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  • Question 1 - A 19-year-old long-distance runner who is currently preparing for a regional marathon seeks...

    Correct

    • A 19-year-old long-distance runner who is currently preparing for a regional marathon seeks an appointment with the team doctor due to an unusual sensation in her legs. She reports feeling numbness below her knee. During the examination, the doctor observes sensory loss below the left knee in a non-dermatomal distribution. The team doctor suspects a non-organic cause of her symptoms. What type of disorder is this an example of?

      Your Answer: Conversion disorder

      Explanation:

      Conversion disorder is a condition that often results in the loss of motor or sensory function and is believed to be triggered by stress.

      Psychiatric Terms for Unexplained Symptoms

      There are various psychiatric terms used to describe patients who exhibit symptoms for which no organic cause can be found. One such disorder is somatisation disorder, which involves the presence of multiple physical symptoms for at least two years, and the patient’s refusal to accept reassurance or negative test results. Another disorder is illness anxiety disorder, which is characterized by a persistent belief in the presence of an underlying serious disease, such as cancer, despite negative test results.

      Conversion disorder is another condition that involves the loss of motor or sensory function, and the patient does not consciously feign the symptoms or seek material gain. Patients with this disorder may be indifferent to their apparent disorder, a phenomenon known as la belle indifference. Dissociative disorder, on the other hand, involves the process of ‘separating off’ certain memories from normal consciousness, and may manifest as amnesia, fugue, or stupor. Dissociative identity disorder (DID) is the most severe form of dissociative disorder and was previously known as multiple personality disorder.

      Factitious disorder, also known as Munchausen’s syndrome, involves the intentional production of physical or psychological symptoms. Finally, malingering is the fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain. Understanding these psychiatric terms can help healthcare professionals better diagnose and treat patients with unexplained symptoms.

    • This question is part of the following fields:

      • Psychiatry
      14.8
      Seconds
  • Question 2 - Primary biliary cholangitis is most commonly associated with middle-aged women and which specific...

    Correct

    • Primary biliary cholangitis is most commonly associated with middle-aged women and which specific antibodies?

      Your Answer: Anti-mitochondrial antibodies

      Explanation:

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

      Primary Biliary Cholangitis: A Chronic Liver Disorder

      Primary biliary cholangitis, previously known as primary biliary cirrhosis, is a chronic liver disorder that is commonly observed in middle-aged women. The exact cause of this condition is not yet fully understood, but it is believed to be an autoimmune disease. The disease is characterized by the progressive damage of interlobular bile ducts due to chronic inflammation, leading to cholestasis and eventually cirrhosis. The most common symptom of primary biliary cholangitis is itching in middle-aged women.

      This condition is often associated with other autoimmune diseases such as Sjogren’s syndrome, rheumatoid arthritis, systemic sclerosis, and thyroid disease. Early symptoms of primary biliary cholangitis may be asymptomatic or may include fatigue, pruritus, and cholestatic jaundice. Late symptoms may progress to liver failure. Diagnosis of primary biliary cholangitis involves immunology tests such as anti-mitochondrial antibodies (AMA) M2 subtype and smooth muscle antibodies, as well as imaging tests to exclude an extrahepatic biliary obstruction.

      The first-line treatment for primary biliary cholangitis is ursodeoxycholic acid, which slows down the progression of the disease and improves symptoms. Cholestyramine is used to alleviate pruritus, and fat-soluble vitamin supplementation is recommended. In severe cases, liver transplantation may be necessary, especially if bilirubin levels exceed 100. However, recurrence in the graft can occur, but it is not usually a problem. Complications of primary biliary cholangitis include cirrhosis, portal hypertension, ascites, variceal hemorrhage, osteomalacia, osteoporosis, and an increased risk of hepatocellular carcinoma.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      4.3
      Seconds
  • Question 3 - A 28-year-old woman is referred to the Neurology Clinic with suspected Guillain–Barré syndrome...

    Incorrect

    • A 28-year-old woman is referred to the Neurology Clinic with suspected Guillain–Barré syndrome (GBS). A lumbar puncture (LP) is performed on the patient to rule out any other causes. The results of the LP show normal white blood cells (WBCs) and elevated proteins.
      What immediate management should be started for this patient?
      Select the SINGLE most appropriate management from the list below.

      Your Answer: High-dose dexamethasone

      Correct Answer: Intravenous immunoglobulins

      Explanation:

      Guillain-Barré syndrome (GBS) can be treated with either plasma exchange or intravenous immunoglobulin (IVIG), both of which are equally effective. The decision on which treatment to use depends on the institution. Plasma exchange is recommended for ambulatory patients within two weeks of symptom onset and for non-ambulatory patients within four weeks. It is most effective when started within seven days of symptom onset, but improvement can still be seen up to 30 days after onset. Patients receiving plasma exchange should be closely monitored for electrolyte abnormalities and coagulopathies, as well as complications such as infection, blood pressure instability, cardiac arrhythmias, and pulmonary embolus. Compared to IVIG, plasma exchange has a higher risk of pneumonia, atelectasis, thrombosis, and hemodynamic difficulties. Urgent referral to oncology is appropriate if the patient has signs of metastatic spinal cord compression. High-dose dexamethasone is not indicated in this case as there is no history of cancer. Intravenous ceftriaxone is used to treat meningitis, which was ruled out by the LP findings. Intravenous itraconazole would be appropriate if fungal meningitis were suspected based on the patient’s history and LP results.

    • This question is part of the following fields:

      • Neurology
      27.2
      Seconds
  • Question 4 - A 12-year-old girl presents to the clinic with complaints of anterior knee pain...

    Correct

    • A 12-year-old girl presents to the clinic with complaints of anterior knee pain for a few weeks, which worsens while walking downstairs. During the examination, a positive shrug test is observed, and she has a valgus knee deformity.
      What is the most probable diagnosis?

      Your Answer: Chondromalacia patellae

      Explanation:

      Common Causes of Knee Pain in Adolescents and Young Adults

      Knee pain is a common complaint among adolescents and young adults. There are several conditions that can cause knee pain, including chondromalacia patellae, osteoarthritis, Osgood-Schlatter disease, osteochondritis dissecans, and patellar subluxation.

