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  • Question 1 - A 29-year-old man has been waiting for surgery to repair a right inguinal...

    Incorrect

    • A 29-year-old man has been waiting for surgery to repair a right inguinal hernia. He is now admitted with abdominal distension and colicky pain, along with vomiting bile and no bowel movements for two days. He is typically healthy and not on any medication. On examination, he appears dehydrated with a red, tender swelling in the right groin. X-rays confirm a small bowel obstruction, and a nasogastric tube is inserted. What is the most appropriate course of treatment for this patient?

      Your Answer: Continued intravenous fluid and nasogastric tube decompression

      Correct Answer: Surgery with decompression of the bowel and hernia repair

      Explanation:

      Management of Small Bowel Obstruction

      Small bowel obstruction is a condition that requires a certain diagnosis before surgery. However, in cases where the cause of the obstruction is an obstructed groin hernia, a contrast study or ultrasound scan of the groin is unnecessary. The patient should be well resuscitated and undergo surgery to reduce and inspect the bowel for viability. Repair of the hernia should proceed, and inspection of incarcerated bowel is important.

      In cases of adhesional obstruction, expectant drip and suck management may be appropriate, as the obstruction may settle with adequate decompression of the bowel. A contrast study may also be helpful in incomplete obstruction, as gastrografin has a therapeutic laxative effect. However, indications for surgery in bowel obstruction are an obstructed hernia and signs of peritonism, which indicate ischaemic bowel.

      In summary, the management of small bowel obstruction depends on the cause of the obstruction. In cases of an obstructed groin hernia, surgery is necessary, while expectant management may be appropriate in adhesional obstruction. A contrast study may also be helpful in incomplete obstruction. It is important to consider the indications for surgery, such as signs of peritonism, to prevent further complications.

    • This question is part of the following fields:

      • Surgery
      166.9
      Seconds
  • Question 2 - A 70-year-old woman presents following a fall. During an assessment of her fall,...

    Correct

    • A 70-year-old woman presents following a fall. During an assessment of her fall, she complained of balance problems, nausea and dizziness whenever she moves her head or looks up, eg to hang laundry on her washing line outside. She denies loss of consciousness and did not injure herself during the fall. Her past medical history consists of osteoarthritis of the knees and lower back.
      On examination, her gait and balance and neurological examination are normal and there are no injuries. The Hallpike test is positive.
      Which of the following is the most appropriate management for this patient’s vertigo?

      Your Answer: Epley manoeuvre

      Explanation:

      Management Options for Benign Paroxysmal Positional Vertigo (BPPV)

      Benign paroxysmal positional vertigo (BPPV) is a common condition that can cause dizziness and vertigo. The best first-line management option for BPPV is the Epley manoeuvre, which can reposition the debris in the vestibular canals and provide rapid relief. If symptoms persist, investigations may be necessary to rule out more serious brain pathologies, but a brain MRI is not typically required for a BPPV diagnosis. Medications such as prochlorperazine or betahistine may help with symptoms in the short term, but they do not treat the underlying cause. Vestibular retraining exercises, such as Brandt-Daroff exercises, can also be effective if symptoms persist despite the Epley manoeuvre.

    • This question is part of the following fields:

      • ENT
      269.7
      Seconds
  • Question 3 - A 25-year-old woman visits her doctor for contraception options after having two children...

    Correct

    • A 25-year-old woman visits her doctor for contraception options after having two children and deciding not to have any more. She expresses interest in long-acting reversible contraception and ultimately chooses the copper IUD. What other condition should be ruled out besides pregnancy?

      Your Answer: Pelvic inflammatory disease

      Explanation:

      If a woman has pelvic inflammatory disease, she cannot have a copper IUD inserted. Women who are at risk of this condition, such as those with multiple sexual partners or symptoms that suggest pelvic inflammatory disease, should be tested for infections like Chlamydia trachomatis and Neisseria gonorrhoeae and treated if necessary. To test for these infections, endocervical swabs are used. While the insertion of a copper IUD does carry a risk of developing pelvic inflammatory disease, this risk is low for women who are at low risk of sexually transmitted infections.

      Intrauterine contraceptive devices include copper IUDs and levonorgestrel-releasing IUS. Both are over 99% effective. The IUD prevents fertilization by decreasing sperm motility, while the IUS prevents endometrial proliferation and thickens cervical mucous. Potential problems include heavier periods with IUDs and initial bleeding with the IUS. There is a small risk of uterine perforation, ectopic pregnancy, and infection. New IUS systems, such as Jaydess® and Kyleena®, have smaller frames and less levonorgestrel, resulting in lower serum levels and different rates of amenorrhea.

    • This question is part of the following fields:

      • Gynaecology
      144
      Seconds
  • Question 4 - What statement is true about fragile X syndrome? ...

    Incorrect

    • What statement is true about fragile X syndrome?

      Your Answer: The condition can only be diagnosed after birth

      Correct Answer: Affected children are taller than average

      Explanation:

      Fragile X Syndrome: Characteristics and Diagnosis

      Fragile X syndrome is a genetic disorder that affects children, causing them to be taller than average and exhibit physical characteristics such as a high arched palate, long ears, a long face, and macro orchidism. The diagnosis of this syndrome was originally based on the expression of a folate-sensitive fragile X site induced in cell culture under conditions of folate deprivation. While affected males usually have learning difficulties, not all do. Additionally, one third of females with the mutation also experience learning difficulties.

      Diagnosis of fragile X syndrome can be made through the detection of the mutant FMR 1 gene by chorionic villus sampling. In some cases, confirmatory amniocentesis may be required. It is important to identify this syndrome early on in order to provide appropriate support and interventions for affected individuals.

    • This question is part of the following fields:

      • Clinical Sciences
      98.6
      Seconds
  • Question 5 - A 32-year-old female (P0 G1) is 28 weeks pregnant and has just been...

    Incorrect

    • A 32-year-old female (P0 G1) is 28 weeks pregnant and has just been informed that her baby is in the breech position. She is considering the external cephalic version (ECV) and wants to know when she can be offered this procedure?

      Your Answer: 38 weeks

      Correct Answer: 36 weeks

      Explanation:

      It is recommended to wait until the lady reaches 36 weeks of pregnancy to check if the baby has changed position, as she is currently only 30 weeks pregnant. For nulliparous women, such as the lady in this case, ECV should be provided at 36 weeks if the baby remains in the breech position. However, if the lady had previous pregnancies, ECV would be offered at 37 weeks.

      Breech presentation occurs when the caudal end of the fetus is in the lower segment, and it is more common at 28 weeks than near term. Risk factors include uterine malformations, placenta praevia, and fetal abnormalities. Management options include spontaneous turning, external cephalic version (ECV), planned caesarean section, or vaginal delivery. The RCOG recommends informing women that planned caesarean section reduces perinatal mortality and early neonatal morbidity, but there is no evidence that the long-term health of babies is influenced by how they are born. ECV is contraindicated in certain cases, such as where caesarean delivery is required or there is an abnormal cardiotocography.

    • This question is part of the following fields:

      • Obstetrics
      20.4
      Seconds
  • Question 6 - A man with known ulcerative colitis presents to Accident and Emergency with a...

