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Question 1
Correct
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A 27-year-old female patient visits the genitourinary medicine clinic seeking treatment for recurring genital warts. Which virus is the most probable cause of this condition?
Your Answer: Human papilloma virus 6 & 11
Explanation:Understanding Genital Warts
Genital warts, also known as condylomata accuminata, are a common reason for visits to genitourinary clinics. These warts are caused by various types of the human papillomavirus (HPV), with types 6 and 11 being the most common culprits. It is important to note that HPV, particularly types 16, 18, and 33, can increase the risk of cervical cancer.
The warts themselves are small, fleshy protrusions that are typically 2-5mm in size and may be slightly pigmented. They can cause discomfort, itching, and even bleeding. Treatment options for genital warts include topical podophyllum or cryotherapy, depending on the location and type of lesion. Topical agents are generally used for multiple, non-keratinised warts, while solitary, keratinised warts respond better to cryotherapy. Imiquimod, a topical cream, is often used as a second-line treatment. It is important to note that genital warts can be resistant to treatment, and recurrence is common. However, most anogenital HPV infections clear up on their own within 1-2 years without intervention.
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This question is part of the following fields:
- Reproductive Medicine
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Question 2
Correct
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A 35-year-old woman attends her first antenatal appointment at 10 weeks’ gestation. This is her second pregnancy. She has a history of hypertension and is taking medication for it. She is offered antenatal screening for chromosomal abnormalities, including Down syndrome.
Which of the following tests is used in antenatal screening for Down syndrome?Your Answer: Nuchal thickness
Explanation:Prenatal Screening Tests for Fetal Abnormalities
During pregnancy, various screening tests are conducted to detect any fetal abnormalities. One such test is the measurement of nuchal thickness, which is the fluid-filled sac between the back of the neck and the skin. An increase in thickness is associated with a decreased chance of normal birth and can detect 60-70% of Down syndrome cases. Other screening tests include measuring pregnancy-associated plasma protein-A (PAPP-A), b-human chorionic gonadotrophin (β-hCG), E3, and α-fetoprotein (AFP). Low PAPP-A, in combination with free β-hCG, is 65% accurate in diagnosing Down syndrome. The biparietal diameter (BPD) is the diameter across the skull and is associated with neurodevelopmental outcomes. Dehydroepiandrosterone sulfate is an adrenal androgen that is not influenced by pregnancy. Ultrasound assessment for herniation of the dural sac is used to screen for spina bifida. Utero-placental Doppler is used to identify at-risk women for pre-eclampsia and intrauterine growth restriction but is not useful in detecting Down syndrome.
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This question is part of the following fields:
- Genetics
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Question 3
Incorrect
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An elderly man aged 76 visits the surgery after a visit to his optician who noted raised intra-ocular pressure and decreased peripheral vision. He has a medical history of asthma and type 2 diabetes mellitus. The patient is referred to ophthalmology. What is the probable treatment he will receive for his likely diagnosis?
Your Answer: Dorzolamide
Correct Answer: Latanoprost
Explanation:Patients with a history of asthma should be prescribed a prostaglandin analogue as the first-line treatment.
Glaucoma is a condition where the optic nerve is damaged due to increased pressure in the eye. Primary open-angle glaucoma is a type where the iris is clear of the trabecular meshwork, which is responsible for draining aqueous humour from the eye. This results in increased resistance to outflow and raised intraocular pressure. The condition affects 0.5% of people over 40 years old and increases with age. Genetics also play a role, with first-degree relatives having a 16% chance of developing the disease. Symptoms are usually absent, and diagnosis is made through routine eye examinations. Investigations include visual field tests, tonometry, and slit lamp examinations. Treatment involves eye drops to lower intraocular pressure, with prostaglandin analogues being the first line of treatment. Surgery may be considered in refractory cases. Regular reassessment is necessary to monitor progression and prevent visual field loss.
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This question is part of the following fields:
- Ophthalmology
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Question 4
Incorrect
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A 54-year-old man with a history of epilepsy presents with a complaint of numbness in his hands and feet after a recent change in medication. Upon examination, he exhibits reduced sensation in a glove-and-stocking distribution and a decreased ankle reflex. Additionally, he has lymphadenopathy in the cervical and inguinal region and bleeding gums. Which medication is most likely responsible for these symptoms?
Your Answer: Lamotrigine
Correct Answer: Phenytoin
Explanation:Phenytoin: Mechanism of Action and Adverse Effects
Phenytoin is a medication used to manage seizures. Its mechanism of action involves binding to sodium channels, which increases their refractory period. However, the drug is associated with a large number of adverse effects, which can be categorized as acute, chronic, idiosyncratic, and teratogenic. Acute effects include dizziness, diplopia, nystagmus, slurred speech, ataxia, confusion, and seizures. Chronic effects include gingival hyperplasia, hirsutism, coarsening of facial features, drowsiness, megaloblastic anemia, peripheral neuropathy, enhanced vitamin D metabolism causing osteomalacia, lymphadenopathy, and dyskinesia. Idiosyncratic effects include fever, rashes, hepatitis, Dupuytren’s contracture, aplastic anemia, and drug-induced lupus. Teratogenic effects are associated with cleft palate and congenital heart disease. Although routine monitoring of phenytoin levels is not necessary, trough levels should be checked before dosing in cases of dose adjustment, suspected toxicity, or non-adherence to the prescribed medication.
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This question is part of the following fields:
- Neurology
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Question 5
Incorrect
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A 54-year-old diabetic patient visits your clinic with a complaint of painless difficulty in swallowing that has been ongoing for the past two months. The patient reports that the difficulty has been getting worse, but is unsure if there has been any weight loss. On examination, there are no notable findings.
What would be your next course of action considering the possible diagnoses?Your Answer: Referral to stroke ward
Correct Answer: Referral for gastroscopy
Explanation:If a patient experiences new-onset dysphagia, urgent endoscopy is necessary regardless of age or other symptoms. In the case of progressive dysphagia, it is crucial to rule out oesophageal or stomach cancer with a two week wait referral for gastroscopy. Gastroparesis, a delay in gastric emptying associated with diabetes, can be treated with metoclopramide. Plummer-vinson syndrome, which is characterized by iron deficiency anaemia and oesophageal webs, can also cause dysphagia along with glossitis and stomatitis. Gaviscon is not a suitable treatment for dysphagia as it only helps with dyspepsia. While a stroke can cause difficulties in initiating swallowing, it is typically sudden onset rather than progressive.
Understanding Dysphagia and its Causes
Dysphagia, or difficulty in swallowing, can be caused by various conditions affecting the esophagus, such as oesophageal cancer, oesophagitis, oesophageal candidiasis, achalasia, pharyngeal pouch, systemic sclerosis, and myasthenia gravis. Each condition has its own characteristic features, which can help in identifying the underlying cause of dysphagia. For instance, dysphagia associated with weight loss, anorexia, or vomiting during eating may indicate oesophageal cancer, while dysphagia of both liquids and solids from the start may suggest achalasia.
