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  • Question 1 - An 80-year-old man presents with complaints of blurred vision. Upon fundoscopy, drusen, retinal...

    Correct

    • An 80-year-old man presents with complaints of blurred vision. Upon fundoscopy, drusen, retinal epithelial changes, and macular neovascularisation are noted. The clinician suspects age-related macular degeneration. What would be the most suitable follow-up investigation?

      Your Answer: Fluorescein angiography

      Explanation:

      Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by the degeneration of the central retina (macula) and the formation of drusen. It is more prevalent in females and is strongly associated with advancing age, smoking, family history, and conditions that increase the risk of ischaemic cardiovascular disease. ARMD can be classified into two forms: dry and wet. Dry ARMD is more common and is characterized by drusen, while wet ARMD is characterized by choroidal neovascularisation and carries a worse prognosis. Clinical features of ARMD include subacute onset of visual loss, difficulties in dark adaptation, and visual disturbances such as photopsia and glare.

      To diagnose ARMD, slit-lamp microscopy and color fundus photography are used to identify any pigmentary, exudative, or haemorrhagic changes affecting the retina. Fluorescein angiography and indocyanine green angiography may also be used to visualize changes in the choroidal circulation. Treatment for dry ARMD involves a combination of zinc with antioxidant vitamins A, C, and E, which has been shown to reduce disease progression by around one third. For wet ARMD, anti-VEGF agents such as ranibizumab, bevacizumab, and pegaptanib are used to limit disease progression and stabilize or reverse visual loss. Laser photocoagulation may also be used to slow progression, but anti-VEGF therapies are usually preferred due to the risk of acute visual loss after treatment.

      In summary, ARMD is a common cause of blindness in the UK that is strongly associated with advancing age, smoking, and family history. It can be classified into dry and wet forms, with wet ARMD carrying a worse prognosis. Diagnosis involves the use of various imaging techniques, and treatment options include a combination of zinc and antioxidant vitamins for dry ARMD and anti-VEGF agents or laser photocoagulation for wet ARMD.

    • This question is part of the following fields:

      • Ophthalmology
      16.4
      Seconds
  • Question 2 - A 36-year-old woman has experienced a stillbirth and wants to stop lactation. What...

    Correct

    • A 36-year-old woman has experienced a stillbirth and wants to stop lactation. What medication should be used for this purpose?

      Your Answer: Bromocriptine

      Explanation:

      Medications for Lactation Suppression

      Lactation is stimulated by the release of prolactin, and drugs that decrease prolactin levels are effective in suppressing lactation. Dopamine agonists like bromocriptine are the most commonly used drugs for this purpose. On the other hand, drugs like domperidone and amitriptyline that increase serum prolactin levels are not effective in suppressing lactation.

      Ondansetron is an antiemetic drug that works by blocking the 5-HT system. It is not used for lactation suppression as it does not affect prolactin levels. L-dopa, another drug that can reduce prolactin levels, is not commonly used due to its side effects. It often causes nausea in patients, making dopamine agonists a preferred choice for lactation suppression.

    • This question is part of the following fields:

      • Pharmacology
      22.1
      Seconds
  • Question 3 - A 75-year-old male with a history of prostate cancer treated with external beam...

    Incorrect

    • A 75-year-old male with a history of prostate cancer treated with external beam radiation therapy 3 years ago visits his general practitioner complaining of crampy abdominal pain, urgency, and diarrhea that have persisted for 4 months. The patient is in good health and has no other medical conditions.
      During the examination, the patient appears thin and has conjunctival pallor. The abdomen is soft and non-tender, and there is no blood or mucous on digital rectal examination.
      What possible diagnosis could account for these symptoms?

      Your Answer: Diverticular disease

      Correct Answer: Colorectal cancer

      Explanation:

      After undergoing radiotherapy for prostate cancer, patients have a higher likelihood of developing bladder, colon, and rectal cancer. This suggests that the pathology is related to the digestive system, rather than a recurrence of prostate cancer. The patient’s lack of symptoms such as bleeding or pain during bowel movements makes anal cancer less probable. Additionally, the patient’s age and lack of prior diagnosis make it unlikely that they have inflammatory bowel disease.

      Management of Prostate Cancer

      Localised prostate cancer (T1/T2) can be managed through various treatment options depending on the patient’s life expectancy and preference. Conservative approaches such as active monitoring and watchful waiting can be considered, as well as radical prostatectomy and radiotherapy (external beam and brachytherapy). On the other hand, localised advanced prostate cancer (T3/T4) may require hormonal therapy, radical prostatectomy, or radiotherapy. However, patients who undergo radiotherapy may develop proctitis and are at a higher risk of bladder, colon, and rectal cancer.

      For metastatic prostate cancer, the primary goal is to reduce androgen levels. A combination of approaches is often used, including anti-androgen therapy, synthetic GnRH agonist or antagonists, bicalutamide, cyproterone acetate, abiraterone, and bilateral orchidectomy. GnRH agonists such as Goserelin (Zoladex) may result in lower LH levels longer term by causing overstimulation, which disrupts endogenous hormonal feedback systems. This may cause a rise in testosterone initially for around 2-3 weeks before falling to castration levels. To prevent a rise in testosterone, anti-androgen therapy is often used initially. However, this may result in a tumour flare, which stimulates prostate cancer growth and may cause bone pain, bladder obstruction, and other symptoms. GnRH antagonists such as degarelix are being evaluated to suppress testosterone while avoiding the flare phenomenon. Chemotherapy with docetaxel may also be an option for the treatment of hormone-relapsed metastatic prostate cancer in patients who have no or mild symptoms after androgen deprivation therapy has failed, and before chemotherapy is indicated.

    • This question is part of the following fields:

      • Surgery
      48.2
      Seconds
  • Question 4 - A 35-year-old woman with G4P3 at 39 weeks gestation presents to the labour...

    Correct

    • A 35-year-old woman with G4P3 at 39 weeks gestation presents to the labour ward following a spontaneous rupture of membranes. She delivers a healthy baby vaginally but experiences excessive bleeding and hypotension. Despite attempts to control the bleeding, the senior doctor decides to perform a hysterectomy. Upon examination, the pathologist observes that the chorionic villi have deeply invaded the myometrium but not the perimetrium.
      What is the diagnosis?

      Your Answer: Placenta increta

      Explanation:

      The correct answer is placenta increta, where the chorionic villi invade the myometrium but not the perimetrium. The patient’s age and history of multiple pregnancies increase the risk of this abnormal placentation, which can be diagnosed through pathological studies. Placenta accreta, percreta, and previa are incorrect answers, as they involve different levels of placental attachment and can cause different symptoms.

      Understanding Placenta Accreta

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

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

    • This question is part of the following fields:

      • Obstetrics
      17.4
      Seconds
  • Question 5 - As a junior doctor in the neonatal unit, you receive a call from...

    Correct

    • As a junior doctor in the neonatal unit, you receive a call from a nurse regarding a delivery where the baby's head has been delivered, but the shoulders are not descending with normal downward traction. What is your initial step in managing this situation?