    Correct

    • A man with known ulcerative colitis presents to Accident and Emergency with a flare-up. He tells you that he is passing eight stools a day with blood and has severe nausea with abdominal pain at present. He normally takes oral mesalazine to control his condition. On examination, the patient is cool peripherally, with a heart rate of 120 bpm and blood pressure of 140/80 mmHg. Blood tests are done and relevant findings shown below.
      Investigation Result Normal value
      Erythrocyte sedimentation rate (ESR) 32 mm/hour < 20 mm/hour
      Albumin 34 g/l 35–50 g/l
      Temperature 37.9 °C 36.1–37.2 °C
      Haemoglobin 98 g/l 115–155 g/l
      Which of the following is the most appropriate management of this patient?

      Your Answer: Admit to hospital for intravenous (IV) corticosteroids, fluids and monitoring

      Explanation:

      Appropriate Treatment Options for Severe Ulcerative Colitis Flare-Ups

      Severe flare-ups of ulcerative colitis (UC) require prompt and appropriate treatment to manage the symptoms and prevent complications. Here are some treatment options that are appropriate for severe UC flare-ups:

      Admit to Hospital for Intravenous (IV) Corticosteroids, Fluids, and Monitoring

      For severe UC flare-ups with evidence of significant systemic upset, hospital admission is necessary. Treatment should involve nil by mouth, IV hydration, IV corticosteroids as first-line treatment, and close monitoring.

      Avoid Topical Aminosalicylates and Analgesia

      Topical aminosalicylates and analgesia are not indicated for severe UC flare-ups with systemic upset.

      Inducing Remission with Topical Aminosalicylates is Inappropriate

      For severe UC flare-ups, inducing remission with topical aminosalicylates is not appropriate. Admission and monitoring are necessary.

      Azathioprine is Not Routinely Used for Severe Flare-Ups

      Immunosuppression with azathioprine is not routinely used to induce remission in severe UC flare-ups. It should only be used in cases where steroids are ineffective or if prolonged use of steroids is required.

      Medical Therapy Before Surgical Options

      Surgical options should only be considered after medical therapy has been attempted for severe UC flare-ups.

    • This question is part of the following fields:

      • Gastroenterology
      843.6
      Seconds
  • Question 7 - As a gynaecologist, you are treating a patient on the ward who has...

    Correct

    • As a gynaecologist, you are treating a patient on the ward who has been diagnosed with endometrial hyperplasia. Can you identify the medication that is linked to the development of this condition?

      Your Answer: Tamoxifen

      Explanation:

      Endometrial hyperplasia is caused by the presence of unopposed estrogen, and tamoxifen is a known risk factor for this condition. Tamoxifen is commonly used to treat estrogen receptor-positive breast cancer, but it has pro-estrogenic effects on the endometrium. This can lead to endometrial hyperplasia if not balanced by progesterone. However, combined oral contraceptive pills and progesterone-only pills contain progesterone, which prevents unopposed estrogen stimulation. While thyroid problems and obesity can also contribute to endometrial hyperplasia, taking levothyroxine or orlistat to treat these conditions does not increase the risk.

      Endometrial hyperplasia is a condition where the endometrium, the lining of the uterus, grows excessively beyond what is considered normal during the menstrual cycle. This abnormal proliferation can lead to endometrial cancer in some cases. There are four types of endometrial hyperplasia: simple, complex, simple atypical, and complex atypical. Symptoms of this condition include abnormal vaginal bleeding, such as intermenstrual bleeding.

      The management of endometrial hyperplasia depends on the type and severity of the condition. For simple endometrial hyperplasia without atypia, high dose progestogens may be prescribed, and repeat sampling is recommended after 3-4 months. The levonorgestrel intra-uterine system may also be used. However, if atypia is present, hysterectomy is usually advised.

    • This question is part of the following fields:

      • Gynaecology
      16.8
      Seconds
  • Question 8 - A 28-year-old woman with polycystic ovarian syndrome is having difficulty getting pregnant. She...

    Incorrect

    • A 28-year-old woman with polycystic ovarian syndrome is having difficulty getting pregnant. She and her partner have been attempting to conceive for 2 years without any luck. During examination, she displays hirsutism and has a BMI of 25 kg/m².

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

      Your Answer: In vitro fertilisation

      Correct Answer: Clomiphene

      Explanation:

      Clomiphene is the recommended first-line treatment for infertility in patients with PCOS. While there is ongoing debate about the use of metformin, current evidence does not support it as a first-line option. In vitro fertilisation is also not typically used as a first-line treatment for PCOS-related infertility.

      Managing Polycystic Ovarian Syndrome

      Polycystic ovarian syndrome (PCOS) is a condition that affects a significant percentage of women of reproductive age. The exact cause of PCOS is not fully understood, but it is associated with high levels of luteinizing hormone and hyperinsulinemia. Management of PCOS is complex and varies depending on the individual’s symptoms. Weight reduction is often recommended, and a combined oral contraceptive pill may be used to regulate menstrual cycles and manage hirsutism and acne. If these symptoms do not respond to the pill, topical eflornithine or medications like spironolactone, flutamide, and finasteride may be used under specialist supervision.

      Infertility is another common issue associated with PCOS. Weight reduction is recommended, and the management of infertility should be supervised by a specialist. There is ongoing debate about the most effective treatment for infertility in patients with PCOS. Clomiphene is often used, but there is a potential risk of multiple pregnancies with anti-oestrogen therapies like Clomiphene. Metformin is also used, either alone or in combination with Clomiphene, particularly in patients who are obese. Gonadotrophins may also be used to stimulate ovulation. The Royal College of Obstetricians and Gynaecologists (RCOG) published an opinion paper in 2008 and concluded that on current evidence, metformin is not a first-line treatment of choice in the management of PCOS.

    • This question is part of the following fields:

      • Gynaecology
      44.8
      Seconds
  • Question 9 - A 28-year-old woman visits her GP and experiences a convulsive episode involving her...

    Incorrect

    • A 28-year-old woman visits her GP and experiences a convulsive episode involving her entire body while in the waiting room. She is unable to speak during the episode but can make eye contact when her name is called. Following the episode, she quickly returns to her normal state and can recall everything that occurred. Her medical history includes alcohol overuse and post-traumatic stress disorder. What is the probable diagnosis?

      Your Answer: Alcohol withdrawal seizure

      Correct Answer: Psychogenic non-epileptic seizure

      Explanation:

      Widespread convulsions without loss of consciousness may indicate a psychogenic non-epileptic seizure (pseudoseizure), especially in a patient with psychiatric comorbidities. A focal aware seizure would not involve whole-body convulsions, while an alcohol withdrawal seizure would involve loss of consciousness. A panic attack may involve involuntary movement, but widespread convulsions would be unusual.

      Understanding Psychogenic Non-Epileptic Seizures

      Psychogenic non-epileptic seizures, also known as pseudoseizures, are a type of seizure that is not caused by abnormal electrical activity in the brain. Instead, they are believed to be caused by psychological factors such as stress, trauma, or anxiety. These seizures can be difficult to diagnose as they often mimic true epileptic seizures, but there are certain factors that can help differentiate between the two.

      Factors that may indicate pseudoseizures include pelvic thrusting, a family history of epilepsy, a higher incidence in females, crying after the seizure, and the seizures not occurring when the individual is alone. On the other hand, factors that may indicate true epileptic seizures include tongue biting and a raised serum prolactin level.

      Video telemetry is a useful tool for differentiating between the two types of seizures. It involves monitoring the individual’s brain activity and behavior during a seizure, which can help determine whether it is caused by abnormal electrical activity in the brain or psychological factors.