To determine the cause of dysphagia, patients usually undergo an upper GI endoscopy, which allows doctors to examine the esophagus and detect any abnormalities. Fluoroscopic swallowing studies may also be done to evaluate motility disorders. Additionally, a full blood count and ambulatory oesophageal pH and manometry studies may be required for certain conditions.
It’s important to note that new-onset dysphagia is a red flag symptom that requires urgent endoscopy, regardless of age or other symptoms. Therefore, understanding the different causes of dysphagia and their characteristic features can aid in prompt diagnosis and treatment.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 6
Incorrect
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A 25-year-old man is brought to the emergency department by his colleagues 30 minutes after being hit in the head with a falling object at a construction site. He did not lose consciousness, has had no problems with memory before or after the injury, and has not had any seizures. Since the injury, he has vomited 3 times but does not currently feel nauseous. The patient has no past medical history. He is responsive to commands, is aware of his surroundings, and his eye movements are normal. There is no visible bruising or fluid discharge from the ear or nose. No delays in investigations are expected. What is the most suitable course of action to take next?
Your Answer: Arrange CT head within 8 hours
Correct Answer: Arrange CT head within 1 hour
Explanation:If a patient experiences more than one episode of vomiting following a head injury, it is necessary to arrange a CT head within one hour. This is because persistent vomiting can indicate the development of neurological complications, such as intracranial bleeds, which can initially present as vomiting. Although the patient in this scenario has a Glasgow coma score of 15 and no other neurological symptoms, the presence of multiple episodes of vomiting warrants urgent imaging. Admitting the patient and arranging neurological observations would not be appropriate unless there was equipment failure preventing the CT scan. Similarly, arranging a CT head within four or eight hours is not appropriate, as the recommended timeframe for imaging in cases of head injury is within one hour for patients with persistent vomiting.
NICE Guidelines for Investigating Head Injuries in Adults
Head injuries can be serious and require prompt medical attention. The National Institute for Health and Care Excellence (NICE) has provided clear guidelines for healthcare professionals to determine which adult patients need further investigation with a CT head scan. Patients who require immediate CT head scans include those with a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment, suspected open or depressed skull fractures, signs of basal skull fractures, post-traumatic seizures, focal neurological deficits, and more than one episode of vomiting.
For patients with any loss of consciousness or amnesia since the injury, a CT head scan within 8 hours is recommended for those who are 65 years or older, have a history of bleeding or clotting disorders, experienced a dangerous mechanism of injury, or have more than 30 minutes of retrograde amnesia of events immediately before the head injury. Additionally, patients on warfarin who have sustained a head injury with no other indications for a CT head scan should also receive a scan within 8 hours of the injury.
It is important for healthcare professionals to follow these guidelines to ensure that patients receive appropriate and timely care for their head injuries. By identifying those who require further investigation, healthcare professionals can provide the necessary treatment and support to prevent further complications and improve patient outcomes.
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This question is part of the following fields:
- Neurology
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Question 7
Incorrect
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A patient in their early 50s with type 2 diabetes mellitus and chronic heart failure (NYHA class II) presents for a check-up. Their diabetes is currently managed through diet, but their HbA1c has increased to 64 mmol/mol (8.0%). Which of the following medications should be avoided due to contraindication?
Your Answer: Exenatide
Correct Answer: Pioglitazone
Explanation:Medications to Avoid in Patients with Heart Failure
Heart failure is a serious condition that requires careful management of medications. Some medications can exacerbate heart failure and should be avoided. Thiazolidinediones, such as pioglitazone, are contraindicated as they cause fluid retention. Verapamil has a negative inotropic effect and should be used with caution. NSAIDs and glucocorticoids can also cause fluid retention and should be used with caution. However, low-dose aspirin is an exception as many patients with heart failure also have coexistent cardiovascular disease and the benefits of taking aspirin easily outweigh the risks. Class I antiarrhythmics, such as flecainide, have a negative inotropic and proarrhythmic effect and should be avoided. It is important for healthcare providers to be aware of these medications and to carefully consider their use in patients with heart failure.
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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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A 54-year-old man presents to your clinic after a routine blood test showed abnormal liver function tests. He denies any alcohol consumption and his hepatitis screen is negative. His cholesterol level is 4.2 and his HBA1c is 38ml/mol. He has a body mass index of 31 kg/m² and an ultrasound reveals non-alcoholic fatty liver disease. What is the most suitable approach to manage this condition?
Your Answer: Cholestyramine
Correct Answer: Diet and exercise
Explanation:The primary management approach for NAFLD is weight loss, achieved through diet and exercise. Medications have not shown to be effective in improving the condition’s outcome.
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 encompasses a range of conditions, from simple steatosis (fat accumulation in the liver) to steatohepatitis (fat with inflammation) and may progress to fibrosis and liver cirrhosis. Insulin resistance is believed to be the primary mechanism leading to steatosis, making NAFLD a hepatic manifestation of metabolic syndrome. Non-alcoholic steatohepatitis (NASH) is a type of liver damage similar to alcoholic hepatitis but occurs in the absence of alcohol abuse. It affects around 3-4% of the general population and may be responsible for some cases of cryptogenic cirrhosis.
NAFLD is usually asymptomatic, but hepatomegaly, increased echogenicity on ultrasound, and elevated ALT levels are common features. The enhanced liver fibrosis (ELF) blood test is recommended by NICE to check for advanced fibrosis in patients with incidental NAFLD. If the ELF blood test is not available, non-invasive tests such as the FIB4 score or NAFLD fibrosis score, in combination with a FibroScan, may be used 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 NAFLD treatment is lifestyle changes, particularly weight loss, and monitoring. Research is ongoing into the role of gastric banding and insulin-sensitizing drugs such as metformin and pioglitazone. While there is no evidence to support screening for NAFLD in adults, NICE guidelines recommend the management of incidental NAFLD findings.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 9
Incorrect
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Nosocomial wound infections are often caused by various factors. However, which of the following is the most frequent cause of such infections?
Your Answer: Inadequate room disinfection
Correct Answer: Inadequate hand disinfection
Explanation:Preventing Hospital-Acquired Wound Infections: Common Causes and Solutions
Hospital-acquired wound infections are a serious concern for patients and healthcare providers alike. While all wounds are contaminated by microbes, proper hygiene and disinfection can greatly reduce the risk of infection. However, there are several common causes of hospital-acquired wound infections that must be addressed to prevent their occurrence.
