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Question 1
Correct
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A 14-year-old girl presents to a gastroenterology clinic with a history of diarrhoea, bloating, and severe abdominal pain for the past 8 months. Her full blood count results are as follows:
Hb 118 g/L Male: (135-180)
Female: (115 - 160)
Platelets 190 * 109/L (150 - 400)
WBC 7.5 * 109/L (4.0 - 11.0)
What would be the most appropriate next investigation?Your Answer: Serum immunoglobulin IgA tissue transglutaminase antibody (tTGA) and total IgA
Explanation: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 2
Correct
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A 68-year-old female is hospitalized due to a pulmonary embolism. She has a medical history of hypertension, type 2 diabetes mellitus, epilepsy, and schizophrenia. The patient is taking ramipril, olanzapine, metformin, gliclazide, and sodium valproate. The junior doctors are hesitant to start her on warfarin due to a potential interaction that could affect the dosage. Which medication is causing this interaction?
Your Answer: Sodium valproate
Explanation:P450 Enzyme System and its Inducers and Inhibitors
The P450 enzyme system is responsible for metabolizing drugs in the body. Induction of this system usually requires prolonged exposure to the inducing drug, unlike P450 inhibitors, which have rapid effects. Some drugs that induce the P450 system include antiepileptics like phenytoin and carbamazepine, barbiturates such as phenobarbitone, rifampicin, St John’s Wort, chronic alcohol intake, griseofulvin, and smoking, which affects CYP1A2 and is the reason why smokers require more aminophylline.
On the other hand, some drugs inhibit the P450 system, including antibiotics like ciprofloxacin and erythromycin, isoniazid, cimetidine, omeprazole, amiodarone, allopurinol, imidazoles such as ketoconazole and fluconazole, SSRIs like fluoxetine and sertraline, ritonavir, sodium valproate, and acute alcohol intake. It is important to be aware of these inducers and inhibitors as they can affect the metabolism and efficacy of drugs in the body. Proper dosing and monitoring can help ensure safe and effective treatment.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 3
Correct
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A 35-year-old woman presents for follow-up. She has a long-standing history of heavy menstrual bleeding, which has worsened over the past six months. She denies experiencing dysmenorrhea, intermenstrual bleeding, or postcoital bleeding. She has completed her family and does not desire any more children. Her gynecological exam is unremarkable, and her cervical screening is current. What is the preferred treatment option?
Your Answer: Intrauterine system (Mirena)
Explanation:The recommended initial treatment for menorrhagia is the intrauterine system (Mirena).
Managing Heavy Menstrual Bleeding
Heavy menstrual bleeding, also known as menorrhagia, is a condition where a woman experiences excessive blood loss during her menstrual cycle. While it was previously defined as total blood loss of over 80 ml per cycle, the management of menorrhagia now depends on the woman’s perception of what is excessive. In the past, hysterectomy was a common treatment for heavy periods, but the approach has changed significantly since the 1990s.
To manage menorrhagia, a full blood count should be performed in all women. If symptoms suggest a structural or histological abnormality, a routine transvaginal ultrasound scan should be arranged. For women who do not require contraception, mefenamic acid or tranexamic acid can be used. If there is no improvement, other drugs can be tried while awaiting referral.
For women who require contraception, options include the intrauterine system (Mirena), combined oral contraceptive pill, and long-acting progestogens. Norethisterone can also be used as a short-term option to rapidly stop heavy menstrual bleeding. The flowchart below shows the management of menorrhagia.
[Insert flowchart here]
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This question is part of the following fields:
- Reproductive Medicine
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Question 4
Correct
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An epidemic of diarrhoea and vomiting has broken out on one of the elderly care wards. The catering suppliers assure you that their food is unlikely to be responsible because they follow the strictest hygiene procedures. A total of 15 elderly patients on the ward have become unwell with a sudden onset of diarrhoea and vomiting. Those infected earlier have recovered with rehydration therapy after about 48 hours. Examination of faeces by electron microscopy has revealed circular virus particles with radiating spokes.
Which virus is most likely to be responsible for this outbreak?Your Answer: Rotavirus
Explanation:Common Viruses that Cause Gastroenteritis
Gastroenteritis is a self-limiting illness caused by several viruses, including rotavirus, enteric adenovirus, small round-structured virus (SRSV), norovirus, and astrovirus. Among these, rotavirus is the most common cause of gastroenteritis in children under 5 years of age, while norovirus affects people of all ages. Rotavirus causes infant deaths worldwide, but acquired immunity develops after one episode. Norovirus is usually transmitted through contaminated food or water, while adenovirus is endemic throughout the year and commonly affects children in daycare settings. SRSV is another name for norovirus, and astrovirus is associated with contaminated food and water. Symptoms of gastroenteritis include anorexia, low-grade fever, vomiting, and watery diarrhea, but most cases do not require medication and can be managed with supportive treatment. Death from dehydration remains common in developing countries.
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This question is part of the following fields:
- Infectious Diseases
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Question 5
Correct
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A 68-year-old man presents with malaise, anorexia and pain in his shoulders and hips over the last 3 months. Examination is unremarkable, except for a mildly painful limitation of his hips and shoulders. His muscles are tender, but not weak. Blood tests reveal a raised erythrocyte sedimentation rate (ESR) of 60 mm/h (normal <20 mm/h).
