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Question 1
Correct
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A 35-year-old man has depression which has not responded to an MAOI. You stop the MAOI (which is of the non reversible kind) and wish to prescribe an SSRI.
How long should you wait before starting the SSRI?Your Answer: 14 days
Explanation:Switching between MAOIs and SSRIs
When switching from an MAOI to an SSRI, it is important to wait at least two weeks before starting the new medication. This is because MAOIs can inactivate the enzymes that break down certain neurotransmitters, such as noradrenaline and 5HT. It can take up to two weeks for these enzymes to resume normal activity after stopping an MAOI, and during this time there is a risk of severe drug reactions if an SSRI is started too soon. Therefore, it is crucial to allow enough time for the body to adjust before switching between these types of antidepressants.
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This question is part of the following fields:
- Smoking, Alcohol And Substance Misuse
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Question 2
Correct
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A 55-year-old man who is taking lithium for bipolar disorder comes in for a check-up. Upon routine examination, he is discovered to have hypertension with a blood pressure of 166/82 mmHg, which is confirmed by two separate readings. His urine dipstick is negative and his renal function is normal. What medication would be the most suitable to initiate?
Your Answer: Amlodipine
Explanation:Lithium toxicity may be caused by diuretics, ACE-inhibitors, and angiotensin II receptor antagonists. According to the BNF, the combination of lithium with diltiazem or verapamil may increase the risk of neurotoxicity, but there is no significant interaction with amlodipine. Although alpha-blockers are not known to interact with lithium, they are not recommended as the first-line treatment for hypertension. The NICE guidelines for hypertension suggest that amlodipine could be a suitable initial option, even if the patient is taking lithium.
Lithium is a drug used to stabilize mood in patients with bipolar disorder and refractory depression. It has a narrow therapeutic range of 0.4-1.0 mmol/L and is primarily excreted by the kidneys. Lithium toxicity occurs when the concentration exceeds 1.5 mmol/L, which can be caused by dehydration, renal failure, and certain drugs such as diuretics, ACE inhibitors, NSAIDs, and metronidazole. Symptoms of toxicity include coarse tremors, hyperreflexia, acute confusion, polyuria, seizures, and coma.
To manage mild to moderate toxicity, volume resuscitation with normal saline may be effective. Severe toxicity may require hemodialysis. Sodium bicarbonate may also be used to increase the alkalinity of the urine and promote lithium excretion, but there is limited evidence to support its use. It is important to monitor lithium levels closely and adjust the dosage accordingly to prevent toxicity.
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This question is part of the following fields:
- Kidney And Urology
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Question 3
Correct
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A 70-year-old man inquires about the 'shingles vaccine'. Which of the following statements about Zostavax is accurate?
Your Answer: Is suitable for patients who've had Chickenpox
Explanation:Regardless of whether a person has had Chickenpox or shingles previously, Zostavax should still be administered.
Varicella-Zoster Vaccination: Protection Against Chickenpox and Shingles
Varicella-zoster is a herpesvirus that causes Chickenpox and shingles. There are two types of vaccines available to protect against these infections. The first type is a live attenuated vaccine that prevents primary varicella infection or Chickenpox. This vaccine is recommended for healthcare workers who are not immune to VZV and for individuals who are in close contact with immunocompromised patients.
The second type of vaccine is designed to reduce the incidence of herpes zoster or shingles caused by reactivation of VZV. This live-attenuated vaccine is given subcutaneously and is offered to patients aged 70-79 years. The vaccine is also available as a catch-up campaign for those who missed out on their vaccinations in the previous two years of the program. However, the shingles vaccine is not available on the NHS to anyone aged 80 and over because it seems to be less effective in this age group.
The main contraindication for both vaccines is immunosuppression. Side effects of the vaccines include injection site reactions, and less than 1 in 10,000 individuals may develop Chickenpox. It is important to note that vaccination is the most effective way to prevent varicella-zoster infections and their complications.
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This question is part of the following fields:
- Dermatology
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Question 4
Incorrect
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Samantha, a 10-year-old girl, visits your clinic with her mother. She reports having a constant headache for several weeks. Her mother is extremely worried. However, Samantha is always anxious during medical appointments and refuses to cooperate with a thorough examination.
As a healthcare provider, you are concerned about Samantha's condition and decide to request an immediate referral. What is the maximum time frame within which she should receive an appointment with a specialist?Your Answer: 2 weeks
Correct Answer: 3 days
Explanation:Referral Guidelines for Children with Suspected Cancer
When a child presents with symptoms and signs of cancer, it is important to refer them to a paediatrician or a specialist children’s cancer service, if appropriate. If the child experiences headaches and vomiting that cause early morning waking or occur on waking, this could be a sign of raised intracranial pressure, and an immediate referral should be made.
It is important to note that patients have a legal right to be seen by a specialist within two weeks of being urgently referred for suspected cancer by their GP. If this is not possible, the NHS must do everything it reasonably can to offer them clinically appropriate alternatives. By following these referral guidelines, healthcare professionals can ensure that children with suspected cancer receive timely and appropriate care.
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This question is part of the following fields:
- Neurology
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Question 5
Correct
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A 25-year-old woman presents with headaches. She suffered headaches occasionally in her early twenties but has had them more frequently over the past 2 months.
Select from the list of options the single feature that would suggest a diagnosis of tension type headache rather than migraine.Your Answer: Generalised headache
Explanation:Understanding Tension-Type Headaches: Symptoms and Differences from Migraines
Tension-type headaches (TTH) are a common type of headache that can interfere with daily activities. Diagnosis of TTH is based on the presence of at least two of the following symptoms in at least ten previous headaches: a mild-to-moderate bilateral or generalised headache, a frontal-occipital headache, a non-pulsatile pressing or tightening quality, and no aggravation by routine physical activity.