      Chondromalacia patellae is characterized by abnormal softening of the cartilage on the underside of the patella. It is more common in females, those with valgus knee deformity, and those who are flat-footed. Patients may experience anterior knee pain that worsens with prolonged sitting or activities such as walking down stairs, jumping, running, or climbing. Treatment involves physiotherapy to alter patella-femoral alignment, along with analgesics and ice for symptom relief.

      Osteoarthritis is a disease of older patients caused by cartilage breakdown in weight-bearing joints. Osgood-Schlatter disease is a common cause of knee pain in young adolescents, particularly sporty boys, and is caused by overuse of quadriceps. Osteochondritis dissecans is caused by separation of subchondral bone articular cartilage from the joint surface and tends to present in teenagers and young adults with vague and achy joint pain. Patellar subluxation describes the temporary but recurring lateral subluxation of the patella, which can cause anterior patellar pain and joint stiffness.

      It is important to note that knee pain in children could be due to hip pathology, such as slipped upper femoral epiphysis. Diagnosis and treatment for these conditions may involve clinical examination, radiographs, and MRI. Treatment may include physiotherapy, analgesics, ice packs, knee braces, and in some cases, surgery.

    • This question is part of the following fields:

      • Musculoskeletal
      42.3
      Seconds
  • Question 5 - A 32-year-old female sex worker presents to the emergency department complaining of a...

    Incorrect

    • A 32-year-old female sex worker presents to the emergency department complaining of a high fever and severe headache. During the physical examination, you observe neck stiffness and mild photophobia, prompting you to perform a lumbar puncture. The results of the lumbar puncture reveal the presence of a yeast and a capsule in the CSF stained with India ink.
      What is the most probable diagnosis?

      Your Answer: Histoplasmosis

      Correct Answer: Cryptococcal meningitis

      Explanation:

      Cryptococcus neoformans is a yeast that has a protective capsule and requires oxygen to survive. It can thrive in both plants and animals, and when it infects humans, it causes cryptococcosis. While the infection typically affects the lungs, it can also lead to fungal meningitis and encephalitis in individuals with weakened immune systems. HIV-positive patients are particularly susceptible to this infection, and given the patient’s history as a sex worker, it’s possible that they have an undiagnosed HIV infection that has progressed to AIDS. Additionally, cryptococcus neoformans can be detected through india ink staining during a lumbar puncture.

      The investigation and management of suspected bacterial meningitis are intertwined due to the potential negative impact of delayed antibiotic treatment. Patients should be urgently transferred to the hospital, and an ABC approach should be taken initially. A lumbar puncture should be delayed in certain circumstances, and IV antibiotics should be given as a priority if there is any doubt. The bloods and CSF should be tested for various parameters, and prophylaxis should be offered to households and close contacts of patients affected with meningococcal meningitis.

    • This question is part of the following fields:

      • Infectious Diseases
      13.1
      Seconds
  • Question 6 - A 30-year-old man visits his doctor's office with complaints of difficulty sleeping. Upon...

    Correct

    • A 30-year-old man visits his doctor's office with complaints of difficulty sleeping. Upon further inquiry, he reveals that he avoids social situations due to a fear of being judged, and experienced a panic attack with rapid heart rate and shortness of breath while at a movie theater a few weeks ago.
      What is the most probable diagnosis?

      Your Answer: Social phobia

      Explanation:

      Differentiating Social Phobia from Other Anxiety Disorders

      Social phobia, also known as social anxiety disorder, is a type of anxiety disorder characterized by intense fear and anxiety in social situations, particularly when being scrutinized. It typically starts in adolescence and affects both men and women equally. Some individuals may have a specific fear of certain situations, while others may experience anxiety in most social situations outside of close family and friends. Low self-esteem is often associated with social phobia, and avoidance of feared situations is common. Treatment typically involves psychological interventions such as cognitive-behavioral therapy.

      It is important to differentiate social phobia from other anxiety disorders. Panic disorder is characterized by recurrent episodes of severe anxiety that occur unpredictably and without an objective danger. Agoraphobia involves a fear of situations where escape to a safe place is difficult or impossible. Generalized anxiety disorder is characterized by non-specific and persistent anxiety, often accompanied by autonomic and motor overactivity. Depression may also be associated with anxiety, but typically involves early morning waking rather than difficulty falling asleep.

      By understanding the specific features of social phobia and how it differs from other anxiety disorders, healthcare professionals can provide appropriate diagnosis and treatment for their patients.

    • This question is part of the following fields:

      • Psychiatry
      17.3
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  • Question 7 - A 6-month-old infant is presented to the emergency department by their caregiver. The...

    Incorrect

    • A 6-month-old infant is presented to the emergency department by their caregiver. The infant is exhibiting a fever, lethargy, and decreased muscle tone. Additionally, a non-blanching rash is observed on the right arm of the infant. What is the best course of treatment?

      Your Answer: IV cefotaxime + amoxicillin

      Correct Answer: IV ceftriaxone

      Explanation:

      For an unwell child with suspected meningitis who is over 3 months old, the recommended initial empirical therapy is IV 3rd generation cephalosporin, such as ceftriaxone. IV cefuroxime, a 2nd generation cephalosporin, is not recommended for this purpose. IV cefotaxime + amoxicillin is recommended for babies at risk of jaundice, but as the child in this case is 4 months old, this is not necessary. IV co-amoxiclav and piperacillin do not provide adequate coverage for meningitis and are not suitable for central nervous system infections.

      Investigation and Management of Meningitis in Children

      Meningitis is a serious condition that can affect children. When investigating meningitis, it is important to note any contraindications to lumbar puncture, such as signs of raised intracranial pressure, focal neurological signs, papilloedema, significant bulging of the fontanelle, disseminated intravascular coagulation, or signs of cerebral herniation. For patients with meningococcal septicaemia, a lumbar puncture is contraindicated, and blood cultures and PCR for meningococcus should be obtained instead.

      The management of meningitis in children involves administering antibiotics, such as IV amoxicillin (or ampicillin) and IV cefotaxime for children under three months, and IV cefotaxime (or ceftriaxone) for children over three months. Steroids should be considered if the lumbar puncture reveals certain findings, such as purulent cerebrospinal fluid, a high white blood cell count, or bacteria on Gram stain. Fluids should be administered to treat shock, and cerebral monitoring should be conducted, including mechanical ventilation if necessary.