Which of the following is the most likely diagnosis?Your Answer: Polymyalgia rheumatica (PMR)
Explanation:Differential Diagnosis for Joint and Muscle Pain: A Case Study
A 75-year-old male patient presents with pain and stiffness in the joints and muscles around the pelvic and shoulder girdles, lasting for longer than 45 minutes in the morning. He also reports constitutional symptoms of malaise, fatigue, anorexia, and sometimes depression. Based on this presentation, the following differential diagnoses can be considered:
Polymyalgia Rheumatica (PMR)
PMR is a rare condition that is most often diagnosed in those over 70 years old and is more common in women than men. Patients with PMR present with pain and stiffness in the joints and muscles around the pelvic and shoulder girdles, along with constitutional symptoms. Diagnosis is made based on the history, and blood tests often show a raised ESR and CRP. Treatment is with prednisolone, and rapid response to corticosteroid treatment is a very good indicator of a diagnosis of PMR.Osteoarthritis
Although osteoarthritis may present with painful hip joints, it is less common in the shoulder. Furthermore, constitutional symptoms, such as malaise and anorexia, are not seen in osteoarthritis. Examination findings in osteoarthritis usually reveal limited range of movement, crepitus, and possible joint instability, and there is unlikely to be any associated muscle tenderness. ESR, a marker of inflammation, is not seen in osteoarthritis.Systemic Lupus Erythematosus (SLE)
SLE is an autoimmune condition that is most common in women of childbearing age and those of Afro-Caribbean origin. While arthritis is one of the symptoms of SLE and there may be a raised ESR, alongside constitutional symptoms, the presentation in this patient, especially given his age and sex, suggests an alternative diagnosis to SLE initially. SLE may present with other symptoms as well, such as the characteristic butterfly rash, which is present in 30–60% of patients.Rheumatoid Arthritis (RA)
The onset of RA is generally in the middle-aged, and women are affected 2.5 times more than men. Although the ESR may be raised and the patient may feel generally unwell, the history given here is not typical of RA. The joints most typically affected by RA are the small joints of the hands and feet and the cervical spine.Gout
Gout presents as a mono -
This question is part of the following fields:
- Musculoskeletal
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Question 6
Correct
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A 64-year-old man with a history of type 2 diabetes mellitus and ischaemic heart disease visits his GP complaining of erectile dysfunction. What medication would make prescribing sildenafil contraindicated?
Your Answer: Isosorbide mononitrate
Explanation:Sildenafil, a PDE 5 inhibitor, should not be taken with nitrates or nicorandil as it can enhance the vasodilating effects of these medications.
Understanding Phosphodiesterase Type V Inhibitors
Phosphodiesterase type V (PDE5) inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. These drugs work by increasing the levels of cGMP, which leads to the relaxation of smooth muscles in the blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which was the first drug of its kind. It is a short-acting medication that is usually taken one hour before sexual activity.
Other PDE5 inhibitors include tadalafil (Cialis) and vardenafil (Levitra). Tadalafil is longer-acting than sildenafil and can be taken on a regular basis, while vardenafil has a similar duration of action to sildenafil. However, these drugs are not suitable for everyone. Patients taking nitrates or related drugs, those with hypotension, and those who have had a recent stroke or myocardial infarction should not take PDE5 inhibitors.
Like all medications, PDE5 inhibitors can cause side effects. These may include visual disturbances, blue discolouration, non-arteritic anterior ischaemic neuropathy, nasal congestion, flushing, gastrointestinal side-effects, headache, and priapism. It is important to speak to a healthcare professional before taking any medication to ensure that it is safe and appropriate for you.
Overall, PDE5 inhibitors are an effective treatment for erectile dysfunction and pulmonary hypertension. However, they should only be used under the guidance of a healthcare professional and with careful consideration of the potential risks and benefits.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 7
Incorrect
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A 56-year-old Caucasian man presents with a rash on the face. He first noticed this six months ago when he experienced episodes of flushing on the face. This has often occurred after he had alcohol or in situations where he felt stressful. A month ago, he started noticing a rash on his cheeks which came on intermittently until three weeks ago when the rash has become permanent. There has been no pain or itch associated with the rash. He is otherwise fit and well. He does not smoke.
On examination of the face, there is marked erythema with papules, pustules and telangiectasia. There are no comedones seen. The rash is distributed across the cheeks and nose. There is no per-oral or peri-orbital involvement.
What is the most likely diagnosis?Your Answer: Systemic lupus erythematosus
Correct Answer: Acne rosacea
Explanation:The features described suggest acne rosacea, with episodic flushing, papules and pustules with telangiectasia on the nose, cheeks and forehead. Other conditions such as acne vulgaris, systemic lupus erythematosus, seborrhoeic dermatitis and shingles are unlikely based on the described symptoms.
Understanding Rosacea: Symptoms and Management
Rosacea, also known as acne rosacea, is a chronic skin condition that has no known cause. It typically affects the nose, cheeks, and forehead, and the first symptom is often flushing. Over time, telangiectasia (visible blood vessels) may appear, followed by persistent redness with papules and pustules. In some cases, rhinophyma (enlarged nose) may develop, and there may be ocular involvement, such as blepharitis. Sunlight can exacerbate symptoms.
Mild cases of rosacea may be treated with topical metronidazole, while topical brimonidine gel may be used for patients with predominant flushing but limited telangiectasia. More severe cases may require systemic antibiotics like oxytetracycline. Patients are advised to apply high-factor sunscreen daily and use camouflage creams to conceal redness. Laser therapy may be appropriate for those with prominent telangiectasia, and patients with rhinophyma should be referred to a dermatologist.
Overall, understanding the symptoms and management of rosacea can help individuals manage their condition and improve their quality of life.
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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 30-year-old male patient comes to you with a rash that has spread all over his body. He has multiple erythematous lesions less than 1 cm in diameter on his torso and limbs, some of which are covered by a fine scale. Two weeks ago, he had exudative tonsillitis when he was seen with a sore throat. Apart from asthma, he has no other medical history. What is the probable diagnosis?
Your Answer: Guttate psoriasis
Explanation:Tear-drop scaly papules suddenly appearing on the trunk and limbs may indicate guttate psoriasis.
Guttate psoriasis is a type of psoriasis that is more commonly seen in children and adolescents. It is often triggered by a streptococcal infection that occurred 2-4 weeks prior to the appearance of the lesions. The name guttate comes from the Latin word for drop, as the lesions appear as small, tear-shaped papules on the trunk and limbs. These papules are pink and scaly, and the onset of the condition is usually acute, occurring over a few days.
In most cases, guttate psoriasis will resolve on its own within 2-3 months. There is no clear evidence to support the use of antibiotics to treat the underlying streptococcal infection. Treatment options for guttate psoriasis include topical agents commonly used for psoriasis and UVB phototherapy. In cases where the condition recurs, a tonsillectomy may be necessary.