Compared to migraines, tension-type headaches have a more gradual onset, variable duration, and are usually shorter in duration. They are also more constant in quality, less severe, and respond better to over-the-counter medication when they are episodic. Understanding the symptoms and differences between TTH and migraines can help individuals manage their headaches more effectively.
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This question is part of the following fields:
- Neurology
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Question 6
Incorrect
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What option indicates managing depression through monitoring and providing general guidance only?
Your Answer: Symptoms of short duration
Correct Answer: No obvious trigger factors
Explanation:Managing Depression Symptoms
A patient experiencing symptoms of depression for less than two weeks or with intermittent symptoms can initially be managed through non-invasive methods. This approach is also suitable if there is a clear stressor or if the patient has good social support. However, if the patient has a family history of depression or has had suicidal thoughts, more active intervention may be necessary. It is important to carefully assess each patient’s individual situation and provide appropriate treatment to ensure the best possible outcome.
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This question is part of the following fields:
- Mental Health
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Question 7
Correct
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A mother is worried about the white reflection in her 11-month-old son's eye. What is the MOST APPROPRIATE test to detect retinoblastoma in a child? Choose ONE option only.
Your Answer: Red reflex test
Explanation:Pediatric Eye Examinations: Tests and Their Significance
Pediatric eye examinations are crucial for detecting eye diseases and disorders in children. Here are some common tests and their significance:
Red Reflex Test: This test involves shining a light source from an ophthalmoscope about 50 cm away from the child’s eyes. A bright and equal red reflex should be seen from each pupil. An abnormal red reflex could indicate serious eye diseases such as cataract or retinoblastoma.
Cover Test: This test is used to detect squint. The child focuses on a near object while a cover is placed briefly over one eye and then removed. The squinting eye will deviate inwards or outwards.
Corneal Light Reflex Test: This test involves the reflection of a light source off the cornea. In people with normal fixation, its position will be symmetrical in each eye. It is used in an examination for squint.
Eye Movements: Eye movement testing is used to assess ocular motor function, particularly cranial nerve palsies.
Visual Acuity: In babies, the ability to follow objects is a guide to visual acuity. In a child with retinoblastoma, visual acuity in the affected eye(s) may be reduced. However, there are other reasons for reduced vision.
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This question is part of the following fields:
- Children And Young People
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Question 8
Correct
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A 62-year-old lady presents to you with complaints of progressive bloating and feeling full for the past two months. She requests a prescription for Colpermin, as her sister found it helpful for her IBS. Additionally, she reports experiencing urinary frequency for several weeks and suspects a UTI. On examination, her abdomen appears non-specifically bloated, and a urine dip reveals trace protein but no blood, glucose, or leukocytes. She went through menopause at 54, is nulliparous, and has a family history of psoriasis. There are no known allergies. What would be the most appropriate course of action?
Your Answer: Arrange abdominal ultrasound scan
Explanation:Consideration of Ovarian Cancer in New Onset IBS after 50
This patient presenting with new onset IBS after the age of 50 should prompt consideration of ovarian cancer. According to NICE guidelines, symptoms such as bloating, early satiety, pelvic/abdominal pain, and urinary frequency/urgency should raise suspicion of ovarian cancer. CA 125 is the test of choice if ovarian cancer is being considered.
Risk factors for ovarian cancer include nulliparity and late menopause. Symptoms that should raise suspicion of ovarian cancer include progressive bloating, early satiety, and urinary frequency. A vaginal examination should be performed if ovarian cancer is suspected since abdominal examination alone can miss an ovarian mass. The family history of psoriasis is not relevant in this case.
Prescribing Colpermin is not necessarily incorrect, but IBS is a diagnosis of exclusion that should be given once serious and common alternatives have been ruled out. Prescribing an antibiotic is inappropriate because there is no evidence of infection here.
An abdominopelvic scan would be an alternative to arranging CA 125, but an abdominal scan by itself is usually not sufficient to fully examine the ovaries. If a CA 125 was high, an ultrasound scan would be arranged to assess the ovaries in more detail, and the results of the two would be combined in an RMI score to assess the risk of malignancy.
In summary, it is important to consider ovarian cancer in cases of new onset IBS after 50, especially if symptoms such as bloating, early satiety, pelvic/abdominal pain, and urinary frequency/urgency are present. A thorough examination and appropriate tests should be performed to rule out this serious condition.
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This question is part of the following fields:
- Gastroenterology
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Question 9
Incorrect
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Samantha is a 30-year-old woman who underwent cervical cancer screening 2 years ago. The result showed positive for high-risk human papillomavirus (hrHPV) but her cervical cytology was normal.
She underwent repeat testing after 12 months and again tested positive for hrHPV with normal cytology. Her next screening was scheduled for another 12 months.
Recently, Samantha underwent her scheduled screening. The results indicate that she is still hrHPV positive and her cytology is normal.
What would be the most appropriate course of action now?Your Answer: Repeat sample in 3 months
Correct Answer: Refer for colposcopy
Explanation:According to the NICE guidelines on cervical cancer screening, if an individual’s second repeat smear at 24 months is still positive for high-risk human papillomavirus (hrHPV), they should be referred for colposcopy. Prior to this, if an individual is positive for hrHPV but receives a negative cytology report, they should have the HPV test repeated at 12 months. If the HPV test is negative at 12 months, they can return to routine recall. However, if they remain hrHPV positive and cytology negative at 12 months, they should have a repeat HPV test in a further 12 months. If they become hrHPV negative at 24 months, they can safely return to routine recall.