      Your Answer: Ask the mother to hyperflex their legs and apply suprapubic pressure

      Explanation:

      In cases where the previous method is unsuccessful, an episiotomy may be necessary to facilitate internal maneuvers. Various alternatives may be considered, such as…

      Shoulder dystocia is a complication that can occur during vaginal delivery when the body of the fetus cannot be delivered after the head has already been delivered. This is usually due to the anterior shoulder of the fetus becoming stuck on the mother’s pubic bone. Shoulder dystocia can cause harm to both the mother and the fetus. Risk factors for shoulder dystocia include fetal macrosomia, high maternal body mass index, diabetes mellitus, and prolonged labor.

      If shoulder dystocia is identified, it is important to call for senior help immediately. The McRoberts’ maneuver is often performed, which involves flexing and abducting the mother’s hips to increase the angle of the pelvis and facilitate delivery. An episiotomy may be performed to provide better access for internal maneuvers, but it will not relieve the bony obstruction. Symphysiotomy and the Zavanelli maneuver are not recommended as they can cause significant maternal morbidity. Oxytocin administration is not indicated for shoulder dystocia.

      Complications of shoulder dystocia can include postpartum hemorrhage and perineal tears for the mother, and brachial plexus injury and neonatal death for the fetus. It is important to manage shoulder dystocia promptly and appropriately to minimize the risk of these complications.

    • This question is part of the following fields:

      • Obstetrics
      16.1
      Seconds
  • Question 6 - A 78-year-old man experiences a sensation of something ‘giving way’ in his right...

    Correct

    • A 78-year-old man experiences a sensation of something ‘giving way’ in his right arm while lifting a heavy bag of garden waste. The arm is visibly bruised, and upon flexing the elbow, a lump appears in the middle of the anterior aspect of the arm. The diagnosis is a rupture of the tendon of the long head of the biceps brachii. Where does this tendon typically attach to a bony point?

      Your Answer: Supraglenoid tubercle of the scapula

      Explanation:

      The supraglenoid tubercle of the scapula is where the tendon of the long head of the biceps brachii attaches within the shoulder joint capsule. The lesser tuberosity of the humerus is where the subscapularis muscle inserts, while the crest of the lesser tuberosity is where the latissimus dorsi and teres major muscles attach. The coracoid process of the scapula is where the short head of the biceps brachii, coracobrachialis, and pectoralis minor muscles attach. The greater tuberosity of the humerus is where the supraspinatus, infraspinatus, and teres minor muscles insert. Lastly, the long head of the triceps brachii attaches to the infraglenoid tubercle of the scapula. These attachments and insertions are important for understanding the anatomy and function of the shoulder and arm muscles.

    • This question is part of the following fields:

      • Orthopaedics
      41.3
      Seconds
  • Question 7 - A 57-year-old man comes to the Emergency Department complaining of a headache and...

    Correct

    • A 57-year-old man comes to the Emergency Department complaining of a headache and blurred vision that started 1 day ago. He reports no pain when touching his scalp or eating and chewing food. He has a medical history of hypertension and type 2 diabetes mellitus, which he manages with metformin. He also mentions that his uncle died of brain cancer, and he is worried that he may have the same condition.

      During the examination, his visual acuity is 6/18 in both eyes. Dilated fundoscopy reveals some arterioles narrower than others, with venules being compressed by arterioles. There is optic disc swelling in both eyes, with some exudates lining up like a star at the macula. Additionally, there are some dot-and-blot and flame-shaped haemorrhages.

      His vital signs are as follows: heart rate 80 bpm, blood pressure 221/119 mmHg, oxygen saturation 98% on room air, respiratory rate 14 per minute, and temperature 37 °C.

      What is the most likely diagnosis?

      Your Answer: Hypertensive retinopathy

      Explanation:

      Diagnosis of Hypertensive Retinopathy: A Case Study

      The patient in question presented with a highly raised blood pressure and complained of headache and blurring of vision. Fundoscopy revealed typical features of hypertensive retinopathy, including bilateral optic disc swelling. Although the patient had a family history of intracranial space-occupying lesions, there were no accompanying symptoms such as early-morning vomiting and weight loss, making this diagnosis unlikely. Additionally, there was no evidence of drusen or choroidal neovascularisation, ruling out age-related macular degeneration. The absence of scalp tenderness and jaw claudication made giant-cell arthritis an unlikely diagnosis as well. Finally, the lack of new vessels at the disc and elsewhere ruled out proliferative diabetic retinopathy. In conclusion, the patient’s symptoms and fundoscopy findings point towards a diagnosis of hypertensive retinopathy.

    • This question is part of the following fields:

      • Ophthalmology
      42.8
      Seconds
  • Question 8 - An 80-year-old man presents with complaints of stiffness and pain in both shoulders....

    Incorrect

    • An 80-year-old man presents with complaints of stiffness and pain in both shoulders. He has experienced a weight loss of one stone over the past eight weeks and reports feeling lethargic with a decreased appetite. Upon investigation, a positive rheumatoid factor, normochromic normocytic anaemia, and a significantly elevated ESR (100 mm/hr) were found. What is the most probable diagnosis?

      Your Answer: SLE

      Correct Answer: Polymyalgia rheumatica

      Explanation:

      Polymyalgia rheumatica is an inflammatory disease that causes pain and stiffness in the shoulder and pelvic girdle muscles, along with systemic symptoms such as fever and weight loss. It is often associated with giant cell arthritis. Diagnosis can be difficult, but response to a moderate dose of steroids is a useful indicator. Non-steroidal anti-inflammatories are not recommended. Other inflammatory conditions should be excluded, such as rheumatoid arthritis, systemic lupus erythematosus, polymyositis, and polyarteritis nodosa.

    • This question is part of the following fields:

      • Rheumatology
      42
      Seconds
  • Question 9 - A 31-year-old woman arrives at 36 weeks gestation in her first pregnancy. She...

    Incorrect

    • A 31-year-old woman arrives at 36 weeks gestation in her first pregnancy. She is admitted after experiencing a seizure following a 2 day period of intense abdominal pain, nausea, vomiting, and visual disturbance. Her family has a history of epilepsy. During the examination, hyperreflexia is observed. What is the probable diagnosis?

      Your Answer: Hyperemesis gravidarum

      Correct Answer: Eclampsia

      Explanation:

      Eclampsia is a medical condition where a pregnant woman with pre-eclampsia experiences seizures. Pre-eclampsia can be identified by early signs such as high blood pressure and protein in the urine. Other symptoms may include abdominal pain, nausea, vomiting, and visual disturbances. While prolonged hyperemesis gravidarum can lead to dehydration and metabolic issues that may cause seizures, this is less likely given the patient’s one-day history. There is no indication in the patient’s history to suggest any other diagnoses.

      Understanding Eclampsia and its Treatment

      Eclampsia is a condition that occurs when seizures develop in association with pre-eclampsia, a pregnancy-induced hypertension that is characterized by proteinuria and occurs after 20 weeks of gestation. To prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop, magnesium sulphate is commonly used. However, it is important to note that this medication should only be given once a decision to deliver has been made. In cases of eclampsia, an IV bolus of 4g over 5-10 minutes should be given, followed by an infusion of 1g/hour. During treatment, it is crucial to monitor urine output, reflexes, respiratory rate, and oxygen saturations. Respiratory depression can occur, and calcium gluconate is the first-line treatment for magnesium sulphate-induced respiratory depression. Treatment should continue for 24 hours after the last seizure or delivery, as around 40% of seizures occur post-partum. Additionally, fluid restriction is necessary to avoid the potentially serious consequences of fluid overload.

