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Question 1
Correct
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A 70-year-old man comes in to discuss the results of laboratory tests for nail clippings taken 8 weeks ago. He had previously presented with thickening and discoloration of all the nails on his right foot. He has a medical history of type 2 diabetes and hypertension. He is currently in good health and taking metformin, simvastatin, and ramipril. The lab report confirms the presence of onychomycosis. What treatment options should be offered to him?
Your Answer: Oral terbinafine
Explanation:Oral terbinafine is recommended for treating dermatophyte nail infections.
Understanding Fungal Nail Infections
Fungal nail infections, also known as onychomycosis, can affect any part of the nail or the entire nail unit. However, toenails are more susceptible to infection than fingernails. The primary cause of fungal nail infections is dermatophytes, with Trichophyton rubrum being the most common. Yeasts, such as Candida, and non-dermatophyte moulds can also cause fungal nail infections. Risk factors include increasing age, diabetes mellitus, psoriasis, and repeated nail trauma.
The most common symptom of fungal nail infections is unsightly nails, which can be thickened, rough, and opaque. Other conditions, such as psoriasis, repeated trauma, lichen planus, and yellow nail syndrome, can mimic fungal nail infections. To confirm a diagnosis, nail clippings and scrapings of the affected nail should be examined under a microscope and cultured.
Asymptomatic fungal nail infections do not require treatment unless the patient is bothered by the appearance. However, if a dermatophyte or Candida infection is confirmed, treatment is necessary. Topical treatment with amorolfine 5% nail lacquer is recommended for limited involvement, while oral terbinafine is the first-line treatment for more extensive dermatophyte infections. Candida infections are best treated with oral itraconazole using a pulsed weekly therapy approach. It is important to note that cultures have a false-negative rate of around 30%, so repeat samples may be necessary if clinical suspicion is high.
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This question is part of the following fields:
- Dermatology
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Question 2
Correct
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A 28-year-old woman is referred to the Neurology Clinic with suspected Guillain–Barré syndrome (GBS). A lumbar puncture (LP) is performed on the patient to rule out any other causes. The results of the LP show normal white blood cells (WBCs) and elevated proteins.
What immediate management should be started for this patient?
Select the SINGLE most appropriate management from the list below.
Your Answer: Intravenous immunoglobulins
Explanation:Guillain-Barré syndrome (GBS) can be treated with either plasma exchange or intravenous immunoglobulin (IVIG), both of which are equally effective. The decision on which treatment to use depends on the institution. Plasma exchange is recommended for ambulatory patients within two weeks of symptom onset and for non-ambulatory patients within four weeks. It is most effective when started within seven days of symptom onset, but improvement can still be seen up to 30 days after onset. Patients receiving plasma exchange should be closely monitored for electrolyte abnormalities and coagulopathies, as well as complications such as infection, blood pressure instability, cardiac arrhythmias, and pulmonary embolus. Compared to IVIG, plasma exchange has a higher risk of pneumonia, atelectasis, thrombosis, and hemodynamic difficulties. Urgent referral to oncology is appropriate if the patient has signs of metastatic spinal cord compression. High-dose dexamethasone is not indicated in this case as there is no history of cancer. Intravenous ceftriaxone is used to treat meningitis, which was ruled out by the LP findings. Intravenous itraconazole would be appropriate if fungal meningitis were suspected based on the patient’s history and LP results.
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This question is part of the following fields:
- Neurology
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Question 3
Incorrect
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A 25-year-old homeless man presents to the emergency department with altered consciousness and abdominal pain after being intoxicated a few hours prior. He has a history of alcohol and overdose admissions.
On examination:
A - Airway is clear.
B - Respiratory rate is 34 breaths per minute with deep labored inspiration. Oxygen saturation is 100%.
C - Heart rate is 124 beats per minute, blood pressure is 95/62 mmHg, and capillary refill is 4 seconds. Mucous membranes are dry.
D - Glasgow Coma Scale score is 10.
Lab results show a pH of 7.18 (normal range: 7.35-7.45), pCO2 of 4.3kPa (normal range: 4.5-6.0kPa), bicarbonate of 14 mmol/L (normal range: 22-28 mmol/L), glucose of 22.3mmol/L, and ketones of 4.5mmol/L.
What is the most likely diagnosis?Your Answer: Alcoholic ketoacidosis
Correct Answer: Diabetic ketoacidosis
Explanation:Abdominal pain can be an initial symptom of DKA, which stands for diabetic ketoacidosis. In this particular case, a young man is showing signs of DKA, such as dehydration, Kussmaul respiration, and a significantly elevated capillary glucose level. DKA patients lose around 5-8 liters of fluids, which require immediate correction. The diagnostic criteria for DKA include a pH level of less than 7.3 and/or bicarbonate level of less than 15mmol/L, blood glucose level of over 11mmol/L or known diabetes mellitus, and ketonaemia level of over 3mmol/L or significant ketonuria ++ on urine dipstick. Alcoholic ketoacidosis is not the correct diagnosis as it usually presents with low or normal glucose levels and occurs due to starvation. Hyperosmolar hyperglycaemic state is also incorrect as it typically presents with marked hyperglycemia without ketoacidosis. Opioid overdose is not the correct diagnosis either as it usually presents with respiratory depression, pinpoint pupils, and a lowered GCS, while this patient has a raised respiratory rate and abnormal respirations consistent with Kussmaul respirations.
Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus, accounting for around 6% of cases. It can also occur in rare cases of extreme stress in patients with type 2 diabetes mellitus. However, mortality rates have decreased from 8% to under 1% in the past 20 years. DKA is caused by uncontrolled lipolysis, resulting in an excess of free fatty acids that are ultimately converted to ketone bodies. The most common precipitating factors of DKA are infection, missed insulin doses, and myocardial infarction. Symptoms include abdominal pain, polyuria, polydipsia, dehydration, Kussmaul respiration, and acetone-smelling breath. Diagnostic criteria include glucose levels above 13.8 mmol/l, pH below 7.30, serum bicarbonate below 18 mmol/l, anion gap above 10, and ketonaemia.
Management of DKA involves fluid replacement, insulin, and correction of electrolyte disturbance. Most patients with DKA are depleted around 5-8 litres, and isotonic saline is used initially, even if the patient is severely acidotic. Insulin is administered through an intravenous infusion, and correction of electrolyte disturbance is necessary. Long-acting insulin should be continued, while short-acting insulin should be stopped. DKA resolution is defined as pH above 7.3, blood ketones below 0.6 mmol/L, and bicarbonate above 15.0mmol/L. Complications may occur from DKA itself or the treatment, such as gastric stasis, thromboembolism, arrhythmias, acute respiratory distress syndrome, acute kidney injury, and cerebral oedema. Children and young adults are particularly vulnerable to cerebral oedema following fluid resuscitation in DKA and often need 1:1 nursing to monitor neuro-observations.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 4
Correct
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A 9-year-old boy with asthma is brought into the GP surgery with a cough and shortness of breath. Examination reveals a respiratory rate of 34 breaths/min, apyrexial, wheeze throughout his chest and a peak expiratory flow rate (PEFR) of half his predicted value.