Understanding Cervical Cancer Screening Results
The cervical cancer screening program has evolved significantly in recent years, with the introduction of HPV testing allowing for further risk stratification. The NHS now uses an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.
If the hrHPV test is negative, individuals can return to normal recall, unless they fall under the test of cure pathway, untreated CIN1 pathway, or require follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer. If the hrHPV test is positive, samples are examined cytologically, and if the cytology is abnormal, individuals will require colposcopy.
If the cytology is normal but the hrHPV test is positive, the test is repeated at 12 months. If the repeat test is still hrHPV positive and cytology is normal, a further repeat test is done 12 months later. If the hrHPV test is negative at 24 months, individuals can return to normal recall, but if it is still positive, they will require colposcopy. If the sample is inadequate, it will need to be repeated within 3 months, and if two consecutive samples are inadequate, colposcopy will be required.
For individuals who have previously had CIN, they should be invited for a test of cure repeat cervical sample in the community 6 months after treatment. The most common treatment for cervical intraepithelial neoplasia is large loop excision of transformation zone (LLETZ), which may be done during the initial colposcopy visit or at a later date depending on the individual clinic. Cryotherapy is an alternative technique.
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This question is part of the following fields:
- Gynaecology And Breast
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Question 10
Incorrect
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A 28-year-old woman presents to your clinic at 36 weeks of pregnancy with complaints of severe itching all over her body that is causing her sleepless nights. She reports experiencing a mild stomach bug, which has resulted in abdominal pain and loss of appetite. During the examination, you notice excoriation marks due to her constant scratching. What would be the most suitable course of action to manage her condition?
Your Answer: Advise regular emollient use
Correct Answer: Arrange a same-day obstetric referral
Explanation:Obstetric cholestasis is the primary cause of itch during pregnancy that is not accompanied by a rash. To diagnose obstetric cholestasis, doctors should look for symptoms such as itchiness that begins in the third trimester, starts on the palms and soles before spreading upwards, worsens at night, and causes severe scratching that leads to excoriation marks. Additionally, patients may report anorexia, malaise, and abdominal pain, which are also associated with obstetric cholestasis.
If a woman displays any of these symptoms, it is recommended that she be admitted to the hospital or referred to an obstetrician on the same day. In secondary care, liver function tests are conducted to confirm the diagnosis, and treatment may include ursodeoxycholic acid and sedating antihistamines.
Jaundice During Pregnancy
During pregnancy, jaundice can occur due to various reasons. One of the most common liver diseases during pregnancy is intrahepatic cholestasis of pregnancy, which affects around 1% of pregnancies and is usually seen in the third trimester. Symptoms include itching, especially in the palms and soles, and raised bilirubin levels. Ursodeoxycholic acid is used for symptomatic relief, and women are typically induced at 37 weeks. However, this condition can increase the risk of stillbirth.
Acute fatty liver of pregnancy is a rare complication that can occur in the third trimester or immediately after delivery. Symptoms include abdominal pain, nausea, vomiting, headache, jaundice, and hypoglycemia. ALT levels are typically elevated. Supportive care is the initial management, and delivery is the definitive management once the patient is stabilized.
Gilbert’s and Dubin-Johnson syndrome may also be exacerbated during pregnancy. Additionally, HELLP syndrome, which stands for Haemolysis, Elevated Liver enzymes, Low Platelets, can also cause jaundice during pregnancy. It is important to monitor liver function tests and seek medical attention if any symptoms of jaundice occur during pregnancy.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 11
Incorrect
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A 42-year-old diabetic man is seen in the Diabetes Clinic with decreased visual acuity. When referred to the Eye Clinic, the Ophthalmologist inquires about the patient's risk factors for macular edema.
What is the most significant risk factor? Choose ONE answer only.Your Answer:
Correct Answer: Proteinuria
Explanation:Factors Associated with Macular Edema in Diabetes
In diabetes, macular edema is a common cause of visual loss and can result from various factors such as macular capillary non-perfusion, vitreous hemorrhage, and distortion or traction detachment of the retina. The severity of diabetic retinopathy, male gender, higher glycosylated hemoglobin, proteinuria, higher systolic and diastolic blood pressure, and smoking history are all associated with a higher incidence of macular edema, according to The Wisconsin Epidemiologic Study of Diabetic Retinopathy.
Contrary to popular belief, low glycosylated hemoglobin is not associated with macular edema. However, hypercholesterolemia and other cardiovascular risk factors can influence the onset and progression of retinopathy and should be monitored. While peripheral vascular disease is a risk factor for diabetes, it is not directly associated with macular edema. Overall, understanding the factors associated with macular edema in diabetes can help healthcare professionals identify and manage patients at risk for this complication.
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This question is part of the following fields:
- Eyes And Vision
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Question 12
Incorrect
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A 17-year-old patient presents requesting emergency contraception after unprotected intercourse the previous evening. She would also like to start a contraceptive pill as she has no regular form of contraception at the moment. She is not sure where she is in her menstrual cycle as her periods are irregular. She smokes 5 cigarettes a day. Her past medical history includes asthma and appendicectomy. Her blood pressure is 102/66 mmHg and her body mass index (BMI) is 28 kg/m.²
What factor in the history above needs to be taken into consideration for the dosage of the latter?Your Answer:
Correct Answer: Body mass index
Explanation:Levonorgestrel dosage should be increased for individuals with a BMI greater than 26 or a weight exceeding 70 kg.
Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, and should be taken as soon as possible after unprotected sexual intercourse (UPSI) for maximum efficacy. The single dose of levonorgestrel is 1.5mg, but should be doubled for those with a BMI over 26 or weight over 70kg. It is safe and well-tolerated, but may cause vomiting in around 1% of women. Ulipristal, on the other hand, is a selective progesterone receptor modulator that inhibits ovulation. It should be taken within 120 hours after intercourse, and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which may inhibit fertilization or implantation. It must be inserted within 5 days of UPSI, or up to 5 days after the likely ovulation date. Prophylactic antibiotics may be given if the patient is at high-risk of sexually transmitted infection. The IUD is 99% effective regardless of where it is used in the cycle, and may be left in-situ for long-term contraception.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 13
Incorrect
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A healthy 26-year-old archaeologist has been experiencing an itchy, raised erythematous rash on his forearms for the past 2 weeks. Loratadine has provided some relief for the itch, and occasionally the rash disappears within a few hours. However, in the last day, the rash has spread to his back and loratadine is no longer effective. The patient has no known allergies or triggers and is feeling well otherwise. What should be the next course of action for management?
Your Answer:
Correct Answer: Trial of an oral corticosteroid
Explanation:It is likely that the patient is experiencing a severe urticarial rash, which is a common condition that doesn’t require a dermatology appointment or further investigations at this stage. The patient is stable and not showing signs of anaphylaxis. To investigate further, a symptom diary would be sufficient, especially with exposure to different work environments as an archaeologist. The first-line treatment would be a non-sedating antihistamine such as loratadine or cetirizine. However, if the urticaria is severe, as in this case, a short course of oral corticosteroids may be necessary.
Urticaria is a condition characterized by the swelling of the skin, either locally or generally. It is commonly caused by an allergic reaction, although non-allergic causes are also possible. The affected skin appears pale or pink and is raised, resembling hives, wheals, or nettle rash. It is also accompanied by itching or pruritus. The first-line treatment for urticaria is non-sedating antihistamines, while prednisolone is reserved for severe or resistant cases.
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This question is part of the following fields:
- Dermatology
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Question 14
Incorrect
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At what age would a child typically develop visual acuity comparable to that of a grown-up?
Your Answer:
Correct Answer: 2 years
Explanation:Vision Testing for Children
A newborn’s visual acuity is not fully developed and only reaches about 6/200. However, it improves to 6/60 by the age of 3 months and reaches adult levels at around 2 years old. When assessing a child’s vision, there are several tests that may be performed. At birth, a red reflex test is typically done. At 6 weeks, the child is asked to fix and follow an object to 90 degrees, such as a red ball 90cm away. By 3 months, the child should be able to fix and follow an object to 180 degrees without any squinting. At 12 months, the child should be able to pick up small objects, such as ‘hundreds and thousands,’ with a pincer grip. For children over 3 years old, letter matching tests are commonly used, while Snellen charts are used for those over 4 years old. Additionally, Ishihara plates may be used to test for color vision. These tests are important in identifying any potential vision problems in children and ensuring they receive appropriate treatment.
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This question is part of the following fields:
- Children And Young People
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Question 15
Incorrect
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A 67-year-old African American male comes to his doctor complaining of muscle weakness and bone pain all over his body. Upon conducting tests, the following results are obtained:
Calcium 2.05 mmol/l
Phosphate 0.68 mmol/l
ALP 270 U/l
What is the probable diagnosis?Your Answer:
Correct Answer: Osteomalacia
Explanation:Osteomalacia may be indicated by bone pain, tenderness, and proximal myopathy (resulting in a waddling gait), as evidenced by low levels of calcium and phosphate and elevated alkaline phosphatase.
Understanding Osteomalacia: Causes, Features, Investigation, and Treatment
Osteomalacia is a condition characterized by the softening of bones due to low levels of vitamin D, which leads to a decrease in bone mineral content. While rickets is the term used for this condition in growing children, osteomalacia is the preferred term for adults. The causes of osteomalacia include vitamin D deficiency, malabsorption, lack of sunlight, diet, chronic kidney disease, drug-induced factors, inherited factors, liver disease, and coeliac disease.
The features of osteomalacia include bone pain, bone/muscle tenderness, fractures (especially femoral neck), proximal myopathy, and a waddling gait. To investigate this condition, blood tests are conducted to check for low vitamin D levels, low calcium and phosphate levels (in around 30% of patients), and raised alkaline phosphatase (in 95-100% of patients). X-rays may also show translucent bands known as Looser’s zones or pseudofractures.
The treatment for osteomalacia involves vitamin D supplementation, with a loading dose often needed initially. Calcium supplementation may also be necessary if dietary calcium is inadequate. By understanding the causes, features, investigation, and treatment of osteomalacia, individuals can take steps to prevent and manage this condition.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 16
Incorrect
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A frail 70-year-old woman has had some routine bloods checked after she complained of feeling tired all the time. The only finding of possible concern is a serum vitamin B12 level of 180 pmol/l (Normal range: 160-900 pmol/l). Her haemoglobin level is 131 g/l (Normal range: 115-155 g/l). She has no neurological symptoms and the clinical examination is normal.
What is the most appropriate next step in management?
Your Answer:
Correct Answer: Repeat the vitamin B12 test in 8 weeks
Explanation:Managing Low Vitamin B12 Levels: Recommendations and Considerations
When a patient presents with a vitamin B12 level at the lower end of the normal range, it is important to determine whether they are deficient or not. This can be complicated by the fact that people within the normal range can still experience symptoms of deficiency. In this case, the patient may have latent pernicious anaemia, dietary deficiency or food malabsorption, or be taking medications that affect gastric acid production.