      It is also important to notify public health authorities and administer antibiotic prophylaxis to contacts. Ciprofloxacin is now preferred over rifampicin for this purpose. Overall, prompt and appropriate management of meningitis in children is crucial for ensuring the best possible outcomes.

    • This question is part of the following fields:

      • Paediatrics
      15.6
      Seconds
  • Question 8 - A neonate is diagnosed with a cardiac congenital abnormality where the foetal aorta...

    Correct

    • A neonate is diagnosed with a cardiac congenital abnormality where the foetal aorta and pulmonary trunk are parallel with an absence of crossing. What medication should be initiated urgently before corrective surgery can be performed?

      Your Answer: Prostaglandin E1

      Explanation:

      The initial management for duct dependent congenital heart disease involves maintaining the ductus arteriosus with prostaglandins. In neonates with transposition of the great arteries (TGA), prostaglandin E1 is given intravenously to ensure the ductus arteriosus remains open, as its closure can lead to circulatory failure and profound cyanosis. Prostaglandins work by dilating vascular smooth muscle, which maintains the patency of the ductus arteriosus. Administering prostaglandins after delivery is necessary as the prostaglandin-rich placenta is no longer present to keep the ductus arteriosus open. Adenosine is not indicated in this case, as the newborn’s issue is circulatory rather than related to cardiac electrical activity. If heart failure occurs, angiotensin-converting enzyme (ACE) inhibitors may be used, but prostaglandins should be the first-line treatment to prevent heart failure. Non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided as they inhibit prostaglandin synthesis, leading to closure of the ductus arteriosus and likely death of the newborn. Prostaglandin E is the most potent type of prostaglandin responsible for maintaining ductus arteriosus patency, not prostaglandin F2.

      Understanding Transposition of the Great Arteries

      Transposition of the great arteries (TGA) is a type of congenital heart disease that results in a lack of oxygenated blood flow to the body. This condition occurs when the aorticopulmonary septum fails to spiral during septation, causing the aorta to leave the right ventricle and the pulmonary trunk to leave the left ventricle. Children born to diabetic mothers are at a higher risk of developing TGA.

      The clinical features of TGA include cyanosis, tachypnea, a loud single S2 heart sound, and a prominent right ventricular impulse. Chest x-rays may show an egg-on-side appearance.

      To manage TGA, it is important to maintain the ductus arteriosus with prostaglandins. Surgical correction is the definitive treatment for this condition. Understanding the basic anatomical changes and clinical features of TGA can help with early diagnosis and appropriate management.

    • This question is part of the following fields:

      • Paediatrics
      9.6
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  • Question 9 - A 35-year-old woman presents to you with concerns about her migraine prophylaxis medication...

    Correct

    • A 35-year-old woman presents to you with concerns about her migraine prophylaxis medication and its potential effects on her unborn child. She reports that her migraines used to occur 1-2 times per week, but since starting the medication, they have decreased to 1-2 times per month. Which medication commonly used for migraine prophylaxis is associated with congenital abnormalities, specifically cleft lip and palate?

      Your Answer: Topiramate

      Explanation:

      If a person experiences more than 2 migraine attacks a month, they should be offered migraine prophylaxis. Propranolol and topiramate are both options for this, but propranolol is preferred for women of child-bearing age due to the risk of cleft lip/cleft palate in infants if topiramate is used during the first trimester of pregnancy. The combined oral contraceptive pill is not typically prescribed for migraines, and if a patient using it becomes pregnant, it will not harm the fetus. Triptan medications like sumatriptan and zolmitriptan are used for acute migraine treatment and should be taken as soon as a migraine starts. They may also be used for menstrual migraine prophylaxis, but should be avoided during pregnancy due to limited safety data.

      Managing Migraines: Guidelines and Treatment Options

      Migraines can be debilitating and affect a significant portion of the population. To manage migraines, it is important to understand the different treatment options available. According to the National Institute for Health and Care Excellence (NICE) guidelines, acute treatment for migraines involves a combination of an oral triptan and an NSAID or paracetamol. For young people aged 12-17 years, a nasal triptan may be preferred. If these measures are not effective, non-oral preparations of metoclopramide or prochlorperazine may be considered, along with a non-oral NSAID or triptan.

      Prophylaxis should be given if patients are experiencing two or more attacks per month. NICE recommends topiramate or propranolol, depending on the patient’s preference, comorbidities, and risk of adverse events. Propranolol is preferred in women of childbearing age as topiramate may be teratogenic and reduce the effectiveness of hormonal contraceptives. Acupuncture and riboflavin may also be effective in reducing migraine frequency and intensity for some people. For women with predictable menstrual migraines, frovatriptan or zolmitriptan may be recommended as a type of mini-prophylaxis.

      Specialists may consider other treatment options, such as candesartan or monoclonal antibodies directed against the calcitonin gene-related peptide (CGRP) receptor, like erenumab. However, pizotifen is no longer recommended due to common adverse effects like weight gain and drowsiness. It is important to exercise caution with young patients as acute dystonic reactions may develop. By following these guidelines and considering various treatment options, migraines can be effectively managed.

    • This question is part of the following fields:

      • Reproductive Medicine
      10
      Seconds
  • Question 10 - A 42-year-old man visits his doctor, reporting crusting of both eyelids that is...

    Correct

    • A 42-year-old man visits his doctor, reporting crusting of both eyelids that is more severe in the morning and accompanied by an itchy feeling. He states that he has not experienced any changes in his vision.
      During the eyelid examination, the doctor observes crusting at the eyelid margins, which are inflamed and red. The conjunctivae seem normal, and the pupils react equally to light.
      What is the probable diagnosis?

      Your Answer: Blepharitis

      Explanation:

      Common Eye Conditions and Their Symptoms

      Blepharitis: This condition presents with crusting of both eyelids, redness, swelling, and itching. It can be treated with eyelid hygiene and warm compress. If necessary, chloramphenicol ointment can be used.

      Conjunctivitis: Patients with conjunctivitis have watery/discharging eyes, a gritty sensation, and conjunctival erythema. Most cases resolve on their own, but some may require topical antibiotics.

      Chalazion: A painless swelling or lump on the eyelid caused by a blocked gland. Patients report a red, swollen, and painless area on the eyelid that settles within a few days but leaves behind a firm, painless swelling. Warm compresses and gentle massaging can help with drainage.

