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Question 1
Incorrect
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As a physician on the night shift cardiac arrest team, you receive an emergency page requesting immediate assistance on the geriatric ward. Upon arrival, you discover the nursing staff performing chest compressions on an unresponsive patient with no carotid pulse. You instruct them to continue compressions while you apply defibrillator pads to the patient's chest. After a brief pause in compressions, the defibrillator monitor displays a monomorphic, broad complex tachycardia. What is the next best course of action?
Your Answer: Immediately give 3 back-to-back defibrillator shocks followed by CPR
Correct Answer: Immediately give 1 defibrillator shock followed by CPR
Explanation:When pulseless ventricular tachycardia (VT) is identified, the immediate and correct treatment is a single defibrillator shock followed by 2 minutes of CPR. This is in contrast to using intravenous adenosine or amiodarone, which are not appropriate in this scenario. The Resuscitation Council (UK) guidelines now recommend a single shock for ventricular fibrillation (VF) or pulseless VT. Administering 3 back-to-back shocks followed by 1 minute of CPR is part of the Advanced Life Support (ALS) algorithm, but it is not the most appropriate next step in management for a delayed recognition of rhythm like in the above case. In contrast, continued CPR with 30 chest compressions to 2 breaths is appropriate in a basic life support scenario where a defibrillator is not yet available.
The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.
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This question is part of the following fields:
- Cardiovascular
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Question 2
Correct
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A 35-year-old woman presents to the Emergency Department with a 2-day history of central abdominal pain, extreme thirst and polyuria. She has no past medical history but her mother and sister both have diabetes. She is noted to be breathing heavily with breath that smells of acetone. An urgent set of investigations is taken.
Which of the following test results are most likely in this patient?
Select the SINGLE most likely results from the list below.
Your Answer: pH 7.21, partial pressure of pCO2 2.1 kPa, partial pressure of pO211.2 kPa, Na+ 131 mmol/l, K+ 3.1 mmol/l, HCO3 12 mmol/l, glucose 31 mmol/l, ketones 4.2 mmol/l
Explanation:Interpreting Blood Test Results: Distinguishing Diabetic Ketoacidosis from Other Conditions
Diabetic ketoacidosis (DKA) is a life-threatening condition that requires urgent treatment. It can occur as a complication of existing type I diabetes mellitus (DM) or be the first presentation of type I DM. To diagnose DKA, the Joint British Diabetes Societies have established specific criteria, including a blood glucose of more than 11 mmol/l or known DM, a venous pH of less than 7.3 and/or a serum bicarbonate of less than 15 mmol/l, and ketonaemia of more than 3 mmol/l or ketonuria 2+ on dipstick.
When interpreting blood test results, it is important to distinguish DKA from other conditions that may present with similar symptoms. For example, a metabolic acidosis may indicate DKA, but it would also be present in other conditions. In DKA, you would expect a combination of high blood glucose, low pH and serum bicarbonate, and high ketone levels.
Normal blood test results would rule out DKA, but hyperkalaemia may be present despite low total body potassium levels. Potassium levels may need to be monitored and adjusted during treatment. Respiratory alkalosis, indicated by low pCO2 and high pH, would suggest hyperventilation rather than DKA.
In summary, interpreting blood test results is crucial in diagnosing and distinguishing DKA from other conditions. Understanding the specific criteria for DKA diagnosis and recognizing the patterns of abnormal results can help healthcare professionals provide timely and appropriate treatment.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 3
Correct
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A 62-year-old female presents with a red eye on one side that is watering but not causing any pain. She has a history of well-managed Crohn's disease and reports feeling generally healthy. Her vital signs are normal. Upon examination, a small area of redness is observed, but there is no vision impairment, and the patient does not display any sensitivity to light. Eye drops are given, resulting in a brief whitening of the blood vessels. What is the probable diagnosis?
Your Answer: Episcleritis
Explanation:Episcleritis is a condition that can cause redness in the eye, but it is typically not accompanied by pain.
Both episcleritis and scleritis can cause unilateral redness in the eye, tearing, and no sensitivity to light. However, a key difference between the two is that the use of phenylephrine or neosynephrine eye drops will cause the blood vessels in episcleritis to become pale, while this will not occur in scleritis.
In contrast, closed-angle glaucoma often presents with a painful, red eye that is unilateral. The cornea may appear hazy, and the pupil may be mid-dilated. Patients may also experience nausea, vomiting, and see halos around lights.
A stye, or hordeolum, is a bacterial infection of one of the glands in the eyelid. This can cause a tender, red bump on the edge of the eyelid.
Retrobulbar hemorrhage can occur due to various factors, such as AV malformation, trauma, or increased venous pressure. Symptoms include a painful, red eye that may protrude, particularly at night. Patients may also experience reduced vision, nausea, vomiting, and double vision.
Understanding Episcleritis
Episcleritis is a condition that involves the sudden onset of inflammation in the episclera of one or both eyes. While the majority of cases are idiopathic, there are some associated conditions such as inflammatory bowel disease and rheumatoid arthritis. Symptoms of episcleritis include a red eye, mild pain or irritation, watering, and mild photophobia. However, unlike scleritis, episcleritis is typically not painful.
One way to differentiate between the two conditions is by applying gentle pressure on the sclera. If the injected vessels are mobile, it is likely episcleritis. In contrast, scleritis involves deeper vessels that do not move. Phenylephrine drops may also be used to distinguish between the two conditions. If the eye redness improves after phenylephrine, a diagnosis of episcleritis can be made.
Approximately 50% of cases of episcleritis are bilateral. Treatment for episcleritis is typically conservative, with artificial tears sometimes being used. Understanding the symptoms and differences between episcleritis and scleritis can help individuals seek appropriate treatment and management for their eye condition.
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This question is part of the following fields:
- Ophthalmology
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Question 4
Correct
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A 70-year-old man with a history of hypothyroidism is admitted to the Emergency Department after experiencing chest pain. He is diagnosed with acute coronary syndrome and iron-deficiency anemia. A percutaneous coronary intervention is performed, and a coronary artery stent is inserted. Endoscopies of the upper and lower gastrointestinal tract are performed and reported as normal. Upon discharge, he is prescribed aspirin, clopidogrel, ramipril, lansoprazole, simvastatin, and ferrous sulfate in addition to his regular levothyroxine. Six weeks later, he reports feeling constantly fatigued to his GP, who orders routine blood tests. The results show a TSH level of 8.2 mu/l, which is elevated compared to the patient's previous two years of TSH levels within range. Which of the newly prescribed drugs is most likely responsible for the raised TSH?
