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Question 1
Correct
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A 3 day old infant who was delivered via ventouse presents with a swelling on the left parietal region of the head. The swelling was not present immediately after birth and the baby is otherwise healthy. Upon examination, the swelling does not cross suture lines and the fontanelles and sutures appear normal. What is the probable diagnosis?
Your Answer: Cephalohaematoma
Explanation:A cephalohaematoma is a swelling caused by bleeding between the skull and periosteum, typically seen in the parietal region of newborns delivered with instruments. It usually appears 2-3 days after birth and does not cross suture lines, resolving over several weeks.
Caput succadeneum is a common condition in newborns immediately after birth, caused by generalised scalp oedema that crosses suture lines. It is associated with prolonged labour and resolves quickly within a few days.
Subaponeurotic haematoma is a rare and potentially life-threatening condition where bleeding occurs outside the periosteum, causing a fluctuant scalp swelling that is not limited by suture lines.
Craniosynostosis is a rare condition where cranial sutures close prematurely, leading to skull deformities that may be evident at birth and associated with genetic syndromes. The shape of the skull depends on which sutures are involved, and other clinical features include early closure of the anterior fontanelle and a raised ridge along the fused suture.
A cephalohaematoma is a swelling that appears on a newborn’s head, usually a few hours after delivery. It is caused by bleeding between the skull and periosteum, with the parietal region being the most commonly affected site. This condition may lead to jaundice as a complication and can take up to three months to resolve.
In comparison to caput succedaneum, which is another type of swelling that can occur on a newborn’s head, cephalohaematoma is more localized and does not cross suture lines. Caput succedaneum, on the other hand, is a diffuse swelling that can cross suture lines and is caused by fluid accumulation in the scalp tissue. Both conditions are usually harmless and resolve on their own, but medical attention may be necessary in severe cases.
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This question is part of the following fields:
- Paediatrics
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Question 2
Incorrect
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A 29-year-old woman visits the genitourinary medicine clinic with four fleshy, pigmented lesions on her vulva after starting a new relationship. What is the best initial course of action?
Your Answer: Oral aciclovir
Correct Answer: Topical podophyllum
Explanation:For the treatment of genital warts, topical podophyllum is recommended for multiple, non-keratinised warts, while cryotherapy is recommended for solitary, keratinised warts. Cryotherapy can also be used as an initial treatment for genital warts.
Understanding Genital Warts
Genital warts, also known as condylomata accuminata, are a common reason for visits to genitourinary clinics. These warts are caused by various types of the human papillomavirus (HPV), with types 6 and 11 being the most common culprits. It is important to note that HPV, particularly types 16, 18, and 33, can increase the risk of cervical cancer.
The warts themselves are small, fleshy protrusions that are typically 2-5mm in size and may be slightly pigmented. They can cause discomfort, itching, and even bleeding. Treatment options for genital warts include topical podophyllum or cryotherapy, depending on the location and type of lesion. Topical agents are generally used for multiple, non-keratinised warts, while solitary, keratinised warts respond better to cryotherapy. Imiquimod, a topical cream, is often used as a second-line treatment. It is important to note that genital warts can be resistant to treatment, and recurrence is common. However, most anogenital HPV infections clear up on their own within 1-2 years without intervention.
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This question is part of the following fields:
- Reproductive Medicine
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Question 3
Incorrect
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Which one of the following statements regarding congenital inguinal hernias is accurate?
Your Answer: The incidence in newborns is 0.1-0.2%
Correct Answer: They are more common on the right side
Explanation:Abdominal wall hernias occur when an organ or the fascia of an organ protrudes through the wall of the cavity that normally contains it. Risk factors for developing these hernias include obesity, ascites, increasing age, and surgical wounds. Symptoms of abdominal wall hernias include a palpable lump, cough impulse, pain, obstruction (more common in femoral hernias), and strangulation (which can compromise the bowel blood supply and lead to infarction). There are several types of abdominal wall hernias, including inguinal hernias (which account for 75% of cases and are more common in men), femoral hernias (more common in women and have a high risk of obstruction and strangulation), umbilical hernias (symmetrical bulge under the umbilicus), paraumbilical hernias (asymmetrical bulge), epigastric hernias (lump in the midline between umbilicus and xiphisternum), incisional hernias (which may occur after abdominal surgery), Spigelian hernias (rare and seen in older patients), obturator hernias (more common in females and can cause bowel obstruction), and Richter hernias (a rare type of hernia that can present with strangulation without symptoms of obstruction). In children, congenital inguinal hernias and infantile umbilical hernias are the most common types, with surgical repair recommended for the former and most resolving on their own for the latter.
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This question is part of the following fields:
- Paediatrics
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Question 4
Correct
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A 65-year-old woman with a history of hypertension and heart failure presents with atrial fibrillation. She is stable with a ventricular rate of 70. Which of the following drug options would be the most suitable for her?
Your Answer: Warfarin or direct oral anticoagulant (DOAC)
Explanation:Treatment Options for Atrial Fibrillation: Warfarin, DOACs, Aspirin, Digoxin, Furosemide, and Lidocaine
Patients with atrial fibrillation and a CHA2DS2-VASC score of 4 require anticoagulation to reduce the risk of a CVA. The two main options are warfarin and DOACs, but the choice depends on other co-morbidities and patient preference. Before starting warfarin, patients should be referred to the Anticoagulation Clinic and screened for contraindications.
Aspirin has no benefit in atrial fibrillation, and digoxin should only be used for short-term rate control due to evidence of increased mortality with long-term use. Furosemide can help with symptoms and edema in heart failure but does not improve mortality. Lidocaine is only appropriate for ventricular arrhythmias in unstable patients and requires specialist support.
In summary, the treatment options for atrial fibrillation vary depending on the patient’s individual circumstances and should be carefully considered by healthcare professionals.
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This question is part of the following fields:
- Cardiovascular
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Question 5
Correct
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A 42-year-old woman arrived at the Emergency Department complaining of a painful and red eye with watering and mild sensitivity to light. The diagnosis was uncertain, but it was suspected to be either episcleritis or scleritis. The on-call ophthalmologist was contacted, and they requested that a specific eye drop be administered to differentiate between the two conditions.
Which of the following eye drops is capable of distinguishing between episcleritis and scleritis?Your Answer: Phenylephrine eye drops
Explanation:Distinguishing between episcleritis and scleritis can be achieved using eye drops. By administering the drops, it is possible to observe whether the redness in the eye blanches or not. If it does, then the condition is episcleritis, but if it doesn’t, then it is scleritis. This skill is particularly valuable for those working in an Emergency Medicine rotation. None of the other options are useful for distinguishing between these two conditions.