Which of the following treatments is the best option?
Your Answer: Inpatient management with nebuliser salbutamol and oral steroids
Explanation:Managing Acute Asthma Exacerbations in Children: Treatment Options and Guidelines
When a child experiences an acute asthma exacerbation, prompt and appropriate management is crucial to prevent further complications. Here are some treatment options and guidelines to consider:
Inpatient Management with Nebuliser Salbutamol and Oral Steroids
For severe asthma exacerbations, hospital transfer is necessary. Inpatient management should include nebulised bronchodilators in combination with early oral steroids. A 3-day steroid course is usually sufficient.Manage as Outpatient with Inhaled Salbutamol via Spacer
Mild to moderate acute asthma can be managed with salbutamol via a spacer. Oral steroids should be considered in all children with an acute exacerbation of asthma. However, all children with features of severe or life-threatening asthma should be transferred to a hospital.Outpatient Management with Antibiotics
Antibiotics would be inappropriate for acute asthma exacerbations unless there are clues in the history to suggest a bacterial infection as the cause of exacerbation.Continue Current Medications with No Changes
In severe acute asthma, urgent treatment with nebulisers and transfer to a hospital is necessary.IV Salbutamol
IV salbutamol is second line and considered only if the symptoms have responded poorly to nebulised therapy.British Thoracic Society (BTS)/Scottish Intercollegiate Guidelines Network (SIGN) guidance suggests that all children with features of severe or life-threatening asthma should be transferred to a hospital. The severity of acute asthma in children over 5 can be determined using the BTS severity scoring.
By following these guidelines and treatment options, healthcare professionals can effectively manage acute asthma exacerbations in children and prevent further complications.
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This question is part of the following fields:
- Paediatrics
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Question 5
Correct
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You are advising a 26-year-old woman who has recently discovered she is expecting a baby. She is a smoker and consumes 20 cigarettes per day. What is the primary risk factor linked to smoking while pregnant?
Your Answer: Increased risk of pre-term labour
Explanation:Risks of Smoking, Alcohol, and Illegal Drugs During Pregnancy
During pregnancy, drug use can have serious consequences for both the mother and the developing fetus. Smoking during pregnancy increases the risk of miscarriage, pre-term labor, stillbirth, and sudden unexpected death in infancy. Alcohol consumption can lead to fetal alcohol syndrome, which can cause learning difficulties, characteristic facial features, and growth restrictions. Binge drinking is a major risk factor for fetal alcohol syndrome. Cannabis use poses similar risks to smoking due to the tobacco content. Cocaine use can lead to hypertension in pregnancy, including pre-eclampsia, and placental abruption. Fetal risks include prematurity and neonatal abstinence syndrome. Heroin use can result in neonatal abstinence syndrome. It is important for pregnant women to avoid drug use to ensure the health and well-being of both themselves and their unborn child.
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This question is part of the following fields:
- Reproductive Medicine
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Question 6
Incorrect
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A 32-year-old woman with epilepsy complains of acne and bleeding gums. Which medication is most likely responsible for these symptoms?
Your Answer: Carbamazepine
Correct Answer: Phenytoin
Explanation:Side Effects of Common Anticonvulsants
Anticonvulsants are medications used to treat seizures and epilepsy. However, they commonly have side effects that patients should be aware of. Here are some of the common or more serious side effects reported for some of the most commonly prescribed anticonvulsants:
Phenytoin: This medication can cause paraesthesia, gingival hypertrophy, tiredness, acne, hirsutism, coarsening of facial appearance, peripheral neuropathy, Steven-Johnson syndrome, and blood dyscrasias (such as aplastic anaemia and megaloblastic anaemia).
Sodium valproate (Epilim®): Side effects of this medication may include weight gain, thrombocytopenia, transient hair loss, aggression and behavioural changes, ataxia and tremors.
Carbamazepine: Dry mouth, fatigue, hyponatraemia, blood dyscrasia (such as aplastic anaemia), thrombocytopenia, haemolytic anaemia, eosinophilia, dermatitis, gynaecomastia, male infertility, hepatitis, and restlessness are all possible side effects of this medication.
Lamotrigine (Lamictal®): Skin rash and hypersensitivity, blurred vision, dizziness, sleep disturbance, and joint pains are some of the side effects that may occur with this medication.
Levetiracetam (Keppra®): Weight change and anorexia, abdominal pains, nausea, diarrhoea, and anxiety are all possible side effects of this medication.
It’s important to note that gingival hypertrophy and tenderness are common effects of phenytoin, but not the other medications listed. Patients taking phenytoin should be encouraged to maintain good oral hygiene. Overall, patients should be aware of the potential side effects of their anticonvulsant medication and discuss any concerns with their healthcare provider.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 7
Correct
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What is the primary mode of operation of Nexplanon (etonogestrel contraceptive implant)?
Your Answer: Inhibition of ovulation
Explanation:The primary way in which Nexplanon works is by preventing ovulation.
Implanon and Nexplanon are subdermal contraceptive implants that slowly release the progestogen hormone etonogestrel to prevent ovulation and thicken cervical mucus. Nexplanon is the newer version and has a redesigned applicator to prevent deep insertions and is radiopaque for easier location. It is highly effective with a failure rate of 0.07/100 women-years and lasts for 3 years. It does not contain estrogen, making it suitable for women with a past history of thromboembolism or migraine. It can be inserted immediately after a termination of pregnancy. However, a trained professional is needed for insertion and removal, and additional contraceptive methods are required for the first 7 days if not inserted on days 1 to 5 of a woman’s menstrual cycle.
The main disadvantage of these implants is irregular and heavy bleeding, which can be managed with a co-prescription of the combined oral contraceptive pill. Other adverse effects include headache, nausea, and breast pain. Enzyme-inducing drugs such as certain antiepileptic and rifampicin may reduce the efficacy of Nexplanon, and women should switch to a method unaffected by enzyme-inducing drugs or use additional contraception until 28 days after stopping the treatment.
There are also contraindications for using these implants, such as ischaemic heart disease/stroke, unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, and liver cancer. Current breast cancer is a UKMEC 4 condition, which represents an unacceptable risk if the contraceptive method is used. Overall, these implants are a highly effective and long-acting form of contraception, but they require careful consideration of the potential risks and contraindications.
