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  • Question 1 - A 45-year-old woman has been diagnosed with Addison's disease. What medications are typically...

    Correct

    • A 45-year-old woman has been diagnosed with Addison's disease. What medications are typically prescribed in combination for this condition?

      Your Answer: Hydrocortisone + fludrocortisone

      Explanation:

      Addison’s disease is a condition that requires patients to undergo both glucocorticoid and mineralocorticoid replacement therapy. This treatment usually involves taking a combination of hydrocortisone and fludrocortisone. Hydrocortisone is typically given in 2 or 3 divided doses, with patients requiring 20-30 mg per day, mostly in the first half of the day. Patient education is crucial, and it is essential to emphasize the importance of not missing glucocorticoid doses. Additionally, patients should consider wearing MedicAlert bracelets and steroid cards, and they should be provided with hydrocortisone for injection with needles and syringes to treat an adrenal crisis.

      During an intercurrent illness, it is crucial to manage the glucocorticoid dose properly. In simple terms, the glucocorticoid dose should be doubled, while the fludrocortisone dose should remain the same. The Addison’s Clinical Advisory Panel has produced guidelines that detail specific scenarios, and patients should refer to these guidelines for more information. It is essential to discuss how to adjust the glucocorticoid dose during an intercurrent illness with a healthcare professional. Proper management of Addison’s disease is crucial to ensure that patients can lead healthy and fulfilling lives.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      20.1
      Seconds
  • Question 2 - A 64-year-old male with a history of mitral regurgitation is scheduled for dental...

    Incorrect

    • A 64-year-old male with a history of mitral regurgitation is scheduled for dental polishing. He has a documented penicillin allergy. What is the recommended prophylaxis for preventing infective endocarditis?

      Your Answer: Oral clindamycin

      Correct Answer: No antibiotic prophylaxis needed

      Explanation:

      In the UK, it is no longer standard practice to use antibiotics as a preventative measure against infective endocarditis during dental or other procedures, as per the 2008 NICE guidelines which have brought about a significant shift in approach.

      Infective endocarditis is a serious infection of the heart lining and valves. The 2008 guidelines from NICE have changed the list of procedures for which antibiotic prophylaxis is recommended. According to NICE, dental procedures, gastrointestinal, genitourinary, and respiratory tract procedures do not require prophylaxis. However, if a person at risk of infective endocarditis is receiving antimicrobial therapy because they are undergoing a gastrointestinal or genitourinary procedure at a site where there is a suspected infection, they should be given an antibiotic that covers organisms that cause infective endocarditis. It is important to note that these recommendations differ from the American Heart Association/European Society of Cardiology guidelines, which still advocate antibiotic prophylaxis for high-risk patients undergoing dental procedures.

      The guidelines suggest that any episodes of infection in people at risk of infective endocarditis should be investigated and treated promptly to reduce the risk of endocarditis developing. It is crucial to follow these guidelines to prevent the development of infective endocarditis, which can lead to severe complications and even death. It is also important to note that these guidelines may change over time as new research and evidence become available. Therefore, healthcare professionals should stay up-to-date with the latest recommendations to provide the best possible care for their patients.

    • This question is part of the following fields:

      • Cardiovascular
      23.3
      Seconds
  • Question 3 - Endometrial cancer is a type of cancer that affects the lining of the...

    Incorrect

    • Endometrial cancer is a type of cancer that affects the lining of the uterus. What is true about this type of cancer?

      Your Answer: It is most effectively treated by a combination of radiotherapy and hormone-based chemotherapy.

      Correct Answer: The tumour is confined to myometrial invasion in stage 1 of the FIGO staging system.

      Explanation:

      Understanding Endometrial Cancer: Causes, Stages, and Treatment Options

      Endometrial cancer is a type of cancer that affects the lining of the uterus. It is the most common female genital cancer in the developing world, and an estimated 3% of women in developed countries will be diagnosed with this malignancy at some point in their lifetime. Here are some key points to understand about endometrial cancer:

      Causes:
      – It is more common among women using progestogen-containing oral contraceptives.
      – Non-hormonal uterine devices have also been found to be strongly protective.
      – There are two pathogenic types of endometrial cancer, one of which is associated with obesity, hyperlipidaemia, signs of hyperoestrogenism, and other disease states.