Understanding Episcleritis
Episcleritis is a condition that involves the sudden onset of inflammation in the episclera of one or both eyes. While the majority of cases are idiopathic, there are some associated conditions such as inflammatory bowel disease and rheumatoid arthritis. Symptoms of episcleritis include a red eye, mild pain or irritation, watering, and mild photophobia. However, unlike scleritis, episcleritis is typically not painful.
One way to differentiate between the two conditions is by applying gentle pressure on the sclera. If the injected vessels are mobile, it is likely episcleritis. In contrast, scleritis involves deeper vessels that do not move. Phenylephrine drops may also be used to distinguish between the two conditions. If the eye redness improves after phenylephrine, a diagnosis of episcleritis can be made.
Approximately 50% of cases of episcleritis are bilateral. Treatment for episcleritis is typically conservative, with artificial tears sometimes being used. Understanding the symptoms and differences between episcleritis and scleritis can help individuals seek appropriate treatment and management for their eye condition.
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This question is part of the following fields:
- Ophthalmology
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Question 6
Correct
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A concerned parent brings her 4-month-old to your clinic with a bright red lump on their scalp that has been gradually increasing in size over the past 6 weeks. What is the probable diagnosis?
Your Answer: Capillary haemangioma
Explanation:Port wine stain and naevus flammeus are two different conditions that are often confused with each other. While they both present as red or purple birthmarks, port wine stains are caused by a malformation of blood vessels in the skin, while naevus flammeus is a type of capillary malformation.
Understanding Strawberry Naevus
Strawberry naevus, also known as capillary haemangioma, is a type of skin condition that usually develops in infants within the first month of life. It is characterized by raised, erythematous, and multilobed tumours that commonly appear on the face, scalp, and back. While it is not present at birth, it can grow rapidly and reach its peak size at around 6-9 months before regressing over the next few years. In fact, around 95% of cases resolve before the child reaches 10 years of age. However, there are potential complications that may arise, such as obstructing visual fields or airway, bleeding, ulceration, and thrombocytopaenia.
Capillary haemangiomas are more common in white infants, particularly in female and premature infants, as well as those whose mothers have undergone chorionic villous sampling. In cases where treatment is necessary, propranolol is now the preferred choice over systemic steroids. Topical beta-blockers like timolol may also be used. It is important to note that there is a deeper type of capillary haemangioma called cavernous haemangioma. Understanding the nature of strawberry naevus is crucial in managing its potential complications and providing appropriate treatment.
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This question is part of the following fields:
- Dermatology
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Question 7
Correct
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An 80-year-old man visits a memory clinic accompanied by his daughter. He has a medical history of hypertension and is a former smoker. The daughter reports that he had been stable for several months before experiencing sudden declines on multiple occasions. The physical examination is normal, and his MoCA score is 18 out of 30. He denies experiencing any visual or auditory hallucinations. What is the probable underlying diagnosis?
Your Answer: Vascular dementia
Explanation:The gradual decline in cognitive function, along with hypertension and smoking as risk factors for cerebrovascular disease, suggest a diagnosis of vascular dementia. This type of dementia is caused by damage to the brain from reduced blood flow or bleeding due to cerebrovascular disease. In contrast, Alzheimer’s dementia progresses slowly over time, while frontotemporal dementia affects personality, behavior, language, and attention. Lewy body dementia is characterized by hallucinations and Parkinsonian symptoms, while Parkinson’s dementia occurs in patients with Parkinson’s disease and affects their mental function and memory, along with physical signs of PD.
Understanding Vascular Dementia: Causes, Symptoms, and Management
Vascular dementia is a type of cognitive impairment that is caused by different mechanisms resulting from cerebrovascular disease. It is the second most common form of dementia after Alzheimer’s disease. Vascular dementia is often recognized as the most severe form of the spectrum of deficits encompassed by the term vascular cognitive impairment. Early detection and an accurate diagnosis are crucial in preventing vascular dementia.
The prevalence of vascular dementia is estimated to be around 17% of dementia cases in the UK. The incidence of vascular dementia increases with age and is often associated with a history of stroke or transient ischemic attack, atrial fibrillation, hypertension, diabetes mellitus, hyperlipidemia, smoking, obesity, coronary heart disease, and a family history of stroke or cardiovascular disease. Rarely, vascular dementia can be inherited as in the case of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy.
Patients with vascular dementia typically present with a sudden or stepwise deterioration of cognitive function, focal neurological abnormalities, difficulty with attention and concentration, seizures, memory disturbance, gait disturbance, speech disturbance, and emotional disturbance. Diagnosis is made based on a comprehensive history and physical examination, formal screening for cognitive impairment, medical review to exclude medication cause of cognitive decline, and MRI scan.
Treatment for vascular dementia is mainly symptomatic with the aim to address individual problems and provide support to the patient and carers. It is important to detect and address cardiovascular risk factors to slow down the progression of the disease. Non-pharmacological management is tailored to the individual and may include cognitive stimulation programs, multisensory stimulation, music and art therapy, and animal-assisted therapy. Pharmacological management is limited, and there is no specific pharmacological treatment approved for cognitive symptoms. Only consider AChE inhibitors or memantine for people with vascular dementia if they have suspected comorbid Alzheimer’s disease, Parkinson’s disease dementia, or dementia with Lewy bodies. There is no evidence that aspirin is effective in treating patients with a diagnosis of vascular dementia, and no randomized trials have evaluated statins for vascular dementia.
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This question is part of the following fields:
- Neurology
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Question 8
Incorrect
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A 32-year-old woman presents to the Emergency Department with right flank pain radiating to her groin. A urine dipstick reveals the presence of blood. You suspect a possible ureteric stone.