      Entropion: The margin of the eyelid turns inwards towards the surface of the eye, causing irritation. It is more common in elderly patients and requires surgical treatment.

      Hordeolum: An acute-onset localised swelling of the eyelid margin that is painful. It is usually localised around an eyelash follicle, and plucking the affected eyelash can aid drainage. Styes are usually self-limiting, but eyelid hygiene and warm compress can help with resolution.

      Understanding Common Eye Conditions and Their Symptoms

    • This question is part of the following fields:

      • Ophthalmology
      18.1
      Seconds
  • Question 11 - A 35-year-old woman experiences a seizure while in the emergency department. The seizure...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Neurology
      11.6
      Seconds
  • Question 12 - In the diagnosis of asthma, which statement is the most appropriate? ...

    Incorrect

    • In the diagnosis of asthma, which statement is the most appropriate?

      Your Answer: 15% reversibility by bronchial dilators is an essential diagnostic test in making this diagnosis

      Correct Answer: Cough is an important diagnostic feature

      Explanation:

      Myths and Facts about Asthma Diagnosis and Treatment

      Cough is a crucial diagnostic feature in asthma, especially if it occurs at night. However, it is not the only symptom, and other factors must be considered to reach a diagnosis. While asthma often presents in childhood, it can also appear later in life, and some patients may experience a recurrence of symptoms after a period of remission. The 15% reversibility test is useful but not essential for diagnosis, and there is no single test that can definitively diagnose asthma. Inhaled corticosteroids are not bronchodilators and do not have an immediate effect, but they are essential for managing inflammation and preventing irreversible airway damage. Finally, family history is a crucial factor in asthma diagnosis, as there is a strong genetic component to the disease.

    • This question is part of the following fields:

      • Respiratory Medicine
      12.6
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  • Question 13 - A 7-year-old child is brought to see you by his parents, who are...

    Incorrect

    • A 7-year-old child is brought to see you by his parents, who are concerned because he still wets his bed every night. A urine culture is normal; urine is negative for glucose and protein.
      What would be the most appropriate approach to managing this child's bedwetting?

      Your Answer: Desmopressin nasal spray

      Correct Answer: Reassurance to parents with general advice

      Explanation:

      Understanding and Managing Nocturnal Enuresis in Children

      Nocturnal enuresis, or bedwetting, is a common issue among children. While it can sometimes be caused by an underlying medical condition, such as a urinary tract infection or diabetes, in most cases it is simply a developmental issue that will resolve on its own over time.

      It is important to have a medical evaluation to rule out any underlying medical conditions, but once those have been ruled out, treatment is generally not recommended until the child is at least six years old. In the meantime, parents can use star charts and enuresis alarms to help motivate their child to stay dry at night.

      It is also important to consider any psychological issues that may be contributing to the problem. Parents should ask their child about their school performance, friendships, and home life, and try to speak to the child alone if possible to get a better understanding of any stressors that may be affecting them.

      There is no need for a referral for an ultrasound scan unless there is a suspicion of a structural abnormality. Desmopressin nasal spray can be prescribed for short-term relief, but oral imipramine is no longer recommended. Prophylactic antibiotics are also not indicated for nocturnal enuresis.

      Overall, parents should be reassured that bedwetting is a common issue that many children experience, and with time and patience, it will likely resolve on its own.

    • This question is part of the following fields:

      • Paediatrics
      16.6
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  • Question 14 - You are in the emergency department assessing a 68-year-old man who has arrived...

    Correct

    • You are in the emergency department assessing a 68-year-old man who has arrived with a fractured femur. He is currently taking anticoagulants for his atrial fibrillation and you have been requested to reverse the anticoagulation to prepare him for surgery. Can you match the correct anticoagulant with its corresponding reversal agent?

      Your Answer: Dabigatran - Idarucizumab

      Explanation:

      Vitamin K is the antidote for warfarin.
      Idarucizumab is the antidote for dabigatran.
      Protamine sulfate is the antidote for heparin.

      Understanding Direct Oral Anticoagulants

      Direct oral anticoagulants (DOACs) are medications used for various indications such as preventing stroke in non-valvular atrial fibrillation, preventing venous thromboembolism (VTE) after hip or knee surgery, and treating deep vein thrombosis (DVT) and pulmonary embolism (PE). To be prescribed DOACs for stroke prevention in non-valvular AF, certain risk factors must be present, such as prior stroke or transient ischaemic attack, age 75 years or older, hypertension, diabetes mellitus, or heart failure.

      There are four DOACs available, namely dabigatran, rivaroxaban, apixaban, and edoxaban, which differ in their mechanism of action and excretion. Dabigatran is a direct thrombin inhibitor, while rivaroxaban, apixaban, and edoxaban are direct factor Xa inhibitors. The majority of dabigatran is excreted through the kidneys, while rivaroxaban is metabolized in the liver, and apixaban and edoxaban are excreted through the feces.

      In terms of reversal agents, idarucizumab is available for dabigatran, while andexanet alfa is available for rivaroxaban and apixaban. However, there is currently no authorized reversal agent for edoxaban, although andexanet alfa has been studied. Understanding the differences between DOACs is important for healthcare professionals to make informed decisions when prescribing these medications.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      16.6
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  • Question 15 - A 75-year-old man visits the doctor's office accompanied by his wife, who is...

    Incorrect

    • A 75-year-old man visits the doctor's office accompanied by his wife, who is worried about his well-being. The man has been experiencing episodes of confusion and drowsiness that appear to occur unpredictably for the past five years. Additionally, he has developed a tremor in his right hand on one side of his body. The man's wife reveals that she has slept in a different bed from her husband for the past three decades due to his frequent nightmares. What is the probable diagnosis?

      Your Answer: Alzheimer's disease

      Correct Answer: Dementia with Lewy bodies

      Explanation:

      The correct answer is Dementia with Lewy bodies, which is a type of dementia that is characterized by fluctuating cognition. This can be confusing as there are different types of dementia, especially non-Alzheimer’s disease dementia. In this case, the man’s symptoms and the classification of dementias point towards DLB. Parkinson’s disease dementia is also a type of dementia that falls under the category of Lewy body dementia, but it is characterized by tremors, bradykinesia, and rigidity that develop before dementia. DLB, on the other hand, presents with dementia before these motor symptoms. Other clues that suggest DLB include the man’s periods of confusion and sleepiness that come and go randomly, as well as his wife’s report of him suffering from bad nightmares, which is a distinctive feature of DLB. In contrast, Alzheimer’s disease dementia typically presents with slowly worsening memory loss and forgetfulness, while frontal lobe dementia primarily presents with behavioural changes and reckless behaviour.