Your Answer: Ferrous sulphate
Explanation:To avoid reduced absorption of levothyroxine, iron/calcium carbonate tablets should be administered four hours apart.
Managing Hypothyroidism: Dosage, Monitoring, and Side-Effects
Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone. The main treatment for hypothyroidism is levothyroxine, a synthetic form of thyroid hormone. When managing hypothyroidism, it is important to consider the patient’s age, cardiac history, and initial starting dose. Elderly patients and those with ischaemic heart disease should start with a lower dose of 25mcg od, while other patients can start with 50-100mcg od. After a change in dosage, thyroid function tests should be checked after 8-12 weeks to ensure the therapeutic goal of normalising the thyroid stimulating hormone (TSH) level is achieved. The target TSH range is 0.5-2.5 mU/l.
Women with hypothyroidism who become pregnant should have their dose increased by at least 25-50 micrograms levothyroxine due to the increased demands of pregnancy. The TSH should be monitored carefully, aiming for a low-normal value. It is important to note that there is no evidence to support combination therapy with levothyroxine and liothyronine.
While levothyroxine is generally well-tolerated, there are some potential side-effects to be aware of. Over-treatment can lead to hyperthyroidism, while long-term use can reduce bone mineral density. In patients with cardiac disease, levothyroxine can worsen angina and lead to atrial fibrillation. It is also important to be aware of drug interactions, particularly with iron and calcium carbonate, which can reduce the absorption of levothyroxine. These medications should be given at least 4 hours apart.
In summary, managing hypothyroidism involves careful consideration of dosage, monitoring of TSH levels, and awareness of potential side-effects and drug interactions. With appropriate management, patients with hypothyroidism can achieve normal thyroid function and improve their overall health.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 5
Correct
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A 26-year-old presents with a rash that developed after a camping trip. He mentions being bitten by a tick during the trip. He explains that the rash is red, not itchy, and began at the site of the bite before spreading outward. The center of the rash has now cleared, resulting in a bulls-eye appearance. What is the name of this rash?
Your Answer: Erythema migrans
Explanation:Lyme Disease: Symptoms and Progression
Lyme disease is a bacterial infection that is transmitted through the bite of an infected tick. The disease progresses in two stages, with early and later features. The early features of Lyme disease include erythema migrans, which is a small papule that often appears at the site of the tick bite. This papule develops into a larger annular lesion with central clearing, resembling a bulls-eye. This occurs in 70% of patients and is accompanied by systemic symptoms such as malaise, fever, and arthralgia.
In the later stages of Lyme disease, patients may experience cardiovascular symptoms such as heart block and myocarditis. Neurological symptoms may also occur, including cranial nerve palsies and meningitis. Additionally, patients may develop polyarthritis, which is inflammation in multiple joints. It is important to seek medical attention if any of these symptoms occur after a tick bite, as early treatment can prevent the progression of the disease.
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This question is part of the following fields:
- Dermatology
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Question 6
Correct
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A patient with pyogenic meningitis has been admitted and the husband is worried about contracting the disease. What is the recommended prophylaxis in this situation? Choose ONE option from the list provided.
Your Answer: Ciprofloxacin
Explanation:Antibiotics for Meningitis: Recommended Drugs and Dosages
Meningitis is a serious infection that affects the membranes surrounding the brain and spinal cord. Antibiotics are the mainstay of treatment for meningitis, and prophylactic antibiotics are also recommended for close contacts of infected individuals. Here are the recommended drugs and dosages for meningitis treatment and prophylaxis:
Ciprofloxacin: This antibiotic is now the preferred choice for prophylaxis in all age groups and in pregnancy. It is a single dose and readily available in pharmacies, and does not interact with oral contraceptives. It should be given to all close contacts of probable or confirmed meningococcal meningitis, with dosages ranging from 250 mg to 500 mg depending on age.
Metronidazole: This drug has no role in the treatment of acute meningitis.
Ceftriaxone: This antibiotic has good penetration into inflamed meninges and can be given via intramuscular or oral route. It can be used in monotherapy in adults under 60 years old, or in dual therapy with amoxicillin in older adults.
Co-trimoxazole: This drug is an alternative to cefotaxime or ceftriaxone in older adults, and is also used in individuals with meningitis from Listeria monocytogenes infection.
Vancomycin: This antibiotic is recommended in cases of penicillin resistance or suspected penicillin-resistant pneumococci, but should never be used in monotherapy due to doubts about its penetration into adult CSF.
Chemoprophylaxis: Close contacts of infected individuals should receive prophylactic antibiotics to prevent nasopharyngeal carriage of the organism. Ciprofloxacin is the first-line choice, with dosages ranging from 10 mg/kg to 600 mg depending on age. Rifampicin can be given as an alternative for those unable to take ciprofloxacin.
It is important to seek microbiology and public health advice if in doubt about the appropriate antibiotics and dosages for meningitis treatment and prophylaxis.
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This question is part of the following fields:
- Infectious Diseases
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Question 7
Correct
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A 25-year-old patient comes to you with a complaint of painful ulcers on the shaft of his penis. He reports having a new sexual partner, but she has not shown any symptoms. The patient feels generally unwell and has tender enlarged inguinal lymph nodes on both sides. He denies experiencing dysuria or urethral discharge. What is the most probable diagnosis?
Your Answer: Herpes simplex
Explanation:Syphilis, Lymphogranuloma venereum (LGV), and donovanosis (granuloma inguinal) can all lead to the development of genital ulcers that are not accompanied by pain. However, in the case of the patient who has recently changed sexual partners and is not experiencing any other symptoms, herpes simplex is the more probable cause of the painful genital ulcers. Behcets may also cause painful genital ulcers.
STI Ulcers: Causes and Symptoms
Genital ulcers are a common symptom of several sexually transmitted infections (STIs). One of the most common causes of genital ulcers is the herpes simplex virus (HSV) type 2, which is responsible for genital herpes. The primary attack of genital herpes is usually severe and accompanied by fever, while subsequent attacks are less severe and localized to one site. The ulcers caused by genital herpes are multiple and painful.
Syphilis is another STI that can cause genital ulcers. It is caused by the spirochaete Treponema pallidum and is characterized by primary, secondary, and tertiary stages. The primary stage of syphilis is marked by the appearance of a painless ulcer, known as a chancre. The incubation period for syphilis is between 9-90 days.
Chancroid is a tropical disease caused by Haemophilus ducreyi. It causes painful genital ulcers that are associated with unilateral, painful inguinal lymph node enlargement. The ulcers typically have a sharply defined, ragged, undermined border.