What is the most suitable imaging modality to confirm the diagnosis?Your Answer: Renal ultrasound
Correct Answer: Non contrast abdominopelvic/kidney, ureters and bladder (KUB) computed tomography (CT)
Explanation:Imaging Modalities for Nephrolithiasis Diagnosis
Nephrolithiasis, or kidney stones, can be diagnosed through various imaging modalities. Non-contrast abdominopelvic computed tomography (CT) scans are the preferred imaging modality due to their high sensitivity and specificity. Contrast scans are not recommended for initial assessment as they can obscure calcific densities. CT scans can also reveal other pathologies. Seriated X-rays, specifically KUB X-rays, can be used in conjunction with CT scans for follow-up of stone patients. Intravenous urography, while widely available and inexpensive, is less sensitive than CT scans and requires IV contrast material and multiple delayed films. Magnetic resonance imaging (MRI) is not recommended for acute renal colic evaluation as it is more expensive and less effective in stone detection. Renal ultrasonography is mainly used in pregnancy or in combination with a KUB X-ray for determining hydronephrosis or ureteral dilatation associated with a urinary tract calculus, but is less accurate in diagnosing ureteral stones and not reliable for stones smaller than 5 mm.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 9
Correct
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A 38-year-old homeless man presents to the emergency department after collapsing on the street. He reports feeling increasingly lethargic over the past week and has been coughing up green sputum. He has a history of alcoholic pancreatitis.
His vital signs are as follows:
- Temperature: 38.4ºC
- Heart rate: 122 bpm
- Blood pressure: 106/54 mmHg
- Respiratory rate: 22 breaths/min
- Oxygen saturations: 94% on 2L nasal cannulae
Upon examination, coarse crackles are heard in the left upper lobe. His heart sounds are normal and his abdomen is soft and nontender.
What is the most likely causative organism?Your Answer: Klebsiella pneumoniae
Explanation:Klebsiella pneumoniae is a gram-negative rod that commonly causes a cavitating pneumonia in the upper lobes, particularly in individuals with a history of diabetes and alcoholism. The presence of upper zone crackles is a sign of Klebsiella pneumoniae infection, while a history of alcoholic pancreatitis suggests chronic alcohol use.
Legionella pneumophila causes Legionnaire’s disease, an atypical pneumonia that typically spreads through contaminated water sources, such as air conditioner vents. Symptoms include fever, cough, and myalgia, with bilateral chest symptoms being more common. Other extra-pulmonary symptoms, such as hyponatremia and hepatitis, may also be present.
Mycoplasma pneumoniae is another cause of atypical pneumonia, with symptoms including coryza and a dry cough. This form of pneumonia is associated with extra-pulmonary symptoms such as haemolytic anaemia and erythema multiforme, which are not present in this case.
Staphylococcus aureus is the most likely cause of pneumonia following influenza virus infection. However, since there is no history of preceding coryza and the patient has upper zone crackles and alcoholism, Staphylococcus aureus is less likely to be the cause of this patient’s pneumonia.
Klebsiella Pneumoniae: A Gram-Negative Rod Causing Infections in Humans
Klebsiella pneumoniae is a type of Gram-negative rod that is typically found in the gut flora of humans. Although it is a normal part of the body’s microbiome, it can also cause a variety of infections in humans, including pneumonia and urinary tract infections. This bacterium is more commonly found in individuals who have diabetes or who consume alcohol regularly. In some cases, Klebsiella pneumoniae infections can occur following aspiration.
One of the distinctive features of Klebsiella pneumoniae infections is the presence of red-currant jelly sputum. This type of sputum is often seen in patients with pneumonia caused by this bacterium. Additionally, Klebsiella pneumoniae infections tend to affect the upper lobes of the lungs.
Unfortunately, Klebsiella pneumoniae infections can be quite serious and even life-threatening. They commonly lead to the formation of lung abscesses and empyema, and the mortality rate for these infections is between 30-50%. It is important for healthcare providers to be aware of the potential for Klebsiella pneumoniae infections, particularly in patients who are at higher risk due to underlying health conditions.
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This question is part of the following fields:
- Respiratory Medicine
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Question 10
Correct
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A 16-year-old girl comes to the clinic with a palpable purpuric rash on her lower limbs and polyarthralgia after experiencing a recent sore throat. What is the probable diagnosis?
Your Answer: Henoch-Schonlein purpura
Explanation:Understanding Henoch-Schonlein Purpura
Henoch-Schonlein purpura (HSP) is a type of small vessel vasculitis that is mediated by IgA. It is often associated with IgA nephropathy, also known as Berger’s disease. HSP is commonly observed in children following an infection.
The condition is characterized by a palpable purpuric rash, which is accompanied by localized oedema over the buttocks and extensor surfaces of the arms and legs. Other symptoms include abdominal pain, polyarthritis, and features of IgA nephropathy such as haematuria and renal failure.
Treatment for HSP involves analgesia for arthralgia, while management of nephropathy is generally supportive. There is inconsistent evidence for the use of steroids and immunosuppressants.
The prognosis for HSP is usually excellent, especially in children without renal involvement. The condition is self-limiting, but around one-third of patients may experience a relapse. It is important to monitor blood pressure and urinalysis to detect any progressive renal involvement.
Overall, understanding Henoch-Schonlein purpura is crucial for prompt diagnosis and management of the condition.
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This question is part of the following fields:
- Haematology/Oncology
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Question 11
Correct
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A 49-year-old male comes to the emergency department complaining of progressive weakness in both legs that started with leg pain a week ago. Upon examination, there is a decrease in patellar reflex bilaterally, and the patient has 3/5 strength throughout the neurological examination in the lower limbs bilaterally, but normal sensation. The patient has no significant medical history and is not taking any regular medications. What is the most probable organism responsible for his symptoms?
Your Answer: Campylobacter jejuni
Explanation:The patient in this scenario is experiencing leg or back pain before the onset of weakness, which is a common symptom of Guillain-Barre syndrome. The ascending weakness of the legs, along with reduced reflexes and normal sensation, is a typical presentation of this disease.
Escherichia coli is a frequent cause of traveller’s diarrhoea and gastroenteritis, but it is not associated with Guillain-Barre syndrome.
Coxsackievirus is the most common cause of viral meningitis in adults, but it is not linked to Guillain-Barre syndrome.
Herpes simplex virus causes genital and labial sores, but it does not play a role in the development of this disease.
Understanding Guillain-Barre Syndrome and Miller Fisher Syndrome
Guillain-Barre syndrome is a condition that affects the peripheral nervous system and is often triggered by an infection, particularly Campylobacter jejuni. The immune-mediated demyelination of the peripheral nervous system occurs due to the cross-reaction of antibodies with gangliosides. Studies have shown a correlation between the clinical features of the syndrome and the presence of anti-ganglioside antibodies, particularly anti-GM1 antibodies, which are present in 25% of patients.
Miller Fisher syndrome is a variant of Guillain-Barre syndrome that is characterized by ophthalmoplegia, areflexia, and ataxia. Unlike other forms of Guillain-Barre syndrome, Miller Fisher syndrome usually presents as a descending paralysis, with the eye muscles typically affected first. In 90% of cases, anti-GQ1b antibodies are present.