      In summary, understanding the development of eclampsia and its treatment is crucial in managing this potentially life-threatening condition. Magnesium sulphate is the primary medication used to prevent and treat seizures, but it should only be given once a decision to deliver has been made. Monitoring vital signs and urine output is essential during treatment, and calcium gluconate should be readily available in case of respiratory depression. Finally, fluid restriction is necessary to avoid complications associated with fluid overload.

    • This question is part of the following fields:

      • Obstetrics
      38.3
      Seconds
  • Question 10 - A 5-year-old boy comes to the clinic with a history of diarrhoea lasting...

    Incorrect

    • A 5-year-old boy comes to the clinic with a history of diarrhoea lasting for 2 weeks. Upon examination, he is found to be dehydrated. Further investigations reveal hypernatraemia. What signs are most likely to be observed during the physical examination?

      Your Answer: Decreased muscle tone

      Correct Answer: Jittery movements

      Explanation:

      Signs indicating hypernatraemic dehydration include tremulous movements, heightened muscle tension, exaggerated reflexes, seizures, and lethargy or unconsciousness.

      Managing Diarrhoea and Vomiting in Children

      Diarrhoea and vomiting are common in young children, with rotavirus being the most common cause of gastroenteritis in the UK. According to the 2009 NICE guidelines, diarrhoea usually lasts for 5-7 days and stops within 2 weeks, while vomiting usually lasts for 1-2 days and stops within 3 days. When assessing hydration status, NICE recommends using normal, dehydrated, or shocked categories instead of the traditional mild, moderate, or severe categories.

      Children younger than 1 year, especially those younger than 6 months, infants who were of low birth weight, and those who have passed six or more diarrhoeal stools in the past 24 hours or vomited three times or more in the past 24 hours are at an increased risk of dehydration. Additionally, children who have not been offered or have not been able to tolerate supplementary fluids before presentation, infants who have stopped breastfeeding during the illness, and those with signs of malnutrition are also at risk.

      If clinical shock is suspected, children should be admitted for intravenous rehydration. For children without evidence of dehydration, it is recommended to continue breastfeeding and other milk feeds, encourage fluid intake, and discourage fruit juices and carbonated drinks. If dehydration is suspected, give 50 ml/kg low osmolarity oral rehydration solution (ORS) solution over 4 hours, plus ORS solution for maintenance, often and in small amounts. It is also important to continue breastfeeding and consider supplementing with usual fluids, including milk feeds or water, but not fruit juices or carbonated drinks.

      In terms of diagnosis, NICE suggests doing a stool culture in certain situations, such as when septicaemia is suspected, there is blood and/or mucous in the stool, or the child is immunocompromised. A stool culture should also be considered if the child has recently been abroad, the diarrhoea has not improved by day 7, or there is uncertainty about the diagnosis of gastroenteritis. Features suggestive of hypernatraemic dehydration include jittery movements, increased muscle tone, hyperreflexia, convulsions, and drowsiness or coma.

    • This question is part of the following fields:

      • Paediatrics
      14.2
      Seconds
  • Question 11 - A 19-year-old woman is admitted to the hospital three days after becoming confused,...

    Correct

    • A 19-year-old woman is admitted to the hospital three days after becoming confused, disoriented, and having an unsteady gait. During the past four months she has been depressed and has declined food. She has lost approximately 12 kg in weight.

      She appears thin and is disoriented in time and place. She reports having double vision. Neither eye abducts normally. Her gait is unsteady although the limbs are strong. The liver and spleen are not enlarged.

      What would be the most appropriate initial step in her treatment?

      Your Answer: Intravenous thiamine

      Explanation:

      Wernicke’s Encephalopathy

      Wernicke’s encephalopathy is a sudden neurological disorder caused by a deficiency of thiamine, a vital nutrient. It is characterized by a triad of symptoms, including acute mental confusion, ataxia, and ophthalmoplegia. The oculomotor findings associated with this condition include bilateral weakness of abduction, gaze evoked nystagmus, internuclear ophthalmoplegia, and vertical nystagmus in the primary position.

      Wernicke’s encephalopathy is commonly linked to chronic alcohol abuse, but it can also occur in individuals with poor nutritional states, such as those with dialysis, advanced malignancy, AIDS, and malnutrition. Urgent treatment is necessary and involves administering 100 mg of fresh thiamine intravenously, followed by 50-100 mg daily. It is crucial to give IV/IM thiamine before treating with IV glucose solutions, as glucose infusions may trigger Wernicke’s disease or acute cardiovascular beriberi in previously unaffected patients or worsen an early form of the disease.

      In summary, Wernicke’s encephalopathy is a serious neurological disorder that requires prompt treatment. It is essential to recognize the symptoms and underlying causes of this condition to prevent further complications. Early intervention with thiamine supplementation can help improve outcomes and prevent the progression of the disease.

    • This question is part of the following fields:

      • Neurology
      38.4
      Seconds
  • Question 12 - A 75-year-old woman comes to the clinic complaining of urinary incontinence when she...

    Incorrect

    • A 75-year-old woman comes to the clinic complaining of urinary incontinence when she coughs or sneezes for the past 6 months. Despite doing pelvic floor exercises for the last 4 months, she has not seen any improvement. She expresses concern about undergoing surgery and prefers medical treatment for her condition. What is the initial pharmacological therapy recommended for her urinary incontinence?

      Your Answer: Oxybutynin

      Correct Answer: Duloxetine

      Explanation:

      Patients with stress incontinence who do not respond to pelvic floor muscle exercises and decline surgical intervention may be prescribed duloxetine, a serotonin-norepinephrine re-uptake inhibitor. This drug increases sphincter tone during the filling phase of urinary bladder function. However, before starting drug therapy, patients should try pelvic floor exercises and consider surgical intervention. Oxybutynin, an anticholinergic drug, is used to treat urge incontinence or symptoms of detrusor overactivity, but it is not recommended for frail, older women at risk of health deterioration. Desmopressin is the preferred drug treatment for children with nocturnal enuresis and may also be used for women with nocturia. Mirabegron is prescribed for patients with urge incontinence who cannot tolerate antimuscarinic/anticholinergic drugs. It is a beta-3 adrenergic agonist that relaxes the bladder.

      Understanding Urinary Incontinence: Causes, Classification, and Management

      Urinary incontinence (UI) is a common condition that affects around 4-5% of the population, with elderly females being more susceptible. Several risk factors contribute to UI, including advancing age, previous pregnancy and childbirth, high body mass index, hysterectomy, and family history. UI can be classified into different types, such as overactive bladder (OAB)/urge incontinence, stress incontinence, mixed incontinence, overflow incontinence, and functional incontinence.