Lymphogranuloma venereum (LGV) is caused by Chlamydia trachomatis and typically occurs in three stages. The first stage is marked by a small, painless pustule that later forms an ulcer. The second stage is characterized by painful inguinal lymphadenopathy, while the third stage is proctocolitis. LGV is treated using doxycycline.
Other causes of genital ulcers include Behcet’s disease, carcinoma, and granuloma inguinale, which is caused by Klebsiella granulomatis (previously called Calymmatobacterium granulomatis).
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This question is part of the following fields:
- Reproductive Medicine
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Question 8
Correct
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A 42-year-old man with a 4-week history of a diagnosed anal fissure returns to the general practice surgery for review. He has been regularly using stool softeners along with eating a healthy diet and drinking adequate water. He is still experiencing bleeding and pain on opening his bowels. Examination reveals an anal fissure with no alarming signs.
Which of the following would be the most appropriate management at this stage?Your Answer: Topical glyceryl trinitrate (GTN)
Explanation:Management of Primary Anal Fissure: Treatment Options and Referral Guidelines
Primary anal fissure is a common condition that can cause significant pain and discomfort. The National Institute for Health and Care Excellence (NICE) provides guidelines for the management of this condition, which include prescribing rectal topical glyceryl trinitrate (GTN) 0.4% ointment for 6-8 weeks to relieve pain and aid healing. Referral to a colorectal surgeon is warranted if the fissure does not heal after this period. Botulinum toxin injections can be considered in secondary care settings for chronic and recurrent cases, but only after a trial of topical GTN. Taking no action is not recommended, as it can lead to chronic non-healing ulcers. Trying different laxatives, such as senna, is also unlikely to help and should not be the first-line treatment for anal fissure. Overall, early intervention with topical GTN and appropriate referral can improve outcomes for patients with primary anal fissure.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 9
Correct
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A 67-year-old woman complains of long-standing issues with her hands, but lately, she has been experiencing pain in the joints of her fingers and difficulty opening jars. She has also observed a lump on the dorsal, distal part of her left index finger. What is the most probable diagnosis?
Your Answer: Herberden's node
Explanation:Nodal osteoarthritis is the usual cause of osteoarthritis in the hands, resulting from genetic factors. This type of arthritis leads to the development of Heberden’s nodes, which is swelling in the distal interphalangeal joints, and Bouchard’s nodes, which is swelling in the proximal interphalangeal joints. These nodes do not require any treatment. Pyogenic granuloma is a lesion that appears as a bright red or blood-crusted area, often following trauma, and is more common in children. A ganglion is a cystic lesion that occurs in the joint or synovial sheath of a tendon, most commonly in the wrist. A sebaceous cyst is a mobile, round cyst with a central punctum.
Clinical Diagnosis of Osteoarthritis
Osteoarthritis can be diagnosed clinically without the need for investigations, according to NICE guidelines. This means that a doctor can diagnose the condition based on the patient’s symptoms and physical examination alone. The guidelines state that if a patient is over 45 years old and experiences pain during exercise, but does not have morning stiffness or morning stiffness lasting more than 30 minutes, they can be diagnosed with osteoarthritis.
This approach to diagnosis is based on the fact that osteoarthritis is a degenerative condition that affects the joints, causing pain and stiffness. The symptoms tend to develop gradually over time, and are often worse after periods of inactivity or overuse. By focusing on the patient’s symptoms and history, doctors can make an accurate diagnosis and start treatment as soon as possible.
Overall, the clinical diagnosis of osteoarthritis is a simple and effective way to identify the condition in patients who meet the criteria. It allows for prompt treatment and management of symptoms, which can improve the patient’s quality of life and prevent further joint damage.
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This question is part of the following fields:
- Musculoskeletal
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Question 10
Incorrect
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A 28-year-old female presents to the ENT specialists with a 1-month-history of severe otalgia, temporal headaches, and purulent otorrhoea. She has a medical history of type one diabetes mellitus and no allergies. On examination, the left external auditory canal and periauricular soft tissue are erythematous and tender. What is the most suitable antibiotic treatment for this patient?
Your Answer: Vancomycin
Correct Answer: Ciprofloxacin
Explanation:For patients with diabetes who present with otitis externa, it is important to consider the possibility of malignant otitis externa, which is a severe bacterial infection that can spread to the bony ear canal and cause osteomyelitis. Pseudomonas aeruginosa is the most common cause of this condition, so treatment should involve coverage for this bacteria. Intravenous ciprofloxacin is the preferred antibiotic for this purpose. It is also important to note that diabetic patients with non-malignant otitis externa should also be treated with ciprofloxacin due to their increased risk of developing malignant otitis externa. Clarithromycin and flucloxacillin are not appropriate choices for this condition, and leaving the infection untreated can lead to serious complications.
Malignant Otitis Externa: A Rare but Serious Infection
Malignant otitis externa is a type of ear infection that is uncommon but can be serious. It is typically found in individuals who are immunocompromised, with 90% of cases occurring in diabetics. The infection starts in the soft tissues of the external auditory meatus and can progress to involve the soft tissues and bony ear canal, eventually leading to temporal bone osteomyelitis.
When diagnosing malignant otitis externa, doctors will typically perform a CT scan. Key features in a patient’s medical history include diabetes or immunosuppression, severe and unrelenting ear pain, temporal headaches, and purulent otorrhea. In some cases, patients may also experience dysphagia, hoarseness, and/or facial nerve dysfunction.
If a patient presents with non-resolving otitis externa and worsening pain, they should be referred urgently to an ear, nose, and throat specialist. Treatment typically involves intravenous antibiotics that cover pseudomonal infections.
Overall, while malignant otitis externa is rare, it is important to be aware of its symptoms and risk factors, particularly in immunocompromised individuals. Early diagnosis and treatment can help prevent the infection from progressing and causing more serious complications.
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This question is part of the following fields:
- ENT
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Question 11
Correct
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A 78-year-old man comes to the clinic complaining of a swollen left upper eyelid that has been bothering him for the past 3 months. He recalls noticing a bump on the eyelid that was uncomfortable at first, but it gradually grew into a hard lump. He denies any pain at present and has not experienced any vision problems. Upon examination, the eye appears to be in good health. What is the probable diagnosis?
Your Answer: Chalazion
Explanation:A painless, firm lump in the eyelid is indicative of a chalazion or Meibomian cyst. This occurs when the Meibomian gland becomes blocked, resulting in the formation of a cyst. It is often a consequence of an internal stye (hordeolum internum). Although cysts may resolve on their own, they may require topical antibiotics if they become infected. The absence of pain and the prolonged history suggest that it is not an internal or external stye. Blepharitis and ectropion are unlikely to cause a lump in the eyelid.