      Understanding Lewy Body Dementia

      Lewy body dementia is a type of dementia that is becoming more recognized as a cause of cognitive impairment, accounting for up to 20% of cases. It is characterized by the presence of alpha-synuclein cytoplasmic inclusions, known as Lewy bodies, in certain areas of the brain. While there is a complicated relationship between Parkinson’s disease and Lewy body dementia, with dementia often seen in Parkinson’s disease, the two conditions are distinct. Additionally, up to 40% of patients with Alzheimer’s disease have Lewy bodies.

      The features of Lewy body dementia include progressive cognitive impairment, which typically occurs before parkinsonism, but both features usually occur within a year of each other. Unlike other forms of dementia, cognition may fluctuate, and early impairments in attention and executive function are more common than memory loss. Other features include parkinsonism, visual hallucinations, and sometimes delusions and non-visual hallucinations.

      Diagnosis of Lewy body dementia is usually clinical, but single-photon emission computed tomography (SPECT) can be used to confirm the diagnosis. Management of Lewy body dementia involves the use of acetylcholinesterase inhibitors and memantine, similar to Alzheimer’s disease. However, neuroleptics should be avoided as patients with Lewy body dementia are extremely sensitive and may develop irreversible parkinsonism. It is important to carefully consider the use of medication in these patients to avoid worsening their condition.

    • This question is part of the following fields:

      • Neurology
      52.7
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  • Question 16 - During a routine opticians appointment, corneal opacities are observed in a 65-year-old woman....

    Correct

    • During a routine opticians appointment, corneal opacities are observed in a 65-year-old woman. Her vision is not affected. Which medication is the most probable culprit for this condition?

      Your Answer: Amiodarone

      Explanation:

      Both corneal opacities and optic neuritis can be caused by amiodarone therapy.

      There are certain drugs that can cause problems with the eyes. For example, steroids can lead to the development of cataracts, while amiodarone and indomethacin can cause corneal opacities. Ethambutol, amiodarone, and metronidazole are known to cause optic neuritis. Additionally, chloroquine and quinine can result in retinopathy. It’s important to note that sildenafil, a medication used to treat erectile dysfunction, can cause both blue discoloration and non-arteritic anterior ischemic neuropathy. It’s crucial to be aware of these potential side effects and to speak with a healthcare provider if any ocular problems arise while taking these medications.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      21.5
      Seconds
  • Question 17 - A 60-year-old patient presents with jaundice and an enlarged, nodular liver. A CT...

    Correct

    • A 60-year-old patient presents with jaundice and an enlarged, nodular liver. A CT scan of the abdomen reveals a cirrhotic liver with a large mass, and CT-guided biopsy of the mass confirms a malignant tumour derived from hepatic parenchymal cells. Which virus is most likely directly related to the development of this tumour?

      Your Answer: Hepatitis B virus

      Explanation:

      Viral Infections and Their Link to Cancer

      Hepatitis B, Epstein-Barr, human herpesvirus type 8, and human papillomavirus are all viral infections that have been linked to the development of cancer. Hepatitis B, for example, can lead to cirrhosis and ultimately hepatocellular carcinoma. Similarly, EBV has been associated with various malignancies, including lymphoproliferative disorders and nasopharyngeal carcinoma. HPV, on the other hand, is a common cause of genital warts and cervical cancer. It is important to recognize the early signs of these viral infections in order to prevent the development of cancer and improve prognosis.

    • This question is part of the following fields:

      • Haematology/Oncology
      13.2
      Seconds
  • Question 18 - A 45-year-old man with type 2 diabetes mellitus presents with fatigue. He is...

    Correct

    • A 45-year-old man with type 2 diabetes mellitus presents with fatigue. He is currently taking metformin and gliclazide, but may need to discontinue the latter due to his obesity. After conducting several blood tests, the following results were obtained:
      - HbA1c: 66 mmol/mol (< 48)
      - Ferritin: 204 ng/mL (25 - 350)
      - Bilirubin: 23 µmol/L (3 - 17)
      - ALP: 162 u/L (30 - 100)
      - ALT: 120 u/L (3 - 40)
      - AST: 109 u/L (3 - 40)

      Upon further discussion, the patient denies consuming alcohol. What is the most likely explanation for these abnormal findings?

      Your Answer: Non-alcoholic fatty liver disease

      Explanation:

      When a patient with type 2 diabetes and obesity presents with abnormal liver function tests, the most probable diagnosis is non-alcoholic fatty liver disease. To confirm this diagnosis, the patient will need to undergo a liver screen, ultrasound, and liver biopsy. While haemochromatosis should be considered in patients with both abnormal LFTs and diabetes, a normal ferritin level makes this diagnosis less likely.

      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.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      27.1
      Seconds
  • Question 19 - Samantha, a 56-year-old teacher, visits you for a check-up regarding her angina. Despite...

    Incorrect

    • Samantha, a 56-year-old teacher, visits you for a check-up regarding her angina. Despite taking the highest dosage of bisoprolol, she experiences chest pain during physical activity, which hinders her daily routine as she frequently needs to take breaks and rest after walking short distances. Her pain never occurs while at rest, and she has no known allergies or drug sensitivities. What is the recommended course of action for managing Samantha's condition?

      Your Answer: Add verapamil

      Correct Answer: Add amlodipine

      Explanation:

      According to NICE guidelines (2019), if a beta-blocker is not effectively controlling angina, a long-acting dihydropyridine calcium-channel blocker (CCB) like amlodipine should be added. It is important to ensure that the patient is taking the highest tolerated dose of their current medications before adding new ones.

      Ramipril is not the best treatment option for this patient as there is no evidence of hypertension in their medical history. While ACE inhibitors like ramipril can be effective in preventing myocardial infarction and stroke in patients with angina and hypertension, they are not indicated in this case.