      Initial investigation of UI involves completing bladder diaries for at least three days, vaginal examination, urine dipstick and culture, and urodynamic studies. Management of UI depends on the predominant type of incontinence. For urge incontinence, bladder retraining and bladder stabilizing drugs such as antimuscarinics are recommended. For stress incontinence, pelvic floor muscle training and surgical procedures such as retropubic mid-urethral tape procedures may be offered. Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor, may also be used as an alternative to surgery.

      In summary, understanding the causes, classification, and management of UI is crucial in providing appropriate care for patients. Early diagnosis and intervention can significantly improve the quality of life for those affected by this condition.

    • This question is part of the following fields:

      • Gynaecology
      18.2
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  • Question 13 - A 60-year-old man visits his GP complaining of hand pain that worsens with...

    Correct

    • A 60-year-old man visits his GP complaining of hand pain that worsens with activity and towards the end of the day. He has a medical history of psoriasis and is not currently taking any medications. During the examination, the doctor notes tender bony swellings in three DIP joints on both hands. What is the probable diagnosis?

      Your Answer: Osteoarthritis

      Explanation:

      The presence of Heberden’s nodes, which are bony swellings at the DIP joints, is a characteristic feature of osteoarthritis in the hand. Pain that worsens with activity, rather than rest, is also more indicative of OA than inflammatory arthritis. Psoriatic arthritis can cause swelling of the DIP joints, but the swelling is typically boggy rather than bony, and the pain tends to be worse in the morning and improve with activity. Reactive arthritis is unlikely to cause a DIP predominant arthritis, as it typically presents as a large joint lower limb oligoarthritis, and there is no recent history of infection. Rheumatoid arthritis does not typically affect the DIP joints.

      Understanding Osteoarthritis of the Hand

      Osteoarthritis of the hand, also known as nodal arthritis, is a condition that occurs when the cartilage at synovial joints is lost, leading to the degeneration of underlying bone. It is more common in women, usually presenting after the age of 55, and may have a genetic component. Risk factors include previous joint trauma, obesity, hypermobility, and certain occupations. Interestingly, osteoporosis may actually reduce the risk of developing hand OA.

      Symptoms of hand OA include episodic joint pain, stiffness that worsens after periods of inactivity, and the development of painless bony swellings known as Heberden’s and Bouchard’s nodes. These nodes are the result of osteophyte formation and are typically found at the distal and proximal interphalangeal joints, respectively. In severe cases, there may be reduced grip strength and deformity of the carpometacarpal joint of the thumb, resulting in fixed adduction.

      Diagnosis is typically made through X-ray, which may show signs of osteophyte formation and joint space narrowing before symptoms develop. While hand OA may not significantly impact a patient’s daily function, it is important to manage symptoms through pain relief and joint protection strategies. Additionally, the presence of hand OA may increase the risk of future hip and knee OA, particularly for hip OA.

    • This question is part of the following fields:

      • Musculoskeletal
      29.5
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  • Question 14 - A worried 28-year-old mother expresses concern about a lump that has emerged on...

    Incorrect

    • A worried 28-year-old mother expresses concern about a lump that has emerged on her infant's head, stating with certainty that it was not present at birth and was only noticed half an hour ago. The baby was delivered vaginally with forceps 10 hours ago at 39 weeks gestation.

      Upon examination, there is a clearly defined, soft swelling that does not cross suture lines and is located on the parietal bone. The baby appears to be in good health otherwise, with normal skin color and tone, as well as regular vital signs.

      What is the most probable diagnosis?

      Your Answer: Caput succedaneum

      Correct Answer: Cephalhaematoma

      Explanation:

      The most likely diagnosis for the newborn baby’s well-demarcated, fluctuant swelling that appeared two days after birth is cephalohaematoma. This is a haemorrhage between the skull and periosteum that occurs when blood vessels crossing the periosteum rupture. The swelling is limited by the individual bones and does not cross suture lines. It may take months to resolve as the blood clot is reabsorbed. Cephalohaematoma is more common in prolonged and/or instrumental deliveries and may lead to jaundice, anaemia or hypotension if severe. It may also indicate a linear skull fracture or risk of infection. Caput succedaneum, chignon, normal skull shape, and subgaleal haemorrhage are less likely diagnoses.

      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.

    • This question is part of the following fields:

      • Paediatrics
      67.1
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  • Question 15 - A general practice is auditing the prescribing of antibiotics in patients diagnosed with...

    Incorrect

    • A general practice is auditing the prescribing of antibiotics in patients diagnosed with acute otitis media.
      Regarding use of patients’ records in clinical audit in general practice, which one of the following statements is true for pediatric patients?

      Your Answer: Patient information must be anonymised for clinical audit within the general practice

      Correct Answer: A generic flyer posted to all the patients under the general practice is sufficient notification that their records may be used in a clinical audit

      Explanation:

      Understanding Confidentiality and Anonymity in Clinical Audits

      Clinical audits are an important part of ensuring quality healthcare, but it is crucial to maintain patient confidentiality and anonymity. The NHS Code of Practice on Confidentiality outlines the guidelines for using patient information in clinical audits.

      Patients must be made aware of how their information will be used within the practice, and generic flyers can be used for this purpose. However, patients must also be informed that they have the right to refuse their information being used. Once patients have been informed, consent does not need to be sought from each individual patient.

      Patient information must be anonymised once it is to be used outside of the GP practice, including for research being undertaken by a medical school or a healthcare trust. The six Caldicott principles should be considered when deciding whether to breach patient confidentiality.

      It is not essential to anonymise patient information if a clinical audit is being done within one practice, but patients must still be informed of how their information will be used. Overall, it is important to prioritize patient confidentiality and anonymity in all clinical audits.

    • This question is part of the following fields:

      • Ethics And Legal
      22.5
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  • Question 16 - A 35 year old pregnant woman undergoes routine pregnancy screening blood tests and...

    Correct

    • A 35 year old pregnant woman undergoes routine pregnancy screening blood tests and is found to have an elevated alpha-fetoprotein level. This prompts investigation with ultrasound scanning. The scan reveals a fetus with an anterior abdominal wall defect and mass protruding through, which appears to still be covered with an amniotic sac. What is the standard course of action for managing this condition, based on the probable diagnosis?

      Your Answer: Caesarian section and staged repair

      Explanation:

      If a fetus is diagnosed with exomphalos, a caesarean section is recommended to lower the risk of sac rupture. Elevated levels of alpha-fetoprotein may indicate abdominal wall defects. The appropriate course of action is a caesarian section with staged repair, as this reduces the risk of sac rupture and surgery is not urgent. Immediate repair during caesarian section would only be necessary if the sac had ruptured. Vaginal delivery with immediate repair is only recommended for gastroschisis, as immediate surgery is required due to the lack of a protective sac. Therefore, the other two options are incorrect.

      Gastroschisis and exomphalos are both types of congenital visceral malformations. Gastroschisis refers to a defect in the anterior abdominal wall located just beside the umbilical cord. In contrast, exomphalos, also known as omphalocele, involves the protrusion of abdominal contents through the anterior abdominal wall, which are covered by an amniotic sac formed by amniotic membrane and peritoneum.