Eyelid problems are quite common and can include a variety of issues. One such issue is blepharitis, which is inflammation of the eyelid margins that can cause redness in the eye. Another problem is a stye, which is an infection of the glands in the eyelids. Chalazion, also known as Meibomian cyst, is another eyelid problem that can occur. Entropion is when the eyelids turn inward, while ectropion is when they turn outward.
Styes can come in different forms, such as external or internal. An external stye is an infection of the glands that produce sebum or sweat, while an internal stye is an infection of the Meibomian glands. Treatment for styes typically involves hot compresses and pain relief, with topical antibiotics only being recommended if there is also conjunctivitis present. A chalazion, on the other hand, is a painless lump that can form in the eyelid due to a retention cyst of the Meibomian gland. While most cases will resolve on their own, some may require surgical drainage.
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This question is part of the following fields:
- Ophthalmology
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Question 12
Incorrect
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What is true about calcium homeostasis?
Your Answer: Decreased renal excretion leads to hypercalcaemia in sarcoidosis
Correct Answer: 98% of filtered Ca2+ is reabsorbed in the kidneys
Explanation:Regulation of Calcium in the Body
Calcium is an essential mineral that plays a crucial role in various physiological processes in the body. Here are some key points about the regulation of calcium in the body:
Reabsorption in the Kidneys: The kidneys filter 250 mmol of calcium ions a day in the glomerular filtrate and reabsorb 245 mmol, leading to a net average loss in the urine of about 5 mmol/day. The quantity of calcium ions excreted in the urine per day is partially under the influence of the plasma parathyroid hormone (PTH) level.
Free Calcium Ions in Serum: In serum, most calcium is bound to albumin, and less than 50% of calcium is in the ionized form. The biological effect of calcium is determined by the amount of ionized calcium, rather than the total calcium.
Bone Regulation: Body calcium content is mainly regulated by bone. Intestinal absorption of calcium is the main regulator of calcium content. The active absorption of calcium from the intestine is regulated by calcitriol concentration in the blood.
Calcitonin and Renal Calcium Excretion: When the concentration of calcium rises, the parafollicular cells of the thyroid gland increase their secretion of calcitonin into the blood. At the same time, the parathyroid glands reduce their rate of PTH secretion into the blood. The resulting high levels of calcitonin in the blood stimulate the skeleton to remove calcium from the blood plasma and deposit it as bone. The reduced levels of PTH inhibit removal of calcium from the skeleton and increase the loss of calcium in the urine.
Hypercalcaemia in Sarcoidosis: Absorptive hypercalcaemia occurs from conditions that produce increased serum calcitriol levels, as occurs in sarcoidosis. Increased calcitriol production from activated pulmonary macrophages leads to increased intestinal absorption of calcium, leading to raised calcium levels.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 13
Correct
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Which of the following causes Scarlet fever?
Your Answer: Streptococcus species (group A haemolytic)
Explanation:Scarlet Fever: Symptoms, Causes, and Treatment
Scarlet fever is a bacterial infection caused by toxin-producing strains of the group A streptococcal bacterium (Streptococcus pyogenes). It is a notifiable disease to Public Health England. The symptoms include a sore throat, fever, and a rash with a red strawberry tongue, cervical lymphadenopathy, fine papular rash, tonsillitis, tiredness, headache, nausea, and vomiting.
The condition is treated with fluids, an antipyretic, and phenoxymethylpenicillin. Other causes such as Influenza pneumoniae, Escherichia coli, Haemophilus influenzae, and Parvovirus B19 are not related to scarlet fever. It is important to seek medical attention if you suspect you or your child has scarlet fever.
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This question is part of the following fields:
- Paediatrics
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Question 14
Correct
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A 57-year-old man of Indian descent presents for a hypertension follow-up. He presents a log of blood pressure readings he has taken at home, consistently showing values above 150/90 mmHg. He is currently taking amlodipine and atorvastatin, with optimal dosing for the past year. What would be the best course of action at this point?
Your Answer: Add indapamide
Explanation:The appropriate next step in the treatment of poorly controlled hypertension in a patient already taking a calcium channel blocker is to add a thiazide-like diuretic such as indapamide. This is in accordance with the NICE treatment algorithm, which recommends adding an ACE inhibitor, angiotensin-receptor-blocker, or thiazide-like diuretic in such cases. Adding a thiazide diuretic like bendroflumethiazide would be incorrect. Continuing blood pressure monitoring and reviewing in one month would not be appropriate, as the patient’s hypertension needs to be escalated. Similarly, stopping amlodipine and trialling ramipril with indapamide instead, or stopping amlodipine and trialling ramipril alone, would also be incorrect. The recommended approach is to add an ACE inhibitor or thiazide-like diuretic in combination with the calcium channel blocker.
NICE Guidelines for Managing Hypertension
Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.
The guidelines also provide a flow chart for the diagnosis and management of hypertension. Lifestyle advice, such as reducing salt intake, caffeine intake, and alcohol consumption, as well as exercising more and losing weight, should not be forgotten and is frequently tested in exams. Treatment options depend on the patient’s age, ethnicity, and other factors, and may involve a combination of drugs.
NICE recommends treating stage 1 hypertension in patients under 80 years old if they have target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For patients with stage 2 hypertension, drug treatment should be offered regardless of age. The guidelines also provide step-by-step treatment options, including adding a third or fourth drug if necessary.
New drugs, such as direct renin inhibitors like Aliskiren, may have a role in patients who are intolerant of more established antihypertensive drugs. However, trials have only investigated the fall in blood pressure and no mortality data is available yet. Patients who fail to respond to step 4 measures should be referred to a specialist. The guidelines also provide blood pressure targets for different age groups.
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This question is part of the following fields:
- Cardiovascular
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Question 15
Correct
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A 38-year-old female patient comes to the clinic and inquires about breast cancer screening. She mentions that her mother was recently diagnosed with breast cancer. Upon further inquiry, she reveals that her aunt (on her mother's side) had ovarian cancer and her uncle (on her father's side) had colorectal cancer. What is the next course of action in managing this patient?
Your Answer: Refer to the breast clinic
Explanation:If an individual has a family history of breast cancer and ovarian cancer, they should be referred to a breast clinic at a younger age. This is especially important if they have a first-degree or second-degree relative who was diagnosed with breast cancer at any age, as well as a first-degree or second-degree relative who was diagnosed with ovarian cancer at any age (with one of these relatives being a first-degree relative). It is not safe to wait for routine screening, as there may be a risk of familial breast cancer. It is also important to note that breast cancer can still be present even if there is no lump detected during examination. A colonoscopy is not necessary in this case, as the individual is at an increased risk of breast cancer.