      Stages:
      – The FIGO staging system is used to determine the stage of endometrial cancer.
      – Staging is the most important prognostic factor.
      – The earlier endometrial cancer is diagnosed, the higher the rate of survival at 5 years.

      Treatment:
      – Standard management of endometrial cancer at diagnosis involves surgery, followed by chemotherapy with or without radiation therapy.
      – It is most effectively treated by a combination of radiotherapy and hormone-based chemotherapy.
      – The prognosis varies depending on the stage and type of endometrial cancer.

      Overall, understanding the causes, stages, and treatment options for endometrial cancer is important for early detection and effective management of this malignancy.

    • This question is part of the following fields:

      • Reproductive Medicine
      18.9
      Seconds
  • Question 4 - A 30-year-old female patient complains of vision problems. Upon examination, a left inferior...

    Incorrect

    • A 30-year-old female patient complains of vision problems. Upon examination, a left inferior homonymous quadrantanopia is observed. What is the most probable location of the lesion?

      Your Answer: Optic chiasm

      Correct Answer: Right parietal lobe

      Explanation:

      A visual field defect known as left homonymous hemianopia indicates a loss of vision to the left side, which is caused by a lesion in the right optic tract. Homonymous quadrantanopias, which affect the parietal-inferior and temporal-superior areas, are also a type of visual field defect. Incongruous defects are caused by optic tract lesions, while congruous defects are caused by lesions in the optic radiation or occipital cortex.

      Understanding Visual Field Defects

      Visual field defects refer to the loss of vision in certain areas of the visual field. One common type of visual field defect is left homonymous hemianopia, which means that there is a visual field defect to the left due to a lesion of the right optic tract. Another type is homonymous quadrantanopias, which can be remembered using the acronym PITS (Parietal-Inferior, Temporal-Superior). Incongruous defects indicate an optic tract lesion, while congruous defects suggest a lesion of the optic radiation or occipital cortex. A congruous defect means complete or symmetrical visual field loss, while an incongruous defect is incomplete or asymmetric.

      Homonymous hemianopia can also be caused by a lesion of the optic tract, with macula sparing indicating a lesion of the occipital cortex. Homonymous quadrantanopias can be caused by a lesion of the inferior optic radiations in the temporal lobe (Meyer’s loop) for superior defects, and a lesion of the superior optic radiations in the parietal lobe for inferior defects.

      Bitemporal hemianopia, on the other hand, is caused by a lesion of the optic chiasm. An upper quadrant defect that is greater than the lower quadrant defect suggests inferior chiasmal compression, which is commonly caused by a pituitary tumor. Conversely, a lower quadrant defect that is greater than the upper quadrant defect suggests superior chiasmal compression, which is commonly caused by a craniopharyngioma. It is important to note that while this information is useful for exams, actual studies suggest that the majority of quadrantanopias are caused by occipital lobe lesions.

    • This question is part of the following fields:

      • Neurology
      34.2
      Seconds
  • Question 5 - While on your GP placement, you hear a cry for help coming from...

    Correct

    • While on your GP placement, you hear a cry for help coming from the reception area. Rushing over, you see a young girl who appears to be around 4 years old collapsed on the floor. Upon checking, you find that there are no signs of life.
      What would be your initial course of action in this situation?

      Your Answer: 5 rescue breaths

      Explanation:

      According to the latest Resuscitation Council guidelines for paediatric BLS, the correct initial action when there are no signs of breathing is to give 5 rescue breaths. This is different from the adult algorithm where chest compressions may be done first. Giving 2 rescue breaths initially is incorrect. Chest compressions are given at a ratio of 30:2 if there is only one rescuer and at a ratio of 15:2 if there are multiple rescuers, but only after the initial 5 rescue breaths have been given. It is important to remember that in children, respiratory arrest is more common than cardiac arrest.