      When it comes to managing gastroschisis, vaginal delivery may be attempted, but newborns should be taken to the operating theatre as soon as possible after delivery, ideally within four hours. As for exomphalos, a caesarean section is recommended to reduce the risk of sac rupture. In cases where primary closure is difficult due to lack of space or high intra-abdominal pressure, a staged repair may be undertaken. This involves allowing the sac to granulate and epithelialise over several weeks or months, forming a shell. As the infant grows, the sac contents will eventually fit within the abdominal cavity, at which point the shell can be removed and the abdomen closed.

      Overall, both gastroschisis and exomphalos require careful management to ensure the best possible outcome for the newborn. By understanding the differences between these two conditions and the appropriate steps to take, healthcare professionals can provide effective care and support to both the infant and their family.

    • This question is part of the following fields:

      • Paediatrics
      49.3
      Seconds
  • Question 17 - A 30-year-old woman with rheumatic fever has ongoing shortness of breath following her...

    Incorrect

    • A 30-year-old woman with rheumatic fever has ongoing shortness of breath following her infection. You suspect she may have mitral stenosis.
      What is the most suitable surface anatomical landmark to listen for this murmur?

      Your Answer: Fifth intercostal space, mid-axillary line

      Correct Answer: At the apex beat

      Explanation:

      Surface Locations for Cardiac Auscultation

      Cardiac auscultation is a crucial part of a physical examination to assess the heart’s function. The surface locations for cardiac auscultation are essential to identify the specific valve sounds. Here are the surface locations for cardiac auscultation:

      1. Apex Beat: The mitral valve is best heard over the palpated apex beat. If it cannot be felt, then it should be assumed to be in the fifth intercostal space, mid-clavicular line.

      2. Fifth Intercostal Space, Mid-Axillary Line: This location is too lateral to hear a mitral valve lesion in a non-dilated ventricle.

      3. Second Intercostal Space, Left of the Sternum: The pulmonary valve is located in the second intercostal space, left of the sternum.

      4. Fourth Intercostal Space, Left of the Sternum: The tricuspid valve is located in the fourth intercostal space, left of the sternum.

      5. Xiphisternum: The xiphisternum is not used as a marker for cardiac auscultation, though it is used to guide echocardiography for certain standard views.

      Knowing the surface locations for cardiac auscultation is crucial to identify the specific valve sounds and assess the heart’s function accurately.

    • This question is part of the following fields:

      • Cardiology
      19.4
      Seconds
  • Question 18 - A 23-year-old male presents to the emergency department with complaints of testicular pain....

    Incorrect

    • A 23-year-old male presents to the emergency department with complaints of testicular pain. The pain has been gradually increasing over the past 24 hours and is localized to the left testicle. On examination, the patient appears uncomfortable. His heart rate is 68/min, blood pressure is 118/92 mmHg, respiratory rate is 18/min, and temperature is 38.5 ºC. The left testicle is swollen and erythematosus, and lifting the scrotal skin provides relief. There is no discharge reported. What is the most appropriate next step given the likely diagnosis?

      Your Answer: Send a mid-stream urine (MSU) for microscopy and culture

      Correct Answer: Send a urine first void sample for nucleic acid amplification tests (NAATs)

      Explanation:

      The appropriate investigation for suspected epididymo-orchitis depends on the patient’s age and sexual history. For sexually active young adults, a nucleic acid amplification test (NAAT) for sexually transmitted infections (STIs) is recommended. For older adults with a low-risk sexual history, a mid-stream urine (MSU) for microscopy and culture is appropriate.

      In the given scenario, the patient is a young, sexually active individual with symptoms of epididymo-orchitis. Therefore, the correct investigation is to send a urine first void sample for NAATs to identify Chlamydia trachomatis and Neisseria gonorrhoeae. Ordering a testicular ultrasound is not necessary at this stage, as it is used to investigate testicular masses and would delay treatment time. Similarly, taking bloods and testing for alpha-fetoprotein is not relevant, as this is used to investigate testicular cancer, which presents differently from epididymo-orchitis. Finally, sending an MSU for microscopy and culture is not the primary investigation in this case, as STIs are more likely to be the cause of the infection.

      Epididymo-orchitis is a condition where the epididymis and/or testes become infected, leading to pain and swelling. It is commonly caused by infections spreading from the genital tract or bladder, with Chlamydia trachomatis and Neisseria gonorrhoeae being the usual culprits in sexually active young adults, while E. coli is more commonly seen in older adults with a low-risk sexual history. Symptoms include unilateral testicular pain and swelling, with urethral discharge sometimes present. Testicular torsion, which can cause ischaemia of the testicle, is an important differential diagnosis and needs to be excluded urgently, especially in younger patients with severe pain and an acute onset.

      Investigations are guided by the patient’s age, with sexually transmitted infections being assessed in younger adults and a mid-stream urine (MSU) being sent for microscopy and culture in older adults with a low-risk sexual history. Management guidelines from the British Association for Sexual Health and HIV (BASHH) recommend ceftriaxone 500 mg intramuscularly as a single dose, plus doxycycline 100 mg orally twice daily for 10-14 days if the organism causing the infection is unknown. Further investigations are recommended after treatment to rule out any underlying structural abnormalities.

    • This question is part of the following fields:

      • Surgery
      28.9
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  • Question 19 - A 25-year-old asthmatic presents to the Emergency Department with acute shortness of breath,...

    Incorrect

    • A 25-year-old asthmatic presents to the Emergency Department with acute shortness of breath, unable to speak in complete sentences, tachypnoeic and with a tachycardia of 122 bpm. Severe inspiratory wheeze is noted on examination. The patient is given nebulised salbutamol and ipratropium bromide, and IV hydrocortisone is administered. After 45 minutes of IV salbutamol infusion, there is no improvement in tachypnea and oxygen saturation has dropped to 80% at high flow oxygen. An ABG is taken, showing a pH of 7.50, pO2 of 10.3 kPa, pCO2 of 5.6 kPa, and HCO3− of 28.4 mmol/l. What is the next most appropriate course of action?

      Your Answer: Administer oral magnesium

      Correct Answer: Request an anaesthetic assessment for the Intensive Care Unit (ICU)

      Explanation:

      Why an Anaesthetic Assessment is Needed for a Severe Asthma Attack in ICU

      When a patient is experiencing a severe asthma attack, it is important to take the appropriate steps to provide the best care possible. In this scenario, the patient has already received nebulisers, an iv salbutamol infusion, and hydrocortisone, but their condition has not improved. The next best step is to request an anaesthetic assessment for ICU, as rapid intubation may be required and the patient may need ventilation support.

      While there are other options such as CPAP and NIPPV, these should only be used in a controlled environment with anaesthetic backup. Administering oral magnesium is also not recommended, and iv aminophylline should only be considered after an anaesthetic review. By requesting an anaesthetic assessment for ICU, the patient can receive the best possible care for their severe asthma attack.

    • This question is part of the following fields:

      • Respiratory
      98.4
      Seconds
  • Question 20 - After a snack, which is the primary lipoprotein present in plasma? ...

    Incorrect

    • After a snack, which is the primary lipoprotein present in plasma?