To determine the cause of the low B12 levels, the serum vitamin B12 test should be repeated after 4-8 weeks. If levels remain unchanged or have fallen further, blood should be taken for intrinsic factor antibodies and a short trial of empirical therapy (oral cyanocobalamin 50 micrograms daily for four weeks) should be given. If the antibody test is positive, lifelong therapy with hydroxocobalamin is recommended. If it is negative, a further vitamin B12 check is recommended after 3-4 months. If this is well within the reference range, food malabsorption as the cause is a strong possibility and long-term low dose cobalamin therapy should be considered.
It is important to provide patients with strict instructions to seek immediate medical attention if symptoms of neuropathy develop. Additionally, failure of the B12 level to rise after oral treatment is an indication for lifelong treatment as for pernicious anaemia. Further investigations (plasma methylmalonic acid or holotranscobalamin) may help confirm biochemical deficiency.
In summary, managing low vitamin B12 levels requires careful consideration of the possible causes and appropriate testing and treatment. Repeat testing, testing for intrinsic factor antibodies, and a trial of oral cyanocobalamin are all important steps in determining the best course of action for each individual patient.
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This question is part of the following fields:
- Haematology
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Question 17
Incorrect
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Can you rearrange the following types of research studies in their correct order according to their level of evidence, starting with the highest level on the left and ending with the lowest level on the right: systematic review of RCTs, RCTs, cohort, case-control, cross-sectional, case-series? Take your time and try to recall the hierarchy.
Your Answer:
Correct Answer: Systematic review of RCTs, RCTs, cohort, case-control, cross-sectional, case-series
Explanation:Levels and Grades of Evidence in Evidence-Based Medicine
In order to evaluate the quality of evidence in evidence-based medicine, levels or grades are often used to organize the evidence. Traditional hierarchies placed systematic reviews or randomized control trials at the top and case-series/report at the bottom. However, this approach is overly simplistic as certain research questions cannot be answered using RCTs. To address this, the Oxford Centre for Evidence-Based Medicine introduced their 2011 Levels of Evidence system which separates the type of study questions and gives a hierarchy for each. On the other hand, the GRADE system is a grading approach that classifies the quality of evidence as high, moderate, low, or very low. The process begins by formulating a study question and identifying specific outcomes. Outcomes are then graded as critical or important, and the evidence is gathered and criteria are used to grade the evidence. Evidence can be promoted or downgraded based on certain circumstances. The use of levels and grades of evidence helps to evaluate the quality of evidence and make informed decisions in evidence-based medicine.
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This question is part of the following fields:
- Evidence Based Practice, Research And Sharing Knowledge
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Question 18
Incorrect
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A 35-year-old woman comes to the clinic complaining of a malodorous vaginal discharge that is white in color. She reports no associated itch or dyspareunia. The healthcare provider suspects bacterial vaginosis. Which organism is most likely responsible for this presentation?
Your Answer:
Correct Answer: Gardnerella
Explanation:Bacterial vaginosis is a condition characterized by the excessive growth of mainly bacteria.
Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.
Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimens. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 19
Incorrect
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A previously healthy 38-year-old woman is 20 weeks pregnant with her first child. She has been experiencing increasing shortness of breath in recent weeks and has started coughing up pink frothy sputum, particularly when lying down. She reports no chest pain. Blood tests reveal no anemia, but upon listening to her chest, you detect a mid-diastolic heart murmur at the apex. Her chest exam is otherwise normal, and her resting pulse is 90 bpm SR with O2 sats at 96%. What is the most probable diagnosis?
Your Answer:
Correct Answer: Mitral stenosis
Explanation:Mitral Stenosis: Symptoms and Findings
Mitral stenosis is a condition where patients experience dyspnoea and pulmonary oedema due to increased left atrial pressure. This is more common in younger patients and can be exacerbated by situations of increased blood volume, such as during pregnancy. As a result, a previously asymptomatic patient may present to their GP during pregnancy.
Typical findings in mitral stenosis include a small pulse that may be irregularly irregular. Jugular venous pressure is only raised if there is heart failure, right ventricular hypertrophy, tapping apex beat, loud S1, loud P2 if pulmonary hypertension, opening snap, mid-diastolic murmur heard at the apex only, or presystolic accentuation murmur if no atrial fibrillation.
In summary, patients with mitral stenosis may experience dyspnoea and pulmonary oedema, and typical findings include a small pulse and irregularly irregular heartbeat. Jugular venous pressure may only be raised in certain situations.
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This question is part of the following fields:
- Cardiovascular Health
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Question 20
Incorrect
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A study was conducted to evaluate the effectiveness of a new autoantibody test for detecting suspected Hashimoto's disease in individuals over the age of 50. The test was administered to 1000 participants who reported fatigue, and all test results were compared to FNA biopsy results, which served as the gold standard for diagnosing Hashimoto's disease. The table below shows the results:
Antibody +ve Antibody -ve Total
Hashimoto's disease confirmed at FNA 35 15 50
No evidence of disease at FNA 30 920 950
What is the approximate sensitivity of the autoantibody test for detecting Hashimoto's disease in individuals over the age of 50?Your Answer:
Correct Answer: 70%
Explanation:Understanding Sensitivity in Medical Testing
Sensitivity is a crucial measure of a medical test’s ability to identify individuals with a particular condition. It is calculated as the proportion of true positives correctly identified by the test. For instance, if 50 individuals have Hashimoto’s disease according to the gold standard test of biopsy, and 35 of these are identified by the antibody test, the sensitivity of the test is 70%. This means that the test correctly identified 35 out of 50 true positives, while 15 were falsely identified as negative. In other words, sensitivity is the ability of a test to detect the presence of a condition in those who have it. Understanding sensitivity is essential in evaluating the accuracy and reliability of medical tests.
