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Question 1
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A 27-year-old man has come back from a vacation at the beach in Tenerife with a fresh rash on his neck and arms. The rash consists of patches that are coppery brown in color and lighter than the surrounding skin. There is no itching or pain associated with the rash. When examined with a Wood's light, the affected areas show yellow-green fluorescence.
What is the recommended initial treatment for this skin condition?Your Answer: Ketoconazole shampoo
Explanation:Ketoconazole shampoo is the recommended first-line therapy for treating pityriasis versicolor, a fungal infection caused by Malassezia furfur that commonly affects the trunk, neck, and arms following sun exposure. While the rash is usually asymptomatic, an emollient may help with any associated itch or irritation, but it is not sufficient to treat the underlying fungal infection. Oral antifungals like itraconazole may be necessary for extensive or unresponsive cases, but for limited non-extensive disease, ketoconazole shampoo is the preferred treatment. Topical steroids and vitamin D analogues are not effective in treating pityriasis versicolor.
Understanding Pityriasis Versicolor
Pityriasis versicolor, also known as tinea versicolor, is a fungal infection that affects the skin’s surface. It is caused by Malassezia furfur, which was previously known as Pityrosporum ovale. This condition is characterized by patches that may be hypopigmented, pink, or brown, and it is most commonly found on the trunk. The patches may become more noticeable following a suntan, and scaling is a common symptom. Mild pruritus may also occur.
Pityriasis versicolor can affect healthy individuals, but it is more likely to occur in those who are immunosuppressed, malnourished, or have Cushing’s syndrome. Treatment typically involves the use of topical antifungal medications, with ketoconazole shampoo being the recommended option due to its cost-effectiveness for larger areas. If topical treatment fails, alternative diagnoses should be considered, and oral itraconazole may be prescribed. Scrapings may also be sent for confirmation of the diagnosis. Understanding the features, predisposing factors, and management of pityriasis versicolor can help individuals recognize and effectively treat this common fungal infection.
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This question is part of the following fields:
- Dermatology
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Question 2
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A 13-year-old boy experiences facial swelling and a red, itchy rash shortly after receiving the first dose of the HPV vaccine. Upon arrival, paramedics observe a bilateral expiratory wheeze and a blood pressure reading of 85/60 mmHg. According to the Gell and Coombs classification of hypersensitivity reactions, what type of reaction is this an example of?
Your Answer: Type I reaction
Explanation:Classification of Hypersensitivity Reactions
Hypersensitivity reactions are classified into four types according to the Gell and Coombs classification. Type I, also known as anaphylactic hypersensitivity, occurs when an antigen reacts with IgE bound to mast cells. This type of reaction is responsible for anaphylaxis and atopy, such as asthma, eczema, and hay fever. Type II, or cytotoxic hypersensitivity, happens when cell-bound IgG or IgM binds to an antigen on the cell surface. This type of reaction is associated with autoimmune hemolytic anemia, ITP, Goodpasture’s syndrome, and other conditions. Type III, or immune complex hypersensitivity, occurs when free antigen and antibody (IgG, IgA) combine to form immune complexes. This type of reaction is responsible for serum sickness, systemic lupus erythematosus, post-streptococcal glomerulonephritis, and extrinsic allergic alveolitis. Type IV, or delayed hypersensitivity, is T-cell mediated and is responsible for tuberculosis, graft versus host disease, allergic contact dermatitis, and other conditions.
In recent times, a fifth category has been added to the classification of hypersensitivity reactions. Type V hypersensitivity occurs when antibodies recognize and bind to cell surface receptors, either stimulating them or blocking ligand binding. This type of reaction is associated with Graves’ disease and myasthenia gravis. Understanding the different types of hypersensitivity reactions is important in diagnosing and treating various conditions. Proper identification of the type of reaction can help healthcare professionals provide appropriate treatment and management strategies.