It is important to differentiate guttate psoriasis from pityriasis rosea, another skin condition that can present with similar symptoms. Guttate psoriasis is often preceded by a streptococcal sore throat, while pityriasis rosea may be preceded by a respiratory tract infection. The appearance of guttate psoriasis is characterized by tear-shaped papules on the trunk and limbs, while pityriasis rosea presents with a herald patch followed by multiple oval lesions with a fine scale. While guttate psoriasis resolves within a few months, pityriasis rosea typically resolves after around 6 weeks.
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This question is part of the following fields:
- Dermatology
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Question 9
Incorrect
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A 32-year-old man presents to his General Practitioner with a 3-day history of flu-like symptoms and jaundice. He is a prison doctor. He sustained a needlestick injury six weeks ago from a high-risk patient after performing venepuncture. He immediately presented to the Emergency Department (ED) and was given a booster vaccination and post-exposure prophylaxis (PPE) treatment for human immunodeficiency virus (HIV). He is awaiting blood-borne virus (BBV) screening.
What is the most likely diagnosis?
Select ONE option only.Your Answer: Hepatitis B
Correct Answer: Hepatitis C
Explanation:Overview of Viral Hepatitis: Types, Transmission, and Risk Factors
Viral hepatitis is a group of infectious diseases that affect the liver and can cause serious health complications. There are five main types of viral hepatitis: A, B, C, D, and E. Each type has its own unique characteristics, transmission routes, and risk factors.
Hepatitis A is transmitted via the faecal-oral route and is most common in developing countries. It can cause symptoms similar to other types of viral hepatitis, but is less severe. Hepatitis B is transmitted via blood-to-blood and bloody fluid contact, and is most prevalent in migrant populations from certain regions. Hepatitis C is highly infectious and is commonly transmitted through shared needles or other injecting paraphernalia used for illicit drugs. Hepatitis D is a rare type of viral hepatitis that can only occur in patients with existing hepatitis B infection. Hepatitis E is also transmitted via the faecal-oral route, but is less common and usually only causes mild illness.
If a healthcare professional sustains a needlestick injury or other high-risk exposure to hepatitis C, they should have blood tests taken at specific intervals to confirm active infection. Hepatitis B vaccination is recommended for individuals working in high-risk clinical areas, and can also prevent hepatitis D infection. Chronic infection is rare for hepatitis E, unless the affected person is immunocompromised.
Understanding the different types of viral hepatitis, their transmission routes, and risk factors is important for preventing and managing these infections.
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This question is part of the following fields:
- Immunology/Allergy
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Question 10
Correct
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Typically, which form of lung disease develops in people with a1-antitrypsin deficiency?
Your Answer: Emphysema
Explanation:Emphysema: Imbalance between Proteases and Anti-Proteases in the Lungs
Emphysema is a lung disease that results from an imbalance between proteases and anti-proteases within the lung. This imbalance is often caused by a1-antitrypsin deficiency, which is associated with the development of emphysema in young people with no history of smoking and a positive family history. The interplay between environmental and genetic factors determines the onset of emphysema. Patients typically present with worsening dyspnoea, and weight loss, cor pulmonale, and polycythaemia occur later in the course of the disease. Chest radiographs show bilateral basal emphysema with paucity and pruning of the basal pulmonary vessels. Early onset of liver cirrhosis, often in combination with emphysema, is also associated with a1-antitrypsin deficiency.
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This question is part of the following fields:
- Respiratory Medicine
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Question 11
Correct
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A 29-year-old pregnant woman presents to the GP clinic for a review. She is currently 8 weeks pregnant and has undergone urine microscopy, culture, and sensitivity tests. Despite having no fever or dysuria, the following results were obtained:
- Red blood cells < 106/L
- White blood cells 100 x 106/L
- Culture Escherichia coli > 106/L colonies
- Sensitivity trimethoprim sensitive, cefalexin sensitive, nitrofurantoin resistant
What would be the most appropriate course of action for management?Your Answer: Cefalexin for 7 days
Explanation:Pregnant women with asymptomatic bacteriuria should receive immediate antibiotic treatment. In this case, cefalexin for 7 days is the appropriate choice based on the sensitivity results of the culture. Amoxicillin is another option, but without sensitivity data, it cannot be recommended. Nitrofurantoin should be avoided as the bacteria are resistant, and a 5-day course is insufficient. No treatment is not an option for pregnant women as it increases the risk of pyelonephritis. Trimethoprim should also be avoided due to its potential impact on fetal development as a folate antagonist.
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 12
Correct
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A 56-year-old man with a history of epilepsy and ischaemic heart disease presents to the clinic with a complaint of feeling lethargic for the past 3 months. Upon conducting blood tests, the following results were obtained: Hb 9.6 g/dl, MCV 123 fl, Plt 164 * 109/l, WCC 4.6 *109/l. Which medication is the most likely cause of his symptoms?
Your Answer: Phenytoin
Explanation:Phenytoin: Mechanism of Action and Adverse Effects
Phenytoin is a medication used to manage seizures. Its mechanism of action involves binding to sodium channels, which increases their refractory period. However, the drug is associated with a large number of adverse effects, which can be categorized as acute, chronic, idiosyncratic, and teratogenic. Acute effects include dizziness, diplopia, nystagmus, slurred speech, ataxia, confusion, and seizures. Chronic effects include gingival hyperplasia, hirsutism, coarsening of facial features, drowsiness, megaloblastic anemia, peripheral neuropathy, enhanced vitamin D metabolism causing osteomalacia, lymphadenopathy, and dyskinesia. Idiosyncratic effects include fever, rashes, hepatitis, Dupuytren’s contracture, aplastic anemia, and drug-induced lupus. Teratogenic effects are associated with cleft palate and congenital heart disease. Although routine monitoring of phenytoin levels is not necessary, trough levels should be checked before dosing in cases of dose adjustment, suspected toxicity, or non-adherence to the prescribed medication.
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This question is part of the following fields:
- Haematology/Oncology
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Question 13
Correct
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A 19-year-old college student presents with results from triple swabs for a yellow vaginal discharge. Microscopy reveals the presence of 'intracellular Gram-negative diplococci'. The patient is in good health with a negative pregnancy test. What course of treatment would you recommend?
Your Answer: IM ceftriaxone
Explanation:Gonorrhoea is best treated with intramuscular ceftriaxone.