Breast cancer screening is offered to women aged 50-70 years through the NHS Breast Screening Programme. Mammograms are provided every three years, and women over 70 years are encouraged to make their own appointments. While the effectiveness of breast screening is debated, it is estimated that the programme saves around 1,400 lives annually.
For those with familial breast cancer, NICE guidelines recommend referral if there is a family history of breast cancer with any of the following: diagnosis before age 40, bilateral breast cancer, male breast cancer, ovarian cancer, Jewish ancestry, sarcoma in a relative under 45 years, glioma or childhood adrenal cortical carcinomas, complicated patterns of multiple cancers at a young age, or paternal history of breast cancer with two or more relatives on the father’s side. Women at increased risk due to family history may be offered screening at a younger age. Referral to a breast clinic is recommended for those with a first-degree relative diagnosed with breast cancer before age 40, a first-degree male relative with breast cancer, a first-degree relative with bilateral breast cancer before age 50, two first-degree relatives or one first-degree and one second-degree relative with breast cancer, or a first- or second-degree relative with breast and ovarian cancer.
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This question is part of the following fields:
- Genetics
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Question 16
Correct
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A 56-year-old man has been diagnosed with gout and you are discussing ways to prevent future attacks. What is the most probable trigger for a gout attack?
Your Answer: Sardines
Explanation:To prevent gout, it is recommended to steer clear of foods that are rich in purines such as liver, kidneys, seafood, oily fish like mackerel and sardines, and yeast-based products.
Gout is caused by chronic hyperuricaemia and is managed acutely with NSAIDs or colchicine. Urate-lowering therapy (ULT) is recommended for patients with >= 2 attacks in 12 months, tophi, renal disease, uric acid renal stones, or prophylaxis if on cytotoxics or diuretics. Allopurinol is first-line ULT, with an initial dose of 100 mg od and titrated to aim for a serum uric acid of < 300 µmol/l. Lifestyle modifications include reducing alcohol intake, losing weight if obese, and avoiding high-purine foods. Consideration should be given to stopping precipitating drugs and losartan may be suitable for patients with coexistent hypertension.
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This question is part of the following fields:
- Musculoskeletal
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Question 17
Correct
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A 62-year-old male presents to the liver clinic with persistently abnormal liver function tests over the past 2 months. He recently completed a course of co-amoxiclav for a respiratory tract infection. The patient has a history of intravenous drug use, hypertension, and type two diabetes mellitus. His BMI is 31 kg/m², and he consumes 15 units of alcohol per week. A liver ultrasound showed increased hepatic echogenicity. The following liver function tests and virology report were obtained:
- Bilirubin: 22 µmol/L (3 - 17)
- ALP: 118 u/L (30 - 100)
- ALT: 170 u/L (5 - 30)
- AST: 63 u/L (10 - 40)
- γGT: 52 u/L (8 - 60)
- Albumin: 32 g/L (35 - 50)
- HBsAg: Negative
- Anti-HBs: Positive
- Anti-HBc: Negative
- Anti-HCV: Negative
- HCV PCR: Negative
What is the most likely cause of this patient's abnormal liver function tests?Your Answer: Non-alcoholic fatty liver disease
Explanation:Abnormal liver function tests in the context of obesity may suggest the presence of non-alcoholic fatty liver disease.
Non-Alcoholic Fatty Liver Disease: Causes, Features, and Management
Non-alcoholic fatty liver disease (NAFLD) is a prevalent liver disease in developed countries, primarily caused by obesity. It encompasses a range of conditions, from simple steatosis (fat accumulation in the liver) to steatohepatitis (fat with inflammation) and may progress to fibrosis and liver cirrhosis. Insulin resistance is believed to be the primary mechanism leading to steatosis, making NAFLD a hepatic manifestation of metabolic syndrome. Non-alcoholic steatohepatitis (NASH) is a type of liver damage similar to alcoholic hepatitis but occurs in the absence of alcohol abuse. It affects around 3-4% of the general population and may be responsible for some cases of cryptogenic cirrhosis.
NAFLD is usually asymptomatic, but hepatomegaly, increased echogenicity on ultrasound, and elevated ALT levels are common features. The enhanced liver fibrosis (ELF) blood test is recommended by NICE to check for advanced fibrosis in patients with incidental NAFLD. If the ELF blood test is not available, non-invasive tests such as the FIB4 score or NAFLD fibrosis score, in combination with a FibroScan, may be used to assess the severity of fibrosis. Patients with advanced fibrosis should be referred to a liver specialist for further evaluation, which may include a liver biopsy to stage the disease more accurately.
The mainstay of NAFLD treatment is lifestyle changes, particularly weight loss, and monitoring. Research is ongoing into the role of gastric banding and insulin-sensitizing drugs such as metformin and pioglitazone. While there is no evidence to support screening for NAFLD in adults, NICE guidelines recommend the management of incidental NAFLD findings.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 18
Correct
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A 68-year-old man comes to the Emergency Department with severe inflammation of his first metatarsophalangeal joint. He reports swelling and tenderness of the joint and a sample of fluid is sent for microscopy. He has a medical history of hypertension and duodenal ulcers.
What is the most suitable initial medication to prescribe?
Choose ONE option from the list provided.Your Answer: Colchicine
Explanation:Managing Gout: Treatment Options and Contraindications
Gout is a type of arthritis caused by the deposition of urate crystals in the synovial fluid. Chronic hyperuricemia is the primary cause of this condition. The acute management of gout involves the use of non-steroidal anti-inflammatory drugs (NSAIDs) or colchicine as first-line treatment. However, the maximum dose of NSAIDs should be prescribed until 1-2 days after the symptoms have settled, and gastroprotection may also be necessary. Colchicine has a slower onset of action and may cause diarrhea as a side effect. Oral steroids or intra-articular steroid injections may be considered if NSAIDs and colchicine are contraindicated. Allopurinol is not recommended during the acute phase but is useful for preventing recurrent attacks of gout. Diclofenac and indomethacin are contraindicated in patients with duodenal ulcers, and colchicine is a suitable alternative for the treatment of gout. Diazepam, a benzodiazepine, is not useful in the treatment of gout as it does not have anti-inflammatory or analgesic properties.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 19
Correct
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A child is admitted for assessment on the Infectious Diseases Ward and is identified to have a notifiable disease. The nurses suggest that you should inform the Consultant in Communicable Disease Control (CCDC).