Understanding the pathogenesis and clinical features of Guillain-Barre syndrome and Miller Fisher syndrome is crucial for accurate diagnosis and effective treatment. Further research is needed to fully understand the mechanisms behind these conditions and to develop more targeted therapies.
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This question is part of the following fields:
- Neurology
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Question 12
Incorrect
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A 61-year-old Caucasian man presents for a routine health check. He has a medical history of asthma and type 2 diabetes mellitus. His most recent HbA1c is 56 mmol/mol (7.3%). During the check-up, his blood pressure is measured at 160/80 mmHg. Subsequently, ambulatory blood pressure monitoring is conducted, which shows an average daytime blood pressure of 150/90 mmHg. What is the appropriate next step in management?
Your Answer: Losartan
Correct Answer: Ramipril
Explanation:For the treatment of hypertension in diabetic patients, the first-line medication should be ACE inhibitors such as ramipril. However, this may not be suitable for individuals of Afro-Caribbean descent or women who may become pregnant. In case of a cough developing with ACE inhibitors, an angiotensin-II receptor antagonist like losartan should be prescribed. If the patient is not diabetic, calcium channel blockers like amlodipine or diuretics such as indapamide would be the preferred initial treatment. Beta blockers like propranolol are not typically the first choice for hypertension treatment, but may be considered for young patients who cannot tolerate ACE inhibitors or women attempting to conceive.
NICE released updated guidelines in 2019 for the management of hypertension, building on previous guidelines from 2011. These guidelines aimed to classify hypertension into stages and recommend the use of ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) to accurately diagnose hypertension. This is important because some patients experience white coat hypertension, where their blood pressure rises in a clinical setting, leading to potential overdiagnosis of hypertension. ABPM and HBPM allow for a more accurate assessment of a patient’s overall blood pressure and can prevent overdiagnosis.
NICE recommends measuring blood pressure in both arms when considering a diagnosis of hypertension and repeating measurements if there is a difference of more than 20 mmHg between arms. If the blood pressure is >= 140/90 mmHg, NICE suggests offering ABPM or HBPM to confirm the diagnosis. If the blood pressure is >= 180/120 mmHg, referral for specialist assessment is recommended if there are signs of retinal haemorrhage or papilloedema or life-threatening symptoms. If target organ damage is identified, antihypertensive drug treatment may be started immediately.
ABPM involves taking at least 2 measurements per hour during the person’s usual waking hours and using the average value of at least 14 measurements. If ABPM is not tolerated, HBPM should be offered. HBPM involves taking two consecutive measurements at least 1 minute apart, twice daily for at least 4 days, and using the average value of all remaining measurements.
Interpreting the results of ABPM/HBPM is important for determining treatment. If the average blood pressure is >= 135/85 mmHg (stage 1 hypertension), treatment may be considered for patients under 80 years of age with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. In 2019, NICE also recommended considering antihypertensive drug treatment for adults under 60 with stage 1 hypertension and an estimated 10-year risk below 10%. If the average blood pressure is >= 150/95 mmHg (stage 2 hypertension), drug treatment should be offered regardless of age.
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This question is part of the following fields:
- Cardiovascular
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Question 13
Correct
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An 80-year-old male presents to the low-risk chest pain clinic with intermittent substernal chest pains. The pain typically comes on with exertion and improves with rest. A trial of GTN has been given by his GP which helps with his pain. He is a known ex-smoker of 35 pack-years. He has no diabetes, hyperlipidaemia, hypertension, and no family history of coronary artery disease.
During examination, his observations are stable. On auscultations of his chest, his first and second heart sounds are audible with no added sounds and his lungs are clear.
What investigation should be prioritized given his risk for coronary artery disease?Your Answer: Contrast-enhanced coronary CT angiography
Explanation:The preferred initial diagnostic test for individuals with stable chest pain suspected to be caused by coronary artery disease is a CT coronary angiogram with contrast enhancement.
Assessment of Patients with Suspected Cardiac Chest Pain
When it comes to assessing patients with suspected cardiac chest pain, NICE has updated its guidelines in 2016. For patients presenting with acute chest pain, immediate management of suspected acute coronary syndrome (ACS) is crucial. This includes administering glyceryl trinitrate and aspirin 300 mg, but not other antiplatelet agents like Clopidogrel outside of the hospital. Oxygen therapy should not be routinely given, but only if sats are less than 94%. Referral depends on the timing of chest pain and ECG results. For patients presenting with stable chest pain, NICE defines anginal pain as constricting discomfort in the front of the chest, neck, shoulders, jaw, or arms, precipitated by physical exertion, and relieved by rest or GTN in about 5 minutes. Non-invasive functional imaging is recommended for patients in whom stable angina cannot be excluded by clinical assessment alone. Examples of non-invasive functional imaging include myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT), stress echocardiography, first-pass contrast-enhanced magnetic resonance (MR) perfusion, or MR imaging for stress-induced wall motion abnormalities.
In summary, assessing patients with suspected cardiac chest pain requires immediate management for acute chest pain and referral based on timing and ECG results. For stable chest pain, NICE defines anginal pain and recommends non-invasive functional imaging for patients in whom stable angina cannot be excluded by clinical assessment alone.
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This question is part of the following fields:
- Cardiovascular
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Question 14
Incorrect
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Which of the following is not an absolute contraindication to using combined oral contraceptive pills for women?
Your Answer: Deep vein thrombosis 9 years ago
Correct Answer: Breast feeding a 10-week-old baby
Explanation:Breastfeeding is classified as UKMEC category 4 if done for less than 6 weeks after giving birth, but it is categorized as UKMEC category 2 if done after this period.
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 15
Correct
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A floppy four-week-old neonate presents with vomiting, weight loss and circulatory collapse. Blood tests demonstrate hyponatraemia and hyperkalaemia. Further tests confirm metabolic acidosis and hypoglycaemia. The paediatrician notices that the penis was enlarged and the scrotum pigmented. The child was treated with both a glucocorticoid and a mineralocorticoid.