      It is important to accurately diagnose and treat psychogenic non-epileptic seizures as they can have a significant impact on an individual’s quality of life. Treatment may involve therapy to address underlying psychological factors, as well as medication to manage any associated symptoms such as anxiety or depression.

    • This question is part of the following fields:

      • Medicine
      39.2
      Seconds
  • Question 10 - A 35-year-old male was given steroids after a kidney transplant. After two years,...

    Correct

    • A 35-year-old male was given steroids after a kidney transplant. After two years, he experienced hip pain and difficulty walking. What is the most probable cause of his symptoms?

      Your Answer: Avascular necrosis

      Explanation:

      Avascular Necrosis and Its Causes

      Avascular necrosis (AVN) is a condition that occurs when the blood supply to the bones is temporarily or permanently lost. This can be caused by various factors, including trauma or vascular disease. Some of the conditions that can lead to AVN include hypertension, sickle cell disease, caisson disease, and radiation-induced arthritis. Additionally, certain factors such as corticosteroid therapy, connective tissue disease, alcohol abuse, marrow storage disease (Gaucher’s disease), and dyslipoproteinaemia can also be associated with AVN in a more complex manner.

      Of all the cases of non-traumatic avascular necrosis, 35% are associated with systemic (oral or intravenous) corticosteroid use. It is important to understand the causes of AVN in order to prevent and manage the condition effectively. By identifying the underlying factors that contribute to AVN, healthcare professionals can develop appropriate treatment plans and help patients manage their symptoms. With proper care and management, individuals with AVN can lead healthy and fulfilling lives.

    • This question is part of the following fields:

      • Nephrology
      18.2
      Seconds
  • Question 11 - A 59-year-old construction worker presents to the Emergency department after a workplace accident....

    Correct

    • A 59-year-old construction worker presents to the Emergency department after a workplace accident. He fell from a ladder and sustained a deep wound on his forearm from a rusty nail.
      Upon examination, the wound appears to be severely contaminated. After obtaining an x-ray to rule out any foreign objects, what is the most effective cleaning agent to use for this wound?

      Your Answer: Sterile 0.9% saline

      Explanation:

      There is no evidence that one cleaning agent is superior for wounds, but alcohol-based agents should be avoided. Hydrogen peroxide is not recommended. Tap water, sterile saline, aqueous chlorhexidine, and weak povidone-iodine solutions are commonly used. Contaminated wounds require thorough cleaning and debridement.

    • This question is part of the following fields:

      • Emergency Medicine
      31.2
      Seconds
  • Question 12 - A 55-year-old woman who reached menopause 2 years ago was diagnosed with hypertension...

    Incorrect

    • A 55-year-old woman who reached menopause 2 years ago was diagnosed with hypertension during a routine health check. She was prescribed a thiazide diuretic and a statin for her dyslipidaemia. However, after a week, she was rushed to the Emergency Department with complaints of severe pain, redness, and swelling in her right big toe. She was diagnosed with acute gouty arthritis and was given colchicine, which she could not tolerate due to diarrhoea. Indomethacin was then administered, and her gout attack subsided. She was advised to take allopurinol for uric acid control but was readmitted three days later with severe abdominal pain, nausea, vomiting, and fever. On examination, she was found to be peritonitic, and a chest X-ray revealed pneumoperitoneum. Which of the drugs prescribed to this patient is most likely responsible for her presenting complaint?

      Your Answer: Allopurinol

      Correct Answer: Indometacin

      Explanation:

      Indomethacin is a non-steroidal anti-inflammatory drug used to treat acute gout attacks. However, it can lead to peptic ulcer disease due to its inhibition of prostaglandin production, which is necessary for intestinal mucosa protection. This can result in life-threatening complications such as bleeding and perforation. Other side-effects include reflux, nausea, vomiting, tinnitus, rash, diarrhea, constipation, and dizziness. Allopurinol, on the other hand, is used to treat recurrent gout and hyperuricemia associated with certain chemotherapy and kidney stones. It works by inhibiting the enzyme xanthine oxidase, which is involved in uric acid production. Side-effects include Stevens-Johnson syndrome, itching, rash, vomiting, and fever, but it is not associated with bowel perforation. Colchicine is used to treat acute gout attacks by inhibiting microtubule polymerization, leading to an anti-inflammatory effect. Side-effects include severe diarrhea, peripheral neuropathy, anemia, and hair loss, but it is not associated with bowel perforation. Thiazide diuretics can precipitate gout by inducing dehydration and increase the risk of developing pancreatitis due to hypercalcemia and hyperlipidemia, but they are not associated with bowel perforation. Statins are used to treat hypercholesterolemia and reduce the risk of cardiovascular disease. They can increase the risk of developing pancreatitis and cause deranged liver function tests, but they are not known to increase the risk of bowel perforation. Other side-effects include muscle cramps, aches, rhabdomyolysis, hepatitis, hair thinning, abdominal pain, reflux symptoms, nausea, and tiredness.

    • This question is part of the following fields:

      • Pharmacology
      65.5
      Seconds
  • Question 13 - A 49-year-old man visits his GP complaining of a recent swelling in his...

    Incorrect

    • A 49-year-old man visits his GP complaining of a recent swelling in his left testicle. He has no medical history and is not taking any medications. During the examination, the doctor observes a swelling on one side of the scrotum that appears distinct from the testicle, does not trans-illuminate, and lacks a superior border at the top of the scrotum. What is the probable diagnosis?

      Your Answer: Epididymal cyst

      Correct Answer: Inguinoscrotal hernia

      Explanation:

      When trying to determine the cause of scrotal swelling, it is important to gather three key pieces of information: whether the swelling involves the testicle, whether it transilluminates when a pen torch is placed below it, and whether it is possible to palpate above the swelling. In this case, the patient’s swelling is separate from the testicle, ruling out epididymal cysts, epididymo-orchitis, and testicular tumors. The swelling does not transilluminate, ruling out hydrocele, and most importantly, it cannot be palpated above the swelling, indicating that it is coming from the groin and passing down into the scrotum. The only possible cause of this type of scrotal swelling is an inguinal hernia that has passed down the inguinal canal and into the scrotum.

      Causes and Management of Scrotal Swelling

      Scrotal swelling can be caused by various conditions, including inguinal hernia, testicular tumors, acute epididymo-orchitis, epididymal cysts, hydrocele, testicular torsion, and varicocele. Inguinal hernia is characterized by inguinoscrotal swelling that cannot be examined above it, while testicular tumors often have a discrete testicular nodule and symptoms of metastatic disease. Acute epididymo-orchitis is often accompanied by dysuria and urethral discharge, while epididymal cysts are usually painless and occur in individuals over 40 years old. Hydrocele is a non-painful, soft fluctuant swelling that can be examined above, while testicular torsion is characterized by severe, sudden onset testicular pain and requires urgent surgery. Varicocele is characterized by varicosities of the pampiniform plexus and may affect fertility.

      The management of scrotal swelling depends on the underlying condition. Testicular malignancy is treated with orchidectomy via an inguinal approach, while torsion requires prompt surgical exploration and testicular fixation. Varicoceles are usually managed conservatively, but surgery or radiological management can be considered if there are concerns about testicular function or infertility. Epididymal cysts can be excised using a scrotal approach, while hydroceles are managed differently in children and adults. In children, an inguinal approach is used to ligate the underlying pathology, while in adults, a scrotal approach is preferred to excise or plicate the hydrocele sac.