Which of the following is the most likely diagnosis (recognised as a notifiable disease)?Your Answer: Malaria
Explanation:Notifiable Diseases in England
In England, Public Health England is responsible for detecting possible outbreaks of disease and epidemics as quickly as possible. The accuracy of diagnosis is not the primary concern, and since 1968, clinical suspicion of a notifiable infection is all that is required. Malaria, caused by various species of Plasmodium, is a notifiable disease. However, Mycoplasma pneumonia, HIV, necrotising fasciitis, and acute rheumatic fever are not notifiable diseases in England.
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This question is part of the following fields:
- Infectious Diseases
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Question 20
Correct
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A 72-year-old man is admitted after a fall and a period of time on the floor. He has a long history of chronic illness and immobility, with medications for hypertension, cardiac failure and chronic chest disease.
On examination, he is obese, with a blood pressure of 110/75 mmHg, a pulse of 100 beats per minute and a temperature of 38.5°C. Respiratory examination reveals evidence of right lower lobe consolidation. He has no signs of traumatic bone injury.
Investigations reveal the following:
Investigation Result Normal value
Chest X-ray Right lower lobe pneumonia
Haemoglobin (Hb) 131 g/l 135–175 g/l
White cell count (WCC) 15.4 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 312 × 109/l 150–400 × 109/l
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 6.7 mmol/l 3.5–5.0 mmol/l
Urea 15.1 mmol/l 2.5–6.5 mmol/l
Creatinine (Cr) 312 μmol/l 50–120 µmol/l
Creatine kinase (CK) 1524 IU/l 23–175 IU/l
Catheter specimen of urine: Red/brown in colour.
+++ for blood.
No red cells on microscopy
Which of the following diagnoses fits best with this clinical picture?Your Answer: Rhabdomyolysis
Explanation:The patient’s elevated CK levels and urine test indicating blood without cells strongly suggest rhabdomyolysis as the cause of their kidney failure, likely due to their fall and prolonged time on the floor. Treatment should focus on managing hyperkalemia and ensuring proper hydration. While acute myocardial infarction cannot be ruled out entirely, the absence of discolored urine and other symptoms make rhabdomyolysis a more likely diagnosis. Acute tubular necrosis is also unlikely, as there are no epithelial cells present on urinalysis. While sepsis should be considered, the presence of red-colored urine and a history of a fall make rhabdomyolysis the most probable cause. Polymyositis, a type of inflammatory myopathy, typically presents with proximal myopathy and is more commonly seen in middle-aged women.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 21
Incorrect
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You are asked to evaluate a 19-year-old student who has recently returned from a gap-year trip to India. He complains of extreme fatigue and loss of appetite during the last week of his journey and noticed that he had jaundice just before his return home. He denies being an intravenous drug user and having unprotected sexual intercourse. Additionally, he did not receive any blood transfusions or tattoos during his trip. He reports having a fever, but it subsided once his jaundice appeared. After conducting liver function tests (LFTs), you find that his alanine aminotransferase (ALT) level is 950 iu/l (reference range 20–60 iu/l), total bilirubin level is 240 μmol/l (reference range <20 μmol/l), and his alkaline phosphatase (ALP) level is slightly above the upper limit of normal. His white blood cell count, albumin level, and prothrombin times are all normal. What is the most probable diagnosis based on this clinical presentation?
Your Answer: Hepatitis B
Correct Answer: Hepatitis A
Explanation:Overview of Viral Infections and Their Clinical Manifestations
Hepatitis A, B, and C, leptospirosis, and cytomegalovirus (CMV) are all viral infections that can cause a range of clinical manifestations. Hepatitis A is typically transmitted through ingestion of contaminated food and is most common in resource-poor regions. Leptospirosis is associated with exposure to rodents and contaminated water or soil. Hepatitis B is transmitted through blood and sexual contact, while hepatitis C is most commonly spread through injection drug use. CMV is typically asymptomatic but can cause severe disease in immunocompromised individuals. Understanding the transmission and clinical manifestations of these viral infections is important for accurate diagnosis and appropriate treatment.
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This question is part of the following fields:
- Infectious Diseases
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Question 22
Correct
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A 32-year-old woman is brought to the Emergency Department after fainting. She is now conscious and able to provide a medical history. The patient mentions having a condition, but cannot recall the name. She shows the doctor the medication she takes, which is a somatostatin analogue.
What medical condition can be treated with somatostatin analogues?Your Answer: Acromegaly
Explanation:Acromegaly is a condition caused by excessive secretion of growth hormone from an anterior pituitary tumor, resulting in enlarged hands, feet, and jaw, as well as other symptoms. While surgery is the preferred treatment, somatostatin analogues such as octreotide and lanreotide can be used if surgery fails. Somatostatin is an inhibitory hormone that can suppress growth hormone release. However, it can also cause side effects such as bradycardia, hypothyroidism, and hypoglycemia. Cushing’s disease, caused by excess adrenocorticotropic hormone, can be treated with pituitary gland removal, radiotherapy, or cortisol-inhibiting medications. Conn syndrome, or primary aldosteronism, is usually treated with surgery. Type I diabetes is treated with insulin, while Type II diabetes is treated with insulin and oral hypoglycemic agents. Parathyroid adenomas are also treated surgically.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 23
Correct
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A 31-year-old female patient visits her doctor with complaints of feeling unwell for the past week. She reports experiencing headaches and mild abdominal discomfort. She denies having any diarrhea but mentions severe constipation. Recently, she returned from a 3-week trip to India. During the examination, her temperature is recorded as 38.5ºC, and she appears bloated. Additionally, a sparse macular rash is observed on her chest. What is the probable causative agent for this presentation?
Your Answer: Salmonella typhi
Explanation:While salmonella can cause diarrhoea, typhoid fever is more likely to result in constipation. This is a typical symptom of typhoid fever, along with the appearance of rose spots. It’s important to note that constipation can be a significant indicator of this illness. In contrast, Campylobacter jejuni infection usually causes bloody diarrhoea and abdominal pain. E. coli is a common cause of watery diarrhoea, but certain strains like E. coli O157:H7 can lead to severe abdominal cramping, vomiting, and bloody diarrhoea. Giardiasis can cause similar symptoms such as bloating and abdominal pain, but it usually results in chronic diarrhoea. Shigellosis typically causes abdominal pain and diarrhoea, which may or may not be bloody.