Understanding Gonorrhoea: Causes, Symptoms, Microbiology, and Management
Gonorrhoea is a sexually transmitted infection caused by the Gram-negative diplococcus Neisseria gonorrhoeae. It can occur on any mucous membrane surface, including the genitourinary tract, rectum, and pharynx. The incubation period of gonorrhoea is typically 2-5 days. Symptoms in males include urethral discharge and dysuria, while females may experience cervicitis leading to vaginal discharge. Rectal and pharyngeal infections are usually asymptomatic.
Immunisation against gonorrhoea is not possible, and reinfection is common due to antigen variation of type IV pili and Opa proteins. Local complications may develop, including urethral strictures, epididymitis, and salpingitis, which can lead to infertility. Disseminated infection may also occur, with gonococcal infection being the most common cause of septic arthritis in young adults.
Management of gonorrhoea involves the use of antibiotics. Ciprofloxacin used to be the treatment of choice, but there is now increased resistance to it. Cephalosporins are now more widely used, with a single dose of IM ceftriaxone 1g being the new first-line treatment. If ceftriaxone is refused, oral cefixime 400mg + oral azithromycin 2g should be used. Disseminated gonococcal infection (DGI) and gonococcal arthritis may also occur, with symptoms including tenosynovitis, migratory polyarthritis, and dermatitis. Later complications include septic arthritis, endocarditis, and perihepatitis.
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This question is part of the following fields:
- Infectious Diseases
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Question 14
Correct
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You are a senior doctor in the paediatrics department. A fifteen year-old whose parents are devout Jehovah's witnesses requires a blood transfusion. Both parents state that they do not wish their child to have a potentially life saving transfusion. The fifteen year-old herself understands the risks and benefits of a transfusion and wishes to have the transfusion regardless.
Which of the following is correct?Your Answer: The blood can be transfused without the parents consent
Explanation:Once a child reaches the age of 16, they are considered competent to provide consent for treatment. In this case, the 16-year-old child can provide consent for the blood transfusion, but cannot refuse it. Therefore, the blood can be given as the child has provided consent. If the child were to refuse the treatment, the blood could still be given in their best interests without the consent of the child or their parents, using the Children Act 1989 and a High Court Order. However, in this particular case, such an order is not necessary. While some Jehovah witnesses may accept certain blood products, such as fresh frozen plasma or albumin, they may decline a complete blood transfusion. However, this is not appropriate in this situation. It may be advisable to contact the hospital liaison representative, but as the child is of age and understands the situation, they are able to provide consent for the treatment.
Understanding Consent in Children
The issue of consent in children can be complex and confusing. However, there are some general guidelines to follow. If a patient is under 16 years old, they may be able to consent to treatment if they are deemed competent. This is determined by the Fraser guidelines, which were previously known as Gillick competence. However, even if a child is competent, they cannot refuse treatment that is deemed to be in their best interest.
For patients between the ages of 16 and 18, it is generally assumed that they are competent to give consent to treatment. Patients who are 18 years or older can consent to or refuse treatment.
When it comes to providing contraceptives to patients under 16 years old, the Fraser Guidelines outline specific requirements that must be met. These include ensuring that the young person understands the advice given by the healthcare professional, cannot be persuaded to inform their parents, is likely to engage in sexual activity with or without treatment, and will suffer physical or mental health consequences without treatment. Ultimately, the young person’s best interests must be taken into account when deciding whether to provide contraceptive advice or treatment, with or without parental consent.
In summary, understanding consent in children requires careful consideration of age, competence, and best interests. The Fraser Guidelines provide a useful framework for healthcare professionals to follow when providing treatment and advice to young patients.
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This question is part of the following fields:
- Paediatrics
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Question 15
Incorrect
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A 58-year-old man complains of recurrent episodes of vertigo and dizziness. These episodes are usually triggered by a change in head position and usually last for about 30 seconds. The examination of the cranial nerves and ears shows no abnormalities. His blood pressure is 122/80 mmHg while sitting and 118/76 mmHg while standing. Assuming that the diagnosis is benign paroxysmal positional vertigo, what is the most suitable course of action to confirm the diagnosis?
Your Answer: Epley manoeuvre
Correct Answer: Dix-Hallpike manoeuvre
Explanation:Understanding Benign Paroxysmal Positional Vertigo
Benign paroxysmal positional vertigo (BPPV) is a common condition that causes sudden dizziness and vertigo triggered by changes in head position. It typically affects individuals over the age of 55 and is less common in younger patients. Symptoms include vertigo triggered by movements such as rolling over in bed or looking upwards, and may be accompanied by nausea. Each episode usually lasts between 10-20 seconds and can be diagnosed through a positive Dix-Hallpike manoeuvre, which involves the patient experiencing vertigo and rotatory nystagmus.
Fortunately, BPPV has a good prognosis and often resolves on its own within a few weeks to months. Treatment options include the Epley manoeuvre, which is successful in around 80% of cases, and vestibular rehabilitation exercises such as the Brandt-Daroff exercises. While medication such as Betahistine may be prescribed, it tends to have limited value. However, it is important to note that around half of people with BPPV will experience a recurrence of symptoms 3-5 years after their initial diagnosis.
Overall, understanding BPPV and its symptoms can help individuals seek appropriate treatment and manage their condition effectively.
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This question is part of the following fields:
- ENT
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Question 16
Correct
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A 3-month-old baby boy is brought to the hospital with suspected meningitis. His parents report that he has been feverish and lethargic for the past day. During the examination, his temperature is recorded as 39.5ºC, heart rate is 165/min, and respiratory rate is 52/min. The anterior fontanelle is visibly swollen, but no petechial rash is observed. Apart from cefotaxime, what other intravenous antibiotic should be administered?
Your Answer: Amoxicillin
Explanation:To ensure coverage for Listeria, it is recommended to administer IV amoxicillin along with cefotaxime when treating meningitis in children under 3 months of age.
Investigation and Management of Meningitis in Children
Meningitis is a serious condition that can affect children. When investigating meningitis, it is important to note any contraindications to lumbar puncture, such as signs of raised intracranial pressure, focal neurological signs, papilloedema, significant bulging of the fontanelle, disseminated intravascular coagulation, or signs of cerebral herniation. For patients with meningococcal septicaemia, a lumbar puncture is contraindicated, and blood cultures and PCR for meningococcus should be obtained instead.