What is the most likely underlying diagnosis?Your Answer: Congenital adrenal hyperplasia
Explanation:Endocrine Disorders: Congenital Adrenal Hyperplasia, Conn Syndrome, Addisonian Crisis, Cushing Syndrome, and Thyrotoxic Crisis
Endocrine disorders are conditions that affect the production and regulation of hormones in the body. Here are five different endocrine disorders and their characteristics:
Congenital Adrenal Hyperplasia (CAH) is a group of autosomal recessive conditions caused by mutations in the enzymes involved in the production of steroids and hormones from the adrenal glands. It can affect both men and women equally, and symptoms include ambiguous genitalia at birth for women and hyperpigmentation and penile enlargement for men. Treatment involves hormone replacement therapy.
Conn Syndrome is a condition associated with primary hyperaldosteronism, which presents with hypernatraemia and hypokalaemia. It is more commonly seen in adult patients, but there are cases reported in childhood.
Addisonian Crisis occurs due to glucocorticoid and mineralocorticoid deficiency, usually occurring in adulthood. It is a potentially fatal episode that presents with hyponatraemia, hyperkalaemia, hypoglycaemia, and hypercalcaemia. Urgent intravenous administration of glucocorticoids is necessary for management.
Cushing Syndrome is due to cortisol excess, either exogenous or endogenous, and is usually diagnosed in adulthood. Symptoms include weight gain, hypertension, oedema, hyperglycaemia, hypokalaemia, and pigmentation of the skin in the axillae and neck.
Thyrotoxic Crisis, also known as a thyroid storm, is a life-threatening condition associated with excessive production of thyroid hormones. It can be the first presentation of undiagnosed hyperthyroidism in neonates and children. Symptoms include tachycardia, hypertension, fever, poor feeding, weight loss, diarrhoea, nausea, vomiting, seizures, and coma. Prompt treatment is necessary to prevent acute congestive heart failure, shock, and death.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 16
Correct
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A 25-year-old male patient comes to you with concerns about changes in his axillary skin. He reports feeling otherwise healthy and denies any other symptoms. Upon examination, you observe thickened and darkened skin in the axillary creases. The patient's BMI is 38 kg/m² and his blood pressure is within normal limits. What is the probable diagnosis?
Your Answer: Acanthosis nigricans
Explanation:A thickened brown velvety patch of skin, often accompanied by skin tags, is a common sign of Acanthosis nigricans (AN). This condition is typically found in the axilla, groin, and back of the neck. However, AN is not a standalone condition, but rather a cutaneous sign of underlying disease. The most common type of AN is associated with obesity and insulin resistance. Other underlying conditions linked to AN include Cushing’s syndrome, polycystic ovary syndrome, and certain medications such as nicotinic acid, insulin, and systemic corticosteroids. In rare cases, AN may indicate an underlying malignancy, particularly stomach cancer. Therefore, it is crucial to consider this possibility when making a diagnosis.
Acanthosis nigricans is a condition characterized by the presence of symmetrical, brown, velvety plaques on the neck, axilla, and groin. This condition can be caused by various factors such as type 2 diabetes mellitus, gastrointestinal cancer, obesity, polycystic ovarian syndrome, acromegaly, Cushing’s disease, hypothyroidism, familial factors, Prader-Willi syndrome, and certain drugs like the combined oral contraceptive pill and nicotinic acid. The pathophysiology of acanthosis nigricans involves insulin resistance, which leads to hyperinsulinemia. This, in turn, stimulates the proliferation of keratinocytes and dermal fibroblasts through interaction with insulin-like growth factor receptor-1 (IGFR1).
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This question is part of the following fields:
- Dermatology
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Question 17
Incorrect
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A 32-year-old woman presents to her General Practitioner with a 4-day history of abdominal cramps and watery diarrhoea. Her symptoms started two days after she ate a salad from a restaurant.
Which of the following is the most likely causative organism?Your Answer: Staphylococcus aureus
Correct Answer: Campylobacter jejuni
Explanation:Campylobacter jejuni is a prevalent cause of bacterial food poisoning in the UK, typically transmitted through contaminated food or drink. Symptoms usually appear 2-5 days after exposure and may include abdominal cramps, diarrhea (which may or may not be bloody), nausea, vomiting, and fever. While symptoms are usually mild and self-limiting, severe cases or immunocompromised patients may require antibiotic treatment. Bacillus cereus and Clostridium perfringens are less likely causes of food poisoning due to their short incubation periods and milder symptoms. Rotavirus is a common cause of viral gastroenteritis in children, but adults are rarely affected due to immunity. Staphylococcus aureus can also cause food poisoning, with symptoms appearing 2-6 hours after ingestion and including nausea, vomiting, and abdominal pain.
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This question is part of the following fields:
- Infectious Diseases
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Question 18
Correct
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A 42-year-old woman who is six weeks pregnant presents to the Cardiovascular Clinic with a swollen right leg. Doppler studies confirm a deep vein thrombosis (DVT). She has no signs or symptoms of a pulmonary embolism (PE) and is haemodynamically stable. What is the most appropriate management choice in this case?
Your Answer: Start subcutaneous low molecular weight heparin (LMWH) throughout pregnancy and change to warfarin in the postpartum period
Explanation:Treatment Options for Deep Vein Thrombosis in Pregnancy
Start subcutaneous low molecular weight heparin (LMWH) throughout pregnancy and change to warfarin in the postpartum period: LMWH is recommended for the treatment of DVT during pregnancy. Treatment should be continued for at least three months and until six weeks postpartum. Warfarin can be used after day five of the postpartum period. Both LMWH and warfarin are safe to use while breastfeeding.
Elastic band compression of the affected leg, bedrest, and foot elevation: These measures have no benefit in treating DVT and may even increase the risk of developing a pulmonary embolism (PE) or another DVT.
Commence intravenous (IV) heparin: IV heparin can be used for the treatment of a shocked patient with PE if thrombolysis is not possible. It should not be used for DVT alone.
Oral anticoagulation with warfarin daily throughout pregnancy and the postpartum period: Warfarin is not recommended during pregnancy as it can cross the placenta and increase the risk of congenital malformations and bleeding.
Aspirin 300 mg daily throughout pregnancy and the postpartum period: Aspirin is not effective in treating DVT or PE as it is an antiplatelet drug, not an anticoagulant.
Treatment Options for Deep Vein Thrombosis in Pregnancy
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This question is part of the following fields:
- Cardiovascular
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Question 19
Incorrect
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A 42-year-old man comes to your clinic complaining of ear pain. He had visited the emergency department 3 days ago but was only given advice. He has been experiencing ear pain for 5 days now.