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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 25-year-old female presents to the emergency department after collapsing. Limited information is available, but an arterial blood gas has been obtained on room air with the following results:
- paO2: 13 kPa (11-13)
- paCO2: 3.5 kPa (4.7-6)
- pH: 7.31 (7.35-7.45)
- Na+: 143 mmol/L (135-145)
- K+: 5 mmol/L (3.5-5.0)
- Bicarbonate: 17 mEq/L (22-29)
- Chloride: 100 mmol/L (98-106)
What potential diagnosis could explain these blood gas findings?Your Answer: Septic shock
Explanation:An anion gap greater than 14 mmol/L typically indicates a raised anion gap metabolic acidosis, rather than a normal anion gap. In the absence of other information about the patient, an arterial blood gas (ABG) can provide a clue to the diagnosis. In this case, the ABG shows a normal paO2, indicating a respiratory cause of the patient’s symptoms is less likely. However, the pH is below 7.35, indicating acidosis, and the bicarbonate is low, suggesting metabolic acidosis. The low paCO2 shows partial compensation. Calculating the anion gap reveals a value of 31 mmol/L, indicating metabolic acidosis with a raised anion gap. Septic shock is the only listed cause of raised anion gap metabolic acidosis, resulting in acidosis due to the production of lactic acid from inadequate tissue perfusion. Addison’s disease is another cause of metabolic acidosis, but it results in normal anion gap metabolic acidosis due to bicarbonate loss from mineralocorticoid deficiency. Prolonged diarrhea can cause normal anion gap metabolic acidosis due to gastrointestinal loss of bicarbonate. Pulmonary embolism is unlikely due to normal oxygen levels and hypocapnia occurring as compensation. Prolonged vomiting can cause metabolic alkalosis, not metabolic acidosis, due to the loss of hydrogen ions in vomit. This patient’s electrolyte profile does not fit with prolonged vomiting.
The anion gap is a measure of the difference between positively charged ions (sodium and potassium) and negatively charged ions (bicarbonate and chloride) in the blood. It is calculated by subtracting the sum of bicarbonate and chloride from the sum of sodium and potassium. A normal anion gap falls between 8-14 mmol/L. This measurement is particularly useful in diagnosing metabolic acidosis in patients.
There are various causes of a normal anion gap or hyperchloraemic metabolic acidosis. These include gastrointestinal bicarbonate loss due to conditions such as diarrhoea, ureterosigmoidostomy, or fistula. Renal tubular acidosis, drugs like acetazolamide, ammonium chloride injection, and Addison’s disease can also lead to a normal anion gap.
On the other hand, a raised anion gap metabolic acidosis can be caused by lactate due to shock or hypoxia, ketones in conditions like diabetic ketoacidosis or alcoholism, urate in renal failure, acid poisoning from substances like salicylates or methanol, and 5-oxoproline from chronic paracetamol use. Understanding the anion gap and its potential causes can aid in the diagnosis and treatment of metabolic acidosis.
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This question is part of the following fields:
- Respiratory Medicine
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Question 9
Correct
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Which of the following treatments has not been demonstrated to enhance survival in individuals with persistent heart failure?
Your Answer: Furosemide
Explanation:Although furosemide is effective in treating the symptoms of both acute and chronic heart failure, it does not provide any predictive advantages.
Drug Management for Chronic Heart Failure: NICE Guidelines
Chronic heart failure is a serious condition that requires proper management to improve patient outcomes. In 2018, the National Institute for Health and Care Excellence (NICE) updated their guidelines on drug management for chronic heart failure. The guidelines recommend first-line therapy with both an ACE-inhibitor and a beta-blocker, with clinical judgement used to determine which one to start first. Second-line therapy involves the use of aldosterone antagonists, which should be monitored for hyperkalaemia. SGLT-2 inhibitors are also increasingly being used to manage heart failure with a reduced ejection fraction. Third-line therapy should be initiated by a specialist and may include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, or cardiac resynchronisation therapy. Other treatments such as annual influenza and one-off pneumococcal vaccines are also recommended.
Overall, the NICE guidelines provide a comprehensive approach to drug management for chronic heart failure. It is important to note that loop diuretics have not been shown to reduce mortality in the long-term, and that ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction. Healthcare professionals should carefully consider the patient’s individual needs and circumstances when determining the appropriate drug therapy for chronic heart failure.
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This question is part of the following fields:
- Cardiovascular
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Question 10
Correct
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A 67-year-old man presents to his Optician for a routine eye check-up. His intraocular pressure (IOP) is 30 mmHg. On examination, fundoscopy reveals cupping of the optic disc. He is referred for assessment with an Ophthalmologist; he is classed as being at high lifetime risk of visual impairment.
What is the most appropriate first-line treatment for this patient?Your Answer: Latanoprost
Explanation:Overview of Glaucoma Medications
Glaucoma is a condition that can lead to vision loss and is often associated with high intraocular pressure (IOP). The first-line treatment recommended by the National Institute for Health and Care Excellence is a prostaglandin analogue such as latanoprost. Patients must meet certain criteria to receive this treatment. Brinzolamide and brimonidine are third-line treatments that may be used if a patient cannot tolerate a prostaglandin analogue or beta-blocker. Sodium cromoglicate eye drops are used for allergic conjunctivitis and do not help manage ocular hypertension. Timolol is a beta-blocker that may be used if a patient cannot tolerate a prostaglandin analogue, but it is not a first-line treatment.
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This question is part of the following fields:
- Ophthalmology
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Question 11
Correct
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A 45-year-old woman with a 30-pack-year history of smoking visits her General Practitioner with complaints of dark urine, nausea and overall weakness. She reports experiencing a seizure and was admitted to the hospital where she was diagnosed with a 'hormone tumor'. What is the most probable diagnosis?
Your Answer: Small-cell carcinoma of the lung (SCLC)
Explanation:Small-cell carcinoma of the lung (SCLC) is a type of lung cancer that is often associated with a condition called syndrome of inappropriate antidiuretic hormone syndrome (SIADH). SIADH is caused by the abnormal release of anti-diuretic hormone (ADH), which leads to impaired water excretion and hyponatremia. This can result in symptoms such as nausea, weakness, confusion, and seizures. While SCLC is the most common cause of SIADH, it can also be caused by other types of cancer, certain drugs, intracranial lesions, and infections. Squamous-cell carcinoma (SCC) of the lung, on the other hand, does not typically result in SIADH as it does not originate from neuroendocrine cells. Pancreatic cancer can also cause SIADH, but it is less common than in SCLC. Prostate cancer, which is the second most common cancer globally, does not usually present with hormonal effects but rather with lower urinary tract symptoms. Bronchial carcinoid tumors, which are neuroendocrine tumors of the lung, can cause hormonal effects such as weight gain, high blood pressure, and hirsutism, but these symptoms are not indicated in the scenario given.
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This question is part of the following fields:
- Haematology/Oncology
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Question 12
Correct
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A 57-year-old man with a history of bipolar disorder, which is well controlled with lithium, presents with a 2-day history of confusion, diarrhoea and tremors. He takes regular analgesia for chronic back pain and has been feeling unwell recently.