    • This question is part of the following fields:

      • Surgery
      47.6
      Seconds
  • Question 14 - In a 30-year-old patient with chronic obstructive pulmonary disease (COPD) and hepatic dysfunction,...

    Correct

    • In a 30-year-old patient with chronic obstructive pulmonary disease (COPD) and hepatic dysfunction, a liver biopsy revealed the presence of eosinophilic, round globules within the periportal hepatocytes. These globules ranged in size from 5 to 40 µm and were surrounded by a halo. Additionally, they were found to be periodic acid-Schiff (PAS)-positive and diastase-resistant. What is the most probable substance that makes up these globules?

      Your Answer: Glycoprotein

      Explanation:

      Identifying a PAS-positive and Diastase-resistant Inclusion: Implications for Diagnosis of α-1-Antitrypsin Deficiency

      Alpha-1-antitrypsin deficiency is a condition where the enzyme is not properly secreted and accumulates inside hepatocytes. A characteristic feature of this condition is the presence of PAS-positive, diastase-resistant inclusions in the cytoplasm of hepatocytes. PAS stains structures high in carbohydrate, such as glycogen, glycoproteins, proteoglycans, and glycolipids. Diastase dissolves glycogen, so a PAS-positive and diastase-resistant inclusion is most likely composed of glycoprotein, proteoglycan, or glycolipid. However, from the clinical information, we can determine that the most probable diagnosis is α-1-antitrypsin deficiency, which is a glycoprotein. Therefore, the correct option is glycoprotein, and proteoglycan and glycolipid are incorrect. Identifying this inclusion can aid in the diagnosis of α-1-antitrypsin deficiency, which predisposes individuals to early-onset COPD and hepatic dysfunction.

    • This question is part of the following fields:

      • Gastroenterology
      33.7
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  • Question 15 - A 28-year-old G2P1 woman arrives at the emergency department in the second stage...

    Correct

    • A 28-year-old G2P1 woman arrives at the emergency department in the second stage of labour with the foetal head visible at the vaginal introitus. She has a history of a previous elective lower-segment Caesarean section, but no other significant medical history. Antenatal imaging revealed chorionic villi invasion into the myometrium, but not the perimetrium. Following delivery of the foetus, the patient experiences post-partum haemorrhage. What is the most probable cause of her post-partum haemorrhage?

      Your Answer: Placenta increta

      Explanation:

      Placenta increta is a condition where the chorionic villi, which are normally found in the endometrium, invade the myometrium. This can lead to significant bleeding during vaginal delivery. Placenta increta is more serious than placenta accreta, where the chorionic villi attach to the myometrium but do not invade it, but less severe than placenta percreta, where the chorionic villi invade the perimetrium.

      Understanding Placenta Accreta

      Placenta accreta is a condition where the placenta attaches to the myometrium instead of the decidua basalis, which can lead to postpartum hemorrhage. This condition is caused by a defective decidua basalis. There are three types of placenta accreta, which are categorized based on the degree of invasion. The first type is accreta, where the chorionic villi attach to the myometrium. The second type is increta, where the chorionic villi invade into the myometrium. The third type is percreta, where the chorionic villi invade through the perimetrium.

      There are certain risk factors that increase the likelihood of developing placenta accreta, such as having a previous caesarean section or placenta previa. It is important for healthcare providers to be aware of these risk factors and monitor patients closely during pregnancy and delivery. Early detection and management of placenta accreta can help prevent complications and ensure the best possible outcome for both the mother and baby.

    • This question is part of the following fields:

      • Obstetrics
      36.6
      Seconds
  • Question 16 - As a healthcare professional, you are requested to address a family who have...

    Incorrect

    • As a healthcare professional, you are requested to address a family who have recently been informed of a diagnosis of pulmonary hypoplasia on fetal MRI. What is the most frequent cause of pulmonary hypoplasia?

      Your Answer: Polyhydramnios

      Correct Answer: Congenital diaphragmatic hernia

      Explanation:

      Pulmonary hypoplasia in CDH is not a direct result of hernial development but rather occurs alongside it as part of a sequence. It is caused by oligohydramnios, which reduces the size of the intrathoracic cavity and prevents foetal lung growth. Other less common causes of pulmonary hypoplasia include diaphragm agenesis, tetralogy of Fallot, and osteogenesis imperfecta.

      Understanding Pulmonary Hypoplasia in Newborns

      Pulmonary hypoplasia is a condition that affects newborn infants, where their lungs are underdeveloped. This means that the lungs are smaller than they should be, and they may not function properly. There are several causes of pulmonary hypoplasia, including oligohydramnios and congenital diaphragmatic hernia.

      Oligohydramnios is a condition where there is a low level of amniotic fluid in the womb. This can happen for a variety of reasons, such as a problem with the placenta or a leak in the amniotic sac. When there is not enough amniotic fluid, the baby may not have enough room to move around and develop properly. This can lead to pulmonary hypoplasia, as the lungs do not have enough space to grow.

      Congenital diaphragmatic hernia is a condition where there is a hole in the diaphragm, which is the muscle that separates the chest cavity from the abdominal cavity. This can allow the organs in the abdomen to move up into the chest cavity, which can put pressure on the lungs and prevent them from developing properly. This can also lead to pulmonary hypoplasia.

      In summary, pulmonary hypoplasia is a condition where newborn infants have underdeveloped lungs. It can be caused by a variety of factors, including oligohydramnios and congenital diaphragmatic hernia. It is important to diagnose and treat this condition as soon as possible, as it can lead to serious health problems for the baby.

    • This question is part of the following fields:

      • Paediatrics
      27.4
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  • Question 17 - A 32-year-old woman visits the gynaecology department with complaints of painful, heavy periods...

    Incorrect

    • A 32-year-old woman visits the gynaecology department with complaints of painful, heavy periods and difficulty getting pregnant. She is worried as she and her partner plan to start a family soon. Upon examination, an ultrasound scan shows a submucosal uterine fibroid measuring 4.5 cm. What is the most suitable treatment option for her fibroids?

      Your Answer: Hysteroscopic endometrial ablation

      Correct Answer: Myomectomy

      Explanation:

      If a woman is experiencing fertility issues due to large fibroids, the most effective treatment is myomectomy. In the case of a woman with a large submucosal fibroid that is distorting the shape of her uterus, options such as levonorgestrel-releasing IUS and tranexamic acid may provide symptomatic relief but will not address the underlying fertility issue. Medical treatment may also be ineffective due to the size of the fibroid. Hysterectomy and hysteroscopic endometrial ablation are not appropriate for women who wish to conceive in the future.

      Understanding Uterine Fibroids

      Uterine fibroids are non-cancerous growths that develop in the uterus. They are more common in black women and are thought to occur in around 20% of white women in their later reproductive years. Fibroids are usually asymptomatic, but they can cause menorrhagia, which can lead to iron-deficiency anaemia. Other symptoms include lower abdominal pain, bloating, and urinary symptoms. Fibroids may also cause subfertility.

      Diagnosis is usually made through transvaginal ultrasound. Asymptomatic fibroids do not require treatment, but periodic monitoring is recommended. Menorrhagia secondary to fibroids can be managed with various treatments, including the levonorgestrel intrauterine system, NSAIDs, tranexamic acid, and hormonal therapies.

      Medical treatment to shrink or remove fibroids may include GnRH agonists or ulipristal acetate, although the latter is not currently recommended due to concerns about liver toxicity. Surgical options include myomectomy, hysteroscopic endometrial ablation, hysterectomy, and uterine artery embolization.