      Your Answer: LDL

      Correct Answer: Chylomicrons

      Explanation:

      Chylomicrons are lipoproteins synthesized in the small intestine from triglyceride and apoproteins. Their primary role is to transport fatty acids to tissues. Chylomicrons contain mainly triglyceride and apoprotein B48, and are released into the lymphatic system before entering the bloodstream. Lipoprotein lipase hydrolyzes triglyceride in chylomicrons, releasing fatty acids to peripheral tissues. Chylomicrons are usually detectable for up to six hours in blood following a meal. Lipoprotein lipase deficiency causes very high chylomicrons, leading to type 1 hyperlipoproteinaemia.

    • This question is part of the following fields:

      • Clinical Sciences
      8.1
      Seconds
  • Question 21 - A 25-year-old man with cystic fibrosis is scheduled for a follow-up appointment with...

    Correct

    • A 25-year-old man with cystic fibrosis is scheduled for a follow-up appointment with his respiratory specialist. He has been experiencing more frequent respiratory infections and is seeking advice on how to minimize his risk of contracting further infections.

      What is the most suitable answer?

      Your Answer: Minimise contact with other cystic fibrosis patients

      Explanation:

      To reduce the risk of getting infections, the 23-year-old woman with cystic fibrosis should minimize contact with other patients with the same condition. It is not recommended to introduce a low-calorie diet, but rather to have a high-calorie diet. Exercise and chest physiotherapy are also recommended. While a salbutamol inhaler can provide relief for breathlessness, it will not reduce the risk of infections. Enzyme supplements are useful in treating cystic fibrosis, but they do not reduce the risk of infection.

      Managing Cystic Fibrosis: A Multidisciplinary Approach

      Cystic fibrosis (CF) is a chronic condition that requires a multidisciplinary approach to management. Regular chest physiotherapy and postural drainage, as well as deep breathing exercises, are essential to maintain lung function and prevent complications. Parents are usually taught how to perform these techniques. A high-calorie diet, including high-fat intake, is recommended to meet the increased energy needs of patients with CF. Vitamin supplementation and pancreatic enzyme supplements taken with meals are also important.

      Patients with CF should try to minimize contact with each other to prevent cross-infection with Burkholderia cepacia complex and Pseudomonas aeruginosa. Chronic infection with Burkholderia cepacia is an important CF-specific contraindication to lung transplantation. In cases where lung transplantation is necessary, careful consideration is required to ensure the best possible outcome.

      Lumacaftor/Ivacaftor (Orkambi) is a medication used to treat cystic fibrosis patients who are homozygous for the delta F508 mutation. Lumacaftor increases the number of CFTR proteins that are transported to the cell surface, while ivacaftor is a potentiator of CFTR that is already at the cell surface. This increases the probability that the defective channel will be open and allow chloride ions to pass through the channel pore.

      It is important to note that the standard recommendation for CF patients has changed from high-calorie, low-fat diets to high-calorie diets to reduce the amount of steatorrhea. With a multidisciplinary approach to management, patients with CF can lead fulfilling lives and manage their condition effectively.

    • This question is part of the following fields:

      • Paediatrics
      182.5
      Seconds
  • Question 22 - A 28-year-old pregnant woman is recuperating from cavernous venous sinus thrombosis. The wall...

    Incorrect

    • A 28-year-old pregnant woman is recuperating from cavernous venous sinus thrombosis. The wall of the sinus has impacted all nerves passing through it.
      What is the most prominent clinical indication of cranial nerve impairment caused by this pathological condition?

      Your Answer: Loss of somatic sensation over the anterior two-thirds of the tongue

      Correct Answer: Ipsilateral corneal reflex absent

      Explanation:

      Trigeminal Nerve Dysfunction and its Effects on Facial and Oral Function

      The trigeminal nerve is responsible for carrying sensory and motor information from the face and oral cavity to the brain. Dysfunction of this nerve can lead to various symptoms affecting facial and oral function.

      One common symptom is the absence of the ipsilateral corneal reflex, which is carried by the ophthalmic division of the trigeminal nerve. Damage to this nerve interrupts the reflex arc of the corneal reflex.

      Another symptom is the inability to resist forced lateral mandibular excursion with the mouth partially open. This is due to damage to the pterygoid muscles, which are innervated by the motor fibers in the mandibular division of the trigeminal nerve.

      Loss of sensation over the lower lip is also a result of trigeminal nerve dysfunction. The mandibular division of the trigeminal nerve carries general somatic afferent nerves from the lower lip.

      Similarly, loss of somatic sensation over the anterior two-thirds of the tongue is also carried by the trigeminal nerve.

      Lastly, the facial nerve innervates the buccinator muscle, which is responsible for the ability to blow out the cheeks. Damage to this nerve can result in the inability to perform this action.

      Overall, dysfunction of the trigeminal nerve can have significant effects on facial and oral function, highlighting the importance of this nerve in everyday activities.

    • This question is part of the following fields:

      • Neurology
      79.5
      Seconds
  • Question 23 - A family planning clinic is consulted by a couple who are hoping to...

    Incorrect

    • A family planning clinic is consulted by a couple who are hoping to have another child. They previously lost their first child to Tay Sachs disease. Upon genetic testing, it is discovered that both parents are carriers of the condition. What is the likelihood that their next child will also be a carrier?

      Your Answer: 25%

      Correct Answer: 50%

      Explanation:

      There are two possible scenarios for inheriting the TSD gene. In the first scenario, known as CC, both parents pass on the TSD gene to their child. In the second scenario, known as Cc, only one parent passes on the TSD gene while the other does not. Regardless of which scenario occurs, the patient will be a carrier and heterozygous. The likelihood of either scenario occurring is 25%.

      Understanding Autosomal Recessive Inheritance

      Autosomal recessive inheritance is a genetic pattern where a disorder is only expressed when an individual inherits two copies of a mutated gene, one from each parent. This means that only homozygotes, individuals with two copies of the mutated gene, are affected. Both males and females are equally likely to be affected, and the disorder may not manifest in every generation, as it can skip a generation.

      When two heterozygote parents, carriers of the mutated gene, have children, there is a 25% chance of having an affected (homozygote) child, a 50% chance of having a carrier (heterozygote) child, and a 25% chance of having an unaffected child. On the other hand, if one parent is homozygote for the gene and the other is unaffected, all the children will be carriers.

      Autosomal recessive disorders are often metabolic in nature and can be life-threatening compared to autosomal dominant conditions. Understanding the inheritance pattern of autosomal recessive disorders is crucial in genetic counseling and family planning.

    • This question is part of the following fields:

      • Paediatrics
      8
      Seconds
  • Question 24 - A mother who has recently moved brings her 9-year-old child to a new...

    Incorrect

    • A mother who has recently moved brings her 9-year-old child to a new local GP for the first time to check for thyroid issues. During the examination, the GP observes that the child has a short neck, flattened nose, and is of short stature. Additionally, the GP notices prominent epicanthic folds and a single palmar crease. What long-term condition is this child at a higher risk for?

      Your Answer: Hyperthyroidism

      Correct Answer: Alzheimer's disease

      Explanation:

      It is believed that around 50% of individuals over the age of 85 may suffer from Alzheimer’s. Asthma is an incorrect option as there is no evidence to suggest that individuals with Down syndrome are at a higher risk of developing the condition. The patient was brought in for a thyroid check as there is a link between hypothyroidism and Down syndrome, but no association between Down syndrome and hyperthyroidism exists, making this option incorrect. While acute lymphocytic leukemia (ALL) is associated with Down syndrome, lymphoma is not, making it an incorrect option.