A blood test shows:
Value Reference
Lithium (serum) 4.2 mmol/L (0.6 - 1)
What is the probable reason for his symptoms?Your Answer: Ibuprofen
Explanation:NSAIDs can cause lithium toxicity by reducing renal excretion of lithium and increasing plasma levels. Therefore, routine monitoring of serum lithium levels is necessary, especially after initiation and dose changes. ACE-I and diuretics should not be used with lithium due to the risk of renal dysfunction. Abruptly stopping lithium does not cause toxicity, but reducing caffeine intake can lead to toxicity by reducing lithium clearance. Cranberry juice does not interact with lithium, but it increases the risk of rhabdomyolysis when taken with statins. Dehydration, not excessive water intake, increases the risk of lithium toxicity by reducing lithium excretion.
Understanding Lithium Toxicity
Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in refractory depression. However, it has a narrow therapeutic range of 0.4-1.0 mmol/L and a long plasma half-life, making it crucial to monitor its levels in the blood. Lithium toxicity occurs when the concentration exceeds 1.5 mmol/L, which can be caused by dehydration, renal failure, and certain medications such as diuretics, ACE inhibitors, NSAIDs, and metronidazole.
Symptoms of lithium toxicity include a coarse tremor, hyperreflexia, acute confusion, polyuria, seizures, and even coma. It is important to manage toxicity promptly, as mild to moderate cases may respond to volume resuscitation with normal saline. However, severe cases may require hemodialysis to remove excess lithium from the body. Some healthcare providers may also use sodium bicarbonate to increase the alkalinity of the urine and promote lithium excretion, although evidence supporting its effectiveness is limited.
In summary, understanding lithium toxicity is crucial for healthcare providers and individuals taking lithium. Monitoring lithium levels in the blood and promptly managing toxicity can prevent serious complications and ensure the safe use of this medication.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 13
Incorrect
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A 20-year-old male patient comes to the GP clinic with a history of lower back pain and stiffness that has been gradually worsening for the past 6 months. He reports that the stiffness is more pronounced in the morning but improves throughout the day and with physical activity. He mentions that his mother has a form of arthritis but cannot remember which type. He denies experiencing any night sweats or weight loss.
What is a red flag symptom of lower back pain?Your Answer: Age of onset <20 years
Correct Answer:
Explanation:One of the warning signs of lower back pain is when it starts before the age of 20 or after the age of 50. Morning stiffness may indicate an inflammatory cause for the pain, but it is not a definitive symptom. The presence of arthritis in the family may be significant, particularly if it is ankylosing spondylitis, which can be inherited through the HLA-B27 gene. However, the specific type of arthritis in the family was not specified. Being male is not considered a warning sign.
Lower back pain is a common issue that is often caused by muscular strain. However, it is important to be aware of potential underlying causes that may require specific treatment. Certain red flags should be considered, such as age under 20 or over 50, a history of cancer, night pain, trauma, or systemic illness. There are also specific causes of lower back pain that should be kept in mind. Facet joint pain may be acute or chronic, worse in the morning and on standing, and typically worsens with back extension. Spinal stenosis may cause leg pain, numbness, and weakness that is worse on walking and relieved by sitting or leaning forward. Ankylosing spondylitis is more common in young men and causes stiffness that is worse in the morning and improves with activity. Peripheral arterial disease may cause pain on walking and weak foot pulses. It is important to consider these potential causes and seek appropriate diagnosis and treatment.
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This question is part of the following fields:
- Musculoskeletal
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Question 14
Correct
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A 5-year-old boy presents to the emergency department with generalised facial swelling. He recently recovered from viral pharyngitis. He is otherwise healthy and meeting developmental milestones.
Upon examination, he is alert and not experiencing any respiratory distress. There is pitting edema in his face and legs.
Urinalysis reveals 4+ protein and no hematuria. Blood tests show a hemoglobin level of 180 g/L (normal range for males: 135-180, females: 115-160), platelets at 450 * 109/L (normal range: 150-400), WBC at 8.0 * 109/L (normal range: 4.0-11.0), bilirubin at 12 µmol/L (normal range: 3-17), ALP at 60 u/L (normal range: 30-100), ALT at 35 u/L (normal range: 3-40), γGT at 32 u/L (normal range: 8-60), and albumin at 10 g/L (normal range: 35-50).
What is the recommended first-line treatment option for this likely diagnosis?Your Answer: Prednisolone
Explanation:The most appropriate treatment for minimal change glomerulonephritis, which is likely the cause of this patient’s facial edema, hypoalbuminemia, and proteinuria, is prednisolone. This medication is a corticosteroid and is considered the mainstay of therapy for this condition. Adrenaline, albumin infusion, and furosemide are not appropriate treatments for this patient’s condition. While albumin infusion may be used as adjunctive therapy, its effects will only be temporary. Adrenaline is used to treat anaphylaxis and would not be effective in treating minimal change disease. Furosemide may be used as adjunctive therapy, but its effects will also be temporary.
Minimal change disease is a condition that typically presents as nephrotic syndrome, with children accounting for 75% of cases and adults accounting for 25%. While most cases are idiopathic, around 10-20% have a known cause, such as certain drugs, Hodgkin’s lymphoma, thymoma, or infectious mononucleosis. The pathophysiology of the disease involves T-cell and cytokine-mediated damage to the glomerular basement membrane, resulting in polyanion loss and reduced electrostatic charge, which increases glomerular permeability to serum albumin. The disease is characterized by nephrotic syndrome, normotension (hypertension is rare), and highly selective proteinuria, with only intermediate-sized proteins such as albumin and transferrin leaking through the glomerulus. Renal biopsy shows normal glomeruli on light microscopy, but electron microscopy reveals fusion of podocytes and effacement of foot processes.
Management of minimal change disease typically involves oral corticosteroids, which are effective in 80% of cases. For steroid-resistant cases, cyclophosphamide is the next step. The prognosis for the disease is generally good, although relapse is common. Approximately one-third of patients have just one episode, one-third have infrequent relapses, and one-third have frequent relapses that stop before adulthood.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 15
Incorrect
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A 35-year-old female patient arrives at the emergency department complaining of diplopia that has been ongoing for 2 months. She reports feeling more fatigued and weak towards the end of the day. Upon examination, anti-acetylcholine receptor antibodies are detected in her blood. A CT scan of her chest is ordered and reveals the presence of an anterior mediastinal mass. What is the most probable diagnosis for this mass?
Your Answer: Sarcoidosis
Correct Answer: Thymoma
Explanation:The most common causes of a mass in the anterior mediastinum are referred to as the 4 T’s: teratoma, terrible lymphadenopathy, thymic mass, and thyroid mass. The woman’s symptoms and positive anti-AChR suggest that she may have myasthenia gravis, which requires a CT chest to check for a thymoma. Other conditions that may show up on a CT chest, such as benign lung nodules, lung tumors, sarcoidosis, and tuberculosis, are unlikely given her presentation. It is important to note that the mediastinum is not the same as the lungs, and therefore, all other answer options are incorrect as the question specifically asks for an anterior mediastinal mass.
The Mediastinum and its Regions
The mediastinum is the area located between the two pulmonary cavities and is covered by the mediastinal pleura. It extends from the thoracic inlet at the top to the diaphragm at the bottom. The mediastinum is divided into four regions: the superior mediastinum, middle mediastinum, posterior mediastinum, and anterior mediastinum.