      Fibroids generally regress after menopause, but complications such as subfertility and iron-deficiency anaemia can occur. Red degeneration, which is haemorrhage into the tumour, is a common complication during pregnancy.

    • This question is part of the following fields:

      • Gynaecology
      22.8
      Seconds
  • Question 18 - A 55-year-old man with known squamous-cell lung cancer presents with facial swelling, shortness...

    Correct

    • A 55-year-old man with known squamous-cell lung cancer presents with facial swelling, shortness of breath and a headache. On examination, he has a raised jugular venous pressure (JVP) and inspiratory stridor when he raises his hands above his head for one minute. Chest X-ray and computed tomography (CT) scan of the chest confirm superior vena cava (SVC) obstruction.
      Which of the following treatments will provide the best long-term symptom relief?

      Your Answer: Superior vena cava (SVC) stenting

      Explanation:

      Treatment Options for Superior Vena Cava Obstruction in Lung Cancer Patients

      Superior vena cava (SVC) obstruction is a common complication in patients with lung cancer. While dexamethasone infusion is the immediate treatment to reduce swelling, it only provides short-term relief. The best option for long-term symptom relief is SVC stenting, which prevents any obstruction. However, it is not always successful, and symptoms may reoccur if the tumour re-compresses the SVC. Inhaled daily steroids and inhaled beta-agonists are not effective in treating SVC obstruction. Brachytherapy is used to treat prostatic cancer and not squamous cell lung cancer. Therefore, SVC stenting remains the best option for long-term symptom relief in lung cancer patients with SVC obstruction.

    • This question is part of the following fields:

      • Oncology
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  • Question 19 - A 68-year-old man visits his doctor with complaints of frequent urination and dribbling....

    Incorrect

    • A 68-year-old man visits his doctor with complaints of frequent urination and dribbling. He reports going to the bathroom six times per hour and waking up multiple times at night to urinate. The patient has a medical history of hypertension and benign prostatic hyperplasia, and is currently taking finasteride and tamsulosin. On physical examination, the doctor notes an enlarged, symmetrical, firm, and non-tender prostate. The patient denies any changes in weight, fever, or appetite. His International Prostate Symptom Score is 20. What is the appropriate course of action?

      Your Answer: Add alfuzosin

      Correct Answer: Add tolterodine

      Explanation:

      Tolterodine should be added to the management plan for patients with an overactive bladder, particularly those with voiding and storage symptoms such as dribbling, frequency, and nocturia, which are commonly caused by benign prostatic hyperplasia in men. If alpha-blockers like tamsulosin are not effective, antimuscarinic agents can be added according to NICE guidelines. Adding alfuzosin or sildenafil would be inappropriate, and changing the alpha-blocker is not recommended.

      Lower urinary tract symptoms (LUTS) are a common issue in men over the age of 50, with benign prostatic hyperplasia being the most common cause. However, other causes such as prostate cancer should also be considered. These symptoms can be classified into three groups: voiding, storage, and post-micturition. To properly manage LUTS, it is important to conduct a urinalysis to check for infection and haematuria, perform a digital rectal examination to assess the size and consistency of the prostate, and possibly conduct a PSA test after proper counselling. Patients should also complete a urinary frequency-volume chart and an International Prostate Symptom Score to guide management.

      For predominantly voiding symptoms, conservative measures such as pelvic floor muscle training, bladder training, and prudent fluid intake can be helpful. If symptoms are moderate or severe, an alpha-blocker may be offered. If the prostate is enlarged and the patient is at high risk of progression, a 5-alpha reductase inhibitor should be offered. If there are mixed symptoms of voiding and storage not responding to an alpha-blocker, an antimuscarinic drug may be added. For predominantly overactive bladder symptoms, moderating fluid intake and bladder retraining should be offered, and antimuscarinic drugs may be prescribed if symptoms persist. Mirabegron may be considered if first-line drugs fail. For nocturia, moderating fluid intake at night, furosemide 40 mg in the late afternoon, and desmopressin may be helpful.

    • This question is part of the following fields:

      • Surgery
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  • Question 20 - A 68-year-old woman comes to the clinic complaining of colicky abdominal pain for...

    Incorrect

    • A 68-year-old woman comes to the clinic complaining of colicky abdominal pain for the past 2 days and vomiting for the past 24 hours. She has a medical history of hypertension, glaucoma, and hysterectomy 20 years ago. During the examination, her abdomen appears distended with tinkling bowel sounds. What is the probable diagnosis?

      Your Answer: Large bowel obstruction

      Correct Answer: Small bowel obstruction

      Explanation:

      Based on the patient’s history of previous intra-abdominal surgery, it is highly probable that they are suffering from small bowel obstruction caused by adhesions. Symptoms typically include early vomiting and later absolute constipation. Treatment involves administering IV fluids and inserting a nasogastric tube. Diagnostic tests such as an abdominal x-ray to check for dilated bowel loops and an erect chest x-ray to detect pneumoperitoneum may be necessary. If conservative treatment fails to improve the patient’s condition, a CT scan may be required to determine the location and type of obstruction. Close collaboration with the surgical team is also recommended.

      Imaging for Bowel Obstruction

      Bowel obstruction is a condition that requires immediate medical attention. One of the key indications for diagnosing this condition is through imaging, particularly an abdominal film. The imaging process is done to identify whether the obstruction is in the small or large bowel.

      In small bowel obstruction, the maximum normal diameter is 35 mm, and the valvulae conniventes extend all the way across. On the other hand, in large bowel obstruction, the maximum normal diameter is 55 mm, and the haustra extend about a third of the way across.

      A CT scan is also used to diagnose small bowel obstruction. The scan shows distension of small bowel loops proximally, such as the duodenum and jejunum, with an abrupt transition to an intestinal segment of normal caliber. Additionally, a small amount of free fluid intracavity may be present.

      In summary, imaging is a crucial tool in diagnosing bowel obstruction. It helps identify the location of the obstruction and the extent of the damage. Early detection and treatment of bowel obstruction can prevent further complications and improve the patient’s prognosis.

    • This question is part of the following fields:

      • Surgery
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  • Question 21 - A 35-year-old woman presents to her primary care physician with concerns about her...

    Incorrect

    • A 35-year-old woman presents to her primary care physician with concerns about her inability to conceive despite trying for two years with her regular partner. She has a BMI of 29 kg/m² and a known history of polycystic ovarian syndrome. What medication would be the most effective in restoring regular ovulation in this scenario?

      Your Answer: Estradiol

      Correct Answer: Metformin

      Explanation:

      For overweight or obese women with polycystic ovarian syndrome (PCOS) who are having difficulty getting pregnant, the initial approach is weight loss. If weight loss is not successful, either due to the woman’s inability to lose weight or failure to conceive despite weight loss, metformin can be used as an additional treatment.

      Managing Polycystic Ovarian Syndrome

      Polycystic ovarian syndrome (PCOS) is a condition that affects a significant percentage of women of reproductive age. The exact cause of PCOS is not fully understood, but it is associated with high levels of luteinizing hormone and hyperinsulinemia. Management of PCOS is complex and varies depending on the individual’s symptoms. Weight reduction is often recommended, and a combined oral contraceptive pill may be used to regulate menstrual cycles and manage hirsutism and acne. If these symptoms do not respond to the pill, topical eflornithine or medications like spironolactone, flutamide, and finasteride may be used under specialist supervision.