      Down’s syndrome is a genetic disorder that is characterized by various clinical features. These features include an upslanting of the palpebral fissures, epicanthic folds, Brushfield spots in the iris, a protruding tongue, small low-set ears, and a round or flat face. Additionally, individuals with Down’s syndrome may have a flat occiput, a single palmar crease, and a pronounced sandal gap between their big and first toe. Hypotonia, congenital heart defects, duodenal atresia, and Hirschsprung’s disease are also common in individuals with Down’s syndrome.

      Cardiac complications are also prevalent in individuals with Down’s syndrome, with multiple cardiac problems potentially present. The most common cardiac defect is the endocardial cushion defect, also known as atrioventricular septal canal defects, which affects 40% of individuals with Down’s syndrome. Other cardiac defects include ventricular septal defect, secundum atrial septal defect, tetralogy of Fallot, and isolated patent ductus arteriosus.

      Later complications of Down’s syndrome include subfertility, learning difficulties, short stature, repeated respiratory infections, hearing impairment from glue ear, acute lymphoblastic leukaemia, hypothyroidism, Alzheimer’s disease, and atlantoaxial instability. Males with Down’s syndrome are almost always infertile due to impaired spermatogenesis, while females are usually subfertile and have an increased incidence of problems with pregnancy and labour.

    • This question is part of the following fields:

      • Paediatrics
      22.1
      Seconds
  • Question 25 - A 25-year-old woman comes to the Emergency Department with complaints of vomiting blood....

    Incorrect

    • A 25-year-old woman comes to the Emergency Department with complaints of vomiting blood. She states that she had a heavy night of drinking and has vomited multiple times this morning. After the fourth time, she noticed about a tablespoon of fresh blood mixed in with the vomit. What is the probable reason for her haematemesis?

      Your Answer: Reflux oesophagitis

      Correct Answer: Mallory–Weiss tear

      Explanation:

      Common Causes of Upper Gastrointestinal Bleeding

      Upper gastrointestinal bleeding can be caused by various conditions. Here are some of the most common causes:

      Mallory-Weiss Tear
      This tear in the mucosa is usually caused by repeated vomiting, resulting in increased abdominal pressure. Young patients with a clear history may not require further investigation, and bleeding usually resolves without treatment.

      Oesophageal Varices
      This condition should be considered in patients with signs of chronic liver disease or a history of heavy alcohol intake. Oesophageal varices can be life-threatening, with mortality rates as high as 30%.

      Peptic Ulceration
      Peptic ulceration is a common cause of upper gastrointestinal bleeding, especially in patients who use non-steroidal anti-inflammatory drugs (NSAIDs), smoke, or have Helicobacter pylori infection. Patients with peptic ulcer disease should be tested for H. pylori and treated accordingly.

      Reflux Oesophagitis
      This condition is characterized by heartburn and can be asymptomatic. It is usually an incidental finding on endoscopy and can be treated with antacid medication.

      Haemophilia
      Haemophilia is a condition that increases the risk of bleeding due to the absence of clotting factors. While spontaneous gastrointestinal bleeding is rare, patients may present with spontaneous bleeding in other parts of the body, such as joints.

    • This question is part of the following fields:

      • Gastroenterology
      48.3
      Seconds
  • Question 26 - What is the most frequent location for a carcinoid tumor? ...

    Incorrect

    • What is the most frequent location for a carcinoid tumor?

      Your Answer: Oesophagus

      Correct Answer: Small bowel

      Explanation:

      Carcinoid Tumours and Neuroendocrine Tumours

      Carcinoid tumours are a type of neuroendocrine tumour that originates from endocrine cells. These tumours can be found in various organs, but the most common location is the gastrointestinal tract, particularly the small intestine. The pancreas and lungs are also potential sites for carcinoid tumours. While some carcinoid tumours may not cause any symptoms, larger tumours and those located in the small intestine can lead to carcinoid syndrome. This occurs when the tumour cells release bioactive substances such as serotonin and bradykinin into the bloodstream, causing symptoms such as bronchospasm, diarrhoea, flushing, and heart damage.

      Other types of neuroendocrine tumours are derived from different endocrine cell types and may secrete different hormones. Examples include insulinoma, gastrinoma (Zollinger-Ellison syndrome), VIPoma, and somatostatinoma. Not all neuroendocrine tumours are functional, meaning they may not secrete hormones even if they originate from an endocrine cell.

      Treatment for carcinoid tumours typically involves surgical resection and/or somatostatin analogues such as octreotide, which can reduce the secretion of serotonin by the tumour. Most carcinoid tumours do not metastasize, but those that do may not be suitable for surgical resection depending on the extent of metastasis. However, some patients may benefit from octreotide and chemotherapy agents to manage symptoms.

    • This question is part of the following fields:

      • Oncology
      14.7
      Seconds
  • Question 27 - A 6-month-old girl is brought to the emergency department by her worried father....

    Correct

    • A 6-month-old girl is brought to the emergency department by her worried father. He reports that she has had a low-grade fever and a runny nose for the past week, and in the last few days, she has been struggling to breathe and making grunting noises. He is concerned because she is not eating well and her diapers are not as wet as usual. Upon examination, you observe chest retractions, wheezing, and bilateral inspiratory crackles.
      What is the most suitable treatment for the probable diagnosis?

      Your Answer: Admit for supportive treatment

      Explanation:

      The appropriate action for a child with bronchiolitis is to admit them for supportive treatment, as antibiotics are not necessary. This condition is typically caused by RSV and can be managed with supportive care. However, if the child is experiencing severe respiratory distress and a significant reduction in feeding, they should be admitted to the hospital for treatment. Admitting for IV antibiotics would not be appropriate unless pneumonia or another bacterial infection was suspected. Salbutamol nebulisers are not typically effective for bronchiolitis. Discharging the child home with advice or oral antibiotics would not be appropriate if they are showing signs of potentially serious illness.

      Bronchiolitis is a condition where the bronchioles become inflamed, and it is most commonly caused by respiratory syncytial virus (RSV). This virus is responsible for 75-80% of cases, with other causes including mycoplasma and adenoviruses. Bronchiolitis is most prevalent in infants under one year old, with 90% of cases occurring in those aged 1-9 months. The condition is more serious in premature babies, those with congenital heart disease or cystic fibrosis. Symptoms include coryzal symptoms, dry cough, increasing breathlessness, and wheezing. Hospital admission is often necessary due to feeding difficulties associated with increasing dyspnoea.

      Immediate referral is recommended if the child has apnoea, looks seriously unwell, has severe respiratory distress, central cyanosis, or persistent oxygen saturation of less than 92% when breathing air. Clinicians should consider referral if the child has a respiratory rate of over 60 breaths/minute, difficulty with breastfeeding or inadequate oral fluid intake, or clinical dehydration. Immunofluorescence of nasopharyngeal secretions may show RSV, and management is largely supportive. Humidified oxygen is given via a head box if oxygen saturations are persistently low, and nasogastric feeding may be necessary if children cannot take enough fluid/feed by mouth. Suction may also be used for excessive upper airway secretions. NICE released guidelines on bronchiolitis in 2015 for more information.