The superior mediastinum is located between the manubriosternal angle and T4/5 and contains important structures such as the superior vena cava, brachiocephalic veins, arch of aorta, thoracic duct, trachea, oesophagus, thymus, vagus nerve, left recurrent laryngeal nerve, and phrenic nerve.
The anterior mediastinum contains thymic remnants, lymph nodes, and fat. The middle mediastinum contains the pericardium, heart, aortic root, arch of azygos vein, and main bronchi. The posterior mediastinum contains the oesophagus, thoracic aorta, azygos vein, thoracic duct, vagus nerve, sympathetic nerve trunks, and splanchnic nerves.
In summary, the mediastinum is a crucial area of the chest that contains many important structures and is divided into four distinct regions.
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This question is part of the following fields:
- Respiratory Medicine
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Question 16
Incorrect
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Both restrictive lung disease and obstructive lung disease may affect a particular pulmonary function test to a similar extent. Which test is this? Please select only one option from the list provided.
Your Answer: Forced expiratory volume in 1 second (FEV1)
Correct Answer: Tidal volume
Explanation:Pulmonary Function Tests: Understanding Tidal Volume, Total Lung Capacity, Residual Volume, FEV1/FVC Ratio, and FEV1
Pulmonary function tests (PFTs) are a group of tests that measure how well the lungs are functioning. There are several parameters that are measured during PFTs, including tidal volume (TV), total lung capacity (TLC), residual volume (RV), forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio, and forced expiratory volume in 1 second (FEV1).
Tidal volume refers to the amount of gas inspired or expired with each breath. It can be reduced in both obstructive and restrictive lung disease, but the underlying mechanism causing the reduction is different. In obstructive lung disease, there is airflow limitation, while in restrictive lung disease, there is reduced lung volume or inability to fully expand the thoracic cage.
Total lung capacity is the volume of air in the lungs after a maximal inspiration. It is increased in obstructive lung disease due to air trapping, but is reduced in restrictive lung disease.
Residual volume is the volume of air remaining in the lungs after a maximal expiration. It cannot be measured with spirometry, but it is increased in obstructive lung disease due to air trapping.
The FEV1/FVC ratio is a measure of how much air a person can forcefully exhale in one second compared to the total amount of air they can exhale. A ratio of less than 70% is indicative of obstructive lung disease, while a ratio greater than 70% is indicative of restrictive lung disease.
FEV1 is the amount of air a person can forcefully exhale in one second. It is characteristically reduced in obstructive lung disease, but normal in restrictive lung disease because there is no airflow limitation.
Understanding these parameters can help healthcare professionals diagnose and manage lung diseases.
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This question is part of the following fields:
- Respiratory Medicine
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Question 17
Correct
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A 56-year-old woman presents to the emergency department with symptoms of malaise and diarrhoea. She reports feeling shivery and achy for the past 3 days and has had 4 watery stools in the past 24 hours. The patient has a history of breast cancer and is currently undergoing chemotherapy. Her last dose of doxorubicin and cyclophosphamide was administered 10 days ago. She has no known allergies and takes no other medications. On examination, her heart rate is 103/min, respiratory rate is 20/min with saturations of 100% in room air, blood pressure is 100/79 mmHg, and temperature is 39.1ºC.
What is the initial management approach for this patient while awaiting the results of her blood culture?Your Answer: Piperacillin with tazobactam (tazocin)
Explanation:The recommended empirical antibiotic for managing neutropenic sepsis is Piperacillin with tazobactam (Tazocin). This is because the patient is displaying symptoms such as malaise, diarrhoea, flu-like aching, mild tachycardia, and a temperature >38ºC, and has a history of chemotherapy within the past 7-14 days. As the patient has no allergies, Tazocin should be administered until blood cultures show a specific sensitivity. Amoxicillin is not effective in treating neutropenic sepsis as it is not broad-spectrum enough. Meropenem is only indicated in patients with previous or suspected ESBL, acute leukaemia, or allogeneic stem cell transplants, and is not recommended as first-line treatment according to NICE guidelines. Teicoplanin is recommended for patients with penicillin or beta-lactam allergies and evidence of neutropenic sepsis, but should be used in combination with another non-penicillin antibiotic as per local guidelines. Vancomycin is an alternative for penicillin-allergic patients, and should be administered with gentamicin, ciprofloxacin, or amikacin depending on local guidelines and the severity of the patient’s presentation.
Neutropenic Sepsis: A Common Complication of Cancer Therapy
Neutropenic sepsis is a frequent complication of cancer therapy, particularly chemotherapy. It typically occurs within 7-14 days after chemotherapy and is characterized by a neutrophil count of less than 0.5 * 109 in patients undergoing anticancer treatment who exhibit a temperature higher than 38ºC or other signs or symptoms consistent with clinically significant sepsis.
To prevent neutropenic sepsis, patients who are likely to have a neutrophil count of less than 0.5 * 109 as a result of their treatment should be offered a fluoroquinolone. In the event of neutropenic sepsis, antibiotics must be initiated immediately, without waiting for the white blood cell count.
According to NICE guidelines, empirical antibiotic therapy should begin with piperacillin with tazobactam (Tazocin) immediately. While some units may add vancomycin if the patient has central venous access, NICE does not support this approach. After initial treatment, patients are typically assessed by a specialist and risk-stratified to determine if they may be able to receive outpatient treatment.
If patients remain febrile and unwell after 48 hours, an alternative antibiotic such as meropenem may be prescribed, with or without vancomycin. If patients do not respond after 4-6 days, the Christie guidelines suggest ordering investigations for fungal infections (e.g. HRCT) rather than blindly initiating antifungal therapy. In selected patients, G-CSF may be beneficial.
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This question is part of the following fields:
- Infectious Diseases
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Question 18
Correct
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A 87-year-old male presents to the emergency department after collapsing. Upon arrival, an ECG reveals complete heart block with a heart rate of 35 bpm. The patient reports feeling dizzy. Despite receiving 500 micrograms of IV atropine, there is no improvement. This is repeated five more times, but the heart rate remains below 40 bpm even after transcutaneous pacing is attempted. What is the next recommended step according to the Resuscitation Council (UK) guidelines?
Your Answer: Transvenous pacing
Explanation:Management of Bradycardia in Peri-Arrest Rhythms
The 2015 Resuscitation Council (UK) guidelines highlight the importance of identifying adverse signs and potential risk of asystole in the management of bradycardia in peri-arrest rhythms. Adverse signs indicating haemodynamic compromise include shock, syncope, myocardial ischaemia, and heart failure. Atropine (500 mcg IV) is the first line treatment in this situation. If there is an unsatisfactory response, interventions such as atropine (up to a maximum of 3mg), transcutaneous pacing, and isoprenaline/adrenaline infusion titrated to response may be used. Specialist help should be sought for consideration of transvenous pacing if there is no response to the above measures.