Enteric fever, also known as typhoid or paratyphoid, is caused by Salmonella typhi and Salmonella paratyphi respectively. These bacteria are not normally found in the gut and are transmitted through contaminated food and water or the faecal-oral route. The symptoms of enteric fever include headache, fever, and joint pain, as well as abdominal pain and distension. Constipation is more common in typhoid than diarrhoea, and rose spots may appear on the trunk in some patients. Complications can include osteomyelitis, gastrointestinal bleeding or perforation, meningitis, cholecystitis, and chronic carriage. Chronic carriage is more likely in adult females and occurs in approximately 1% of cases.
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This question is part of the following fields:
- Infectious Diseases
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Question 24
Correct
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A 45-year-old woman has been diagnosed with Addison's disease. What medications are typically prescribed in combination for this condition?
Your Answer: Hydrocortisone + fludrocortisone
Explanation:Addison’s disease is a condition that requires patients to undergo both glucocorticoid and mineralocorticoid replacement therapy. This treatment usually involves taking a combination of hydrocortisone and fludrocortisone. Hydrocortisone is typically given in 2 or 3 divided doses, with patients requiring 20-30 mg per day, mostly in the first half of the day. Patient education is crucial, and it is essential to emphasize the importance of not missing glucocorticoid doses. Additionally, patients should consider wearing MedicAlert bracelets and steroid cards, and they should be provided with hydrocortisone for injection with needles and syringes to treat an adrenal crisis.
During an intercurrent illness, it is crucial to manage the glucocorticoid dose properly. In simple terms, the glucocorticoid dose should be doubled, while the fludrocortisone dose should remain the same. The Addison’s Clinical Advisory Panel has produced guidelines that detail specific scenarios, and patients should refer to these guidelines for more information. It is essential to discuss how to adjust the glucocorticoid dose during an intercurrent illness with a healthcare professional. Proper management of Addison’s disease is crucial to ensure that patients can lead healthy and fulfilling lives.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 25
Incorrect
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A 48-year-old woman is referred to the oncology clinic by the local general surgeon. She has undergone a mastectomy for carcinoma of the right breast.
Which of the following factors is associated with a poor prognosis in patients with breast cancer?Your Answer: Oestrogen receptor-positive tumour
Correct Answer: Young age
Explanation:Prognostic Factors in Breast Cancer and Their Impact on Survival
Breast cancer prognosis is influenced by several factors, including axillary nodal status, tumour type and grade, lymphatic/vascular invasion/proliferation markers, ethnicity, patient age at diagnosis, oestrogen receptor and progesterone receptor status, and HER2/neu overexpression. Younger patients tend to have more aggressive tumours, which increases their risk of recurrence and mortality over their lifetimes.
Oestrogen receptor-positive tumours have a better prognosis and can be treated with tamoxifen, which increases survival rates. Progesterone receptor-positive tumours also have a good prognosis and can be targeted using HER2 receptor modulators like tamoxifen. On the other hand, oestrogen receptor-negative and progesterone receptor-negative tumours are associated with a poor prognosis.
Tumour grade is another important prognostic factor, with high-grade tumours being linked to a poorer prognosis. Additionally, a positive lymph node status is a poor prognostic factor, as the risk of recurrence increases with the number of affected nodes.
In summary, understanding these prognostic factors can help healthcare professionals tailor treatment plans and provide patients with more accurate information about their prognosis and survival.
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This question is part of the following fields:
- Haematology/Oncology
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Question 26
Correct
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A 59 year old man with a history of aortic stenosis presents to his cardiology clinic with complaints of worsening shortness of breath and fainting episodes. His recent ECHO reveals a mean gradient of 45 mmHg and mild aortic regurgitation, while his ECG shows left ventricular hypertrophy, left bundle branch block, and a prolonged PR interval. What factor is most indicative of the need for valve replacement surgery?
Your Answer: Presence of symptoms
Explanation:Aortic valve replacement is typically recommended for patients with severe aortic stenosis who are experiencing symptoms such as dyspnea, chest pain, and syncope. Without treatment, these symptoms can lead to a mortality rate of 2-3 years. However, the decision to perform valve replacement on asymptomatic patients is a topic of debate.
Aortic Stenosis: Symptoms, Causes, and Management
Aortic stenosis is a condition characterized by the narrowing of the aortic valve, which can lead to various symptoms. These symptoms include chest pain, dyspnea, syncope, and a characteristic ejection systolic murmur that radiates to the carotids. Severe aortic stenosis can also cause a narrow pulse pressure, slow rising pulse, delayed ESM, soft/absent S2, S4, thrill, and left ventricular hypertrophy or failure. The most common causes of aortic stenosis are degenerative calcification in older patients and bicuspid aortic valve in younger patients.
If a patient is asymptomatic, observation is usually recommended. However, if the patient is symptomatic or has a valvular gradient greater than 40 mmHg with features such as left ventricular systolic dysfunction, valve replacement is necessary. Surgical AVR is the preferred treatment for young, low/medium operative risk patients, while TAVR is used for those with a high operative risk. Balloon valvuloplasty may be used in children without aortic valve calcification and in adults with critical aortic stenosis who are not fit for valve replacement.
In summary, aortic stenosis is a condition that can cause various symptoms and requires prompt management to prevent complications. The causes of aortic stenosis vary, and treatment options depend on the patient’s age, operative risk, and overall health.
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This question is part of the following fields:
- Cardiovascular
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Question 27
Correct
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A 39-year-old male patient comes to the clinic complaining of scrotal swelling and discomfort that has been going on for three months. Upon examination, there is swelling on one side of the scrotum that illuminates when light is shone on it. The swelling is soft and painless, and the testis cannot be fully felt due to the presence of fluid. What is the best next step to take?
Your Answer: Refer urgently for testicular ultrasound
Explanation:An ultrasound is necessary for adult patients with a hydrocele to rule out any underlying causes, such as a tumor. Although the most common cause of a non-acute hydrocele is unknown, it is crucial to exclude malignancy first. Therefore, providing reassurance or reevaluating the patient at a later time would only be appropriate after a testicular ultrasound has ruled out cancer. Testicular biopsy should not be used to investigate suspected testicular cancer as it may spread the malignancy through seeding along the needle’s track. While a unilateral hydrocele may be an uncommon presentation of a renal carcinoma invading the renal vein, a CTAP would not be the initial investigation in this case. If malignancy is confirmed, CT may be useful in staging the malignancy.
A hydrocele is a condition where fluid accumulates within the tunica vaginalis. There are two types of hydroceles: communicating and non-communicating. Communicating hydroceles occur when the processus vaginalis remains open, allowing peritoneal fluid to drain into the scrotum. This type of hydrocele is common in newborn males and usually resolves within a few months. Non-communicating hydroceles occur when there is excessive fluid production within the tunica vaginalis. Hydroceles can develop secondary to conditions such as epididymo-orchitis, testicular torsion, or testicular tumors.
