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Question 1
Incorrect
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A 55 year old male is brought to the emergency department by his wife after falling down a flight of 12 stairs at home and hitting his head. Despite his wife's concerns, the patient does not believe he needs medical attention. He denies experiencing any headache, nausea, vomiting, seizures, or loss of consciousness. He is not taking any regular medications, including anticoagulants, and can recall the entire incident except for a 30-second period after landing at the bottom of the stairs. Upon examination, there is no limb weakness or loss of sensation, and his pupils are equal and reactive bilaterally. What is the most appropriate course of action?
Your Answer: CT head immediately
Correct Answer: CT head within 8 hours of injury
Explanation:The patient experienced a fall caused by a mechanical issue, with a potentially harmful mechanism of injury.
NICE Guidelines for Investigating Head Injuries in Adults
Head injuries can be serious and require prompt medical attention. The National Institute for Health and Care Excellence (NICE) has provided clear guidelines for healthcare professionals to determine which adult patients need further investigation with a CT head scan. Patients who require immediate CT head scans include those with a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment, suspected open or depressed skull fractures, signs of basal skull fractures, post-traumatic seizures, focal neurological deficits, and more than one episode of vomiting.
For patients with any loss of consciousness or amnesia since the injury, a CT head scan within 8 hours is recommended for those who are 65 years or older, have a history of bleeding or clotting disorders, experienced a dangerous mechanism of injury, or have more than 30 minutes of retrograde amnesia of events immediately before the head injury. Additionally, patients on warfarin who have sustained a head injury with no other indications for a CT head scan should also receive a scan within 8 hours of the injury.
It is important for healthcare professionals to follow these guidelines to ensure that patients receive appropriate and timely care for their head injuries. By identifying those who require further investigation, healthcare professionals can provide the necessary treatment and support to prevent further complications and improve patient outcomes.
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This question is part of the following fields:
- Neurology
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Question 2
Correct
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A 65-year-old man is brought to the emergency department due to self-neglect and suspected neurological event causing motor function loss. Upon examination, he presents with hypothermia and weakness on the right side. The patient reports discontinuing his regular medications and experiencing dizziness, restlessness, and electric shock sensations throughout his body. Which medication cessation is most likely responsible for these symptoms?
Your Answer: Paroxetine
Explanation:Discontinuation syndrome, characterized by dizziness, electric shock sensations, and anxiety, is a common occurrence when SSRIs are abruptly stopped. This is why it is recommended to gradually taper off the medication. The patient in this scenario stopped their medication abruptly due to a suspected neurological event, leading to the onset of discontinuation syndrome. Atorvastatin, bisoprolol, and gabapentin are not typically associated with these symptoms when stopped abruptly.
Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.
The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.
When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.
When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.
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This question is part of the following fields:
- Psychiatry
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Question 3
Correct
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A 35-year-old woman came to your GP clinic with a cold sore and left eye discomfort. She reported experiencing a red, painful eye with watering and sensitivity to light for the past 3 days. During fluorescein examination, you observed a dendritic ulcer on the cornea that was stained with fluorescein.
What is the primary treatment for this condition?Your Answer: Topical aciclovir drops
Explanation:The appropriate treatment for herpes simplex keratitis is the use of topical aciclovir. Antibiotics are ineffective against viral infections and should not be used. The use of steroids can worsen the condition and should be avoided. If the patient is already using topical steroids for another eye condition, the dosage should be decreased.
Understanding Herpes Simplex Keratitis
Herpes simplex keratitis is a condition that affects the cornea of the eye and is caused by the herpes simplex virus. The most common symptom of this condition is a dendritic corneal ulcer, which can cause a red, painful eye, photophobia, and epiphora. In some cases, visual acuity may also be decreased. Fluorescein staining may show an epithelial ulcer, which can help with diagnosis. One common treatment for this condition is topical aciclovir, which can help to reduce the severity of symptoms and prevent further damage to the cornea.
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This question is part of the following fields:
- Ophthalmology
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Question 4
Correct
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A 68-year-old man comes to the Emergency Department complaining of left-sided chest pain that has been ongoing for 2 hours. He mentions experiencing similar pains that occur during exercise and subside when he rests. The patient appears to be in distress, sweating, and having difficulty breathing. An ECG is conducted, revealing new T-wave inversion in V3-V6. His troponin and d-dimer levels are as follows:
Troponin 223 ng/L (<5)
D-Dimer 932 ng/mL (< 400)
What is the most probable diagnosis?Your Answer: Non-ST-elevation myocardial infarction (NSTEMI)
Explanation:Acute coronary syndrome (ACS) is a term that covers various acute presentations of ischaemic heart disease, including ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina. ACS develops in patients with ischaemic heart disease, which is the gradual build-up of fatty plaques in the coronary arteries. ACS can cause chest pain, dyspnoea, sweating, and nausea and vomiting. The two most important investigations for ACS are an ECG and cardiac markers. Treatment for ACS includes preventing worsening of presentation, revascularising the vessel is occluded, and treating pain. Patients who have had an ACS require lifelong drug therapy to reduce the risk of a further event.