The management of meningitis in children involves administering antibiotics, such as IV amoxicillin (or ampicillin) and IV cefotaxime for children under three months, and IV cefotaxime (or ceftriaxone) for children over three months. Steroids should be considered if the lumbar puncture reveals certain findings, such as purulent cerebrospinal fluid, a high white blood cell count, or bacteria on Gram stain. Fluids should be administered to treat shock, and cerebral monitoring should be conducted, including mechanical ventilation if necessary.
It is also important to notify public health authorities and administer antibiotic prophylaxis to contacts. Ciprofloxacin is now preferred over rifampicin for this purpose. Overall, prompt and appropriate management of meningitis in children is crucial for ensuring the best possible outcomes.
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This question is part of the following fields:
- Paediatrics
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Question 17
Incorrect
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A breathless 65-year-old smoker presents with the following lung function tests:
FEV1 (forced expiratory volume in 1 second) 1.5 l (60%)
FVC (forced vital capacity) 1.8 l (55%)
FEV1:FVC ratio = 84%
TLC (total lung capacity) = 66% predicted
RV (residual volume) = 57% predicted
TLCO (carbon monoxide transfer factor) = 55% predicted
KCO (carbon monoxide transfer coefficient) = 60% predicted
Which of the following is the most likely diagnosis in this case?
Select the SINGLE most likely diagnosis.Your Answer: Emphysema
Correct Answer: Idiopathic pulmonary fibrosis
Explanation:Understanding Idiopathic Pulmonary Fibrosis: Differential Diagnosis with Other Respiratory Conditions
Idiopathic pulmonary fibrosis (IPF), also known as fibrosing alveolitis, is a chronic and progressive lung disease that affects people between the ages of 50 and 70 years. The disease is characterized by a significant restrictive defect in lung function tests, reduced KCO, and breathlessness. While there is no definitive treatment for IPF, up to 20% of patients can survive more than 5 years from diagnosis.
When considering a differential diagnosis, it is important to rule out other respiratory conditions that may present with similar symptoms. Anaemia, for example, may cause breathlessness but would not produce a defect in lung function tests. Emphysema, on the other hand, would produce an obstructive pattern with a FEV1:FVC ratio of less than 70%. Obesity may also fit the picture of a restrictive defect, but it would not affect the KCO. In the case of asthma, an obstructive pattern with a FEV1:FVC ratio of less than 70% would be expected.
In summary, understanding the differential diagnosis of IPF is crucial in providing appropriate treatment and management for patients with respiratory conditions.
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This question is part of the following fields:
- Respiratory Medicine
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Question 18
Correct
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An 80-year-old man arrives at the emergency department complaining of difficulty breathing. He had been diagnosed with community-acquired pneumonia by his doctor and treated with antibiotics at home. However, his condition suddenly worsened, and he now has a heart rate of 120/min, respiratory rate of 22/min, oxygen saturation of 77%, and a temperature of 38°C. The patient has a medical history of COPD and is a carbon dioxide retainer. What is the best course of action to address his low oxygen saturation?
Your Answer: 28% Venturi mask at 4 litres/min
Explanation:Guidelines for Emergency Oxygen Therapy
The British Thoracic Society has updated its guidelines for emergency oxygen therapy in 2017. The guidelines recommend that in critically ill patients, such as those experiencing anaphylaxis or shock, oxygen should be administered via a reservoir mask at 15 l/min. However, certain conditions, such as stable myocardial infarction, are excluded from this recommendation.
The guidelines also provide specific oxygen saturation targets for different patient groups. Acutely ill patients should aim for a saturation range of 94-98%, while patients at risk of hypercapnia, such as those with COPD, should aim for a lower range of 88-92%. Oxygen therapy should be reduced in stable patients with satisfactory oxygen saturation.
For COPD patients, a 28% Venturi mask at 4 l/min should be used prior to availability of blood gases. The target oxygen saturation range for these patients should be 88-92% if they have risk factors for hypercapnia but no prior history of respiratory acidosis. If the pCO2 is normal, the target range can be adjusted to 94-98%.
The guidelines also highlight situations where oxygen therapy should not be used routinely if there is no evidence of hypoxia. These include myocardial infarction and acute coronary syndromes, stroke, obstetric emergencies, and anxiety-related hyperventilation.
Overall, these guidelines provide clear recommendations for the administration of emergency oxygen therapy in different patient groups and situations.
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This question is part of the following fields:
- Respiratory Medicine
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Question 19
Incorrect
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A 60-year-old man presents with a sudden onset of vision loss in his left eye upon waking up this morning. He reports no pain in his eye. His medical history includes diabetes mellitus and hypertension. Upon fundoscopic examination, the right eye appears normal, but the left eye shows multiple retinal haemorrhages. What is the most probable diagnosis?
Your Answer: Hypertensive retinopathy
Correct Answer: Central retinal vein occlusion
Explanation:The sudden painless loss of vision and severe retinal haemorrhages observed on fundoscopy in this patient are indicative of central retinal vein occlusion. Amaurosis fugax, which is caused by atheroembolism from the carotid arteries, results in temporary vision loss that resolves within a few minutes. In contrast, this patient’s vision loss is persistent. While central retinal artery occlusion also causes acute painless vision loss, it is characterized by a loss of relative afferent pupillary defect, a cherry-red macula, and a white/pale retina on fundoscopy. Hypertensive retinopathy may cause flame-shaped haemorrhages and cotton wool spots on the retina, but it does not result in sudden vision loss.
Understanding Central Retinal Vein Occlusion
Central retinal vein occlusion (CRVO) is a possible cause of sudden, painless loss of vision. It is more common in older individuals and those with hypertension, cardiovascular disease, glaucoma, or polycythemia. The condition is characterized by a sudden reduction or loss of visual acuity, usually affecting only one eye. Fundoscopy reveals widespread hyperemia and severe retinal hemorrhages, which are often described as a stormy sunset.