The most frequent cause of nosocomial wound infection is inadequate hand disinfection. Hands are a major source of transmission for hospital infections, and compliance with handwashing protocols can be suboptimal for a variety of reasons. These include lack of accessible equipment, insufficient knowledge of staff about risks and procedures, and too long a duration recommended for washing.
Inadequate instrument disinfection is another common cause of hospital-acquired wound infections. Different levels of disinfection are recommended for patient equipment depending on the type of care, with surgical instruments presenting a critical level of risk. Sterilisation or high-level disinfection is necessary to minimise the risk of infection.
While strict schedules for cleaning and disinfection of rooms are in place in hospitals, inadequate room disinfection is still a concern. However, this is not the main cause of surgical wound infection.
The use of wrong disinfectants during skin disinfection can also contribute to hospital-acquired wound infections. Specific hand disinfectants are used for skin disinfection, including alcoholic rubs and emollient gels.
Finally, too frequent skin disinfection can lead to the destruction of the normal skin flora, which can increase the risk of infection. Disinfecting agents must be chosen with care to avoid sensitisation or irritation of the skin.
In conclusion, preventing hospital-acquired wound infections requires a multifaceted approach that addresses the common causes of infection. Proper hand hygiene, instrument disinfection, and skin disinfection are all essential components of a comprehensive infection prevention program.
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This question is part of the following fields:
- Infectious Diseases
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Question 10
Incorrect
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You perform a medication review for a 75-year-old woman who comes in for a regular check-up. She has a medical history of ischaemic heart disease, stage 2 CKD, hypertension, and gout. Despite her conditions, she is able to function well on her own and her blood pressure today is 125/72 mmHg. Which medication would you suggest discontinuing?
Your Answer: Ramipril
Correct Answer: Bendroflumethiazide
Explanation:Assessing medications in elderly patients can be challenging, as they may be taking unnecessary or harmful drugs. The STOPP-START Criteria (Gallagher et al., 2008) provides guidance on medications that should be considered for discontinuation in the elderly. In this case, the patient has gout, which can be aggravated by bendroflumethiazide, an outdated thiazide diuretic that is no longer recommended by NICE. Additionally, her blood pressure is well below the target for her age, which is 150/90 mmHg in clinic. Ramipril is a more suitable antihypertensive medication to continue for now, but it may also be discontinued if her blood pressure remains low. The patient requires aspirin and atorvastatin for her ischemic heart disease, and allopurinol for her gout.
NICE Guidelines for Managing Hypertension
Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.
The guidelines also provide a flow chart for the diagnosis and management of hypertension. Lifestyle advice, such as reducing salt intake, caffeine intake, and alcohol consumption, as well as exercising more and losing weight, should not be forgotten and is frequently tested in exams. Treatment options depend on the patient’s age, ethnicity, and other factors, and may involve a combination of drugs.
NICE recommends treating stage 1 hypertension in patients under 80 years old if they have target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For patients with stage 2 hypertension, drug treatment should be offered regardless of age. The guidelines also provide step-by-step treatment options, including adding a third or fourth drug if necessary.
New drugs, such as direct renin inhibitors like Aliskiren, may have a role in patients who are intolerant of more established antihypertensive drugs. However, trials have only investigated the fall in blood pressure and no mortality data is available yet. Patients who fail to respond to step 4 measures should be referred to a specialist. The guidelines also provide blood pressure targets for different age groups.
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This question is part of the following fields:
- Cardiovascular
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Question 11
Incorrect
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An itchy rash over the extensor surfaces in a patient with gluten intolerance:
Your Answer: Psoriasis
Correct Answer: Dermatitis herpetiformis
Explanation:Dermatitis herpetiformis is the correct answer, which is a skin rash that is closely linked to coeliac disease. This is a persistent skin condition that causes blisters, but it is not caused by or related to the herpes virus. It is important to note that dapsone is an effective treatment for Dermatitis herpetiformis, which is a common question in exams. Additionally, a gluten-free diet can also help alleviate symptoms.
Understanding Dermatitis Herpetiformis
Dermatitis herpetiformis is a skin condition that is linked to coeliac disease and is caused by the deposition of IgA in the dermis. It is an autoimmune blistering disorder that is characterized by itchy, vesicular skin lesions that appear on the extensor surfaces of the body, such as the elbows, knees, and buttocks.
To diagnose dermatitis herpetiformis, a skin biopsy is required, which will show the deposition of IgA in a granular pattern in the upper dermis. This condition can be managed by following a gluten-free diet and taking dapsone medication.
It is important to understand the symptoms and management of dermatitis herpetiformis to ensure that proper treatment is given. By following a gluten-free diet and taking medication, individuals with this condition can manage their symptoms and improve their quality of life.
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This question is part of the following fields:
- Dermatology
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Question 12
Incorrect
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A 28-year-old female visits her GP with complaints of recurring lower abdominal pain. The pain occurs every month, around midcycle, and lasts for 1-2 days. She experiences a cramping sensation and there is no associated vaginal bleeding. She reports feeling well otherwise during these episodes and denies any gastrointestinal issues or changes to her menstrual cycle. Physical examination today is unremarkable. What is the probable cause of her symptoms?
Your Answer: Irritable bowel syndrome
Correct Answer: Mittelschmerz
Explanation:If a woman experiences pelvic pain during ovulation but does not have any vaginal bleeding, it may be Mittelschmerz. This type of pain is typically felt in the middle of the menstrual cycle. It is unlikely that a young patient with normal examination and intermittent abdominal pain during ovulation has ovarian malignancy. Additionally, there are no symptoms of hirsutism or changes to periods that suggest PCOS, nor are there any gastrointestinal symptoms that suggest IBS.
Understanding Mittelschmerz: Abdominal Pain Associated with Ovulation
Mittelschmerz, which translates to middle pain, is a type of abdominal pain that occurs during ovulation in approximately 20% of women. The exact cause of this mid-cycle pain is not fully understood, but there are several theories. One theory suggests that the pain is caused by the leakage of follicular fluid containing prostaglandins during ovulation. Another theory suggests that the growth of the follicle stretches the surface of the ovary, leading to pain.
The pain associated with Mittelschmerz typically presents suddenly in either iliac fossa and then spreads to the pelvic area. The pain is usually not severe and can last from minutes to hours. It is self-limiting and resolves within 24 hours of onset. The pain may switch sides from month to month, depending on the site of ovulation.
There are no specific tests to confirm Mittelschmerz, and it is diagnosed clinically after taking a full history and examination to exclude other conditions. Abdominal and pelvic examinations typically do not reveal any abnormal signs.
Mittelschmerz is not harmful and can be managed with simple analgesia. Understanding this condition can help women recognize and manage the pain associated with ovulation.