      Infertility is another common issue associated with PCOS. Weight reduction is recommended, and the management of infertility should be supervised by a specialist. There is ongoing debate about the most effective treatment for infertility in patients with PCOS. Clomiphene is often used, but there is a potential risk of multiple pregnancies with anti-oestrogen therapies like Clomiphene. Metformin is also used, either alone or in combination with Clomiphene, particularly in patients who are obese. Gonadotrophins may also be used to stimulate ovulation. The Royal College of Obstetricians and Gynaecologists (RCOG) published an opinion paper in 2008 and concluded that on current evidence, metformin is not a first-line treatment of choice in the management of PCOS.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 22 - An adolescent with Down's syndrome is being seen at the cardiology clinic due...

    Incorrect

    • An adolescent with Down's syndrome is being seen at the cardiology clinic due to a heart murmur detected during a routine check-up. It is known that approximately half of infants with Down's syndrome have congenital heart defects, and the prevalence remains high throughout their lifespan. What are the five most frequent types of congenital heart disease observed in individuals with Down's syndrome? Please list them in order of decreasing incidence, starting with the most common cause and ending with the least common cause.

      Your Answer: Mitral regurgitation, pulmonary regurgitation, hypoplastic left ventricle, ventricular septal defect, atrial septal defect

      Correct Answer: Atrioventricular septal defect, ventricular septal defect, tetralogy of Fallot, atrial septal defect, patent ductus arteriosus

      Explanation:

      Congenital Heart Defects in Down’s Syndrome

      Congenital heart defects are common in individuals with Down’s syndrome, with five specific pathologies accounting for approximately 99% of cases. Atrioventricular septal defects and ventricular septal defects occur in roughly a third of cases each, while the remaining third is accounted for by the other three defects. Chromosomal abnormalities, such as trisomy 21, which is commonly associated with Down’s syndrome, can predispose individuals to congenital heart disease. Around 50% of people with Down’s syndrome have one of the five cardiac defects listed above, but the exact cause for this is not yet known.

      The development of endocardial cushions is often impaired in individuals with Down’s syndrome, which can lead to defects in the production of the atrial and ventricular septae, as well as the development of the atrioventricular valves. This explains why atrioventricular septal defects are a common congenital defect in Down’s syndrome, as they involve a common atrioventricular orifice and valve. The severity of the defect depends on its size and the positioning of the leaflets of the common atrioventricular valve, which contribute to defining the degree of shunt. Additionally, the type of ventricular septal defects and atrial septal defects that commonly occur in Down’s syndrome can be explained by the impaired development of endocardial cushions. VSDs are usually of the inlet type, while ASDs are more commonly of the prium type, representing a failure of the endocardial cushion to grow in a superior direction.

    • This question is part of the following fields:

      • Cardiology
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  • Question 23 - A 25-year-old woman presents with an ectopic pregnancy that has been confirmed by...

    Incorrect

    • A 25-year-old woman presents with an ectopic pregnancy that has been confirmed by ultrasound. However, the ultrasound report only mentions that the ectopic pregnancy is located in the 'left fallopian tube' without providing further details. To ensure appropriate management, you contact the ultrasound department to obtain more specific information. Which location of ectopic pregnancy is most commonly associated with a higher risk of rupture?

      Your Answer: Ampulla

      Correct Answer: Isthmus

      Explanation:

      The risk of rupture is higher in ectopic pregnancies that are located in the isthmus of the fallopian tube. This is because the isthmus is not as flexible as other locations and cannot expand to accommodate the growing embryo/fetus. It should be noted that ectopic pregnancies can occur in various locations, including the ovary, cervix, and even outside the reproductive organs in the peritoneum.

      Understanding Ectopic Pregnancy: The Pathophysiology

      Ectopic pregnancy is a medical condition where the fertilized egg implants outside the uterus, usually in the fallopian tube. According to statistics, 97% of ectopic pregnancies occur in the fallopian tube, with most of them happening in the ampulla. However, if the implantation occurs in the isthmus, it can be more dangerous. The remaining 3% of ectopic pregnancies can occur in the ovary, cervix, or peritoneum.

      During ectopic pregnancy, the trophoblast, which is the outer layer of the fertilized egg, invades the tubal wall, leading to bleeding that may dislodge the embryo. The natural history of ectopic pregnancy involves three possible outcomes: absorption, tubal abortion, or tubal rupture.

      Tubal abortion occurs when the embryo dies, and the body expels it along with the blood. On the other hand, tubal absorption occurs when the tube does not rupture, and the blood and embryo are either shed or converted into a tubal mole and absorbed. However, if the tube ruptures, it can lead to severe bleeding, shock, and even death.

      In conclusion, understanding the pathophysiology of ectopic pregnancy is crucial in diagnosing and managing this potentially life-threatening condition. Early detection and prompt treatment can help prevent complications and improve outcomes.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 24 - A hairy 27-year-old woman visits the medical clinic with concerns about her missing...

    Incorrect

    • A hairy 27-year-old woman visits the medical clinic with concerns about her missing menstrual cycles. What is one of the diagnostic criteria for polycystic ovarian syndrome (PCOS)?

      Your Answer: Body mass index of >28

      Correct Answer: Oligomenorrhoea

      Explanation:

      Although clinical features such as infrequent or absent ovulation and hyperandrogenism can suggest PCOS, NICE CKS recommends using specific diagnostic criteria. To diagnose PCOS, at least 2 out of 3 of the following criteria should be present: infrequent or no ovulation, signs of hyperandrogenism or elevated testosterone levels, and polycystic ovaries or increased ovarian volume on ultrasonography. It is important to note that a high BMI is not part of the diagnostic criteria, but signs of insulin resistance such as acanthosis nigricans may aid in diagnosis.

      Polycystic ovary syndrome (PCOS) is a condition that affects a significant percentage of women of reproductive age. The exact cause of PCOS is not fully understood, but it is believed to involve both high levels of luteinizing hormone and hyperinsulinemia, with some overlap with the metabolic syndrome. PCOS is characterized by a range of symptoms, including subfertility and infertility, menstrual disturbances such as oligomenorrhea and amenorrhea, hirsutism, acne, obesity, and acanthosis nigricans.

      To diagnose PCOS, a range of investigations may be performed, including pelvic ultrasound to detect multiple cysts on the ovaries. Other useful baseline investigations include FSH, LH, prolactin, TSH, testosterone, and sex hormone-binding globulin (SHBG). While a raised LH:FSH ratio was once considered a classical feature of PCOS, it is no longer thought to be useful in diagnosis. Testosterone may be normal or mildly elevated, but if markedly raised, other causes should be considered. SHBG is typically normal to low in women with PCOS, and impaired glucose tolerance should also be checked.

      To formally diagnose PCOS, other conditions must first be excluded. The Rotterdam criteria state that a diagnosis of PCOS can be made if at least two of the following three criteria are present: infrequent or no ovulation, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries on ultrasound scan. Polycystic ovaries are defined as the presence of at least 12 follicles measuring 2-9 mm in diameter in one or both ovaries, and/or an increased ovarian volume of over 10 cm³.

    • This question is part of the following fields:

      • Gynaecology
      11.9
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  • Question 25 - A 75-year-old woman is scheduled for a hip replacement at 2 pm. It...