The main feature of a hydrocele is a soft, non-tender swelling of the hemi-scrotum that is usually located anterior to and below the testicle. The swelling is confined to the scrotum and can be transilluminated with a pen torch. If the hydrocele is large, the testis may be difficult to palpate. Diagnosis can be made clinically, but ultrasound is necessary if there is any doubt about the diagnosis or if the underlying testis cannot be palpated.
Management of hydroceles depends on the severity of the presentation. Infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years. In adults, a conservative approach may be taken, but further investigation, such as an ultrasound, is usually warranted to exclude any underlying cause, such as a tumor.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 28
Correct
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A 68-year-old man presents with complaints of weight loss and fatigue that have been ongoing for several months. Upon examination, the only notable finding is pallor. A blood film reveals the presence of immature blasts, and genetic testing shows the presence of a chromosomal translocation t(9;22) - the Philadelphia chromosome. Further investigations reveal the following results: Hb of 95 g/l (normal range: 135-175 g/l), leukocytes of 62 × 109/l (normal range: 4.0-11.0 × 109/l), and PLT of 101 × 109/l (normal range: 150-400 × 109/l). What is the most likely diagnosis?
Your Answer: Chronic myeloid leukaemia (CML)
Explanation:Chronic myeloid leukaemia (CML) is a rare form of cancer that occurs due to the abnormal growth of myeloid precursors or blasts. This leads to an increase in white blood cells and a decrease in the normal functions of the bone marrow, resulting in anaemia and thrombocytopenia. CML is most commonly seen in people between the ages of 60 and 70 and has a slow onset that can last for months or even years. The majority of cases are caused by a genetic mutation called the Philadelphia chromosome, which produces a protein that promotes the growth of cancer cells. Symptoms of CML include fatigue, weight loss, night sweats, abdominal distension, and left upper quadrant pain. Treatment for CML involves inhibiting the genetic mutation with a drug called imatinib.
Acute lymphocytic leukaemia (ALL) is a type of cancer that occurs due to the abnormal growth of immature lymphocytes, which replace the normal cells of the bone marrow and lead to a decrease in blood cell production. ALL is most commonly seen in children and presents with symptoms such as anaemia, fever, and abdominal pain. Diagnosis is made through bone marrow biopsy and genetic analysis, which can reveal chromosomal abnormalities associated with the disease.
Hodgkin’s lymphoma (HL) is a type of cancer that typically presents with enlarged lymph nodes and is associated with the presence of Reed-Sternberg cells, which are abnormal B cells. Multiple myeloma (MM) is a cancer that affects plasma cells in the bone marrow, leading to a decrease in blood cell production and other symptoms such as hypercalcemia and kidney dysfunction. Non-Hodgkin’s lymphoma (NHL) is a type of cancer that arises from the abnormal growth of B cells, T cells, or natural killer cells and can be caused by genetic mutations, infections, or chronic inflammation. Symptoms of NHL include enlarged lymph nodes throughout the body.
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This question is part of the following fields:
- Haematology/Oncology
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Question 29
Correct
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A 52-year-old woman presents with lethargy and pruritus. She reports having a normal appetite and no weight loss. Upon examination, there is no clinical jaundice or organomegaly. The following blood test results are obtained:
- Hb: 12.8 g/dl
- Platelets: 188 * 109/l
- WBC: 6.7 * 109/l
- Na+: 140 mmol/l
- K+: 3.9 mmol/l
- Urea: 6.2 mmol/l
- Creatinine: 68 µmol/l
- Bilirubin: 30 µmol/l
- ALP: 231 u/l
- ALT: 38 u/l
- γGT: 367 u/l
- Albumin: 39 g/l
What additional test is most likely to lead to a diagnosis?Your Answer: Anti-mitochondrial antibodies
Explanation:Primary Biliary Cholangitis: A Chronic Liver Disorder
Primary biliary cholangitis, previously known as primary biliary cirrhosis, is a chronic liver disorder that is commonly observed in middle-aged women. The exact cause of this condition is not yet fully understood, but it is believed to be an autoimmune disease. The disease is characterized by the progressive damage of interlobular bile ducts due to chronic inflammation, leading to cholestasis and eventually cirrhosis. The most common symptom of primary biliary cholangitis is itching in middle-aged women.
This condition is often associated with other autoimmune diseases such as Sjogren’s syndrome, rheumatoid arthritis, systemic sclerosis, and thyroid disease. Early symptoms of primary biliary cholangitis may be asymptomatic or may include fatigue, pruritus, and cholestatic jaundice. Late symptoms may progress to liver failure. Diagnosis of primary biliary cholangitis involves immunology tests such as anti-mitochondrial antibodies (AMA) M2 subtype and smooth muscle antibodies, as well as imaging tests to exclude an extrahepatic biliary obstruction.
The first-line treatment for primary biliary cholangitis is ursodeoxycholic acid, which slows down the progression of the disease and improves symptoms. Cholestyramine is used to alleviate pruritus, and fat-soluble vitamin supplementation is recommended. In severe cases, liver transplantation may be necessary, especially if bilirubin levels exceed 100. However, recurrence in the graft can occur, but it is not usually a problem. Complications of primary biliary cholangitis include cirrhosis, portal hypertension, ascites, variceal hemorrhage, osteomalacia, osteoporosis, and an increased risk of hepatocellular carcinoma.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 30
Correct
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A 27-year-old female patient visits the genitourinary medicine clinic seeking treatment for recurring genital warts. Which virus is the most probable cause of this condition?
Your Answer: Human papilloma virus 6 & 11
Explanation:Understanding Genital Warts
Genital warts, also known as condylomata accuminata, are a common reason for visits to genitourinary clinics. These warts are caused by various types of the human papillomavirus (HPV), with types 6 and 11 being the most common culprits. It is important to note that HPV, particularly types 16, 18, and 33, can increase the risk of cervical cancer.
The warts themselves are small, fleshy protrusions that are typically 2-5mm in size and may be slightly pigmented. They can cause discomfort, itching, and even bleeding. Treatment options for genital warts include topical podophyllum or cryotherapy, depending on the location and type of lesion. Topical agents are generally used for multiple, non-keratinised warts, while solitary, keratinised warts respond better to cryotherapy. Imiquimod, a topical cream, is often used as a second-line treatment. It is important to note that genital warts can be resistant to treatment, and recurrence is common. However, most anogenital HPV infections clear up on their own within 1-2 years without intervention.
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This question is part of the following fields:
- Reproductive Medicine
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