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This question is part of the following fields:
- Reproductive Medicine
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Question 13
Correct
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A 75-year-old man presents to the emergency department with nosebleeds, extensive bruising, and mucosal bleeding. His vital signs are stable, and laboratory results reveal a platelet count of 23 * 109/L (150 - 400), which is significantly lower than his previous blood test taken a week ago. The patient reports taking a new medication for nocturnal leg cramps. Which of the following medications could be responsible for his thrombocytopenia?
Your Answer: Quinine
Explanation:Quinine is the only medication in this list that is strongly linked to the development of drug-induced thrombocytopaenia. However, excessive consumption of tonic water containing quinine can also lead to this condition in certain individuals. While all the other medications in the list can be used to treat nocturnal leg cramps, they do not have a significant association with thrombocytopaenia.
Understanding Drug-Induced Thrombocytopenia
Drug-induced thrombocytopenia is a condition where a person’s platelet count drops due to the use of certain medications. This type of thrombocytopenia is believed to be immune-mediated, meaning that the body’s immune system mistakenly attacks and destroys platelets. Some of the drugs that can cause this condition include quinine, abciximab, NSAIDs, diuretics like furosemide, antibiotics such as penicillins, sulphonamides, and rifampicin, anticonvulsants like carbamazepine and valproate, and heparin.
It is important to note that not everyone who takes these medications will develop drug-induced thrombocytopenia. However, those who do may experience symptoms such as easy bruising, bleeding gums, nosebleeds, and prolonged bleeding from cuts. In severe cases, the condition can lead to life-threatening bleeding.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 14
Incorrect
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A 70-year-old with chronic kidney disease stage 4 and metastatic prostate cancer is experiencing uncontrolled pain despite taking co-codamol. Considering his impaired renal function, which opioid would be the most suitable option to alleviate his pain?
Your Answer: Morphine
Correct Answer: Buprenorphine
Explanation:Patients with chronic kidney disease are recommended to use alfentanil, buprenorphine, and fentanyl as their preferred opioids.
Palliative care prescribing for pain is guided by NICE and SIGN guidelines. NICE recommends starting treatment with regular oral modified-release or immediate-release morphine, with immediate-release morphine for breakthrough pain. Laxatives should be prescribed for all patients initiating strong opioids, and antiemetics should be offered if nausea persists. Drowsiness is usually transient, but if it persists, the dose should be adjusted. SIGN advises that the breakthrough dose of morphine is one-sixth the daily dose, and all patients receiving opioids should be prescribed a laxative. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred to morphine in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and all patients should be considered for referral to a clinical oncologist for further treatment. When increasing the dose of opioids, the next dose should be increased by 30-50%. Conversion factors between opioids are also provided. Opioid side-effects are usually transient, such as nausea and drowsiness, but constipation can persist. In addition to strong opioids, bisphosphonates, and radiotherapy, denosumab may be used to treat metastatic bone pain.
Overall, the guidelines recommend starting with regular oral morphine and adjusting the dose as needed. Laxatives should be prescribed to prevent constipation, and antiemetics may be needed for nausea. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and referral to a clinical oncologist should be considered. Conversion factors between opioids are provided, and the next dose should be increased by 30-50% when adjusting the dose. Opioid side-effects are usually transient, but constipation can persist. Denosumab may also be used to treat metastatic bone pain.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 15
Incorrect
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A 35-year-old woman experiences a seizure while in the emergency department. The seizure began suddenly with an abrupt loss of consciousness and an initial period of stiff muscle contraction, followed by intermittent jerky movements. She has a history of epilepsy and takes carbamazepine, but has been noted to have poor adherence in the past. The seizure persists for more than five minutes despite a dose of IV lorazepam. What is the next best pharmacological approach?
Your Answer: Rectal diazepam
Correct Answer: Intravenous lorazepam
Explanation:Convulsive status epilepticus should be initially managed with IV lorazepam, with a repeat dose given 10 minutes later if the seizure persists or recurs. Buccal midazolam may be used if IV access is not available or if the seizure occurs outside of a hospital setting. It is important to note that a maximum of two doses of IV benzodiazepines should be administered during convulsive status epilepticus. Intravenous carbamazepine is not appropriate for acute seizure management, as it is primarily used for preventing tonic-clonic seizures. Intravenous phenytoin should not be given until two doses of benzodiazepines have been administered, and at this point, critical care and anesthesia should also be involved. Rectal diazepam is typically not used unless there is no IV access or the emergency occurs outside of a hospital setting.
Status epilepticus is a medical emergency that occurs when a person experiences a single seizure lasting more than five minutes or two seizures within a five-minute period without returning to normal between them. It is crucial to terminate seizure activity as soon as possible to prevent irreversible brain damage. The first step in managing status epilepticus is to ensure the patient’s airway is clear and provide oxygen while checking their blood glucose levels. The first-line treatment is IV benzodiazepines, such as diazepam or lorazepam, with PR diazepam or buccal midazolam given in the prehospital setting. In the hospital, IV lorazepam is typically used and may be repeated once after 10-20 minutes. If the status epilepticus persists, a second-line agent such as phenytoin or phenobarbital infusion may be administered. If there is no response within 45 minutes, induction of general anesthesia is the best way to achieve rapid control of seizure activity.
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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 4-year-old child is presented to your allergy clinic by anxious parents. The child has a previous medical record of a mild non-IgE mediated egg allergy. What course of action would you suggest?
Your Answer: Avoidance of egg and egg products
Correct Answer: Gradual reintroduction of egg based products using the egg ladder
Explanation:The egg ladder can be used to reintroduce egg in children with non-IgE mediated allergy, starting with baked egg in biscuits. Chlorpheniramine and adrenaline pen are not appropriate choices.
Identifying and Managing Food Allergies in Children and Young People
Food allergies in children and young people can be categorized into IgE-mediated and non-IgE-mediated allergies. It is important to note that food intolerance is not caused by immune system dysfunction and is not covered by the 2011 NICE guidelines. Symptoms of IgE-mediated allergies include skin reactions such as pruritus, erythema, urticaria, and angioedema, gastrointestinal symptoms like nausea, colicky abdominal pain, vomiting, and diarrhea, and respiratory symptoms such as nasal itching, sneezing, rhinorrhea, congestion, cough, chest tightness, wheezing, and shortness of breath. Non-IgE-mediated allergies may present with symptoms like gastro-oesophageal reflux disease, loose or frequent stools, blood and/or mucus in stools, abdominal pain, infantile colic, food refusal or aversion, constipation, perianal redness, pallor and tiredness, and faltering growth.
If the history suggests an IgE-mediated allergy, skin prick tests or blood tests for specific IgE antibodies to the suspected foods and likely co-allergens should be offered. On the other hand, if the history suggests a non-IgE-mediated allergy, the suspected allergen should be eliminated for 2-6 weeks and then reintroduced. It is recommended to consult a dietitian with appropriate competencies about nutritional adequacies, timings, and follow-up. By identifying and managing food allergies in children and young people, we can prevent severe allergic reactions and improve their quality of life.