During the examination, his temperature is 38.5ºC and his right ear drum is red and bulging. What is the appropriate management for this patient?Your Answer: Start co-amoxiclav
Correct Answer: Start amoxicillin
Explanation:To improve treatment of tonsillitis and otitis media without relying on antibiotics, medical guidelines suggest waiting 2-3 days before considering treatment if symptoms do not improve. This approach is especially important when a patient has a fever, indicating systemic involvement. Therefore, recommending regular paracetamol is not appropriate in this case. While erythromycin can be a useful alternative for patients with a penicillin allergy, it should not be the first choice for those who can take penicillin. Penicillin V is the preferred antibiotic for tonsillitis, as amoxicillin can cause a rash in cases of glandular fever. However, it is not typically used for otitis media. For otitis media, amoxicillin is the recommended first-line medication at a dosage of 500mg TDS for 7 days. Co-amoxiclav is only used as a second-line option if amoxicillin is ineffective, and is not recommended as a first-line treatment according to current medical guidelines. These recommendations are based on NICE Guidelines and Clinical Knowledge Summaries.
Acute Otitis Media: Causes, Symptoms, and Management
Acute otitis media is a common condition in young children, with around 50% experiencing three or more episodes by the age of 3 years. While viral upper respiratory tract infections often precede otitis media, bacterial infections, particularly Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, are the primary cause. Viral infections disrupt the normal nasopharyngeal microbiome, allowing bacteria to infect the middle ear through the Eustachian tube.
Symptoms of acute otitis media include ear pain, fever, hearing loss, and recent viral upper respiratory tract infection symptoms. Otoscopy may reveal a bulging tympanic membrane, opacification or erythema of the tympanic membrane, perforation with purulent otorrhoea, or decreased mobility when using a pneumatic otoscope. Diagnosis is typically based on the acute onset of symptoms, otalgia or ear tugging, the presence of a middle ear effusion, bulging of the tympanic membrane, otorrhoea, decreased mobility on pneumatic otoscopy, or inflammation of the tympanic membrane.
Acute otitis media is generally self-limiting and does not require antibiotic treatment. However, antibiotics should be prescribed if symptoms last more than four days or do not improve, if the patient is systemically unwell but not requiring admission, if the patient is immunocompromised or at high risk of complications, if the patient is younger than 2 years with bilateral otitis media, or if there is otitis media with perforation and/or discharge in the canal. Amoxicillin is the first-line antibiotic, but erythromycin or clarithromycin should be given to patients with penicillin allergy.
Common sequelae of acute otitis media include perforation of the tympanic membrane, unresolved acute otitis media with perforation leading to chronic suppurative otitis media, hearing loss, and labyrinthitis. Complications may include mastoiditis, meningitis, brain abscess, and facial nerve paralysis. Parents should seek medical help if symptoms worsen or do not improve after three days.
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This question is part of the following fields:
- ENT
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Question 20
Incorrect
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A 45-year-old man with known permanent AF (atrial fibrillation) on warfarin has a fast, irregularly irregular pulse. He has no other past medical history. The ECG confirms AF with a rate of 132 beats/min. He is haemodynamically stable and well. He denies any history of palpitations, shortness of breath or syncope.
Which of the following is the most appropriate intervention?Your Answer: DC cardioversion
Correct Answer: Bisoprolol
Explanation:Treatment Options for Atrial Fibrillation: A Comprehensive Guide
Atrial fibrillation (AF) is a common cardiac arrhythmia that requires prompt and appropriate management to prevent complications. Here are some treatment options for AF:
Rate Control: This is recommended for patients who have had AF for more than 48 hours. Beta-blockers are the first-line treatment unless there is a contraindication such as asthma. Calcium channel blockers can also be used.
Digoxin: This drug can be used as rate control if the patient cannot have beta-blockers or calcium channel blockers. However, it should only be used as a third-line treatment or as an adjunct because it has been shown to increase mortality. It is also only effective in sedentary patients.
DC Cardioversion: This can be used to treat new-onset AF if the patient has had it for less than 48 hours. It can also be considered in patients who have had it for longer than that, once they have been on stable anticoagulation for at least 3 weeks.
Flecainide: This is a class Ic antiarrhythmic drug that can be used as chemical cardioversion in new AF (<48 hours) or if a patient has been anticoagulated for >3 weeks.
Rhythm Control: Nice guidelines advise that rhythm control can be used if AF onset was <48 hours ago, but should be avoided if longer ago because it can increase the risk of stroke from an atrial thrombus. In longer cases, rate control should be used, which is with beta-blockers or rate-limiting calcium channel blockers. Digoxin can be used third line or as an adjunct. In conclusion, the appropriate treatment for AF depends on the duration of the arrhythmia, the patient’s comorbidities, and other factors. It is important to consult with a healthcare professional to determine the best course of action.
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This question is part of the following fields:
- Cardiovascular
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Question 21
Correct
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A feature of a severe acute asthma exacerbation in an adult is:
Your Answer: Cannot complete full sentences
Explanation:Understanding the Indicators of Acute Asthma Exacerbations
Acute asthma exacerbations can range from mild to life-threatening, and it is important to recognize the indicators of each level of severity. In a severe exacerbation, the individual may not be able to complete full sentences, have a peak expiratory flow rate of 33-50% best or predicted, a respiratory rate of ≥25 breaths/min, a heart rate of ≥110 beats/min, use of accessory muscles, and oxygen saturation of ≥92%. A life-threatening exacerbation is characterized by a peak expiratory flow rate of <33% best or predicted, oxygen saturation of <92%, silent chest, cyanosis, cardiac arrhythmia or hypotension, confusion, coma, or altered consciousness. A moderate exacerbation may include talking in full sentences, a peak expiratory flow rate of >50-75% best or predicted, a respiratory rate of <25 breaths per minute, and a heart rate of <110 beats/min. Finally, a life-threatening exacerbation may also include a peak expiratory flow rate of <33% best or predicted, oxygen saturation of <92%, silent chest, cyanosis, cardiac arrhythmia or hypotension, confusion, coma, or altered consciousness, as well as exhaustion and poor respiratory effort. It is important to understand these indicators in order to properly assess and treat acute asthma exacerbations.
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This question is part of the following fields:
- Respiratory Medicine
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Question 22
Correct
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A 35-year-old man with a history of asthma and bipolar disorder visits his local GP clinic complaining of 'tonsillitis' and requesting an antibiotic. Upon examination, he has inflamed tonsils on both sides, a temperature of 37.8ºC, and a pulse rate of 90/min. He is currently taking salbutamol inhaler as needed, Clenil inhaler 2 puffs twice daily, co-codamol 30/500 2 tablets four times a day, and quetiapine 100mg twice daily. The decision is made to prescribe penicillin. What is the most appropriate next step?