    • This question is part of the following fields:

      • Paediatrics
      14.9
      Seconds
  • Question 28 - A 70-year-old man is referred to the medical team on call. He has...

    Incorrect

    • A 70-year-old man is referred to the medical team on call. He has been feeling fatigued for two months and is now experiencing shortness of breath with minimal exertion. He has also had several episodes of syncope with postural hypotension. The GP conducted a blood count and the results showed:

      - Haemoglobin 64 g/L (120-160)
      - MCV 62 fL (80-96)
      - WCC 11.6 ×109L (4-11)
      - Platelets 170 ×109L (150-400)
      - MCH 22 pg (28-32)

      What is the most appropriate next step?

      Your Answer: Emergency upper GI endoscopy

      Correct Answer: Transfuse packed red cells

      Explanation:

      Microcytic Hypochromic Anaemia and the Importance of Blood Transfusion

      This patient is presenting with a microcytic hypochromic anaemia, which is commonly caused by iron deficiency due to occult gastrointestinal (GI) blood loss in a Caucasian population. To determine the cause of the anaemia, a full history and examination should be conducted to look for clues of GI blood loss. Given the microcytic hypochromic picture, it is likely that blood loss has been ongoing for some time.

      Although there is no evidence of haemodynamic compromise or congestive cardiac failure (CCF), the patient is experiencing breathlessness on minimal exertion. This justifies an upfront transfusion to prevent the patient from going into obvious cardiorespiratory failure. At a Hb of 64 g/L in a 72-year-old, the benefits of transfusion outweigh the risks.

      While haematinics such as ferritin, vitamin B12, and folate are important investigations, the most crucial management step is organising a blood transfusion. This will help to address the immediate issue of anaemia and prevent further complications.

    • This question is part of the following fields:

      • Haematology
      28.6
      Seconds
  • Question 29 - A 9-month-old girl is brought to the Emergency Department with a fever, cough,...

    Incorrect

    • A 9-month-old girl is brought to the Emergency Department with a fever, cough, and difficulty breathing. Her vital signs are as follows: temperature 38.5˚C, heart rate 170 bpm, respiratory rate 60/min, oxygen saturation 92% on room air, blood pressure 100/65 mmHg, capillary refill time is 3 seconds. Her parents report that she has been eating poorly for the past few days and has had a high temperature for the past 24 hours. A senior clinician has admitted her and started IV antibiotics, IV fluids, and supplemental oxygen. The patient is currently awake and alert.

      According to the NICE pediatric traffic light system, which of the following in her presentation is a red flag?

      Your Answer: Oxygen saturations

      Correct Answer: Tachypnoea

      Explanation:

      The child’s capillary refill time is normal, as it falls within the acceptable range of less than 3 seconds. However, his tachycardia is a cause for concern, as a heart rate over 160 bpm is considered an amber flag for his age. Although reduced skin turgor is not mentioned, it would be considered a red flag indicating severe dehydration and poor circulation according to the NICE traffic light system. As the child is older than 3 months, a temperature above 38˚C would not be considered a red flag.

      The NICE Feverish illness in children guidelines were introduced in 2007 and updated in 2013. These guidelines use a ‘traffic light’ system to assess the risk of children under 5 years old presenting with a fever. It is important to note that these guidelines only apply until a clinical diagnosis of the underlying condition has been made. When assessing a febrile child, their temperature, heart rate, respiratory rate, and capillary refill time should be recorded. Signs of dehydration should also be looked for. Measuring temperature should be done with an electronic thermometer in the axilla if the child is under 4 weeks old or with an electronic/chemical dot thermometer in the axilla or an infrared tympanic thermometer.

      The risk stratification table includes green for low risk, amber for intermediate risk, and red for high risk. The table includes categories such as color, activity, respiratory, circulation and hydration, and other symptoms. If a child is categorized as green, they can be managed at home with appropriate care advice. If they are categorized as amber, parents should be provided with a safety net or referred to a pediatric specialist for further assessment. If a child is categorized as red, they should be urgently referred to a pediatric specialist. It is important to note that oral antibiotics should not be prescribed to children with fever without an apparent source, and a chest x-ray does not need to be routinely performed if a pneumonia is suspected but the child is not going to be referred to the hospital.

    • This question is part of the following fields:

      • Paediatrics
      31734.6
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  • Question 30 - A 30-year-old woman, who recently gave birth, visits her GP for a regular...

    Incorrect

    • A 30-year-old woman, who recently gave birth, visits her GP for a regular check-up. She expresses her worries about the medications she is taking for different health issues and their potential impact on her breastfeeding baby. Can you advise her on which medications are safe to continue taking?

      Your Answer: Diazepam

      Correct Answer: Lamotrigine

      Explanation:

      Breastfeeding is generally safe with most anti-epileptic drugs, including Lamotrigine which is commonly prescribed for seizures. It is a preferred option for women as it does not affect their ability to bear children. However, Carbimazole and Diazepam active metabolite can be passed on to the baby through breast milk and should be avoided. Isotretinoin effect on breastfed infants is not well studied, but oral retinoids should generally be avoided while breastfeeding.

      Pregnancy and breastfeeding can be a concern for women with epilepsy. It is generally recommended that women continue taking their medication during pregnancy, as the risks of uncontrolled seizures outweigh the potential risks to the fetus. However, it is important for women to take folic acid before pregnancy to reduce the risk of neural tube defects. The use of antiepileptic medication during pregnancy can increase the risk of congenital defects, but this risk is still relatively low. It is recommended to aim for monotherapy and there is no need to monitor drug levels. Sodium valproate is associated with neural tube defects, while carbamazepine is considered the least teratogenic of the older antiepileptics. Phenytoin is associated with cleft palate, and lamotrigine may require a dose increase during pregnancy. Breastfeeding is generally safe for mothers taking antiepileptics, except for barbiturates. Pregnant women taking phenytoin should be given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn.

      A warning has been issued about the use of sodium valproate during pregnancy and in women of childbearing age. New evidence suggests a significant risk of neurodevelopmental delay in children following maternal use of this medication. Therefore, it should only be used if clearly necessary and under specialist neurological or psychiatric advice. It is important for women with epilepsy to discuss their options with their healthcare provider and make informed decisions about their treatment during pregnancy and breastfeeding.

    • This question is part of the following fields:

      • Obstetrics
      15
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SESSION STATS - PERFORMANCE PER SPECIALTY

Ophthalmology (2/2) 100%
Pharmacology (1/1) 100%
Surgery (0/2) 0%
Obstetrics (2/4) 50%
Orthopaedics (1/1) 100%
Rheumatology (0/1) 0%
Paediatrics (3/8) 38%
Neurology (1/2) 50%
Gynaecology (0/1) 0%
Musculoskeletal (1/1) 100%
Ethics And Legal (0/1) 0%
Cardiology (0/1) 0%
Respiratory (0/1) 0%
Clinical Sciences (0/1) 0%
Gastroenterology (0/1) 0%
Oncology (0/1) 0%
Haematology (0/1) 0%
Passmed