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This question is part of the following fields:
- Evidence Based Practice, Research And Sharing Knowledge
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Question 21
Incorrect
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In a certain population, the occurrence of Rett syndrome is one per 10 000. A diagnostic test is being created for use in infancy, with a sensitivity of 90% and a specificity of 99.99%. What is the anticipated positive predictive value (PPV)?
Your Answer:
Correct Answer: The PPV is 47.9%; negative predictive value (NPV) is greater than 99.99%
Explanation:Understanding Positive and Negative Predictive Values in Diagnostic Testing
When interpreting the results of a diagnostic test, it is important to understand the concepts of positive predictive value (PPV) and negative predictive value (NPV). PPV refers to the proportion of true positives among all positive test results, while NPV refers to the proportion of true negatives among all negative test results.
To illustrate this, let’s consider a hypothetical example of a test for Rett syndrome. Out of a population of 1 million, 100 individuals have Rett syndrome. If the test has a sensitivity of 90% and a specificity of 99.99%, we can calculate the expected numbers of true positives, false positives, true negatives, and false negatives.
Based on these calculations, we can determine that the PPV is 47.9%, meaning that less than half of all positive test results will be true positives. On the other hand, the NPV is greater than 99.99%, indicating that almost all negative test results will be true negatives.
It is important to note that sensitivity and specificity are not the same as PPV and NPV. While sensitivity and specificity describe the accuracy of the test itself, PPV and NPV take into account the prevalence of the condition in the population being tested.
In summary, understanding PPV and NPV can help clinicians and patients interpret the results of diagnostic tests and make informed decisions about further testing or treatment.
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This question is part of the following fields:
- Population Health
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Question 22
Incorrect
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A 35-year-old man presents to the Emergency Department claiming to have lost the vision in his left eye. While sitting at his desk he started to see a shower of black spots in his vision. These rapidly increased, becoming larger and more numerous until he could not see at all. This has persisted over a period of five hours. He has diabetes, which has been very poorly controlled in the past. He previously had laser treatment to both eyes; however, he has not attended follow-up appointments in the last 12 months.
What is the most likely explanation for this patient's presentation?Your Answer:
Correct Answer: He has had a vitreous haemorrhage due to diabetic retinopathy
Explanation:Differentiating Causes of Visual Disturbances in a Diabetic Patient
Visual disturbances in diabetic patients can have various causes, and it is important to differentiate between them to provide appropriate treatment. In the case of proliferative diabetic retinopathy, new blood vessels grow in the eyes and can bleed spontaneously, causing visual disturbances. Laser treatment is necessary, and follow-up is crucial to ensure sufficient therapy. Acute retinal detachment requires urgent surgery to prevent further vision loss. Fungal eye infections are rare and usually follow an injury. Visual disturbances due to hypoglycaemia are transient and resolve when blood glucose stabilises. In contrast, persistent and progressive loss of vision suggests a vitreous haemorrhage, as seen in poorly controlled diabetic retinopathy. Proper diagnosis and treatment can prevent further vision loss in diabetic patients.
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This question is part of the following fields:
- Eyes And Vision
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Question 23
Incorrect
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During a 4-week baby check, you observe a flat, pink-colored, vascular skin lesion measuring 30x20mm over the baby's nape. The lesion blanches on pressure and has been present since birth without any significant changes. The baby is developing normally. What is the probable underlying diagnosis?
Your Answer:
Correct Answer: Salmon patch
Explanation:Salmon patches are a type of birthmark caused by excess blood vessels, but they typically go away on their own. If a person has a flat birthmark that was present from birth, it could only be a port-wine stain or a salmon patch. Salmon patches are more common and often appear as a pink discoloration on the back of the neck. Atopic dermatitis, a type of eczema, doesn’t appear at birth but may develop later in life, often on the neck and other areas that bend. Strawberry birthmarks, on the other hand, usually appear shortly after birth and are raised above the skin’s surface. They can either disappear, shrink, or remain the same over time.
Understanding Salmon Patches in Newborns
Salmon patches, also known as stork marks or stork bites, are a type of birthmark that can be found in approximately 50% of newborn babies. These marks are characterized by their pink and blotchy appearance and are commonly found on the forehead, eyelids, and nape of the neck. While they may cause concern for new parents, salmon patches typically fade over the course of a few months. However, marks on the neck may persist. These birthmarks are caused by an overgrowth of blood vessels and are completely harmless. It is important for parents to understand that salmon patches are a common occurrence in newborns and do not require any medical treatment.
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This question is part of the following fields:
- Dermatology
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Question 24
Incorrect
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A 55-year-old man has been drinking alcohol heavily for over 20 years but now needs to drink more to feel drunk as well as to avoid being irritable. He works as a bank manager and gave up driving 5 years ago at the insistence of his wife. There is no evidence of chronic liver disease on physical examination. Assessment of his mental state reveals episodes of low mood. He no longer goes out with friends.
Select from the list the single most correct diagnosis.Your Answer:
Correct Answer: Alcohol dependence
Explanation:Alcohol Dependence and Social Withdrawal: Understanding the Symptoms
Alcohol dependence is a syndrome characterized by withdrawal symptoms, tolerance, and loss of control over alcohol use. The CAGE questionnaire is a useful screening tool for alcohol-related disorders. Episodes of low mood may be related to alcohol dependence. Social withdrawal is a feature of various mental health conditions, including schizophrenia, personality disorders, autism spectrum disorders, depression, social anxiety disorder, and traumatic brain injury. Understanding the symptoms of alcohol dependence and social withdrawal can help individuals seek appropriate treatment and support.