Furthermore, the presence of risk factors for asystole such as complete heart block with broad complex QRS, recent asystole, Mobitz type II AV block, and ventricular pause > 3 seconds should be considered. Even if there is a satisfactory response to atropine, specialist help is indicated to consider the need for transvenous pacing. Effective management of bradycardia in peri-arrest rhythms is crucial in preventing further deterioration and improving patient outcomes.
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This question is part of the following fields:
- Cardiovascular
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Question 19
Incorrect
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A 35-year-old man attends his cousin's bachelor party where they go to a seafood buffet. After consuming eight plates of food, he finally feels full and they head to a nearby bar.
Four hours later, he is at a dart tournament when he suddenly feels sick and starts vomiting uncontrollably. He goes home and the vomiting stops overnight. The next day, he feels better and is relieved that he did not experience any diarrhea.
What is the probable organism responsible for his illness?Your Answer: Escherichia coli
Correct Answer: Staphylococcus aureus
Explanation:Gastroenteritis can occur either at home or while traveling, known as travelers’ diarrhea. This condition is characterized by at least three loose to watery stools in 24 hours, accompanied by abdominal cramps, fever, nausea, vomiting, or blood in the stool. The most common cause of travelers’ diarrhea is Escherichia coli. Acute food poisoning is another pattern of illness that results in sudden onset of nausea, vomiting, and diarrhea after ingesting a toxin. Staphylococcus aureus, Bacillus cereus, or Clostridium perfringens are typically responsible for acute food poisoning.
There are several types of infections that can cause gastroenteritis, each with its own typical presentation. Escherichia coli is common among travelers and causes watery stools, abdominal cramps, and nausea. Giardiasis results in prolonged, non-bloody diarrhea, while cholera causes profuse, watery diarrhea and severe dehydration leading to weight loss. Shigella causes bloody diarrhea, vomiting, and abdominal pain, while Staphylococcus aureus results in severe vomiting with a short incubation period. Campylobacter typically starts with a flu-like prodrome and progresses to crampy abdominal pains, fever, and diarrhea, which may be bloody and mimic appendicitis. Bacillus cereus can cause two types of illness, vomiting within six hours, typically due to rice, or diarrheal illness occurring after six hours. Amoebiasis has a gradual onset of bloody diarrhea, abdominal pain, and tenderness that may last for several weeks.
The incubation period for gastroenteritis varies depending on the type of infection. Staphylococcus aureus and Bacillus cereus have an incubation period of 1-6 hours, while Salmonella and Escherichia coli have an incubation period of 12-48 hours. Shigella and Campylobacter have an incubation period of 48-72 hours, while Giardiasis and Amoebiasis have an incubation period of more than seven days.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 20
Correct
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Which of the following neonatal complications is least frequently observed in pregnancies of women with diabetes?
Your Answer: Microsomia
Explanation:Macrosomia is more likely to occur in individuals with diabetes than microsomia.
Complications of Diabetes during Pregnancy
Diabetes during pregnancy can lead to various complications for both the mother and the baby. Maternal complications may include polyhydramnios, which occurs in 25% of cases and may be due to fetal polyuria. Preterm labor is also a common complication, occurring in 15% of cases and often associated with polyhydramnios.
Neonatal complications may include macrosomia, although diabetes can also cause small for gestational age babies. Hypoglycemia is another potential complication, which can occur due to beta cell hyperplasia. Respiratory distress syndrome may also occur, as surfactant production is delayed. Polycythemia, which leads to more neonatal jaundice, is also a possibility.
Malformation rates may increase 3-4 fold, with sacral agenesis, CNS and CVS malformations (hypertrophic cardiomyopathy) being some of the potential risks. Stillbirth is also a possibility. Hypomagnesemia and hypocalcemia may occur, and shoulder dystocia may cause Erb’s palsy.
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This question is part of the following fields:
- Paediatrics
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Question 21
Incorrect
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A 67-year-old woman comes to the clinic complaining of experiencing electric shock-like pains on the right side of her face for the past two months. She reports having 10-20 episodes per day, each lasting for 30-60 seconds. She recently had a dental check-up, which was normal. Upon neurological examination, no abnormalities were found. What is the most appropriate initial treatment?
Your Answer: Atenolol
Correct Answer: Carbamazepine
Explanation:Carbamazepine is the first-line treatment for trigeminal neuralgia.
Understanding Trigeminal Neuralgia
Trigeminal neuralgia is a type of pain syndrome that is characterized by severe pain on one side of the face. While most cases are idiopathic, some may be caused by compression of the trigeminal roots due to tumors or vascular problems. According to the International Headache Society, trigeminal neuralgia is defined as a disorder that causes brief electric shock-like pains that are limited to one or more divisions of the trigeminal nerve. The pain is often triggered by light touch, such as washing, shaving, or brushing teeth, and can occur spontaneously. Certain areas of the face, such as the nasolabial fold or chin, may be more susceptible to pain. The pain may also remit for varying periods.
Red flag symptoms and signs that suggest a serious underlying cause include sensory changes, ear problems, a history of skin or oral lesions that could spread perineurally, pain only in the ophthalmic division of the trigeminal nerve, optic neuritis, a family history of multiple sclerosis, and onset before the age of 40.
The first-line treatment for trigeminal neuralgia is carbamazepine. If there is a failure to respond to treatment or atypical features are present, such as onset before the age of 50, referral to neurology is recommended. Understanding the symptoms and management of trigeminal neuralgia is important for proper diagnosis and treatment.
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This question is part of the following fields:
- Neurology
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Question 22
Incorrect
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A 28-year-old female patient presents to her GP complaining of a foul-smelling vaginal discharge that has persisted for 5 days after having unprotected sex. She reports feeling generally well and denies any fever or urinary symptoms. The patient also confirms that she is not pregnant. During the examination, the doctor observes multiple punctate lesions on her cervix and a green discharge with a strong odor. What is the probable diagnosis?
Your Answer: Bacterial vaginosis
Correct Answer: Trichomoniasis
Explanation:The patient is likely suffering from trichomoniasis caused by Trichomonas vaginalis, a sexually transmitted disease that results in a yellow/green discharge with a foul odor, vulval itching, and dysuria. During a speculum examination, the cervix may appear as a strawberry cervix due to multiple punctate haemorrhages. Bacterial vaginosis, which is not a sexually transmitted disease and can be caused by various factors, is less likely to be the diagnosis due to the recent unprotected sexual intercourse and the presence of an offensive discharge. Chlamydia and gonorrhoea, both sexually transmitted diseases, can also cause dysuria and vaginal discharge, but the punctate cervical haemorrhages and malodorous green discharge make them less likely diagnoses. Syphilis, which presents in three stages, is unlikely due to the acute onset of symptoms and the absence of genital lesions.
Understanding Trichomonas vaginalis and its Comparison to Bacterial Vaginosis
Trichomonas vaginalis is a type of protozoan parasite that is highly motile and flagellated. It is known to cause trichomoniasis, which is a sexually transmitted infection. The infection is characterized by symptoms such as offensive, yellow/green, frothy vaginal discharge, vulvovaginitis, and strawberry cervix. The pH level is usually above 4.5, and in men, it may cause urethritis.