      Paediatric Basic Life Support Guidelines

      Paediatric basic life support guidelines were updated in 2015 by the Resuscitation Council. Lay rescuers should use a compression:ventilation ratio of 30:2 for children under 1 year and between 1 year and puberty, a child is defined. If there are two or more rescuers, a ratio of 15:2 should be used.

      The algorithm for paediatric basic life support starts with checking if the child is unresponsive and shouting for help. The airway should be opened, and breathing should be checked by looking, listening, and feeling for breaths. If the child is not breathing, five rescue breaths should be given, and signs of circulation should be checked.

      For infants, the brachial or femoral pulse should be used, while children should use the femoral pulse. Chest compressions should be performed at a ratio of 15:2, with a rate of 100-120 compressions per minute for both infants and children. The depth of compressions should be at least one-third of the anterior-posterior dimension of the chest, which is approximately 4 cm for an infant and 5 cm for a child.

      In children, the lower half of the sternum should be compressed, while in infants, a two-thumb encircling technique should be used for chest compressions. These guidelines are crucial for anyone who may need to perform basic life support on a child, and it is essential to follow them carefully to ensure the best possible outcome.

    • This question is part of the following fields:

      • Paediatrics
      15.9
      Seconds
  • Question 6 - A 48-year-old man presents to the clinic in the morning with a deformity...

    Correct

    • A 48-year-old man presents to the clinic in the morning with a deformity in his right hand. He denies any tingling or numbness but mentions experiencing slight difficulty in using his hand, particularly when writing. The little and ring fingers appear to be slightly flexed, with no observable weakness. What could be the probable cause of his symptoms?

      Your Answer: Dupuytren's contracture

      Explanation:

      Dupuytren’s contracture is characterized by the thickening of the palmar aponeurosis, resulting in the inward bending of the medial digits. This can severely affect hand function, but does not involve any sensory issues, making nerve palsy unlikely. Ganglions typically appear as cystic swellings on the back of the hand, while trigger finger is associated with a digit catching or snapping during flexion.

      Understanding Dupuytren’s Contracture

      Dupuytren’s contracture is a condition that affects about 5% of the population. It is more common in older men and those with a family history of the condition. The causes of Dupuytren’s contracture include manual labor, phenytoin treatment, alcoholic liver disease, diabetes mellitus, and trauma to the hand.

      The condition typically affects the ring finger and little finger, causing them to become bent and difficult to straighten. In severe cases, the hand may not be able to be placed flat on a table.

      Surgical treatment may be necessary when the metacarpophalangeal joints cannot be straightened.

    • This question is part of the following fields:

      • Musculoskeletal
      44.2
      Seconds
  • Question 7 - A 32-year-old woman presents for follow-up regarding her frequent migraine attacks. Despite taking...

    Correct

    • A 32-year-old woman presents for follow-up regarding her frequent migraine attacks. Despite taking a combination of paracetamol and ibuprofen, she has not experienced significant relief. Her current medications include as-needed paracetamol and ibuprofen, as well as Cerazette, a progestogen-only pill. What is the most suitable medication to consider for reducing the frequency of her migraines?

      Your Answer: Propranolol

      Explanation:

      For women of childbearing age who suffer from migraines, propranolol is a better option than topiramate. This is because NICE recommends both drugs for migraine prophylaxis, but the combined oral contraceptive pill cannot be used due to the patient’s migraine history. While zolmitriptan can be used to stop attacks, it is not effective for prophylaxis.

      Managing Migraines: Guidelines and Treatment Options

      Migraines can be debilitating and affect a significant portion of the population. To manage migraines, it is important to understand the different treatment options available. According to the National Institute for Health and Care Excellence (NICE) guidelines, acute treatment for migraines involves a combination of an oral triptan and an NSAID or paracetamol. For young people aged 12-17 years, a nasal triptan may be preferred. If these measures are not effective, non-oral preparations of metoclopramide or prochlorperazine may be considered, along with a non-oral NSAID or triptan.