      Verapamil is a CCB that can be used to manage angina, but it should not be used in combination with a beta-blocker as this can increase the risk of severe bradycardia and heart failure.

      As the patient is not displaying any signs of unstable angina, such as pain at rest or rapidly progressing symptoms, admission to the emergency department is not necessary.

      If there is evidence of extensive ischaemia on an electrocardiograph (ECG) or the patient is not responding well to an optimised drug treatment, referral to cardiology for angioplasty may be necessary.

      Angina pectoris is a condition that can be managed through various methods, including lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. The first-line medication should be either a beta-blocker or a calcium channel blocker, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If the initial treatment is not effective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, other drugs such as long-acting nitrates, ivabradine, nicorandil, or ranolazine can be considered. Nitrate tolerance is a common issue, and patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. This effect is not seen in patients who take once-daily modified-release isosorbide mononitrate. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.

    • This question is part of the following fields:

      • Cardiovascular
      42
      Seconds
  • Question 20 - A 16-year-old complains of left knee pain that has been present for the...

    Correct

    • A 16-year-old complains of left knee pain that has been present for the last 4 weeks. No injury history is reported. The pain is located in the front of the joint and is aggravated when ascending or descending stairs. Physical examination reveals no significant findings. What is the probable diagnosis?

      Your Answer: Chondromalacia patellae

      Explanation:

      Common Knee Problems in Children and Young Adults

      Knee problems are common in children and young adults, especially those who are active in sports.
      Chondromalacia patellae is a condition that is more common in teenage girls. It is characterized by the softening of the cartilage of the patella, which can cause anterior knee pain when walking up and down stairs or rising from prolonged sitting. This condition usually responds well to physiotherapy.

      Osgood-Schlatter disease, also known as tibial apophysitis, is often seen in sporty teenagers. It causes pain, tenderness, and swelling over the tibial tubercle.

      Osteochondritis dissecans can cause pain after exercise, as well as intermittent swelling and locking of the knee.

      Patellar subluxation can cause medial knee pain due to lateral subluxation of the patella. The knee may also give way.

      Patellar tendonitis is more common in athletic teenage boys. It causes chronic anterior knee pain that worsens after running. On examination, the area below the patella is tender. It is important to note that referred pain may come from hip problems such as slipped upper femoral epiphysis.

    • This question is part of the following fields:

      • Paediatrics
      32
      Seconds
  • Question 21 - A 68-year-old man comes to the clinic complaining of intermittent swallowing difficulties for...

    Correct

    • A 68-year-old man comes to the clinic complaining of intermittent swallowing difficulties for the past two years. His wife has noticed that he has bad breath and coughs at night. He has a history of type 2 diabetes mellitus but reports that he is generally healthy. Despite having a good appetite, his weight has remained stable. Upon clinical examination, no abnormalities are found. What is the probable diagnosis?

      Your Answer: Pharyngeal pouch

      Explanation:

      Esophageal cancer is unlikely due to the individual’s good health and two-year history.

      Understanding Pharyngeal Pouch or Zenker’s Diverticulum

      A pharyngeal pouch, also known as Zenker’s diverticulum, is a condition where there is a posteromedial diverticulum through Killian’s dehiscence. This triangular area is found in the wall of the pharynx between the thyropharyngeus and cricopharyngeus muscles. It is more common in older patients and is five times more common in men.

      The symptoms of pharyngeal pouch include dysphagia, regurgitation, aspiration, neck swelling that gurgles on palpation, and halitosis. To diagnose this condition, a barium swallow combined with dynamic video fluoroscopy is usually done.

      Surgery is the most common management for pharyngeal pouch. It is important to address this condition promptly to prevent complications such as aspiration pneumonia. Understanding the symptoms and seeking medical attention early can help in the proper management of pharyngeal pouch.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      13.1
      Seconds
  • Question 22 - A 35-year-old woman who is currently 33 weeks pregnant has been monitoring her...

    Correct

    • A 35-year-old woman who is currently 33 weeks pregnant has been monitoring her capillary blood glucose (CBG) at home since being diagnosed with gestational diabetes mellitus (GDM) 3 weeks ago. She has received appropriate dietary and exercise advice, as well as review by a dietitian. Additionally, she has been taking metformin and has been on the maximum dose for the past week. Fetal growth scans have been normal, with no signs of macrosomia or polyhydramnios. Today, she presents her CBG diary, which indicates a mean pre-meal CBG of 6.0 mmol/L and a mean 1-hour postprandial CBG of 8.4 mmol/L. What is the most suitable management plan?

      Your Answer: Commence insulin

      Explanation:

      If blood glucose targets are not achieved through diet and metformin in gestational diabetes, insulin should be added. Pregnant women with GDM should aim to keep their CBGs below specific levels, including fasting at 5.3mmol/L and 1 hour postprandial at 7.8 mmol/L or 2 hours postprandial at 6.4 mmol/L. If these targets are not met, insulin should be offered as an additional therapy. Gliclazide is not recommended, and the use of any sulphonylurea in GDM is an off-license indication. Gliptins are not recommended due to insufficient evidence of their safety in pregnancy. It is not appropriate to continue the same management or de-escalate treatment by stopping metformin if CBG readings are above target levels. Failure to achieve glycaemic control can result in serious risks to both mother and fetus, including pre-eclampsia, pre-term labour, stillbirth, and neonatal hypoglycaemia, even if fetal growth appears normal.

      Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      23.5
      Seconds
  • Question 23 - Which one of the following statements regarding the HPV vaccine is incorrect? ...

    Incorrect

    • Which one of the following statements regarding the HPV vaccine is incorrect?

      Your Answer: MMR is a live attenuated vaccine

      Correct Answer: Children who received another live vaccine 2 weeks ago can safely have MMR

      Explanation:

      The MMR Vaccine: Information on Contraindications and Adverse Effects

      The Measles, Mumps and Rubella (MMR) vaccine is given to children in the UK twice before they enter primary school. The first dose is administered at 12-15 months, while the second dose is given at 3-4 years old. This vaccine is part of the routine immunisation schedule.

      However, there are certain contraindications to the MMR vaccine. Children with severe immunosuppression, allergies to neomycin, or those who have received another live vaccine by injection within four weeks should not receive the MMR vaccine. Pregnant women should also avoid getting vaccinated for at least one month following the MMR vaccine. Additionally, if a child has undergone immunoglobulin therapy within the past three months, there may be no immune response to the measles vaccine if antibodies are present.