To diagnose trichomoniasis, a wet mount microscopy is conducted to observe the motile trophozoites. The treatment for trichomoniasis involves oral metronidazole for 5-7 days, although a one-off dose of 2g metronidazole may also be used.
When compared to bacterial vaginosis, trichomoniasis has distinct differences. Bacterial vaginosis is caused by an overgrowth of bacteria in the vagina, while trichomoniasis is caused by a protozoan parasite. The symptoms of bacterial vaginosis include a thin, grayish-white vaginal discharge with a fishy odor, and a pH level above 4.5. Unlike trichomoniasis, bacterial vaginosis is not considered a sexually transmitted infection.
In conclusion, understanding the differences between trichomoniasis and bacterial vaginosis is crucial in diagnosing and treating these conditions effectively. Proper diagnosis and treatment can help prevent complications and improve overall health and well-being.
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This question is part of the following fields:
- Reproductive Medicine
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Question 23
Correct
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A 32-year-old woman is referred for an evaluation of dysphagia. On examination, she has bilateral ptosis, facial weakness and atrophy of the temporalis. She says that she has difficulties relaxing her grip, especially in cold weather, and that her father had similar problems.
Which of the following is the most likely diagnosis?
Your Answer: Myotonia dystrophica
Explanation:Myotonic dystrophy is a genetic disorder that causes muscle stiffness and wasting. It is inherited in an autosomal dominant pattern and typically presents between the ages of 15 and 40. The disease progresses slowly and can lead to cataracts, hypogonadism, frontal balding, and cardiac issues. Patients may experience weakness, wasting, and myotonia in affected muscles, particularly in the face and limbs. Other symptoms include hollowing of the cheeks, swan neck appearance, and difficulty releasing a handshake. This patient’s presentation is consistent with myotonic dystrophy and likely inherited from her father.
Myasthenia gravis is an autoimmune disorder that causes weakness, particularly in the periocular, facial, bulbar, and girdle muscles. Fatigue is a hallmark symptom, and dysphagia may occur in advanced cases. Temporalis atrophy is not a feature.
Motor neurone disease is a rare condition that typically presents with mixed upper and lower motor neuron signs in the same limb. Symptoms may include weakness, wasting, cramps, stiffness, and problems with speech and swallowing. Dysphagia and speech problems become more common as the disease progresses. MND is unlikely in a woman of this age, and there is typically no familial link.
Multiple sclerosis is a more common condition in women that typically presents with transient episodes of optic neuritis or limb weakness/paraesthesiae. Only a small percentage of sufferers have a family history of MS.
Polymyositis is a connective tissue disease that causes proximal muscle weakness and tenderness. Atrophy is a late feature, and patients may have difficulty rising from chairs. Dysphagia may occur in advanced cases, but ptosis and temporalis wasting are not features. Polymyositis is not typically inherited.
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This question is part of the following fields:
- Neurology
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Question 24
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A 6-year-old boy is brought to his General Practitioner by his mother, who reports that he has been feeling tired and has developed mouth sores. Additionally, he has bruises on his knees and palms. A bone marrow aspirate reveals a hypocellular image.
What is the most probable diagnosis?
Your Answer: Aplastic anaemia
Explanation:Differential Diagnosis for a Patient with Hypocellular Bone Marrow and Thrombocytopenia
Aplastic anaemia is a condition characterized by bone marrow failure, resulting in peripheral pancytopenia and bone-marrow hypoplasia. This leads to a deficiency in the production of red blood cells, causing anaemia, and a reduced production of white blood cells, leading to immunodeficiency. Patients may experience symptoms such as shortness of breath, lethargy, pallor, mouth ulcers, and increased frequency of infections. The reduced production of platelets causes easy bruising.
Idiopathic thrombocytopenic purpura (ITP) is a condition characterized by an isolated reduction in platelets with normal bone marrow, in the absence of another identifiable cause. Patients may present with abnormal bleeding and bruising, petechiae, and purpura.
Haemophilia A is an X-linked-recessive condition causing a deficiency in clotting factor VIII, leading to easy bruising, prolonged bleeding after injury, or spontaneous bleeding in severe cases.
Infectious mononucleosis is the result of Epstein–Barr virus infection, characterized by fever, pharyngitis, lymphadenopathy, and a macular or maculopapular rash.
Autoimmune neutropenia is associated with opportunistic infections, most commonly otitis media. However, this condition would not account for the thrombocytopenia observed in this patient.
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This question is part of the following fields:
- Paediatrics
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Question 25
Correct
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A 15-year-old student presents with low back pain that radiates to the back of their legs. They have an elevated ESR and negative serum rheumatoid factor. A spine radiograph reveals anterior squaring of the vertebrae.
What is the most probable diagnosis?Your Answer: Ankylosing spondylitis (AS)
Explanation:Ankylosing spondylitis (AS) is a type of arthritis that is characterized by morning stiffness lasting more than 30 minutes, improvement of back pain with exercise but not rest, awakening due to back pain during the second half of the night, and alternating buttock pain. It is a seronegative spondyloarthropathy, meaning that the rheumatoid factor will be negative. Radiographically, sacroiliitis is often the first abnormality seen. ESR and CRP are usually raised, and HLA-B27 testing may provide supporting evidence. Lumbar disc prolapse with sciatica, rheumatoid arthritis, spinal stenosis, and Paget’s disease of bone are other conditions that may cause similar symptoms but have different characteristics and diagnostic criteria.
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This question is part of the following fields:
- Musculoskeletal
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Question 26
Correct
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A mother brings in her 2-day-old baby girl to the GP surgery. She expresses concern about some white discharge from the baby's vagina. Upon examination, a small amount of mucoid white discharge is observed at the entrance of the vagina. The external appearance of the genitalia is otherwise normal. What is the recommended next step in management?
Your Answer: Reassure the mother that it is normal at this age
Explanation:It is common for newborn girls to experience a mucoid white vaginal discharge, which typically resolves by the age of 3 months. Reassurance is the most suitable course of action, and there is no need to refer to paediatrics or suspect sexual abuse. Arranging a transvaginal ultrasound for these symptoms is not necessary.
Gynaecological Problems in Children
In children, gynaecological problems are not uncommon. However, it is important to note that vaginal examinations and vaginal swabs should not be performed. Instead, referral to a paediatric gynaecologist is appropriate for persistent problems. One of the most common gynaecological disorders in girls is vulvovaginitis. This condition can be caused by bacterial or fungal organisms and is often associated with poor hygiene, tight clothing, lack of labial fat pads protecting the vaginal orifice, and lack of protective acid secretion found in the reproductive years. In some cases, vulvovaginitis may be a result of sexual abuse, which can present as bloody discharge.