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This question is part of the following fields:
- Paediatrics
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Question 17
Incorrect
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A 56-year-old Caucasian man presents with a rash on the face. He first noticed this six months ago when he experienced episodes of flushing on the face. This has often occurred after he had alcohol or in situations where he felt stressful. A month ago, he started noticing a rash on his cheeks which came on intermittently until three weeks ago when the rash has become permanent. There has been no pain or itch associated with the rash. He is otherwise fit and well. He does not smoke.
On examination of the face, there is marked erythema with papules, pustules and telangiectasia. There are no comedones seen. The rash is distributed across the cheeks and nose. There is no per-oral or peri-orbital involvement.
What is the most likely diagnosis?Your Answer: Seborrhoeic dermatitis
Correct Answer: Acne rosacea
Explanation:The features described suggest acne rosacea, with episodic flushing, papules and pustules with telangiectasia on the nose, cheeks and forehead. Other conditions such as acne vulgaris, systemic lupus erythematosus, seborrhoeic dermatitis and shingles are unlikely based on the described symptoms.
Understanding Rosacea: Symptoms and Management
Rosacea, also known as acne rosacea, is a chronic skin condition that has no known cause. It typically affects the nose, cheeks, and forehead, and the first symptom is often flushing. Over time, telangiectasia (visible blood vessels) may appear, followed by persistent redness with papules and pustules. In some cases, rhinophyma (enlarged nose) may develop, and there may be ocular involvement, such as blepharitis. Sunlight can exacerbate symptoms.
Mild cases of rosacea may be treated with topical metronidazole, while topical brimonidine gel may be used for patients with predominant flushing but limited telangiectasia. More severe cases may require systemic antibiotics like oxytetracycline. Patients are advised to apply high-factor sunscreen daily and use camouflage creams to conceal redness. Laser therapy may be appropriate for those with prominent telangiectasia, and patients with rhinophyma should be referred to a dermatologist.
Overall, understanding the symptoms and management of rosacea can help individuals manage their condition and improve their quality of life.
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This question is part of the following fields:
- Dermatology
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Question 18
Incorrect
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A 52-year-old woman had a anterior myocardial infarction (MI) three weeks ago and has been prescribed various drugs by the cardiology team.
Which of the following medications is most likely to decrease this patient’s mortality post-MI?
Your Answer: Nicorandil
Correct Answer: Bisoprolol
Explanation:Common Medications for Cardiovascular Conditions
Bisoprolol is a beta-blocker that specifically targets the heart, reducing strain by decreasing pre-load and after-load. It has been found to be effective in reducing mortality after a heart attack, especially in patients with heart failure.
Amiodarone is an anti-arrhythmic drug that can be used to prevent irregular heartbeats. However, it does not improve mortality rates in post-heart attack patients.
Isosorbide mononitrate is a medication that helps lower blood pressure and can alleviate chest pain in stable angina. It does not improve mortality rates and should be used with caution when taken with sildenafil.
Nicorandil works by dilating the coronary arteries, reducing chest pain in stable angina. While it does not improve prognostic outcomes, it can improve symptoms.
Patients who have experienced a myocardial infarction (MI) should be started on a combination of medications to improve their outcomes. The following medications are recommended for post-MI patients:
1. Statin: This medication helps to lower cholesterol levels and reduce the risk of future cardiovascular events.
2. ACE inhibitor: This medication helps to lower blood pressure and reduce the risk of heart failure.
3. Beta blocker: This medication helps to reduce the workload on the heart and improve its function.
4. Aspirin: This medication helps to prevent blood clots and reduce the risk of future cardiovascular events.
Other medications may be used to relieve symptoms, such as ISMN and nicorandil, but they do not offer any mortality benefit. It is important for post-MI patients to take their medications as prescribed and to follow up with their healthcare provider regularly to monitor their progress.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 19
Incorrect
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A 45-year-old female patient visits the clinic and expresses concern about breast cancer screening. She is anxious because her sister was recently diagnosed with breast cancer. She wants to know if she should undergo breast cancer screening. The patient is in good health and has no other family history. What is the best course of action to take next?
Your Answer: Ask her to come back for review if she finds a breast lump herself
Correct Answer: Refer to the breast clinic
Explanation:A referral to secondary care is necessary when there is a history of breast cancer in the patient’s paternal family. This is because breast cancer may not be detectable during a routine breast examination, and waiting for a screening appointment could result in a delayed diagnosis. It is important to note that a review in one year may also lead to a delay in diagnosis, as the patient is at a high risk for familial breast cancer.
Breast cancer screening is offered to women aged 50-70 years through the NHS Breast Screening Programme. Mammograms are provided every three years, and women over 70 years are encouraged to make their own appointments. While the effectiveness of breast screening is debated, it is estimated that the programme saves around 1,400 lives annually.
For those with familial breast cancer, NICE guidelines recommend referral if there is a family history of breast cancer with any of the following: diagnosis before age 40, bilateral breast cancer, male breast cancer, ovarian cancer, Jewish ancestry, sarcoma in a relative under 45 years, glioma or childhood adrenal cortical carcinomas, complicated patterns of multiple cancers at a young age, or paternal history of breast cancer with two or more relatives on the father’s side. Women at increased risk due to family history may be offered screening at a younger age. Referral to a breast clinic is recommended for those with a first-degree relative diagnosed with breast cancer before age 40, a first-degree male relative with breast cancer, a first-degree relative with bilateral breast cancer before age 50, two first-degree relatives or one first-degree and one second-degree relative with breast cancer, or a first- or second-degree relative with breast and ovarian cancer.
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This question is part of the following fields:
- Genetics
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Question 20
Incorrect
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A 42-year-old woman has a history of excessive sweating, palpitations and weight loss for the past six months. She now has a headache.
On examination, her blood pressure is 230/130 mmHg, with a postural drop to 180/110 mmHg. Her pulse is bounding and 115 beats per minute and she has a tremor and looks pale. The rest of the examination is normal.