      While the MMR vaccine is generally safe, there are some adverse effects that may occur. After the first dose of the vaccine, some children may experience malaise, fever, and rash. These symptoms typically occur after 5-10 days and last for around 2-3 days. It is important to be aware of these potential side effects and to consult with a healthcare professional if any concerns arise.

    • This question is part of the following fields:

      • Paediatrics
      21.8
      Seconds
  • Question 24 - Which one of the following statements regarding juvenile idiopathic arthritis is accurate? ...

    Incorrect

    • Which one of the following statements regarding juvenile idiopathic arthritis is accurate?

      Your Answer: It is equally common in men and women

      Correct Answer: Achilles tendonitis is a recognised association

      Explanation:

      Ankylosing spondylitis is a type of spondyloarthropathy that is associated with HLA-B27. It is more commonly seen in young males, with a sex ratio of 3:1, and typically presents with lower back pain and stiffness that develops gradually. The stiffness is usually worse in the morning and improves with exercise, while pain at night may improve upon getting up. Clinical examination may reveal reduced lateral and forward flexion, as well as reduced chest expansion. Other features associated with ankylosing spondylitis include apical fibrosis, anterior uveitis, aortic regurgitation, Achilles tendonitis, AV node block, amyloidosis, cauda equina syndrome, and peripheral arthritis (more common in females).

    • This question is part of the following fields:

      • Musculoskeletal
      27
      Seconds
  • Question 25 - A 25-year-old woman presents to the Genitourinary Medicine Clinic with a 1-week history...

    Correct

    • A 25-year-old woman presents to the Genitourinary Medicine Clinic with a 1-week history of lower abdominal pain and deep dyspareunia. She has also noticed a creamy foul-smelling vaginal discharge. There is no past medical history of note and she takes no regular medications.
      On examination, her temperature is 38.1 °C. The remainder of her observations are within normal limits. There is palpable lower abdominal tenderness and guarding in the left iliac fossa. Bimanual examination elicits bilateral adnexal tenderness. There is no inguinal lymphadenopathy.
      Given the likely diagnosis, what is the most appropriate investigation to confirm the causative organism?

      Select ONE option only

      Your Answer: Nucleic acid amplification testing (NAAT)

      Explanation:

      Investigations for Pelvic Inflammatory Disease

      Pelvic inflammatory disease (PID) is a condition that can cause deep dyspareunia and lower abdominal and adnexal tenderness. The most common cause of PID is Chlamydia trachomatis, which can be diagnosed through nucleic acid amplification testing (NAAT). This involves taking a urine sample and a swab from the vagina or cervix to test for the organism. While a blood culture may be considered for a febrile patient, it is not routinely used for diagnosing C. trachomatis. Vaginal microscopy and culture used to be the preferred method for diagnosis, but NAAT is now recommended. Testing vaginal pH is commonly used for vaginal infections, but is not useful for PID. Urine microscopy and culture is used for UTIs, but the presence of vaginal discharge and deep dyspareunia suggests PID instead.

    • This question is part of the following fields:

      • Infectious Diseases
      24.2
      Seconds
  • Question 26 - A 20-year-old girl presented at the age of 5 years with progressive ataxia....

    Correct

    • A 20-year-old girl presented at the age of 5 years with progressive ataxia. She is now wheelchair-bound. On examination, she is now dysarthric, with bilateral optic atrophy. There is ataxia in both upper limbs. Reflexes in her lower limbs are absent, with bilateral extensor plantar response. She has absent vibration and impaired joint position in both feet. Bilateral pes cavus is apparent. An electrocardiogram (ECG) shows inverted T waves. Echocardiogram reveals left ventricular hypertrophy.
      Which of the following is the most likely diagnosis?
      Select the SINGLE most appropriate diagnosis from the list below. Select ONE option only.

      Your Answer: Friedreich’s ataxia

      Explanation:

      Friedreich’s ataxia is a common inherited progressive ataxia in the UK that typically presents in childhood or adolescence. The earliest symptom is gait ataxia, followed by limb ataxia, absent lower limb reflexes, and later weakness and wasting of the limbs. Other common features include reduced or absent vibration sense and proprioception, spasticity, dysarthria, dysphagia, cardiac abnormalities, scoliosis, pes cavus, equinovarus, sleep apnea, and urinary frequency/urgency. The history is classic for this condition, and the ECG may show left ventricular hypertrophy. Charcot-Marie-Tooth disease, Huntington’s disease, and multiple sclerosis are not consistent with this history, while vitamin B12 deficiency may cause similar symptoms but is generally a condition of adults and does not fit the clinical picture as well as Friedreich’s ataxia.

    • This question is part of the following fields:

      • Neurology
      18.1
      Seconds
  • Question 27 - A 12-year-old boy with a history of eczema and asthma suddenly experiences breathlessness,...

    Correct

    • A 12-year-old boy with a history of eczema and asthma suddenly experiences breathlessness, nausea, and swelling of the face after eating a chicken skewer at a party. A 999 call is made, and his friends report that his skin is covered in raised red bumps and his lips are turning blue. What is the most appropriate immediate management for this patient?

      Your Answer: Intramuscular (IM) adrenaline 0.5 mg (1 : 1000)

      Explanation:

      Emergency Management of Anaphylaxis: Medications and Interventions

      Anaphylaxis is a severe and potentially life-threatening allergic reaction that requires immediate intervention. The following medications and interventions are commonly used in the emergency management of anaphylaxis:

      Intramuscular (IM) adrenaline 0.5 mg (1 : 1000): This is the first-line treatment for anaphylaxis and should be administered immediately. It can be repeated every 5 minutes as needed, guided by vital signs, until the patient is stable.

      Intravenous (IV) adrenaline 0.5 ml of 1 : 10 000: This is used in severe cases of anaphylaxis that do not respond to initial treatment. It should only be administered by experienced specialists and titrated carefully.

      IV chlorphenamine in 0.9% saline (500 ml): Chlorphenamine is no longer recommended for initial emergency anaphylaxis management.

      Reassurance and breathing exercises: These may be appropriate for a panic attack, but anaphylaxis requires immediate medical intervention.