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This question is part of the following fields:
- Mental Health
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Question 25
Incorrect
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A mother brings in her three-week-old baby boy who was delivered vaginally at term without any complications. She is worried about his frequent feeding, especially in the evenings when he can nurse for hours and seems a bit more fussy than during the day. However, he has no vomiting and is producing an adequate amount of wet and dirty diapers. The mother wants to continue breastfeeding and reports that she feels comfortable during feedings with no pain. Upon examination, the baby appears well-hydrated and is not jaundiced. His temperature, heart rate, and respiratory rate are all within normal range for his age. There are no concerns about his weight.
What is the most appropriate course of action?Your Answer:
Correct Answer: Offer reassurance, encourage continuing to breastfeed and offer signposting to local breastfeeding team for further support
Explanation:Frequent feeding in a breastfed baby doesn’t necessarily indicate low milk supply in the mother. It is uncommon for a mother to have low milk supply, and if the baby is growing well and producing enough urine, it is a good sign that the milk supply is sufficient. In fact, frequent feeding or cluster feeding is normal in the early weeks and helps to establish a good milk supply. Breastfeeding mothers should be encouraged to seek support from local and national breastfeeding groups and consult with a trained professional to ensure proper infant positioning and latch.
There is no need to refer the baby to a pediatrician at this stage. It is not recommended to supplement breastfeeding with formula, especially in the early weeks, as this can decrease milk supply. It is important to feed the baby on demand to stimulate milk production. If milk is not removed from the breast, milk production will decrease.
While maternal prolactin deficiency is a rare cause of low milk supply, testing for it is not necessary in this scenario. If there are signs of low milk supply, such as a baby failing to thrive or becoming dehydrated, and after addressing positioning and latch issues, maternal prolactin deficiency may be considered. Factors that increase the likelihood of this condition include a history of maternal thyroid disorder, eating disorder, hypoplastic breasts, or breast surgery.
For more information on breastfeeding problems, refer to the NICE clinical knowledge summary.
Breastfeeding Problems and Management
Breastfeeding can come with its own set of challenges, but most of them can be managed with proper care and attention. Some common issues include frequent feeding, nipple pain, blocked ducts, and nipple candidiasis. These problems can be addressed by seeking advice on positioning, breast massage, and using appropriate creams and suspensions.
Mastitis is a more serious condition that affects around 1 in 10 breastfeeding women. It is important to seek treatment if symptoms persist or worsen, including systemic illness, nipple fissures, or infection. The first-line antibiotic is flucloxacillin, and breastfeeding or expressing should continue during treatment. If left untreated, mastitis can lead to a breast abscess, which requires incision and drainage.
Breast engorgement is another common issue that can cause pain and discomfort. It usually occurs in the first few days after birth and can affect both breasts. Hand expression of milk can help relieve the discomfort of engorgement, and complications can be avoided by addressing the issue promptly.
Raynaud’s disease of the nipple is a less common but still significant problem that can cause pain and blanching of the nipple. Treatment options include minimizing exposure to cold, using heat packs, avoiding caffeine and smoking, and considering oral nifedipine.
Concerns about poor infant weight gain can also arise, prompting consideration of the above breastfeeding problems and an expert review of feeding. Monitoring of weight until weight gain is satisfactory is also recommended. With proper management and support, most breastfeeding problems can be overcome, allowing for a successful and rewarding breastfeeding experience.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 26
Incorrect
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A concerned mother brings in her 7 month old baby boy, worried about the shape of his skull. The baby's development and birth have been normal, and there are no known conditions in the family. Upon examination, the baby's head circumference is at the 40th percentile, while his height and weight are at the 30th percentile. The left side of his occiput is flattened, his left ear protrudes slightly forward, and his left forehead is more prominent than the right. No other abnormalities are detected. What is the most appropriate course of action?
Your Answer:
Correct Answer: Reassurance
Explanation:Plagiocephaly has become more prevalent due to campaigns promoting the practice of placing babies on their backs while sleeping to reduce the risk of sudden infant death syndrome (SIDS). This condition causes unilateral flattening of the occipital region of the skull, resulting in the forehead and ear on the same side being pushed forward, giving the head a parallelogram appearance. However, most cases of plagiocephaly improve by the age of 3-5 years as the child adopts a more upright posture. The use of helmets is not typically recommended, as a randomized controlled trial showed no significant difference between groups. One simple solution is to turn the baby’s cot around to encourage them to look in the opposite direction and relieve pressure on the affected side. Other methods include supervised tummy time during the day, supported sitting, and changing the position of toys and mobiles in the cot to shift the child’s focus. It is important to ensure that all advice given is consistent with SIDS prevention guidelines.
Common Skull Problems in Children
Plagiocephaly is a condition where a child’s head becomes parallelogram-shaped. This condition has become more prevalent in recent years, possibly due to the success of the ‘Back to Sleep’ campaign. This campaign encourages parents to place their infants on their backs to sleep, reducing the risk of sudden infant death syndrome (SIDS). However, prolonged time spent on the back of the head can lead to flattening of the skull. Plagiocephaly can be corrected with physical therapy or the use of a special helmet.
Craniosynostosis is a condition where the skull bones fuse prematurely, leading to an abnormal head shape. This condition can cause pressure on the brain and may require surgery to correct. It is important to diagnose and treat craniosynostosis early to prevent potential developmental delays or neurological problems.
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This question is part of the following fields:
- Children And Young People
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Question 27
Incorrect
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A 5-year-old boy has been brought into see you. During the last three days of his holiday he was very tired and reluctant to play with his sister and had a temperature without any obvious cause.