Branch retinal vein occlusion (BRVO) is a similar condition that affects a smaller area of the fundus. It occurs when a vein in the distal retinal venous system is blocked, usually at arteriovenous crossings.
Most patients with CRVO are managed conservatively, but treatment may be necessary in some cases. For instance, intravitreal anti-vascular endothelial growth factor (VEGF) agents may be used to manage macular edema, while laser photocoagulation may be necessary to treat retinal neovascularization.
Overall, understanding the risk factors, features, and management options for CRVO is essential for prompt diagnosis and appropriate treatment. Proper management can help prevent further vision loss and improve the patient’s quality of life.
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This question is part of the following fields:
- Ophthalmology
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Question 20
Correct
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A 50-year-old woman presents with shiny, flat-topped papules on the palmar aspect of the wrists. She is mainly bothered by the troublesome and persistent itching.
Given the likely diagnosis, which of the following is the best management?Your Answer: Topical clobetasone butyrate
Explanation:Management of Lichen Planus: Topical Clobetasone Butyrate
Lichen planus is a skin condition that can be managed with daily potent topical steroids, such as clobetasone butyrate. As the lesions improve, the potency of the steroid can be decreased. It is important to advise patients to only treat the active, itchy lesions and not the post-inflammatory hyperpigmentation to minimize side effects. These treatments can also be used on the genital skin and scalp. Sedating antihistamines may help with itching at night, but should only be used periodically. Emollients and oral antihistamines are not first-line treatments for lichen planus. Referring for a punch biopsy is not necessary unless the presentation is atypical. The characteristic histological findings of lichen planus include irregular acanthosis of the epidermis, irregular thickening of the granular layer, and compact hyperkeratosis in the center of the papule. Topical clotrimazole and dapsone are not first-line treatments for lichen planus.
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This question is part of the following fields:
- Dermatology
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Question 21
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 22
Correct
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Which one of the following statements regarding scabies is untrue?
Your Answer: Patients who complain of pruritus 4 weeks following treatment should be retreated
Explanation:It is typical for itching to continue for a period of 4-6 weeks after elimination.
Scabies: Causes, Symptoms, and Treatment
Scabies is a skin condition caused by the Sarcoptes scabiei mite, which is spread through prolonged skin contact. It is most commonly seen in children and young adults. The mite burrows into the skin and lays its eggs in the stratum corneum, leading to intense itching. This itching is caused by a delayed-type IV hypersensitivity reaction to the mites/eggs, which occurs about 30 days after the initial infection. Symptoms of scabies include widespread itching, linear burrows on the fingers, interdigital webs, and flexor aspects of the wrist. In infants, the face and scalp may also be affected. Scratching can lead to secondary features such as excoriation and infection.
The first-line treatment for scabies is permethrin 5%, while malathion 0.5% is second-line. Patients should be advised to avoid close physical contact with others until treatment is complete. All household and close physical contacts should be treated at the same time, even if asymptomatic. Clothing, bedding, and towels should be laundered, ironed, or tumble-dried on the first day of treatment to kill off mites. The insecticide should be applied to all areas, including the face and scalp, contrary to the manufacturer’s recommendation. Patients should apply the insecticide cream or liquid to cool, dry skin, paying close attention to areas between fingers and toes, under nails, armpit area, and creases of the skin such as at the wrist and elbow. The insecticide should be left on the skin for 8-12 hours for permethrin or 24 hours for malathion before washing off. Treatment should be repeated 7 days later.
Crusted scabies, also known as Norwegian scabies, is seen in patients with suppressed immunity, especially HIV. The crusted skin will be teeming with hundreds of thousands of organisms. Isolation is essential, and ivermectin is the treatment of choice.
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This question is part of the following fields:
- Dermatology
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Question 23
Correct
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A 42-year-old woman is admitted to the gastroenterology ward with persistent bloody diarrhoea, abdominal pain and fever. She has a history of Crohn's disease and is suspected to be experiencing an acute flare. Methotrexate is prescribed as part of her treatment. What potential side-effect should be monitored for?
Your Answer: Pneumonitis
Explanation:Methotrexate has the potential to cause pneumonitis, which is characterized by symptoms such as cough, fever, and difficulty breathing. Failure to promptly identify and treat pneumonitis can result in permanent lung damage. Therefore, the British National Formulary advises patients to seek medical attention if they experience any of these symptoms, and physicians should monitor for signs of pneumonitis during each visit and discontinue the medication if it is suspected. It should be noted that acute respiratory distress syndrome is not a known side effect of methotrexate.
Methotrexate: An Antimetabolite with Potentially Life-Threatening Side Effects
Methotrexate is an antimetabolite drug that inhibits the enzyme dihydrofolate reductase, which is essential for the synthesis of purines and pyrimidines. It is commonly used to treat inflammatory arthritis, psoriasis, and some types of leukemia. However, it is considered an important drug due to its potential for life-threatening side effects. Careful prescribing and close monitoring are essential to ensure patient safety.
The adverse effects of methotrexate include mucositis, myelosuppression, pneumonitis, pulmonary fibrosis, and liver fibrosis. The most common pulmonary manifestation is pneumonitis, which typically develops within a year of starting treatment and presents with non-productive cough, dyspnea, malaise, and fever. Women should avoid pregnancy for at least 6 months after treatment has stopped, and men using methotrexate need to use effective contraception for at least 6 months after treatment.
When prescribing methotrexate, it is important to follow guidelines and monitor patients regularly. Methotrexate is taken weekly, and FBC, U&E, and LFTs need to be regularly monitored. The starting dose is 7.5 mg weekly, and folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after the methotrexate dose. Only one strength of methotrexate tablet should be prescribed, usually 2.5 mg. It is also important to avoid prescribing trimethoprim or co-trimoxazole concurrently, as it increases the risk of marrow aplasia, and high-dose aspirin increases the risk of methotrexate toxicity.
In case of methotrexate toxicity, the treatment of choice is folinic acid. Methotrexate is a drug with a high potential for patient harm, and it is crucial to be familiar with guidelines relating to its use to ensure patient safety.
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This question is part of the following fields:
- Musculoskeletal
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Question 24
Incorrect
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In patients with carcinoma of the prostate, which laboratory test is the most effective for screening and monitoring therapy?