    Incorrect

    • A 75-year-old woman is scheduled for a hip replacement at 2 pm. It is currently 11:30 am and she admits to having a cup of black coffee earlier. What should be the next course of action?

      Your Answer: Ring up the anaesthetist to ask if the patient can still have his operation at 11am

      Correct Answer: Inform him he should not drink anything from now on

      Explanation:

      Patients are allowed to consume clear fluids up to 2 hours prior to their surgery. As black coffee is considered a clear fluid, the patient can proceed with their scheduled operation at 1 pm, provided they refrain from drinking anything further. It would be incorrect to contact the theatre to cancel or reschedule the operation, as it is still permissible for the patient to undergo the procedure. However, if the patient had consumed fluids within 2 hours of the operation, it would be appropriate to contact the anaesthetist to seek their advice on whether the surgery can proceed. It is important to note that informing the patient that they can consume fluids up to 1 hour before the operation is incorrect, as the permissible time frame is 2 hours.

      Preparation for surgery varies depending on whether the patient is undergoing an elective or emergency procedure. For elective cases, it is important to address any medical issues beforehand through a pre-admission clinic. Blood tests, urine analysis, and other diagnostic tests may be necessary depending on the proposed procedure and patient fitness. Risk factors for deep vein thrombosis should also be assessed, and a plan for thromboprophylaxis formulated. Patients are advised to fast from non-clear liquids and food for at least 6 hours before surgery, and those with diabetes require special management to avoid potential complications. Emergency cases require stabilization and resuscitation as needed, and antibiotics may be necessary. Special preparation may also be required for certain procedures, such as vocal cord checks for thyroid surgery or bowel preparation for colorectal cases.

    • This question is part of the following fields:

      • Surgery
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  • Question 26 - A 32-year-old Welsh Guard returning from operational duty overseas has been suffering from...

    Correct

    • A 32-year-old Welsh Guard returning from operational duty overseas has been suffering from nightmares and intrusive memories of his military experiences for the past 6 months. He avoids anything that reminds him of his tour of duty and is emotionally detached. He has trouble sleeping, concentrating, and is easily startled by loud noises. Additionally, he has been abusing alcohol. What is the probable diagnosis?

      Your Answer: Post-traumatic stress disorder (PTSD)

      Explanation:

      Understanding Different Types of Anxiety Disorders

      Post-traumatic stress disorder (PTSD) is characterized by a mix of anxiety and dissociative symptoms that persist for several months. Patients with PTSD often experience unintentional recollection, flashbacks, and nightmares of the traumatic event. They may also exhibit symptoms of chronic hyperarousal, such as sleep disruptions, irritability, and hypervigilance.

      Panic disorder with agoraphobia is diagnosed in patients who avoid situations that they believe may trigger a panic attack or where it would be dangerous or embarrassing to have one.

      Acute stress disorder is a condition that typically subsides within a month and is most common in patients who use dissociation to separate the events from the associated painful emotions.

      Generalized anxiety disorder is characterized by a mental state of dread or fear and somatic manifestations, such as palpitations, churning stomach, and muscle tension. Patients with this disorder often have fears concerning many aspects of their personal security.

      Somatization disorder is a condition where patients seek medical attention for cryptic physical symptoms that are difficult to explain. Patients with this disorder complain of problems in at least four different organ systems, usually without clear physical cause. They often deny anxiety or psychic distress, except for distress about their physical condition.

      Overall, understanding the different types of anxiety disorders and their symptoms can help with proper diagnosis and treatment.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 27 - A mother arrives with her 3-year-old son who was diagnosed with cow's milk...

    Correct

    • A mother arrives with her 3-year-old son who was diagnosed with cow's milk protein allergy (CMPA) at 6 months old. He has been on a dairy-free diet and fed hydrolysed milk until he turned 1. Recently, he successfully completed the milk ladder and has been drinking raw milk for the past month without any reactions or diarrhoea. The mother is curious if this is typical or if her son was misdiagnosed earlier. IgE testing was conducted and came back normal. What advice would you give to the mother regarding her son's situation?

      Your Answer: Milk tolerance is common by 3 years

      Explanation:

      By the age of 3, most children with non-IgE-mediated cow’s milk protein allergy will become tolerant to milk. The milk ladder is designed to gradually expose children like Gabriel, who has normal IgE levels, to increasing levels of milk protein through their diet. Diagnosis of CMPA is based on clinical symptoms such as growth faltering, constipation, and irritability, and confirmed by withdrawal of cow’s milk protein-containing substances followed by re-exposure. Lactose intolerance is rare in children under 3 years old. Milk tolerance is not unusual in non-IgE mediated cow’s milk protein allergy by the age of 3.

      Understanding Cow’s Milk Protein Intolerance/Allergy

      Cow’s milk protein intolerance/allergy (CMPI/CMPA) is a condition that affects around 3-6% of children, typically presenting in the first 3 months of life in formula-fed infants. Both immediate and delayed reactions can occur, with CMPA used for immediate reactions and CMPI for mild-moderate delayed reactions. Symptoms include regurgitation, vomiting, diarrhea, urticaria, atopic eczema, colic symptoms, wheeze, chronic cough, and rarely, angioedema and anaphylaxis. Diagnosis is often clinical, with investigations including skin prick/patch testing and total IgE and specific IgE (RAST) for cow’s milk protein.

      Management for formula-fed infants includes using extensive hydrolyzed formula (eHF) milk as the first-line replacement formula for mild-moderate symptoms and amino acid-based formula (AAF) for severe CMPA or if no response to eHF. Around 10% of infants are also intolerant to soya milk. For breastfed infants, mothers should eliminate cow’s milk protein from their diet and consider prescribing calcium supplements to prevent deficiency. eHF milk can be used when breastfeeding stops until at least 6 months and up to 12 months of age.

      The prognosis for CMPI is usually good, with most children becoming milk tolerant by the age of 3-5 years. However, a challenge is often performed in a hospital setting as anaphylaxis can occur. It is important to refer infants with severe symptoms to a pediatrician for management. Understanding CMPI/CMPA and its management can help parents and healthcare providers provide appropriate care for affected children.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 28 - A 44-year-old man is being evaluated on the psychiatric ward due to a...

    Incorrect

    • A 44-year-old man is being evaluated on the psychiatric ward due to a worsening of his mental health condition. Upon admission, the patient was diagnosed with a major depressive disorder accompanied by hallucinations.
      Lately, the patient has been persistently expressing the belief that he is deceased. Consequently, he has ceased eating and displays obvious signs of self-neglect. The patient has no known medical conditions other than his mental health problems.
      What is the name of the syndrome that this patient is experiencing?

      Your Answer: De Clérambault syndrome

      Correct Answer: Cotard syndrome

      Explanation:

      Cotard syndrome is a psychiatric disorder that is characterized by a person’s belief that they are dead or do not exist. This rare condition is often associated with severe depression or psychotic disorders and can lead to self-neglect and withdrawal from others. Treatment options include medication and electroconvulsive therapy.

      Capgras syndrome is a delusional disorder where patients believe that a loved one has been replaced by an identical impostor. This condition is typically associated with schizophrenia, but it can also occur in patients with brain trauma or dementia.

      Charles Bonnet syndrome is a visual disorder that affects patients with significant vision loss. These patients experience vivid visual hallucinations, which can be simple or complex. However, they are aware that these hallucinations are not real and do not experience any other forms of hallucinations or delusions.