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This question is part of the following fields:
- Musculoskeletal
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Question 3
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A 25-year-old woman comes in with recurring headaches. During the cranial nerve examination, it is observed that her right pupil is 3 mm while the left pupil is 5 mm. The right pupil reacts to light, but the left pupil is slow to respond. The peripheral neurological examination is normal except for challenging to elicit knee and ankle reflexes. What is the probable diagnosis?
Your Answer: Holmes-Adie syndrome
Explanation:Understanding Holmes-Adie Pupil
Holmes-Adie pupil is a condition that is more commonly observed in women and is considered a benign condition. It is one of the possible causes of a dilated pupil. In about 80% of cases, it affects only one eye. The main characteristic of this condition is a dilated pupil that remains small for an unusually long time after it has constricted. The pupil also reacts slowly to accommodation but poorly or not at all to light.
Holmes-Adie syndrome is a condition that is associated with Holmes-Adie pupil. It is characterized by the absence of ankle and knee reflexes. This condition is not harmful and does not require any treatment.
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This question is part of the following fields:
- Ophthalmology
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Question 4
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A 32-year-old woman who is 8 weeks pregnant comes in with symptoms of 'cystitis'. She reports experiencing dysuria, suprapubic pains, and frequency for the past two days. She denies any vaginal bleeding. Upon urine dipstick testing, leucocytes and nitrites are present. Her temperature is 37.6ºC. What is the best course of action for management?
Your Answer: Oral nitrofurantoin
Explanation:This expectant woman displays indications that align with a urinary tract infection. According to the BNF, trimethoprim should not be used during the initial trimester as it can hinder folate. Ciprofloxacin is not recommended for use during pregnancy. Since the patient is clearly experiencing a UTI and has a fever, prompt treatment is necessary instead of waiting for the MSU.
Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is teratogenic in the first trimester. Asymptomatic bacteriuria in pregnant women should also be treated to prevent progression to acute pyelonephritis. Men with UTIs should be offered a seven-day course of trimethoprim or nitrofurantoin unless prostatitis is suspected. A urine culture should be sent before antibiotics are started. Catheterised patients should not be treated for asymptomatic bacteria, but if symptomatic, a seven-day course of antibiotics should be given. Acute pyelonephritis requires hospital admission and treatment with a broad-spectrum cephalosporin or quinolone for 10-14 days. Referral to urology is not routinely required for men who have had one uncomplicated lower UTI.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 5
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A 30-year-old woman has been diagnosed with breast cancer. She had been using the combined pill for contraception before her diagnosis. Now, she wants to switch to a different method of contraception before starting chemotherapy. What would be the most suitable option?
Your Answer: Copper Intrauterine Device
Explanation:The copper intrauterine device is the recommended form of contraception for individuals with breast cancer. Hormonal forms of contraception are not recommended and are rated as a Category 4 risk, which is deemed unacceptable for the patient’s health.
The decision to prescribe the combined oral contraceptive pill is now based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential contraindications and cautions on a four-point scale. UKMEC 1 indicates no restrictions for use, while UKMEC 2 suggests that the benefits outweigh the risks. UKMEC 3 indicates that the disadvantages may outweigh the advantages, and UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, a family history of thromboembolic disease in first-degree relatives under 45 years old, and current gallbladder disease. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. In 2016, breast feeding between 6 weeks and 6 months postpartum was changed from UKMEC 3 to UKMEC 2.
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This question is part of the following fields:
- Reproductive Medicine
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Question 6
Correct
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A 56-year-old woman presents to the emergency department complaining of right upper quadrant pain and rigors that have been ongoing for 2 days. She had previously seen her GP 6 months ago for biliary colic and was referred for an elective cholecystectomy. Upon examination, her blood work reveals elevated levels of WCC, CRP, and bilirubin. Based on these findings, what is the most probable diagnosis?
Your Answer: Ascending cholangitis
Explanation:If a patient with a history of gallstones experiences RUQ pain along with elevated inflammatory markers, it is more likely to be acute cholecystitis or cholangitis rather than biliary colic. The presence of fever and abnormal LFTs suggests ascending cholangitis, as opposed to cholecystitis, which is indicated by Charcot’s triad of RUQ pain, fever, and jaundice. Acute pancreatitis is unlikely if amylase levels are normal, and the sudden onset of symptoms makes malignancy, particularly cholangiocarcinoma, less probable.