Excess production of which of the following hormones is most likely to be the cause of this woman’s signs and symptoms?Your Answer: Renin
Correct Answer: Catecholamines
Explanation:Explanation of Hypertension and Possible Causes
Hypertension, or high blood pressure, can have various underlying causes. In the case of this patient, their symptoms suggest a rare tumour called phaeochromocytoma, which secretes catecholamines and can lead to malignant hypertension. Hyperaldosteronism and excess cortisol production (Cushing’s syndrome) are other possible causes of hypertension, but they do not explain the patient’s symptoms. Abnormalities in renin, which regulates blood pressure, can also contribute to hypertension. Hyperthyroidism could explain most of the patient’s symptoms, but it is less likely to cause severe hypertension or headaches. Therefore, further investigation is needed to confirm the diagnosis and determine the appropriate treatment.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 21
Incorrect
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As a junior doctor in General Practice, you come across a 27-year-old woman who is worried about her declining work performance. Her boss has labeled her as 'neurotic' due to her frequent missing of deadlines. She identifies herself as a 'perfectionist' and is unable to comprehend why this is happening. She has always found solace in keeping her workspace clean and organized and struggles to handle situations where she is not in control, especially at work. She recalls being an anxious child but has never sought help from a psychiatrist. What is the most probable cause of her difficulties?
Your Answer: Borderline personality disorder
Correct Answer: Obsessive compulsive personality disorder
Explanation:The individual in question is exhibiting symptoms of anankastic personality disorder, also known as obsessive-compulsive personality disorder (OCPD). This disorder is characterized by a preoccupation with orderliness, perfectionism, and an excessive focus on details, as well as a need for control over one’s environment and interpersonal relationships. However, this often comes at the expense of flexibility, openness to new experiences, and efficiency. Unlike obsessive-compulsive disorder (OCD), where thoughts and behaviors are seen as unwanted and unhealthy, those with OCPD view their behaviors as rational and desirable. This can lead to difficulty completing tasks, as the individual becomes overly focused on perfectionism and attention to detail. Generalized anxiety disorder is less likely to be the diagnosis in this case, as the individual’s worries are specific to work-related issues. Schizoid personality disorder, on the other hand, is characterized by a lack of interest in forming close relationships with others and a preference for solitude. These individuals may appear cold and uninterested in intimacy or pleasure from life.
Personality disorders are a set of personality traits that are maladaptive and interfere with normal functioning in life. It is estimated that around 1 in 20 people have a personality disorder, which are typically categorized into three clusters: Cluster A, which includes Odd or Eccentric disorders such as Paranoid, Schizoid, and Schizotypal; Cluster B, which includes Dramatic, Emotional, or Erratic disorders such as Antisocial, Borderline (Emotionally Unstable), Histrionic, and Narcissistic; and Cluster C, which includes Anxious and Fearful disorders such as Obsessive-Compulsive, Avoidant, and Dependent.
Paranoid individuals exhibit hypersensitivity and an unforgiving attitude when insulted, a reluctance to confide in others, and a preoccupation with conspirational beliefs and hidden meanings. Schizoid individuals show indifference to praise and criticism, a preference for solitary activities, and emotional coldness. Schizotypal individuals exhibit odd beliefs and magical thinking, unusual perceptual disturbances, and inappropriate affect. Antisocial individuals fail to conform to social norms, deceive others, and exhibit impulsiveness, irritability, and aggressiveness. Borderline individuals exhibit unstable interpersonal relationships, impulsivity, and affective instability. Histrionic individuals exhibit inappropriate sexual seductiveness, a need to be the center of attention, and self-dramatization. Narcissistic individuals exhibit a grandiose sense of self-importance, lack of empathy, and excessive need for admiration. Obsessive-compulsive individuals are occupied with details, rules, and organization to the point of hampering completion of tasks. Avoidant individuals avoid interpersonal contact due to fears of criticism or rejection, while dependent individuals have difficulty making decisions without excessive reassurance from others.
Personality disorders are difficult to treat, but a number of approaches have been shown to help patients, including psychological therapies such as dialectical behavior therapy and treatment of any coexisting psychiatric conditions.
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This question is part of the following fields:
- Psychiatry
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Question 22
Incorrect
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A 35-year-old woman presents to her General Practitioner complaining of pain in the outer aspect of the left elbow. This pain has been going on for a few months and she occasionally feels the pain in the outer aspect of the left forearm as well.
She is otherwise healthy and physically active. She mentions that she enjoys rock climbing and often participates in climbing competitions.
Which one of the following findings on examination would necessitate a referral to an orthopaedic surgeon for further evaluation?
Select the SINGLE best answer from the list below.
Your Answer: Pain on middle finger extension against resistance
Correct Answer: Loss of sensation over the dorsum of the right hand
Explanation:Understanding Lateral Epicondylitis: Symptoms and Diagnosis
Lateral epicondylitis, commonly known as tennis elbow, is a condition that affects the tendons of the forearm extensor muscles. It is often caused by repetitive activities such as typing, playing tennis, or manual work. While it is a self-limiting condition, it can cause significant pain and functional impairment.
Symptoms of lateral epicondylitis include tenderness on palpation of the bony prominence of the lateral epicondyle, reduced grip strength, and pain on resisted middle finger extension and wrist extension. Diagnosis is usually clinical, and management can be initiated at primary care.
If a patient presents with loss of sensation over the dorsum of the hand, it may be an indication to refer them to an orthopaedic surgeon to rule out differential diagnoses. However, normal sensation is a common finding in lateral epicondylitis.
Overall, understanding the symptoms and diagnosis of lateral epicondylitis is important for proper management and treatment of this condition.
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This question is part of the following fields:
- Musculoskeletal
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Question 23
Incorrect
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Which of the following is most commonly linked to elevated levels of CA 19-9?
Your Answer: Breast cancer
Correct Answer: Pancreatic cancer
Explanation:CA 19-9 and Pancreatic Cancer
Understanding Tumour Markers
Tumour markers are substances that can be found in the blood, urine, or tissues of people with cancer. They are often used to help diagnose and monitor cancer, as well as to determine the effectiveness of treatment. Tumour markers can be divided into different categories, including monoclonal antibodies against carbohydrate or glycoprotein tumour antigens, tumour antigens, enzymes, and hormones.
Monoclonal antibodies are used to target specific tumour antigens, which are proteins or other molecules that are found on the surface of cancer cells. Some common tumour markers include CA 125 for ovarian cancer, CA 19-9 for pancreatic cancer, and CA 15-3 for breast cancer. However, it is important to note that tumour markers usually have a low specificity, meaning that they can also be found in people without cancer.
Tumour antigens are proteins that are produced by cancer cells and can be detected in the blood or tissues of people with cancer. Some examples of tumour antigens include prostate specific antigen (PSA) for prostatic carcinoma, alpha-feto protein (AFP) for hepatocellular carcinoma and teratoma, and carcinoembryonic antigen (CEA) for colorectal cancer.
Enzymes and hormones can also be used as tumour markers. For example, alkaline phosphatase and neurone specific enolase are enzymes that can be elevated in people with cancer, while hormones such as calcitonin and ADH can be used to detect certain types of cancer.