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This question is part of the following fields:
- Cardiovascular
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Question 5
Incorrect
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A 47-year-old man comes to the clinic complaining of fatigue. Upon examination, his blood pressure is found to be 190/110 mmHg. Routine blood tests show the following results:
- Sodium: 145 mmol/L
- Potassium: 2.5 mmol/L
- Bicarbonate: 33 mmol/L
- Urea: 5.6 mmol/L
- Creatinine: 80 µmol/L
What is the probable diagnosis?Your Answer: Phaeochromocytoma
Correct Answer: Primary hyperaldosteronism
Explanation:Understanding Primary Hyperaldosteronism
Primary hyperaldosteronism is a medical condition that was previously believed to be caused by an adrenal adenoma, also known as Conn’s syndrome. However, recent studies have shown that bilateral idiopathic adrenal hyperplasia is the cause in up to 70% of cases. It is important to differentiate between the two as this determines the appropriate treatment. Adrenal carcinoma is an extremely rare cause of primary hyperaldosteronism.
The common features of primary hyperaldosteronism include hypertension, hypokalaemia, and alkalosis. Hypokalaemia can cause muscle weakness, but this is seen in only 10-40% of patients. To diagnose primary hyperaldosteronism, the 2016 Endocrine Society recommends a plasma aldosterone/renin ratio as the first-line investigation. This should show high aldosterone levels alongside low renin levels due to negative feedback from sodium retention caused by aldosterone.
If the plasma aldosterone/renin ratio is high, a high-resolution CT abdomen and adrenal vein sampling are used to differentiate between unilateral and bilateral sources of aldosterone excess. If the CT is normal, adrenal venous sampling (AVS) can be used to distinguish between unilateral adenoma and bilateral hyperplasia. The management of primary hyperaldosteronism depends on the underlying cause. Adrenal adenoma is treated with surgery, while bilateral adrenocortical hyperplasia is treated with an aldosterone antagonist such as spironolactone.
In summary, primary hyperaldosteronism is a medical condition that can be caused by adrenal adenoma, bilateral idiopathic adrenal hyperplasia, or adrenal carcinoma. It is characterized by hypertension, hypokalaemia, and alkalosis. Diagnosis involves a plasma aldosterone/renin ratio, high-resolution CT abdomen, and adrenal vein sampling. Treatment depends on the underlying cause and may involve surgery or medication.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 6
Incorrect
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A 28-year-old woman returns home from hospital after the birth of her first child. Over the next week, she becomes increasingly irritable, feels low in mood and is very anxious that she is not taking good care of her baby.
Which of the following is the most likely diagnosis?Your Answer: Postpartum depression
Correct Answer: Postpartum blues
Explanation:Understanding Postpartum Blues: Symptoms and Differential Diagnosis
Postpartum blues, also known as baby blues, is a common condition that affects many new mothers. It typically occurs within the first week after delivery and is characterized by short-lived episodes of irritability, crying, emotional lability, and mildly low mood. Unlike postpartum psychosis or major depression, postpartum blues does not involve confusion, delusional beliefs, or frank major depressive symptoms.
While anxiety is a common feature of many affective disorders, it is not sufficient to warrant a diagnosis of a specific anxiety disorder in the case of postpartum blues. However, it is important to consider depression as a possible diagnosis when a patient presents with low mood, anxiety, and irritability.
It is essential to follow up with patients experiencing postpartum blues to ensure that their symptoms resolve within a few days. If symptoms persist or worsen, further evaluation may be necessary to rule out other conditions such as postpartum depression. By understanding the symptoms and differential diagnosis of postpartum blues, healthcare providers can provide appropriate reassurance and support to new mothers during this challenging time.
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This question is part of the following fields:
- Psychiatry
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Question 7
Correct
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A 56-year-old man visits his doctor. He was prescribed fluoxetine for depression eight weeks ago and now wants to discontinue the medication as he feels much better. What advice should be given regarding his treatment?
Your Answer: It should be continued for at least 6 months
Explanation:The risk of relapse is significantly decreased, and patients should be comforted by the fact that antidepressants are non-addictive.
Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.
The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.
When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.
When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.
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This question is part of the following fields:
- Psychiatry
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Question 8
Correct
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A 60-year-old woman has effort-related angina. She has no other cardiac risk factors and no other relevant medical history. Her QRisk is calculated as 12.2%. She has already been prescribed a GTN spray which she can use for immediate relief of her symptoms.
Which of the following is the most appropriate initial treatment?Your Answer: Beta blocker and statin
Explanation:The National Institute for Health and Care Excellence recommends using a β blocker or calcium channel blocker as the first-line treatment for angina, along with a statin. If a patient is intolerant to β blockers or not responding to a CCB alone, a long-acting nitrate can be added. An ACE inhibitor is not indicated for angina treatment. Beta blockers and CCBs can be used together if one alone does not control symptoms, but caution is needed to avoid conduction problems. Long-acting nitrates should only be used in isolation if CCB or β blocker use is contraindicated. Aspirin is recommended for secondary prevention, and short-acting nitrates can be used for symptom relief. The 4S study showed that statins significantly reduce the risk of MI in patients with angina and high cholesterol levels.
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This question is part of the following fields:
- Cardiovascular
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Question 9
Correct
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A 29-year-old male arrives at the Emergency Department complaining of feeling extremely sick. He reports that his GP had prescribed him antibiotics for a chest infection. Upon examination, an ECG reveals polymorphic ventricular tachycardia (torsades de pointes). What medication is he likely taking?
Your Answer: Clarithromycin
Explanation:Torsades de pointes can be caused by macrolides, particularly clarithromycin, due to its potential to prolong the QT interval and trigger polymorphic ventricular tachycardia. This risk is higher in patients with an underlying channelopathy. Long QT syndrome can be caused by genetic factors such as potassium or sodium channel mutations, as well as electrolyte imbalances like hypocalcaemia, hypomagnesaemia, and hypokalaemia. Certain drugs, including antiarrhythmics, antibiotics, and psychotropic medications, can also cause long QT syndrome.
Torsades de Pointes: A Life-Threatening Condition
Torsades de pointes is a type of ventricular tachycardia that is associated with a prolonged QT interval. This condition can lead to ventricular fibrillation, which can cause sudden death. There are several causes of a prolonged QT interval, including congenital conditions such as Jervell-Lange-Nielsen syndrome and Romano-Ward syndrome, as well as certain medications like antiarrhythmics, tricyclic antidepressants, and antipsychotics. Other causes include electrolyte imbalances, myocarditis, hypothermia, and subarachnoid hemorrhage.
The management of torsades de pointes involves the administration of intravenous magnesium sulfate. This can help to stabilize the heart rhythm and prevent further complications.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 10
Correct
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A 56-year-old man with a history of type 2 diabetes mellitus and benign prostatic hyperplasia presents to dermatology with multiple lesions on his shin. Upon examination, symmetrical, tender, erythematous nodules are observed. The lesions are healing without scarring. What is the probable diagnosis?
Your Answer: Erythema nodosum
Explanation:The relevant diagnosis for this question relies solely on the description of the lesions, as the patient’s medical history is not a factor. Specifically, the tender shin lesions are indicative of erythema nodosum.
Understanding Shin Lesions: Differential Diagnosis and Characteristic Features
Shin lesions can be caused by a variety of conditions, and it is important to differentiate between them in order to provide appropriate treatment. The four most common conditions that can cause shin lesions are erythema nodosum, pretibial myxoedema, pyoderma gangrenosum, and necrobiosis lipoidica diabeticorum.
Erythema nodosum is characterized by symmetrical, tender, erythematous nodules that heal without scarring. It is often caused by streptococcal infections, sarcoidosis, inflammatory bowel disease, or certain medications such as penicillins, sulphonamides, or oral contraceptive pills.
Pretibial myxoedema, on the other hand, is seen in Graves’ disease and is characterized by symmetrical, erythematous lesions that give the skin a shiny, orange peel appearance.
Pyoderma gangrenosum initially presents as a small red papule, which later develops into deep, red, necrotic ulcers with a violaceous border. It is idiopathic in 50% of cases, but may also be seen in inflammatory bowel disease, connective tissue disorders, and myeloproliferative disorders.
Finally, necrobiosis lipoidica diabeticorum is characterized by shiny, painless areas of yellow/red skin typically found on the shin of diabetics. It is often associated with telangiectasia.
In summary, understanding the differential diagnosis and characteristic features of shin lesions can help healthcare professionals provide appropriate treatment and improve patient outcomes.
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This question is part of the following fields:
- Dermatology
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