Understanding Ascending Cholangitis
Ascending cholangitis is a bacterial infection that affects the biliary tree, with E. coli being the most common culprit. This condition is often associated with gallstones, which can predispose individuals to the infection. Patients with ascending cholangitis may present with Charcot’s triad, which includes fever, right upper quadrant pain, and jaundice. However, this triad is only present in 20-50% of cases. Other common symptoms include hypotension and confusion. In severe cases, Reynolds’ pentad may be observed, which includes the additional symptoms of hypotension and confusion.
To diagnose ascending cholangitis, ultrasound is typically used as a first-line investigation to look for bile duct dilation and stones. Raised inflammatory markers may also be observed. Treatment involves intravenous antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction.
Overall, ascending cholangitis is a serious condition that requires prompt diagnosis and treatment. Understanding the symptoms and risk factors associated with this condition can help individuals seek medical attention early and improve their chances of a successful recovery.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 7
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A 5-year-old girl is presented to your GP clinic by her father with a complaint of erythematous sores on her face for the past 2 days. The lesions are limited to her face and have started to weep and progress to honey crusted lesions over the last 24 hours. The child is otherwise healthy. Previously, topical hydrogen peroxide was ineffective for a similar episode. What is the most appropriate treatment option?
Your Answer: Topical fusidic acid
Explanation:If hydrogen peroxide is not appropriate, topical fusidic acid can be used for impetigo.
Understanding Impetigo: Causes, Symptoms, and Management
Impetigo is a common bacterial skin infection that affects both children and adults. It is caused by either Staphylococcus aureus or Streptococcus pyogenes and can develop anywhere on the body, but lesions tend to occur on the face, flexures, and limbs not covered by clothing. The infection can be a primary infection or a complication of an existing skin condition such as eczema, scabies, or insect bites. Impetigo is highly contagious and can spread through direct contact with discharges from the scabs of an infected person or indirectly through toys, clothing, equipment, and the environment.
The symptoms of impetigo include ‘golden’, crusted skin lesions typically found around the mouth. The infection can be managed with limited, localized disease by using hydrogen peroxide 1% cream or topical antibiotic creams such as fusidic acid or mupirocin. However, if the disease is extensive, oral flucloxacillin or oral erythromycin may be prescribed. It is important to note that MRSA is not susceptible to either fusidic acid or retapamulin, so topical mupirocin should be used in this situation.
Children with impetigo should be excluded from school until the lesions are crusted and healed or 48 hours after commencing antibiotic treatment. It is also important to practice good hygiene, such as washing hands regularly and avoiding close contact with infected individuals, to prevent the spread of impetigo. By understanding the causes, symptoms, and management of impetigo, individuals can take steps to prevent and treat this common bacterial skin infection.
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This question is part of the following fields:
- Dermatology
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Question 8
Correct
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A 45-year-old woman presents to her General Practitioner with a 2-month history of fatigue and muscle weakness.