In summary, tumour markers are an important tool in the diagnosis and monitoring of cancer. However, they should be used in conjunction with other diagnostic tests and imaging studies, as they are not always specific to cancer and can also be elevated in people without cancer.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 24
Incorrect
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A 27-year-old female patient presents to her doctor seeking guidance on pregnancy and the postpartum period. She is currently 12 weeks pregnant and has not experienced any complications thus far. The patient has a history of HIV and is currently taking antiretroviral medication. She has expressed a desire to breastfeed her baby once it is born.
What recommendations should be given to this patient?Your Answer: She can breastfeed if she continues to take her antiretrovirals
Correct Answer: She should not breastfeed
Explanation:In the UK, it is recommended that all women who are HIV-positive should not breastfeed their babies. This advice remains the same even if the mother’s viral load is undetectable. The decision should not be left to the HIV consultant as the national guidelines are clear on this matter. Although breastfeeding may reduce the risk of transmission if the maternal viral load is less than 50 copies/ml, there is still a risk involved. Therefore, the advice remains not to breastfeed. Continuing with antiretroviral therapy is expected regardless of the decision not to breastfeed as it significantly reduces the risk of vertical transmission during pregnancy. Babies born to HIV-positive mothers are given antiretroviral therapy, either zidovudine alone if the maternal viral load is less than 50 copies/ml or triple-therapy if it is higher. However, this does not change the advice to avoid breastfeeding.
HIV and Pregnancy: Guidelines for Minimizing Vertical Transmission
With the increasing prevalence of HIV infection among heterosexual individuals, there has been a rise in the number of HIV-positive women giving birth in the UK. In fact, in London alone, the incidence may be as high as 0.4% of pregnant women. The primary goal of treating HIV-positive women during pregnancy is to minimize harm to both the mother and fetus, and to reduce the chance of vertical transmission.
To achieve this goal, various factors must be considered. Firstly, all pregnant women should be offered HIV screening, according to NICE guidelines. Additionally, antiretroviral therapy should be offered to all pregnant women, regardless of whether they were taking it previously. This therapy has been shown to significantly reduce vertical transmission rates, which can range from 25-30% to just 2%.
The mode of delivery is also an important consideration. Vaginal delivery is recommended if the viral load is less than 50 copies/ml at 36 weeks. If the viral load is higher, a caesarean section is recommended, and a zidovudine infusion should be started four hours before the procedure. Neonatal antiretroviral therapy is also typically administered to the newborn, with zidovudine being the preferred medication if the maternal viral load is less than 50 copies/ml. If the viral load is higher, triple ART should be used, and therapy should be continued for 4-6 weeks.
Finally, infant feeding is an important consideration. In the UK, all women should be advised not to breastfeed, as this can increase the risk of vertical transmission. By following these guidelines, healthcare providers can help to minimize the risk of vertical transmission and ensure the best possible outcomes for both mother and child.
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This question is part of the following fields:
- Reproductive Medicine
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Question 25
Incorrect
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A 68 year old male presents to the emergency department with a 2 day history of worsening flank pain. He has felt hot, feverish and been unable to keep fluids down. Examination reveals a blood pressure of 110/70 mmHg, tachycardia 120 beats per minute and left flank pain to palpation. Urine dipstick is positive for leucocytes +++ and nitrites +++. A diagnosis of pyelonephritis is made and intravenous gentamicin is prescribed.
What is the most common complication associated with gentamicin?Your Answer: Ankle swelling
Correct Answer: Nephrotoxicity
Explanation:Nephrotoxicity is a known side effect of aminoglycosides.
Gentamicin, an aminoglycoside antibiotic, is highly effective against gram negative bacteria and is often used to treat severe infections, particularly those affecting the urinary tract and abdomen. However, one of the common complications associated with gentamicin use is nephrotoxicity, which occurs due to the narrow therapeutic window required to achieve a therapeutic dose. Exceeding this index can lead to kidney damage. Ototoxicity is another potential complication that is often tested in final exams.
Gentamicin is a type of antibiotic belonging to the aminoglycoside class. It is not easily soluble in lipids, which is why it is administered either parentally or topically. Gentamicin is commonly used to treat infective endocarditis and otitis externa. However, it is important to note that gentamicin can cause adverse effects such as ototoxicity and nephrotoxicity. Ototoxicity is caused by damage to the auditory or vestibular nerve, which can be irreversible. Nephrotoxicity occurs when gentamicin accumulates in the body, particularly in patients with renal failure, leading to acute tubular necrosis. The risk of toxicity is increased when gentamicin is used in conjunction with furosemide. Therefore, lower doses and more frequent monitoring are required.
It is important to note that gentamicin is contraindicated in patients with myasthenia gravis. Due to the potential for toxicity, it is crucial to monitor plasma concentrations of gentamicin. Both peak levels (measured one hour after administration) and trough levels (measured just before the next dose) are monitored. If the trough level is high, the interval between doses should be increased. If the peak level is high, the dose should be decreased. By carefully monitoring gentamicin levels, healthcare providers can ensure that patients receive the appropriate dose without experiencing adverse effects.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 26
Incorrect
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A 30-year-old man comes to you with a painful and swollen left knee. He recently returned from a trip to Spain about 4 weeks ago. He denies any history of knee problems or trauma. Upon examination, you notice that his left knee is warm and swollen, but he has a full range of motion. Additionally, he complains of pain when moving his ankle joints, but there is no visible swelling. You also observe a waxy yellow rash on the soles of both feet. What is the most probable diagnosis?
Your Answer: Gout
Correct Answer: Reactive arthritis
Explanation:Keratoderma blenorrhagica is the cause of the rash on the soles. The reactive arthritis he is experiencing could be a result of a gastrointestinal infection or Chlamydia.
Understanding Reactive Arthritis: Symptoms and Features
Reactive arthritis is a type of seronegative spondyloarthropathy that is associated with HLA-B27. It was previously known as Reiter’s syndrome, which was characterized by a triad of urethritis, conjunctivitis, and arthritis following a dysenteric illness during World War II. However, later studies revealed that patients could also develop symptoms after a sexually transmitted infection, now referred to as sexually acquired reactive arthritis (SARA).
Reactive arthritis is defined as an arthritis that develops after an infection, but the organism cannot be recovered from the joint. The symptoms typically develop within four weeks of the initial infection and last for around 4-6 months. Approximately 25% of patients experience recurrent episodes, while 10% develop chronic disease. The arthritis is usually an asymmetrical oligoarthritis of the lower limbs, and patients may also experience dactylitis.
Other symptoms of reactive arthritis include urethritis, conjunctivitis (seen in 10-30% of patients), and anterior uveitis. Skin symptoms may also occur, such as circinate balanitis (painless vesicles on the coronal margin of the prepuce) and keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles). A helpful mnemonic to remember the symptoms of reactive arthritis is Can’t see, pee, or climb a tree.