      Prophylaxis should be given if patients are experiencing two or more attacks per month. NICE recommends topiramate or propranolol, depending on the patient’s preference, comorbidities, and risk of adverse events. Propranolol is preferred in women of childbearing age as topiramate may be teratogenic and reduce the effectiveness of hormonal contraceptives. Acupuncture and riboflavin may also be effective in reducing migraine frequency and intensity for some people. For women with predictable menstrual migraines, frovatriptan or zolmitriptan may be recommended as a type of mini-prophylaxis.

      Specialists may consider other treatment options, such as candesartan or monoclonal antibodies directed against the calcitonin gene-related peptide (CGRP) receptor, like erenumab. However, pizotifen is no longer recommended due to common adverse effects like weight gain and drowsiness. It is important to exercise caution with young patients as acute dystonic reactions may develop. By following these guidelines and considering various treatment options, migraines can be effectively managed.

    • This question is part of the following fields:

      • Neurology
      19.3
      Seconds
  • Question 8 - A 28-year-old woman visits her doctor to discuss her fertility and the possibility...

    Correct

    • A 28-year-old woman visits her doctor to discuss her fertility and the possibility of conceiving. She is worried about the risk of spina bifida after a friend had a baby with the condition. The patient has no notable medical history and no family history of birth defects. What is the recommended dosage of the supplement used to prevent neural tube defects during the first 12 weeks of pregnancy?

      Your Answer: 400 micrograms

      Explanation:

      To prevent neural tube defects in the foetus, it is crucial to consume folic acid. It is advised that women who are planning to conceive should take a supplement of 400 micrograms of folic acid daily. This dose should be continued until the 12th week of pregnancy. If there is a family history or a previous pregnancy affected by neural tube defects, the recommended dose should be increased.

      Folic Acid: Importance, Deficiency, and Prevention

      Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

      To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.

      In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.

    • This question is part of the following fields:

      • Reproductive Medicine
      11.8
      Seconds
  • Question 9 - A 5-year-old boy presents with learning difficulties and macrocephaly. What is the probable...

    Correct

    • A 5-year-old boy presents with learning difficulties and macrocephaly. What is the probable diagnosis?

      Your Answer: Fragile X

      Explanation:

      Fragile X is a condition characterized by learning difficulties, macrocephaly, large ears, and macro-orchidism in young boys.

      Childhood syndromes are a group of medical conditions that affect children and are characterized by a set of common features. Patau syndrome, also known as trisomy 13, is a syndrome that is characterized by microcephaly, small eyes, cleft lip/palate, polydactyly, and scalp lesions. Edward’s syndrome, also known as trisomy 18, is characterized by micrognathia, low-set ears, rocker bottom feet, and overlapping of fingers. Fragile X syndrome is characterized by learning difficulties, macrocephaly, long face, large ears, and macro-orchidism. Noonan syndrome is characterized by a webbed neck, pectus excavatum, short stature, and pulmonary stenosis. Pierre-Robin syndrome is characterized by micrognathia, posterior displacement of the tongue, and cleft palate. Prader-Willi syndrome is characterized by hypotonia, hypogonadism, and obesity. William’s syndrome is characterized by short stature, learning difficulties, friendly, extrovert personality, and transient neonatal hypercalcaemia. Cri du chat syndrome, also known as chromosome 5p deletion syndrome, is characterized by a characteristic cry, feeding difficulties and poor weight gain, learning difficulties, microcephaly and micrognathism, and hypertelorism. It is important to note that Treacher-Collins syndrome is similar to Pierre-Robin syndrome, but it is autosomal dominant and usually has a family history of similar problems.

    • This question is part of the following fields:

      • Paediatrics
      9.9
      Seconds
  • Question 10 - A 30-year-old female presents to her GP after a missed period and a...

    Correct

    • A 30-year-old female presents to her GP after a missed period and a positive pregnancy test. She is thrilled to be pregnant but is worried about her epilepsy medication. What medications are safe for epileptics during pregnancy?