It is important to manage vulvovaginitis appropriately. Advising children about hygiene is crucial, and soothing creams may be useful. Topical antibiotics or antifungals may also be prescribed. In resistant cases, oestrogen cream may be recommended. It is important to note that most newborn girls have some mucoid white vaginal discharge, which usually disappears by three months of age.
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This question is part of the following fields:
- Paediatrics
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Question 27
Incorrect
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A 35-year-old man with psoriatic arthritis presents with a severely painful red eye. The pain has been affecting his sleep for a few days. On examination, his visual acuity is normal but there is inflammation of the scleral, episcleral and conjunctival vessels. Both pupils are equal and react normally to light. There is no blanching of the episcleral vessels when 2.5% phenylephrine is applied to the eye.
Which of the following is this patient most likely to be suffering from?
Your Answer: Episcleritis
Correct Answer: Scleritis
Explanation:Differentiating Ocular Inflammatory Conditions: Symptoms and Treatment
Scleritis: A severe inflammation of the sclera, often associated with underlying inflammatory conditions such as rheumatoid arthritis. Symptoms include severe eye pain, watering, photophobia, and affected visual acuity. Treatment requires systemic medication such as non-steroidal anti-inflammatory drugs, corticosteroids, or immunosuppressants.
Sjögren Syndrome: An association of dry eye and/or dry mouth with rheumatoid arthritis or other connective-tissue disorders. Pain is not a feature, but conjunctival hyperemia may be present.
Anterior Uveitis: Inflammation of the iris with or without ciliary body involvement, often seen in patients with inflammatory bowel disease or ankylosing spondylitis. Symptoms include an acutely painful red eye with photophobia and a small, irregular, poorly reactive pupil.
Conjunctivitis: Inflammation of the conjunctival vessels, causing sore red eyes with a sticky discharge. Pain is not a feature, and scleral and episcleral vessels are not affected. Often caused by bacterial or viral infections or irritants/allergens, it is usually self-limiting but may require topical antibiotics.
Episcleritis: A mild inflammation of the episclera, often seen as an extra-articular manifestation of rheumatoid arthritis. Symptoms include mild eye irritation, redness, and sometimes photophobia. Application of 2.5% phenylephrine causes episcleral vessels to blanch, distinguishing it from scleritis. Visual acuity is unaffected, and it is usually self-limiting.
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This question is part of the following fields:
- Musculoskeletal
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Question 28
Correct
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A 49-year-old woman presents to her GP with tearfulness and a low mood for the past few weeks. The GP notes from her medical history that she has a history of renal stones.
What is the most probable diagnosis?Your Answer: Primary hyperparathyroidism
Explanation:Differential Diagnosis for a Patient with Low Mood and Renal Stones
Primary Hyperparathyroidism:
This condition can cause hypercalcemia, which may present as renal stones, osteoporosis, arthritis, nausea and vomiting, peptic ulcer disease, constipation, polyuria, depression, memory loss, and delirium.Hyperthyroidism:
Hyperthyroidism may present with restlessness, irritability, insomnia, tremor, palpitations, weight loss, sweating, heat intolerance, diarrhea, oligomenorrhea, hair thinning, and muscle weakness. Graves’ disease may also cause a goiter and thyroid eye disease, presenting as proptosis, dry eyes, periorbital edema, and lagophthalmos.Hypothyroidism:
Typical features of hypothyroidism include dry skin, brittle and diminished hair, lethargy, cold intolerance, dull or blank expression, puffy eyelids, and weight gain. Patients may also experience cerebellar ataxia, ascites, non-pitting edema of the hands and feet, and congestive cardiac failure.Pseudopseudohypoparathyroidism:
This condition may present with short fourth and fifth metacarpals, round face, short stature, basal ganglia calcification, and decreased IQ.Secondary Hyperparathyroidism:
This condition may present with signs and symptoms of hypocalcemia, including perioral paresthesia, seizures, spasms, anxiety, increased smooth muscle tone, disorientation, dermatitis, impetigo herpetiformis, cataracts, Chvostek’s sign, and long Q–T interval.Differential Diagnosis for a Patient with Low Mood and Renal Stones
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 29
Correct
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A 28-year-old woman visits her family doctor with a lump under her chin that causes her discomfort and swelling, especially after eating a big meal. The facial nerve appears to be unaffected. Upon examination, there is a tender swelling in the submandibular triangle. What is the probable diagnosis?
Your Answer: Sialolithiasis
Explanation:Differential Diagnosis for a Painful Submandibular Swelling
One possible diagnosis for a painful submandibular swelling is sialolithiasis, which is the formation of stones within the salivary glands. This condition is more common in men over 40 and typically causes pain and swelling after eating. Adenoid cystic carcinoma, on the other hand, presents as a slowly enlarging mass over the parotid area and can invade local structures such as the facial nerve. Pleomorphic adenomas usually present as a painless lump that slowly enlarges, while Sjögren syndrome causes dry mouth, dry eyes, and swelling of the salivary glands bilaterally. Warthin’s tumour, which is commonly found in the tail of the parotid gland, does not typically present as a painful lump.
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This question is part of the following fields:
- ENT
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Question 30
Incorrect
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A 27-year-old female patient presents to you for her cervical cancer screening and expresses interest in learning more about HPV (human papillomavirus). What is a true statement regarding HPV?
Your Answer: HPV 6 and 16 are most commonly associated with genital warts
Correct Answer: HPV 16 and 18 are most commonly associated with cervical cancer
Explanation:The most significant risk factor for cervical cancer is infection with the human papillomavirus (HPV), particularly types 16, 18, and 33. Among the approximately 15 types of HPV that are considered high-risk for cervical cancer, HPV 16 and 18 are responsible for about 70% of cases. HPV 6 and 11, on the other hand, are associated with the formation of genital warts.
Understanding Cervical Cancer: Risk Factors and Mechanism of HPV
Cervical cancer is a type of cancer that affects the cervix, which is the lower part of the uterus. It is most commonly diagnosed in women under the age of 45, with the highest incidence rates occurring in those aged 25-29. The cancer can be divided into two types: squamous cell cancer and adenocarcinoma. Symptoms may include abnormal vaginal bleeding, postcoital bleeding, intermenstrual bleeding, or postmenopausal bleeding, as well as vaginal discharge.
The most important factor in the development of cervical cancer is the human papillomavirus (HPV), particularly serotypes 16, 18, and 33. Other risk factors include smoking, human immunodeficiency virus, early first intercourse, many sexual partners, high parity, and lower socioeconomic status. While the association between combined oral contraceptive pill use and cervical cancer is sometimes debated, a large study published in the Lancet confirmed the link.
The mechanism by which HPV causes cervical cancer involves the production of oncogenes E6 and E7 by HPV 16 and 18, respectively. E6 inhibits the p53 tumour suppressor gene, while E7 inhibits the RB suppressor gene. Understanding the risk factors and mechanism of HPV in the development of cervical cancer is crucial for prevention and early detection. Regular cervical cancer screening is recommended for all women.
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This question is part of the following fields:
- Reproductive Medicine
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