Your Answer: Carcinoembryonic antigen (CEA)
Correct Answer: Prostate-specific antigen (PSA)
Explanation:Tumor Markers: Understanding Their Role in Cancer Diagnosis and Therapy Control
Tumor markers are substances produced by cancer cells or normal cells in response to cancer. They can be used in the diagnosis and therapy control of various types of cancer. However, it is important to note that tumor markers are non-specific and can also be elevated in non-cancerous conditions.
Prostate-specific antigen (PSA) is a commonly used tumor marker for prostate cancer. It should be offered to those who request testing or for those who have symptoms suggestive of prostate cancer. PSA levels increase with age, so interpretation should take into account the age of the patient. However, PSA levels can also be elevated in benign prostatic enlargement and prostate inflammation, and can be normal in prostate carcinoma.
Alpha-fetoprotein (AFP) is a tumor marker for hepatocellular carcinoma. However, AFP levels can also be normal in this type of cancer. Lactate dehydrogenase (LDH)-1 isoenzyme levels can be elevated in testicular germ cell tumors, while alkaline phosphatase levels can be raised in cholestasis and Paget’s disease.
Carcinoembryonic antigen (CEA) is a tumor marker for colon cancer, but it is non-specific. The introduction of the PSA test has led to earlier diagnosis of prostate cancer, before metastases into lymph nodes or bone are evident. Bone scans are unnecessary in patients with a PSA <20 ng/ml, and repeated scans during treatment are unnecessary in the absence of clinical indications. In summary, tumor markers can be useful in cancer diagnosis and therapy control, but their interpretation should take into account the patient’s age and other non-cancerous conditions that can elevate their levels.
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This question is part of the following fields:
- Haematology/Oncology
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Question 25
Correct
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What is the most appropriate statement regarding GI bleeding caused by NSAID therapy? Choose only one option from the list.
Your Answer: It is due to depletion of mucosal prostaglandin E (PGE) levels
Explanation:Misconceptions about Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to relieve pain and inflammation. However, there are several misconceptions about their side effects. Here are some clarifications:
Clarifying Misconceptions about NSAIDs
Misconception 1: NSAIDs cause gastrointestinal (GI) bleeding by depleting mucosal prostaglandin E (PGE) levels.
Clarification: While it is true that NSAIDs can irritate the GI tract and reduce the levels of protective prostaglandins, not all NSAIDs have the same risk of causing GI bleeding. High-risk NSAIDs such as piroxicam have a higher prevalence of gastric side effects, while ibuprofen and diclofenac have lower rates. Additionally, GI bleeding can occur in patients without pre-existing peptic ulcers. Therefore, NSAIDs should be used at the lowest effective dose and for the shortest period possible.
Misconception 2: NSAIDs cause GI bleeding only in patients with pre-existing gastric and/or duodenal ulcers.
Clarification: While patients with pre-existing peptic ulcer disease are at higher risk of GI bleeding, NSAIDs can also cause GI bleeding in patients without ulcers. Therefore, caution should be exercised when prescribing NSAIDs to all patients.
Misconception 3: Severe dyspepsia is the only symptom of GI bleeding caused by NSAIDs.
Clarification: While dyspepsia is a common symptom of NSAID use, endoscopic evidence of peptic ulceration can be seen in up to 20% of asymptomatic patients taking NSAIDs. Therefore, regular monitoring and endoscopic evaluation may be necessary in patients taking NSAIDs.
Misconception 4: NSAIDs increase platelet adhesiveness.
Clarification: NSAIDs actually reduce platelet aggregation and adhesiveness, except for aspirin, which irreversibly inhibits COX-1 and is indicated for inhibition of platelet aggregation. However, aspirin use increases the risk of bleeding.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 26
Incorrect
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A 60-year-old man with a history of high blood pressure and high cholesterol presents to the Emergency Department with occasional episodes of chest pain, lasting only for a few minutes. This occurs while at rest and is accompanied by palpitations. He is currently stable, with a blood pressure of 140/95 mmHg, oxygen saturation of 98% and a heart rate of 160 bpm. An electrocardiogram (ECG) is done which shows no P waves, with regular narrow QRS complexes interspersed along a saw-tooth baseline. Vagal manoeuvres have failed and three boluses of adenosine fail to control the arrhythmia.
Given the likely diagnosis, which of the following treatments is indicated?
Select the SINGLE best treatment option from the list below.
Your Answer: Synchronised direct-current (DC) cardioversion
Correct Answer: Bisoprolol
Explanation:Management of Atrial Flutter: Medications and Procedures
Atrial flutter is a type of arrhythmia that can be managed through various medications and procedures. The first step in treatment is to control the ventricular rate, which can be achieved through the administration of beta-blockers or rate-limiting calcium-channel blockers. For patients with diabetes mellitus, cardio-selective beta-blockers such as atenolol, bisoprolol, metoprolol, and nebivolol are preferred.
Amiodarone is not the first-line treatment for atrial flutter and is mainly used for ventricular tachycardias and chemical cardioversion in atrial fibrillation. Propranolol can be used for rate control, but cardio-selective beta-blockers are preferred for patients with diabetes mellitus.
Synchronised direct-current (DC) cardioversion is the first-line treatment for patients with haemodynamic instability caused by a tachyarrhythmia. However, if the patient exhibits no adverse signs, DC cardioversion is not indicated. Unsynchronised DC cardioversion is only given in cases of ventricular fibrillation.
All patients should be assessed for their risk of stroke and the need for thromboprophylaxis, with the choice of anticoagulant based on scoring criteria such as CHA2DS2-VASc. Overall, the management of atrial flutter involves a tailored approach based on the individual patient’s needs and medical history.
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This question is part of the following fields:
- Cardiovascular
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Question 27
Incorrect
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A 28-year-old man with psoriasis affecting the scalp and legs visits his General Practitioner with ongoing symptoms despite using once-daily Betnovate® (a potent steroid) and a vitamin D analogue for six weeks.