In conclusion, understanding the symptoms and features of reactive arthritis is crucial for early diagnosis and treatment. While the condition can be recurrent or chronic, prompt management can help alleviate symptoms and improve quality of life for affected individuals.
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This question is part of the following fields:
- Musculoskeletal
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Question 27
Incorrect
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A 63-year-old woman who is undergoing treatment for bladder cancer presents to the Emergency Department because she has noticed that the urine in her catheter is blood-stained.
On examination, the urine is pink in colour. Her observations are normal.
What would be the next most appropriate step in this patient’s management?
Select the SINGLE most likely option.
Your Answer: Remove the urinary catheter
Correct Answer: Arrange a full blood count
Explanation:Management of a Patient with Suspected Bladder Tumour and Bleeding
When managing a patient with suspected bladder tumour and bleeding, it is important to consider the appropriate steps to take. Here are some options and their potential outcomes:
1. Arrange a full blood count: This test can help assess the degree of blood loss and guide the urgency of treatment.
2. Transfuse two units of O-negative blood: While patients with bladder tumours can bleed extensively, it is important to first assess the need for transfusion through a full blood count.
3. Flush the urinary catheter using normal saline: This step is appropriate for a blocked catheter, but not for a patient with active bleeding.
4. Remove the urinary catheter: This step can cause blood clots and urinary retention, and is not indicated for this patient.
5. Transfer to theatre for resection of tumour: While this may be necessary in cases of catastrophic bleeding, it is important to first assess the patient’s stability and obtain blood tests before planning definitive management.
In summary, careful consideration of the appropriate steps is crucial in managing a patient with suspected bladder tumour and bleeding.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 28
Correct
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A 15-year-old boy presents with a history of seasonal 'watering eyes' for the past 2 years. His symptoms have worsened this year. He complains of bilateral itchy eyes and difficulty in doing school work due to excessive tearing. There is no history of nasal symptoms, asthma or eczema. On examination, there is conjunctival redness, bulging tarsal conjunctivae and mild eyelid swelling. What is the initial management approach for this patient?
Your Answer: Topical antihistamines
Explanation:The symptoms exhibited by this patient are indicative of allergic conjunctivitis. The initial treatment approach for this condition involves the use of topical antihistamines. In case of additional symptoms like rhinosinusitis, oral antihistamines may also be prescribed.
Understanding Allergic Conjunctivitis
Allergic conjunctivitis is a condition that can occur on its own, but is often associated with hay fever. It is characterized by bilateral symptoms such as conjunctival erythema and swelling, as well as itchiness and swelling of the eyelids. Those with a history of atopy may be more prone to developing allergic conjunctivitis, which can be seasonal (due to pollen) or perennial (due to exposure to dust mites, washing powder, or other allergens).
When it comes to managing allergic conjunctivitis, first-line treatment typically involves the use of topical or systemic antihistamines. If these prove ineffective, second-line treatment options such as topical mast-cell stabilizers like Sodium cromoglicate and nedocromil may be recommended. By understanding the symptoms and treatment options for allergic conjunctivitis, individuals can take steps to manage their condition and reduce discomfort.
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This question is part of the following fields:
- Ophthalmology
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Question 29
Incorrect
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A 25-year-old woman has given birth to her first child. During delivery, the midwife had to perform McRoberts manoeuvre due to shoulder dystocia, but there were no other complications. After the placenta was delivered, the midwife discovered a perineal tear that involved the external anal sphincter (EAS) but did not extend to the internal anal sphincter (IAS) or rectal mucosa. What is the best course of action for management?
Your Answer: Allow a suitably trained midwife to suture the perineal tear on the ward
Correct Answer: Repair in theatre by a suitably trained clinician as it is a third degree tear
Explanation:The patient has suffered a third degree perineal tear that has extended beyond the perineal mucosa and muscle, involving the EAS but not the rectal mucosa. Therefore, it is classified as a third degree tear. The appropriate course of action is to repair the tear in theatre by a clinician who is suitably trained. Repairing the tear on the ward by a midwife is not an option as it is a third degree tear. Similarly, repairing it in theatre by a clinician trained for fourth degree tears is not necessary. It is important to note that first degree tears do not require repair, but in this case, as it is a third degree tear, not repairing it would not be appropriate as it may not heal properly.
Perineal tears are a common occurrence during childbirth, and the Royal College of Obstetricians and Gynaecologists (RCOG) has developed guidelines to classify them based on their severity. First-degree tears are superficial and do not require any repair, while second-degree tears involve the perineal muscle and require suturing by a midwife or clinician. Third-degree tears involve the anal sphincter complex and require repair in theatre by a trained clinician, with subcategories based on the extent of the tear. Fourth-degree tears involve the anal sphincter complex and rectal mucosa and also require repair in theatre by a trained clinician.
There are several risk factors for perineal tears, including being a first-time mother, having a large baby, experiencing a precipitant labour, and having a shoulder dystocia or forceps delivery. It is important for healthcare providers to be aware of these risk factors and to provide appropriate care and management during childbirth to minimize the risk of perineal tears. By following the RCOG guidelines and providing timely and effective treatment, healthcare providers can help ensure the best possible outcomes for both mother and baby.
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This question is part of the following fields:
- Reproductive Medicine
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Question 30
Incorrect
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A 75-year-old woman presents to the breast clinic with a painless lump in her left breast. After undergoing triple assessment, she is diagnosed with oestrogen receptor-positive breast cancer and her oncologist prescribes anastrozole as treatment. What potential risks may this medication pose for her?
Your Answer:
Correct Answer: Osteoporosis
Explanation:Anastrozole, an aromatase inhibitor, may lead to the development of osteoporosis. This medication is commonly used to treat oestrogen receptor-positive breast cancer in postmenopausal women by reducing the production of peripheral oestrogen. However, patients taking this medication are at an increased risk of developing osteoporosis. On the other hand, selective oestrogen receptor modulators (SERM) like tamoxifen may cause amenorrhoea, endometrial cancer, vaginal bleeding, and venous thromboembolism. Tamoxifen is typically used to treat oestrogen receptor-positive breast cancer in pre-menopausal women.
Anti-oestrogen drugs are used in the management of oestrogen receptor-positive breast cancer. Selective oEstrogen Receptor Modulators (SERM) such as Tamoxifen act as an oestrogen receptor antagonist and partial agonist. However, Tamoxifen can cause adverse effects such as menstrual disturbance, hot flushes, venous thromboembolism, and endometrial cancer. On the other hand, aromatase inhibitors like Anastrozole and Letrozole reduce peripheral oestrogen synthesis, which is important in postmenopausal women. Anastrozole is used for ER +ve breast cancer in this group. However, aromatase inhibitors can cause adverse effects such as osteoporosis, hot flushes, arthralgia, myalgia, and insomnia. NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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