During the examination, her blood pressure is found to be 160/95 mmHg. The rest of the examination is normal. The General Practitioner decides to order routine blood tests. The results are as follows:
Investigation Result Normal value
Sodium (Na+) 151 mmol
Potassium (K+) 3.0 mmol
Bicarbonate 29 mmol/l
Urea 5.2 mmol/l
Creatinine 70.5 µmol/l
Random glucose 5.8 mmol/l
What is the most appropriate first-line investigation to make a diagnosis?Your Answer: Aldosterone/renin ratio
Explanation:The patient’s symptoms of hypertension, hypokalaemia, and hypernatraemia suggest a diagnosis of hyperaldosteronism, which is characterized by increased water and sodium reabsorption in the kidneys and potassium loss due to high aldosterone levels. While muscle weakness and lethargy are common symptoms, they are only present in 40% of cases. Metabolic alkalosis is another common finding. Primary hyperaldosteronism is often caused by bilateral idiopathic adrenal hyperplasia, rather than an adrenal adenoma. To diagnose hyperaldosteronism, a plasma aldosterone/renin ratio is recommended as the first-line investigation, followed by a high-resolution CT scan of the abdomen and adrenal vein sampling to differentiate between unilateral and bilateral sources of aldosterone excess. While an overnight dexamethasone suppression test is useful for diagnosing Cushing syndrome, it is not relevant in this case. Urine dipstick and formal urinalysis would be helpful in identifying renal causes of secondary hypertension, but are not necessary in this case.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 9
Incorrect
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A 65-year-old woman is referred to the general medical clinic with a history of about 10 attacks of pins and needles in her right arm and leg over a period of 4 weeks. Her GP is concerned that this patient will soon have a completed stroke despite already being on aspirin. Typical attacks lasted for about 5 min and there were no additional symptoms. On closer enquiry she said that the sensation started in her right foot and then, over a period of about 1 min, spread ‘like water running up my leg’ to involve her whole leg and arm. Each attack was identical. Her past medical history includes hypertension and diabetes, for which she already takes aspirin. There are no abnormalities on neurological examination, but her blood pressure is 180/100 mmHg.
Which of the following is the most likely diagnosis?
Your Answer: TIAs affecting the right hemisphere
Correct Answer: Partial epileptic seizure affecting the right hemisphere
Explanation:Differential Diagnosis for Recurrent Neurological Symptoms
Recurrent neurological symptoms can be caused by a variety of conditions, and a thorough differential diagnosis is necessary to determine the underlying cause. In the case of a patient experiencing march-like progression of symptoms affecting the left side of the body, several possibilities must be considered.
A partial epileptic seizure affecting the right hemisphere is a likely cause, as the positive sensory symptoms and stereotyped nature of the episodes are typical of epilepsy. The rapid progression of symptoms over seconds to a minute is also characteristic of seizure activity.
Transient ischaemic attacks (TIAs) affecting the right hemisphere are less likely, as the march-like progression of symptoms and positive sensory symptoms are not typical of a vascular cause. TIAs are more likely to present with loss of sensation rather than abnormal sensations.
Recurrent, deep, white-matter microhaemorrhages are a possibility due to the patient’s risk factors, but the stereotyped nature of the attacks and positive sensory symptoms make this diagnosis less likely. Microhaemorrhages would typically present with numbness affecting the entire left side at onset.
Migraine equivalent is a rare possibility, but the rapid progression of symptoms and frequency of episodes make this diagnosis unlikely. Migraine aura without headache typically spreads over 20-30 minutes and is more common in patients with a history of previous migraine.
Cerebral venous thrombosis is also unlikely, as the absence of headache makes this diagnosis less probable. CVT typically presents with headache and other neurological symptoms.
In conclusion, the positive sensory features, stereotyped nature, and march of symptoms suggest epilepsy as the most likely cause of the patient’s recurrent neurological symptoms.
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This question is part of the following fields:
- Neurology
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Question 10
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A 72-year-old man is being evaluated after being diagnosed with atrial fibrillation during his recent hospitalization. He has a history of mitral stenosis and takes ramipril for hypertension. He was started on warfarin during his admission and was discharged with plans for follow-up in the cardiology clinic. However, he is now found to be in sinus rhythm during his current review. What is the appropriate course of action regarding anticoagulation?
Your Answer: Continue lifelong warfarin
Explanation:Warfarin should be continued indefinitely due to the patient’s risk factors for stroke and history of atrial fibrillation. It is preferred over direct oral anticoagulants due to his valvular heart disease.
NICE recommends using the CHA2DS2-VASc score to determine the need for anticoagulation in patients with any history of AF. The ORBIT scoring system should be used to assess bleeding risk, but anticoagulation should not be withheld solely on the grounds of age or risk of falls. DOACs are now recommended as the first-line anticoagulant for patients with AF, with warfarin used second-line if a DOAC is contraindicated or not tolerated. Aspirin is not recommended for reducing stroke risk in patients with AF.
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This question is part of the following fields:
- Cardiovascular
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