What should be the next course of action in managing this patient?Your Answer: Start an ultra-potent steroid regime
Correct Answer: Stop steroid treatment and continue vitamin D analogue twice daily
Explanation:Psoriasis management follows a stepwise approach, as per NICE guidelines. In this case, the patient has already received eight weeks of potent steroid with a vitamin D analogue. The next step is to stop the steroid and increase the vitamin D analogue to twice daily. Steroids should not be used at the same site for more than eight weeks, and patients require a 4-week steroid-free break. If symptoms persist, twice-daily steroids or a coal tar preparation can be tried. Referral to Dermatology may be necessary for severe cases, but starting the next stage of treatment while awaiting review is appropriate. An ultra-potent steroid may be considered after the steroid-free break or as a short course if necessary.
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This question is part of the following fields:
- Dermatology
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Question 28
Incorrect
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A 64-year-old woman presents to her GP complaining of worsening dyspnea. Upon taking a detailed medical history and conducting a thorough physical examination, the GP orders an outpatient chest CT scan. The results reveal lung fibrosis as the likely cause of the patient's symptoms. The patient has a medical history of gout and rheumatoid arthritis. Which medication prescribed to the patient is most likely responsible for causing lung fibrosis?
Your Answer:
Correct Answer: Sulfasalazine
Explanation:Drugs that can lead to lung fibrosis
Lung fibrosis is a condition where the lung tissue becomes scarred and thickened, making it difficult for the lungs to function properly. There are several drugs that can cause lung fibrosis as a side effect. These drugs include amiodarone, which is used to treat heart rhythm problems, cytotoxic agents such as busulphan and bleomycin, which are used to treat cancer, and anti-rheumatoid drugs like methotrexate and sulfasalazine. Nitrofurantoin, an antibiotic used to treat urinary tract infections, and ergot-derived dopamine receptor agonists like bromocriptine, cabergoline, and pergolide, which are used to treat Parkinson’s disease, can also cause lung fibrosis. It is important to be aware of the potential side effects of these drugs and to discuss any concerns with a healthcare provider. Proper monitoring and management can help prevent or minimize the risk of lung fibrosis.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 29
Incorrect
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A 27-year-old woman comes in for her 8th week of pregnancy and reports an uncomplicated pregnancy thus far. She is currently in good health and not experiencing any symptoms. However, she expresses concern about not being vaccinated against rubella as a child due to her parents' anti-vaccine beliefs. She is aware of the potential harm rubella can cause to her developing fetus and blood tests confirm that she is not immune to the virus.
What advice should be given to her?Your Answer:
Correct Answer: She can have the MMR vaccine postnatally
Explanation:In the case of a pregnant woman who is not immune to rubella, it is recommended to offer the MMR vaccination after giving birth. Rubella can cause severe harm to the developing foetus, especially during the first 8-10 weeks of pregnancy. Although congenital rubella syndrome is now rare due to widespread MMR vaccination, there has been a resurgence of measles, mumps, and rubella outbreaks in developed countries due to the anti-vaccination movement. The woman should avoid contact with individuals who may have rubella and cannot receive the vaccine while pregnant. Referral to an obstetrician is not necessary at this time since the woman is asymptomatic and in good health. The MMR vaccine should not be administered at 20 weeks of pregnancy, and if the woman is not immune, it should be offered postnatally. If there is a suspicion of rubella based on the woman’s clinical presentation, the local Health Protection Team should be notified, but this is not necessary in this case since there is no suspicion.
Rubella and Pregnancy: Risks, Features, Diagnosis, and Management
Rubella, also known as German measles, is a viral infection caused by the togavirus. Thanks to the introduction of the MMR vaccine, it is now rare. However, if contracted during pregnancy, there is a risk of congenital rubella syndrome, which can cause serious harm to the fetus. It is important to note that the incubation period is 14-21 days, and individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash.
The risk of damage to the fetus is highest in the first 8-10 weeks of pregnancy, with a risk as high as 90%. However, damage is rare after 16 weeks. Features of congenital rubella syndrome include sensorineural deafness, congenital cataracts, congenital heart disease (e.g. patent ductus arteriosus), growth retardation, hepatosplenomegaly, purpuric skin lesions, ‘salt and pepper’ chorioretinitis, microphthalmia, and cerebral palsy.
If a suspected case of rubella in pregnancy arises, it should be discussed immediately with the local Health Protection Unit (HPU) as type/timing of investigations may vary. IgM antibodies are raised in women recently exposed to the virus. It should be noted that it is very difficult to distinguish rubella from parvovirus B19 clinically. Therefore, it is important to also check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss.
If a woman is tested at any point and no immunity is demonstrated, they should be advised to keep away from people who might have rubella. Non-immune mothers should be offered the MMR vaccination in the post-natal period. However, MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant.
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This question is part of the following fields:
- Reproductive Medicine
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Question 30
Incorrect
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A 65-year-old woman is brought to the Emergency Department (ED) following a fall at home. During examination in the ED, there is no evidence of external bleeding, but her blood pressure is 100/50 mmHg, and her heart rate is 110 bpm. She has distended neck veins and muffled heart sounds. What is the most probable finding on an echocardiogram?
Your Answer:
Correct Answer: Pericardial effusion
Explanation:Medical Conditions and Trauma: Understanding the Differences
Pericardial Effusion: A Serious Condition
When a patient presents with hypotension, tachycardia, and Beck’s triad (hypotension, distended neck veins, and muffled heart sounds), it is suggestive of pericardial effusion. This condition occurs when fluid accumulates in the pericardial space, compressing the heart and causing low cardiac output. Trauma to the chest is a common cause of pericardial effusion, leading to bleeding into the pericardial space.
Haemothorax, Mitral Regurgitation, Pleural Effusion, and Pneumothorax: Other Trauma-Related Conditions
While haemothorax refers to blood in the pleural space, it would not cause Beck’s triad or be detected on an echocardiogram. Mitral regurgitation could be detected on an echocardiogram, but it would not likely lead to Beck’s triad as blood would remain within the heart chambers. Pleural effusion refers to any fluid in the pleural space and would not cause Beck’s triad, nor would it be detected on echocardiography. Pneumothorax, which refers to air in the pleural space, can also occur with trauma. Tension pneumothorax may cause Beck’s triad, but it would not be detected on an echocardiogram.
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This question is part of the following fields:
- Cardiovascular
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