Your Answer: Arrange a full blood count
Explanation:Monitoring FBC is crucial in patients taking clozapine as agranulocytosis/neutropenia, a potentially fatal side effect, can occur. It is imperative to rule out neutropenia in case of infections.
Atypical antipsychotics are now recommended as the first-line treatment for patients with schizophrenia, as per the 2005 NICE guidelines. These medications have the advantage of significantly reducing extrapyramidal side-effects. However, they can also cause adverse effects such as weight gain, hyperprolactinaemia, and in the case of clozapine, agranulocytosis. The Medicines and Healthcare products Regulatory Agency has issued warnings about the increased risk of stroke and venous thromboembolism when antipsychotics are used in elderly patients. Examples of atypical antipsychotics include clozapine, olanzapine, risperidone, quetiapine, amisulpride, and aripiprazole.
Clozapine, one of the first atypical antipsychotics, carries a significant risk of agranulocytosis and requires full blood count monitoring during treatment. Therefore, it should only be used in patients who are resistant to other antipsychotic medication. The BNF recommends introducing clozapine if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs, one of which should be a second-generation antipsychotic drug, each for at least 6-8 weeks. Adverse effects of clozapine include agranulocytosis, neutropaenia, reduced seizure threshold, constipation, myocarditis, and hypersalivation. Dose adjustment of clozapine may be necessary if smoking is started or stopped during treatment.
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This question is part of the following fields:
- Psychiatry
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Question 23
Correct
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A 28-year-old female patient complains of symptoms that suggest coeliac disease. What is the primary test that should be employed for screening individuals with coeliac disease?
Your Answer: Tissue transglutaminase antibodies
Explanation:According to NICE, the initial serological test for coeliac disease should be tissue transglutaminase antibodies.
Investigating Coeliac Disease
Coeliac disease is a condition caused by sensitivity to gluten, which can lead to villous atrophy and malabsorption. It is often associated with other conditions such as dermatitis herpetiformis and autoimmune disorders. Diagnosis of coeliac disease is made through a combination of serology and endoscopic intestinal biopsy. The gold standard for diagnosis is the biopsy, which should be performed in all patients with suspected coeliac disease to confirm or exclude the diagnosis. The biopsy traditionally takes place in the duodenum, but jejunal biopsies are also sometimes performed. Findings supportive of coeliac disease include villous atrophy, crypt hyperplasia, an increase in intraepithelial lymphocytes, and lamina propria infiltration with lymphocytes. Serology tests for coeliac disease include tissue transglutaminase antibodies and endomyseal antibodies, while anti-gliadin antibodies are not recommended. Patients who are already on a gluten-free diet should reintroduce gluten for at least six weeks prior to testing. Rectal gluten challenge is not widely used. A gluten-free diet can reverse villous atrophy and immunology in patients with coeliac disease.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 24
Incorrect
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As a foundation doctor in general practice, you have a patient who is a sexually active sixteen-year-old seeking advice about her contraceptive patch. She typically changes the patch on Saturday mornings but forgot to do so this week. What guidance should you provide?
Your Answer: Change the patch now and use barrier contraceptives for two days and consider emergency contraception
Correct Answer: Change the patch now, use barrier contraceptives for seven days and consider emergency contraception
Explanation:To ensure the effectiveness of the contraceptive patch, it should be applied to clean, dry skin on a weekly basis for three weeks, followed by a patch-free week to stimulate a withdrawal bleed. However, if the patch change is delayed for more than 48 hours, it is important to change it immediately and use a barrier method of contraception for the next 7 days. In case of unprotected intercourse, emergency contraceptives should be considered.
The Evra patch is the only contraceptive patch that is approved for use in the UK. The patch cycle lasts for four weeks, during which the patch is worn every day for the first three weeks and changed weekly. During the fourth week, the patch is not worn, and a withdrawal bleed occurs.
If a woman delays changing the patch at the end of week one or two, she should change it immediately. If the delay is less than 48 hours, no further precautions are necessary. However, if the delay is more than 48 hours, she should change the patch immediately and use a barrier method of contraception for the next seven days. If she has had unprotected sex during this extended patch-free interval or in the last five days, emergency contraception should be considered.
If the patch removal is delayed at the end of week three, the woman should remove the patch as soon as possible and apply a new patch on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed.
If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for seven days following any delay at the start of a new patch cycle. For more information, please refer to the NICE Clinical Knowledge Summary on combined hormonal methods of contraception.
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This question is part of the following fields:
- Reproductive Medicine
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Question 25
Incorrect
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A 28-year-old Afro-Caribbean woman presents with a 3-month history of a non-productive cough, dyspnoea and pleuritic chest pain, especially when climbing stairs. She reports intermittent fevers of up to 39°C and a 3.5-kg weight loss. She complains of wrist and ankle pain that has interfered with her work. She smokes two packets of cigarettes per day. Her full blood count is normal and serum ANA is negative. On examination there are red nodules over her lower legs.
Which of the following is the most likely diagnosis?Your Answer: Histoplasmosis
Correct Answer: Sarcoidosis
Explanation:Sarcoidosis is a condition where non-caseating granulomata develop in at least two organs, causing systemic inflammation. It is most common in African-Caribbean women and often affects the lungs, causing symptoms such as dry cough, dyspnea, and weight loss. Erythema nodosum is also frequently seen in patients with sarcoidosis. Histoplasmosis, Goodpasture’s syndrome, adenocarcinoma of the lung, and systemic lupus erythematosus are all possible differential diagnoses, but the absence of specific features makes sarcoidosis more likely in this case.
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This question is part of the following fields:
- Respiratory Medicine
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Question 26
Incorrect
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A 55-year-old man visits his General Practitioner (GP) complaining of tingling in both hands that began a month ago and has progressively worsened. He has no significant medical history. During the examination, you observe that the man has large hands, widely spaced teeth, and a prominent brow. You suspect that he may have acromegaly. What is the most suitable initial investigation for acromegaly?