      Salbutamol: While bronchodilator therapy may be considered after initial resuscitation, the most important treatment for anaphylaxis is oxygen administration and IM adrenaline.

      It is important to recognize the signs and symptoms of anaphylaxis and to act quickly to administer appropriate medications and interventions.

    • This question is part of the following fields:

      • Immunology/Allergy
      20.4
      Seconds
  • Question 28 - A 32-year-old woman with a history of primary generalised epilepsy visits her GP...

    Correct

    • A 32-year-old woman with a history of primary generalised epilepsy visits her GP as she intends to conceive. She is currently on lamotrigine as a single therapy. What guidance should be provided to prevent neural tube defects?

      Your Answer: Folic acid 5 mg per day starting now

      Explanation:

      During pregnancy, women with epilepsy should take 5mg of folic acid. Additionally, due to the potential harm of antiepileptic drugs to the fetus, they should receive specialized medical care.

      Pregnancy and breastfeeding can be a concern for women with epilepsy. It is generally recommended that women continue taking their medication during pregnancy, as the risks of uncontrolled seizures outweigh the potential risks to the fetus. However, it is important for women to take folic acid before pregnancy to reduce the risk of neural tube defects. The use of antiepileptic medication during pregnancy can increase the risk of congenital defects, but this risk is still relatively low. It is recommended to aim for monotherapy and there is no need to monitor drug levels. Sodium valproate is associated with neural tube defects, while carbamazepine is considered the least teratogenic of the older antiepileptics. Phenytoin is associated with cleft palate, and lamotrigine may require a dose increase during pregnancy. Breastfeeding is generally safe for mothers taking antiepileptics, except for barbiturates. Pregnant women taking phenytoin should be given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn.

      A warning has been issued about the use of sodium valproate during pregnancy and in women of childbearing age. New evidence suggests a significant risk of neurodevelopmental delay in children following maternal use of this medication. Therefore, it should only be used if clearly necessary and under specialist neurological or psychiatric advice. It is important for women with epilepsy to discuss their options with their healthcare provider and make informed decisions about their treatment during pregnancy and breastfeeding.

    • This question is part of the following fields:

      • Reproductive Medicine
      15
      Seconds
  • Question 29 - A female patient with a history of renal cell carcinoma presents with enlarged...

    Correct

    • A female patient with a history of renal cell carcinoma presents with enlarged legs bilaterally from the groin area downwards, along with dilated veins around the belly button. What is the underlying mechanism responsible for this?

      Your Answer: Inferior vena cava obstruction

      Explanation:

      Medical Conditions that Cause Bilateral Oedema: Inferior Vena Cava Obstruction, Hypoalbuminaemia, Deep Venous Thrombosis, Heart Failure, and Hyponatraemia

      Bilateral oedema, or swelling in both legs, can be caused by various medical conditions. One of these is inferior vena cava obstruction, which occurs when a renal mass or thrombus compresses the inferior vena cava, preventing venous drainage of the lower limbs. This obstruction can also cause venous engorgement and dilated veins around the umbilicus. Hypoalbuminaemia, on the other hand, causes a generalised oedema that can be seen in the face, upper and lower limbs, and abdomen. Deep venous thrombosis, which presents with painful swelling and erythema in the affected lower limb, can also cause bilateral symptoms if it occurs in the inferior vena cava. Heart failure, which causes bilateral dependent oedema due to fluid overload, is another possible cause of bilateral oedema. Finally, severe hyponatraemia resulting from fluid overload can cause a generalised symmetrical pattern of oedema that affects the upper limbs as well. Treatment for bilateral oedema depends on the underlying cause.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      15.8
      Seconds
  • Question 30 - A 26-year-old female presents for follow-up. She was diagnosed with asthma four years...

    Correct

    • A 26-year-old female presents for follow-up. She was diagnosed with asthma four years ago and is currently utilizing a salbutamol inhaler 100mcg as needed in combination with beclometasone dipropionate inhaler 200 mcg twice daily. However, her asthma remains poorly controlled. Upon examination, her chest is clear and she demonstrates proper inhaler technique. In accordance with NICE recommendations, what is the most suitable course of action for further management?

      Your Answer: Add a leukotriene receptor antagonist

      Explanation:

      According to NICE 2017 guidelines, if a patient with asthma is not effectively managed with a SABA + ICS, the first step should be to add a LTRA rather than a LABA.

      The management of asthma in adults has been updated by NICE in 2017, following the 2016 BTS guidelines. One of the significant changes is in ‘step 3’, where patients on a SABA + ICS whose asthma is not well controlled should be offered a leukotriene receptor antagonist instead of a LABA. NICE does not follow the stepwise approach of the previous BTS guidelines, but to make the guidelines easier to follow, we have added our own steps. The steps range from newly-diagnosed asthma to SABA +/- LTRA + one of the following options, including increasing ICS to high-dose, a trial of an additional drug, or seeking advice from a healthcare professional with expertise in asthma. Maintenance and reliever therapy (MART) is a form of combined ICS and LABA treatment that is only available for ICS and LABA combinations in which the LABA has a fast-acting component. It should be noted that NICE does not recommend changing treatment in patients who have well-controlled asthma simply to adhere to the latest guidance. The definitions of what constitutes a low, moderate, or high-dose ICS have also changed, with <= 400 micrograms budesonide or equivalent being a low dose, 400 micrograms - 800 micrograms budesonide or equivalent being a moderate dose, and > 800 micrograms budesonide or equivalent being a high dose for adults.

    • This question is part of the following fields:

      • Respiratory Medicine
      24.9
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Psychiatry (2/2) 100%
Gastroenterology/Nutrition (3/3) 100%
Neurology (2/4) 50%
Musculoskeletal (1/2) 50%
Infectious Diseases (1/2) 50%
Paediatrics (2/5) 40%
Reproductive Medicine (2/2) 100%
Ophthalmology (1/1) 100%
Respiratory Medicine (1/2) 50%
Pharmacology/Therapeutics (2/2) 100%
Haematology/Oncology (1/1) 100%
Cardiovascular (0/1) 0%
Endocrinology/Metabolic Disease (1/1) 100%
Immunology/Allergy (1/1) 100%
Renal Medicine/Urology (1/1) 100%
Passmed