      De Clérambault syndrome, also known as erotomania, is a rare delusional disorder where patients believe that someone is in love with them, even if that person is imaginary, deceased, or someone they have never met. Patients may also perceive messages from their supposed admirer through everyday events, such as number plates or television messages.

      Understanding Cotard Syndrome

      Cotard syndrome is a mental disorder that is characterized by the belief that the affected person or a part of their body is dead or non-existent. This rare condition is often associated with severe depression and psychotic disorders, making it difficult to treat. Patients with Cotard syndrome may stop eating or drinking as they believe it is unnecessary, leading to significant health problems.

      The delusion experienced by those with Cotard syndrome can be challenging to manage, and it can have a significant impact on their quality of life. The condition is often accompanied by feelings of hopelessness and despair, which can make it challenging for patients to seek help. Treatment for Cotard syndrome typically involves a combination of medication and therapy, but it can take time to find an effective approach.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 29 - A 30-year-old woman comes to the clinic 8 weeks after her last menstrual...

    Incorrect

    • A 30-year-old woman comes to the clinic 8 weeks after her last menstrual period with complaints of severe nausea, vomiting, and vaginal spotting. Upon examination, she is found to be pregnant and a transvaginal ultrasound reveals an abnormally enlarged uterus. What would be the expected test results for this patient?

      Your Answer: High beta hCG, high TSH, high thyroxine

      Correct Answer: High beta hCG, low TSH, high thyroxine

      Explanation:

      The symptoms described in this question are indicative of a molar pregnancy. To answer this question correctly, a basic understanding of physiology is necessary. Molar pregnancies are characterized by abnormally high levels of beta hCG for the stage of pregnancy, which serves as a tumor marker for gestational trophoblastic disease. Beta hCG has a similar biochemical structure to luteinizing hormone (LH), follicle-stimulating hormone (FSH), and thyroid-stimulating hormone (TSH). Consequently, elevated levels of beta hCG can stimulate the thyroid gland to produce thyroxine (T4) and triiodothyronine (T3), leading to symptoms of thyrotoxicosis. High levels of T4 and T3 negatively impact the pituitary gland, reducing TSH levels overall.
      Sources:
      Best Practice- Molar Pregnancy
      Medscape- Hydatidiform Mole Workup

      Gestational trophoblastic disorders refer to a range of conditions that originate from the placental trophoblast. These disorders include complete hydatidiform mole, partial hydatidiform mole, and choriocarcinoma. Complete hydatidiform mole is a benign tumor of trophoblastic material that occurs when an empty egg is fertilized by a single sperm that duplicates its own DNA, resulting in all 46 chromosomes being of paternal origin. Symptoms of this disorder include bleeding in the first or early second trimester, exaggerated pregnancy symptoms, a uterus that is large for dates, and very high levels of human chorionic gonadotropin (hCG) in the serum. Hypertension and hyperthyroidism may also be present. Urgent referral to a specialist center is necessary, and evacuation of the uterus is performed. Effective contraception is recommended to avoid pregnancy in the next 12 months, as around 2-3% of cases may develop choriocarcinoma.

      Partial hydatidiform mole, on the other hand, occurs when a normal haploid egg is fertilized by two sperms or by one sperm with duplication of the paternal chromosomes. As a result, the DNA is both maternal and paternal in origin, and the fetus may have triploid chromosomes, such as 69 XXX or 69 XXY. Fetal parts may also be visible. It is important to note that hCG can mimic thyroid-stimulating hormone (TSH), which may lead to hyperthyroidism.

      In summary, gestational trophoblastic disorders are a group of conditions that arise from the placental trophoblast. Complete hydatidiform mole and partial hydatidiform mole are two types of these disorders. While complete hydatidiform mole is a benign tumor of trophoblastic material that occurs when an empty egg is fertilized by a single sperm that duplicates its own DNA, partial hydatidiform mole occurs when a normal haploid egg is fertilized by two sperms or by one sperm with duplication of the paternal chromosomes. It is important to seek urgent medical attention and effective contraception to avoid pregnancy in the next 12 months.

    • This question is part of the following fields:

      • Obstetrics
      57
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  • Question 30 - A 28-year-old man suddenly developed a severe headache and was diagnosed with a...

    Incorrect

    • A 28-year-old man suddenly developed a severe headache and was diagnosed with a condition that caused increased attenuation of certain areas in his brain. He underwent surgery and has been receiving IV fluids since admission. On the third day of his hospital stay, his routine blood tests showed hyponatremia. What is the probable cause of his low sodium levels?

      Your Answer: Diabetes insipidus

      Correct Answer: Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

      Explanation:

      The syndrome of inappropriate antidiuretic hormone secretion (SIADH) involves the continued secretion or action of arginine vasopressin (AVP) despite normal or increased plasma volume. The resulting impairment of water secretion and consequent water retention produces the hyponatremia. The etiology of SIADH is divided into four main clinical categories: malignancy, pulmonary, pharmacologic, and neurologic causes.

      SIADH is also commonly associated with intracranial diseases, particularly traumatic brain injury, where almost all cases resolve spontaneously with recovery from brain injury. Over 50% of patients with subarachnoid hemorrhage develop hyponatremia in the first week following the bleed, and 80% of these are due to SIADH.

      A subarachnoid haemorrhage (SAH) is a type of bleed that occurs within the subarachnoid space of the meninges in the brain. It can be caused by head injury or occur spontaneously. Spontaneous SAH is often caused by an intracranial aneurysm, which accounts for around 85% of cases. Other causes include arteriovenous malformation, pituitary apoplexy, and mycotic aneurysms. The classic symptoms of SAH include a sudden and severe headache, nausea and vomiting, meningism, coma, seizures, and ECG changes.

      The first-line investigation for SAH is a non-contrast CT head, which can detect acute blood in the basal cisterns, sulci, and ventricular system. If the CT is normal within 6 hours of symptom onset, a lumbar puncture is not recommended. However, if the CT is normal after 6 hours, a lumbar puncture should be performed at least 12 hours after symptom onset to check for xanthochromia and other CSF findings consistent with SAH. If SAH is confirmed, referral to neurosurgery is necessary to identify the underlying cause and provide urgent treatment.

      Management of aneurysmal SAH involves supportive care, such as bed rest, analgesia, and venous thromboembolism prophylaxis. Vasospasm is prevented with oral nimodipine, and intracranial aneurysms require prompt intervention to prevent rebleeding. Most aneurysms are treated with a coil by interventional neuroradiologists, but some require a craniotomy and clipping by a neurosurgeon. Complications of aneurysmal SAH include re-bleeding, hydrocephalus, vasospasm, and hyponatraemia. Hyponatremia following subarachnoid hemorrhage occurs due to the inappropriate secretion of antidiuretic hormone (SIADH). However; it is also associated with certain dehydration states.

      Predictive factors for SAH include conscious level on admission, age, and amount of blood visible on CT head.

    • This question is part of the following fields:

      • Surgery
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SESSION STATS - PERFORMANCE PER SPECIALTY

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ENT (1/1) 100%
Gynaecology (2/7) 29%
Clinical Sciences (0/1) 0%
Obstetrics (1/3) 33%
Gastroenterology (2/2) 100%
Medicine (0/1) 0%
Nephrology (1/1) 100%
Emergency Medicine (1/1) 100%
Pharmacology (0/1) 0%
Paediatrics (1/2) 50%
Oncology (1/1) 100%
Cardiology (0/1) 0%
Psychiatry (1/2) 50%
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