Your Answer: Serum growth hormone
Correct Answer: Serum IGF1 levels
Explanation:Investigations for Acromegaly: Serum IGF1 Levels, CT/MRI Head, and Visual Field Testing
Acromegaly is a condition caused by excess growth hormone (GH) production, often from a pituitary macroadenoma. To diagnose acromegaly, insulin-like growth factor 1 (IGF1) levels are measured instead of GH levels, as IGF1 has a longer half-life and is more stable in the blood. If IGF1 levels are high, a glucose tolerance test is used to confirm the diagnosis. CT scans of the head are not as sensitive as MRI scans for detecting pituitary tumors, which are often the cause of acromegaly. Visual field testing is also important to determine if a pituitary tumor is compressing the optic chiasm, but it is not a specific investigation for acromegaly.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 27
Incorrect
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Which one of the following statements regarding gestational diabetes is accurate?
Your Answer: The majority of women are managed with insulin
Correct Answer: Women of Afro-Caribbean origin are at an increased risk
Explanation:Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 28
Correct
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What is the most frequent reason for recurrent spontaneous miscarriage in the first trimester?
Your Answer: Antiphospholipid syndrome
Explanation:The prevalence of aPL is significantly higher in women with recurrent miscarriage compared to those with a low risk obstetric history, with the former having a much higher incidence rate. In fact, the prevalence of aPL in the latter group is less than 2%.
Understanding Recurrent Miscarriage
Recurrent miscarriage is a condition that affects approximately 1% of women and is characterized by three or more consecutive spontaneous abortions. There are several potential causes of recurrent miscarriage, including antiphospholipid syndrome, endocrine disorders such as poorly controlled diabetes mellitus or thyroid disorders, polycystic ovarian syndrome, uterine abnormalities like a uterine septum, parental chromosomal abnormalities, and smoking.
It is important to note that while these factors may increase the risk of recurrent miscarriage, they do not necessarily guarantee that a woman will experience this condition. Additionally, there may be other underlying causes that have yet to be identified.
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This question is part of the following fields:
- Reproductive Medicine
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Question 29
Correct
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A 30-year-old woman with a family history of renal disease presents with gross haematuria. She reports that her sister recently underwent a kidney transplant and that her mother passed away due to renal failure. During physical examination, a significant mass is palpated in the left lumbar region, and a smaller mass is felt in the right flank. Elevated levels of blood urea and serum creatinine are observed.
What is the most likely diagnosis?Your Answer: Adult polycystic kidney disease
Explanation:Common Kidney Disorders and their Clinical Presentations
Autosomal Dominant Polycystic Kidney Disease (ADPKD)
ADPKD is a progressive disorder characterized by cyst formation and enlargement in the kidney and other organs. Patients may experience pain in the abdomen, flank or back, and hypertension is a common early manifestation. Palpable, bilateral flank masses are present in advanced ADPKD.Renal Cell Carcinoma (RCC)
RCC is the most common type of kidney cancer in adults. It may remain clinically occult for most of its course, with only 10% of patients presenting with the classic triad of flank pain, haematuria, and unilateral palpable flank mass. RCC presents with hypercalcaemia manifestations in 5% of cases and with varicocele in 2% of men.Renal Calculi
Renal calculi, or nephrolithiasis, classically present with sudden onset of severe pain originating in the flank and radiating inferiorly and anteriorly. On examination, there is dramatic costovertebral angle tenderness.Prostatic Carcinoma
Most cases of prostate cancer are identified by screening in asymptomatic men. Symptoms include urinary complaints or retention, back pain, and haematuria. Findings in patients with advanced disease include bony tenderness, lower-extremity oedema or deep venous thrombosis, and an overdistended bladder due to outlet obstruction.Renal Amyloidosis
Patients with renal amyloidosis typically present with proteinuria and/or hypertension, followed by progressive renal failure. Haematuria is not a feature.Clinical Presentations of Common Kidney Disorders
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 30
Incorrect
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A 38-year-old male presents with left-sided dull chest pain that has been present for five days. He reports no associated shortness of breath, cough, collapse, or pleuritic nature of the chest pain. The patient had a recent sore throat and headache last week, which has since resolved. There is no family history of sudden cardiac death in a first-degree relative, and the patient has never smoked.
Upon examination, the patient's blood pressure is 125/89 mmHg, heart rate is 95/min, temperature is 37.3ºC, and oxygen saturations are 97% on room air. Pulsus paradoxus is not present. Blood results reveal Hb of 154 g/L, platelets of 425 * 109/L, WBC of 11.5 * 109/L, Na+ of 137 mmol/L, K+ of 4.6 mmol/L, urea of 6.4 mmol/L, creatinine of 100 µmol/L, CRP of 40 mg/L, and Troponin T of 13 ng/L. The ECG shows ST-segment elevation in lead I, II, III, aVL, V5, and V6, and PR segment elevation in aVR.
What is the most likely diagnosis for this patient?Your Answer: Infective endocarditis
Correct Answer: Pericarditis
Explanation:The ECG changes in this patient suggest pericarditis, given their young age, widespread ST-segment elevation, and normal troponin levels. While PR segment depression is typically seen in pericarditis, note that the PR segment may be elevated in aVR. Myocarditis would be a possible diagnosis if the troponin levels were elevated. Infective endocarditis is less likely due to the absence of fever and ECG changes consistent with pericarditis. Although cardiac tamponade is a potential complication of pericarditis, it is unlikely in this case as the patient’s blood pressure is normal and pulsus paradoxus is not present.
Understanding Acute Pericarditis
Acute pericarditis is a medical condition characterized by inflammation of the pericardial sac that lasts for less than 4-6 weeks. The condition can be caused by various factors such as viral infections, tuberculosis, uraemia, post-myocardial infarction, autoimmune pericarditis, radiotherapy, connective tissue disease, hypothyroidism, malignancy, and trauma. Symptoms of acute pericarditis include chest pain, non-productive cough, dyspnoea, and flu-like symptoms. Patients may also experience pericardial rub.
To diagnose acute pericarditis, doctors may perform an electrocardiogram (ECG) to check for changes in the heart’s electrical activity. Blood tests may also be conducted to check for inflammatory markers and troponin levels. Patients suspected of having acute pericarditis should undergo transthoracic echocardiography.
Treatment for acute pericarditis depends on the underlying cause. Patients with high-risk features such as fever or elevated troponin levels may need to be hospitalized. However, most patients with pericarditis secondary to viral infection can be managed as outpatients. Strenuous physical activity should be avoided until symptoms resolve and inflammatory markers normalize. A combination of nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine is typically used as first-line treatment for patients with acute idiopathic or viral pericarditis. The medication is usually tapered off over 1-2 weeks.
Overall, understanding acute pericarditis is important for prompt diagnosis and appropriate management of the condition.
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This question is part of the following fields:
- Cardiovascular
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