Which of the following other features would prompt you to order a full blood count to investigate further?Your Answer:
Correct Answer: Generalised lymphadenopathy
Explanation:Symptoms and Signs that Require Investigation in Children
Leukaemia can present with symptoms such as pallor, fatigue, unexplained irritability, fever, recurrent infections, lymphadenopathy, bone pain, and unexplained bruising. If any of these symptoms are present, a full blood count and blood film should be conducted to investigate the possibility of leukaemia. If the results indicate leukaemia, an urgent referral should be made.
Generalised lymphadenopathy with the above symptoms also requires further investigation. On the other hand, a healthy 3-year-old may experience two fevers a month due to exposure to new pathogens, especially if they have older siblings or attend nursery. A fever of 39°C makes a bacterial infection more likely, and a thorough history and examination should be carried out to identify the source of the fever.
If a child has a vesicular rash, it is often caused by Chickenpox, which is associated with a prodromal period of being non-specifically unwell. If the rash looks like Chickenpox, no further investigations are required. Erythema in the throat and ears is usually caused by a viral illness, and no further investigations are necessary unless there are other concerning symptoms.
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This question is part of the following fields:
- Haematology
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Question 28
Incorrect
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You operate a clinic for smoking cessation and respiratory disease intervention at your practice in northern England. Concerning inequalities, what is accurate regarding the emergence of bronchial carcinoma and related risk factors?
Your Answer:
Correct Answer: The incidence is higher in patients from higher socio-economic groups
Explanation:Inequalities in Lung Cancer Rates in the UK
Unfortunately, there are significant inequalities in lung cancer rates across the UK. Scotland, Northern Ireland, and Wales have higher rates compared to England, with the north of England having higher rates than the south. These disparities are concerning and require attention to ensure that all individuals have access to the same level of care and resources.
Furthermore, patients from lower socio-economic groups have lower survival rates from bronchial carcinoma than those from higher socio-economic backgrounds. This highlights the need for additional resources in areas with substantial deprivation, particularly in terms of smoking cessation services and management of associated respiratory diseases. By addressing these inequalities, we can work towards improving outcomes for all individuals affected by lung cancer.
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This question is part of the following fields:
- People With Long Term Conditions Including Cancer
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Question 29
Incorrect
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A 25-year-old woman comes in with complaints of hearing loss. She appears to be in good health and there are no noticeable abnormalities during otoscopy. Tuning fork tests are conducted, revealing a negative Rinne test on the right side (bone conduction is better than air conduction) and a positive Rinne test on the left side. The Weber test shows lateralisation to the right ear. How should these tuning fork test results be interpreted?
Your Answer:
Correct Answer: Right-sided conductive hearing loss
Explanation:Tuning Fork Tests for Hearing Loss
Tuning fork tests are commonly used to differentiate between conductive and sensorineural hearing loss. Two tests are usually performed: the Rinne test and the Weber test. The Rinne test compares air conduction to bone conduction by placing the tuning fork against the mastoid and adjacent to the ear canal on both sides. Normally, sound is heard better by air conduction than bone conduction, resulting in a Rinne-positive outcome. However, conductive hearing loss can reverse this result, causing a Rinne-negative pattern where bone conduction is better than air conduction. On the other hand, sensorineural hearing loss and normal hearing both result in a Rinne-positive outcome, requiring the Weber test for further information.
The Weber test involves placing the tuning fork on the forehead and checking if sound waves are transmitted equally to both ears. If the sound is heard equally in both ears, the result is normal. However, conductive hearing loss in one ear causes the sound to be heard on the same side as the conductive loss. In contrast, sensorineural hearing loss causes sound to be heard on the opposite side.
In this particular case, the Rinne test resulted in a negative outcome on the right side, indicating right-sided conductive hearing loss. The Weber test confirmed this by lateralizing to the affected side. Tuning fork tests are a quick and non-invasive way to determine the type and location of hearing loss, allowing for appropriate treatment to be initiated.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 30
Incorrect
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A 16-year-old male with a history of cystic fibrosis comes for his yearly check-up. What is the most suitable recommendation for his diet?
Your Answer:
Correct Answer: High calorie and high fat with pancreatic enzyme supplementation for every meal
Explanation:Managing Cystic Fibrosis: A Multidisciplinary Approach
Cystic fibrosis (CF) is a chronic condition that requires a multidisciplinary approach to management. Regular chest physiotherapy and postural drainage, as well as deep breathing exercises, are essential to maintain lung function and prevent complications. Parents are usually taught how to perform these techniques. A high-calorie diet, including high-fat intake, is recommended to meet the increased energy needs of patients with CF. Vitamin supplementation and pancreatic enzyme supplements taken with meals are also important.
Patients with CF should try to minimize contact with each other to prevent cross-infection with Burkholderia cepacia complex and Pseudomonas aeruginosa. Chronic infection with Burkholderia cepacia is an important CF-specific contraindication to lung transplantation. In cases where lung transplantation is necessary, careful consideration is required to ensure the best possible outcome.
Lumacaftor/Ivacaftor (Orkambi) is a medication used to treat CF patients who are homozygous for the delta F508 mutation. Lumacaftor increases the number of CFTR proteins that are transported to the cell surface, while ivacaftor is a potentiator of CFTR that is already at the cell surface. This combination increases the probability that the defective channel will be open and allow chloride ions to pass through the channel pore.
In summary, managing cystic fibrosis requires a comprehensive approach that involves a range of healthcare professionals. Regular chest physiotherapy, a high-calorie diet, and vitamin and enzyme supplementation are essential components of CF management. Patients with CF should also take steps to minimize contact with others with the condition to prevent cross-infection. Finally, the use of medications such as Lumacaftor/Ivacaftor can help improve outcomes for patients with CF.
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This question is part of the following fields:
- Children And Young People
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