      Your Answer: Lamotrigine

      Explanation:

      The use of anti-epileptic medication during pregnancy is a complex issue due to the risk of severe congenital defects. Therefore, it is important to provide good contraceptive advice and planning to women of childbearing age who are taking these medications. However, in cases where a woman becomes pregnant while on anti-epileptic medication, it is crucial to seek medical advice as soon as possible.

      According to recent guidelines from MBRRACE-UK and NICE, lamotrigine is the preferred medication for most women with epilepsy who are of childbearing age. In some cases, a dose increase may be necessary during pregnancy. Other medications such as phenytoin, phenobarbitone, and sodium valproate are known to have adverse effects on cognitive abilities and are generally avoided unless absolutely necessary.

      For pregnant women with epilepsy, lamotrigine, carbamazepine, and levetiracetam are considered to have the least impact on the developing fetus. However, it is important for all pregnant women with epilepsy to receive specialist care and guidance throughout their pregnancy.

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

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

    • This question is part of the following fields:

      • Neurology
      14.2
      Seconds
  • Question 11 - A 25-year-old man is brought into the emergency department resus, after being involved...

    Correct

    • A 25-year-old man is brought into the emergency department resus, after being involved in a road traffic collision, where he, a motorbike rider, collided with a car. As one of the doctors receiving the patient into resus, you are tasked with calculating the current Glasgow coma score (GCS) of the patient. The patient's eyes are open, but he seems disoriented and asks you if he's on a spaceship.

      Your Answer: 13

      Explanation:

      The patient’s GCS score is 13, with a breakdown of 4 out of 4 for eye opening, 4 out of 5 for verbal response (due to confusion), and 5 out of 6 for motor response (exhibiting localisation to pain). A helpful mnemonic to remember this breakdown is 654…MoVE.

      Understanding the Glasgow Coma Scale for Adults

      The Glasgow Coma Scale (GCS) is a tool used to assess the level of consciousness in adults who have suffered a brain injury or other neurological condition. It is based on three components: motor response, verbal response, and eye opening. Each component is scored on a scale from 1 to 6, with a higher score indicating a better level of consciousness.

      The motor response component assesses the patient’s ability to move in response to stimuli. A score of 6 indicates that the patient is able to obey commands, while a score of 1 indicates no movement at all.

      The verbal response component assesses the patient’s ability to communicate. A score of 5 indicates that the patient is fully oriented, while a score of 1 indicates no verbal response at all.

      The eye opening component assesses the patient’s ability to open their eyes. A score of 4 indicates that the patient is able to open their eyes spontaneously, while a score of 1 indicates no eye opening at all.

      The GCS score is expressed as a combination of the scores from each component, with the motor response score listed first, followed by the verbal response score, and then the eye opening score. For example, a GCS score of 13, M5 V4 E4 at 21:30 would indicate that the patient had a motor response score of 5, a verbal response score of 4, and an eye opening score of 4 at 9:30 PM.

      Overall, the Glasgow Coma Scale is a useful tool for healthcare professionals to assess the level of consciousness in adults with neurological conditions.

    • This question is part of the following fields:

      • Neurology
      70.7
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  • Question 12 - A 63-year-old male is being seen in the nurse-led heart failure clinic. Despite...

    Correct

    • A 63-year-old male is being seen in the nurse-led heart failure clinic. Despite being on current treatment with furosemide, bisoprolol, enalapril, and spironolactone, he continues to experience breathlessness with minimal exertion. Upon examination, his chest is clear to auscultation and there is minimal ankle edema. Recent test results show sinus rhythm with a rate of 84 bpm on ECG, cardiomegaly with clear lung fields on chest x-ray, and an ejection fraction of 35% on echo. Isosorbide dinitrate with hydralazine was recently attempted but had to be discontinued due to side effects. What additional medication would be most effective in alleviating his symptoms?

      Your Answer: Digoxin

      Explanation:

      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.

    • This question is part of the following fields:

      • Cardiovascular
      30.2
      Seconds
  • Question 13 - Samantha is a 28-year-old who comes to your GP clinic seeking information about...

