) 0%
Musculoskeletal Health (0/1) 0%
Ear, Nose And Throat, Speech And Hearing (0/1) 0%
Gastroenterology (1/2) 50%
Children And Young People (1/1) 100%
Maternity And Reproductive Health (0/1) 0%
Eyes And Vision (1/1) 100%
Kidney And Urology (0/1) 0%
Improving Quality, Safety And Prescribing (1/1) 100%
Passmed