    Incorrect

    • Samantha is a 28-year-old who comes to your GP clinic seeking information about cystic fibrosis. She is in a committed relationship and wants to start a family. Samantha mentions that her partner's family has a history of cystic fibrosis and she wants to know more about it. She has already done some research and knows that cystic fibrosis is caused by mutations in the CF transmembrane conductance regulator gene (CFTR) on chromosome 7. Samantha asks you to explain how cystic fibrosis is inherited.

      Can you help her understand the inheritance pattern of cystic fibrosis?

      Your Answer: Autosomal dominant inheritance

      Correct Answer: Autosomal recessive inheritance

      Explanation:

      Cystic fibrosis is a genetic disorder that follows an autosomal recessive pattern of inheritance. The carrier frequency is estimated to be 1 in 25 individuals, while the prevalence of the disease is 1 in 2500 newborns. Having a positive family history is the only known risk factor for CF, and parents should receive appropriate counseling before conception or during pregnancy if they are carriers.

      Understanding Cystic Fibrosis and the Organisms that Affect Patients

      Cystic fibrosis is a genetic disorder that causes thickened secretions in the lungs and pancreas. This condition is caused by a defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which regulates chloride channels. In the UK, 80% of CF cases are due to delta F508 on chromosome 7, and the carrier rate is approximately 1 in 25.

      CF patients are susceptible to colonization by certain organisms, including Staphylococcus aureus, Pseudomonas aeruginosa, Burkholderia cepacia, and Aspergillus. These organisms can cause infections and exacerbate symptoms in CF patients. It is important for healthcare providers to monitor and manage these infections to improve patient outcomes. By understanding the genetic basis of CF and the organisms that affect patients, healthcare providers can provide better care for those with this condition.

    • This question is part of the following fields:

      • Paediatrics
      29
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  • Question 14 - A 26-year-old woman in her first pregnancy visits her GP at 12 weeks...

    Correct

    • A 26-year-old woman in her first pregnancy visits her GP at 12 weeks gestation complaining of dysuria. Apart from this, she is healthy and her pregnancy has been uneventful so far. Upon urine dip, leucocytes, nitrates, blood, and protein are detected. What is the most suitable course of treatment?

      Your Answer: Nitrofurantoin

      Explanation:

      Although UTI in pregnancy may not show any symptoms, it still needs to be treated promptly to prevent the development of pyelonephritis. The common medications used to treat UTIs are nitrofurantoin and trimethoprim. Nitrofurantoin can be used during pregnancy, but it should be avoided at term as it can cause neonatal haemolysis. Trimethoprim should be avoided in the first trimester of pregnancy. Penicillins and cephalosporins are safe to use during pregnancy, but sulfonamides (such as sulfasalazine) and quinolones (such as ciprofloxacin) should be avoided.

      Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is teratogenic in the first trimester. Asymptomatic bacteriuria in pregnant women should also be treated to prevent progression to acute pyelonephritis. Men with UTIs should be offered a seven-day course of trimethoprim or nitrofurantoin unless prostatitis is suspected. A urine culture should be sent before antibiotics are started. Catheterised patients should not be treated for asymptomatic bacteria, but if symptomatic, a seven-day course of antibiotics should be given. Acute pyelonephritis requires hospital admission and treatment with a broad-spectrum cephalosporin or quinolone for 10-14 days. Referral to urology is not routinely required for men who have had one uncomplicated lower UTI.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      19.3
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  • Question 15 - A 67-year-old woman is brought to the Emergency Department after being found near-unconscious...

    Correct

    • A 67-year-old woman is brought to the Emergency Department after being found near-unconscious by her husband. Her husband indicates that she has a long-term joint disorder for which she has been taking oral steroids for many years. She has recently been suffering from depression and has had poor compliance with medications.
      On examination, she is responsive to pain. Her pulse is 130 beats per minute, and her blood pressure is 90/60 mmHg. She is afebrile.
      Basic blood investigations reveal the following:
      Investigation Patient Normal value
      Haemoglobin (Hb) 121 g/l 135–175 g/l
      White cell count (WCC) 6.1 × 109/l 4.0–11.0 × 109/l
      Platelets (PLT) 233 × 109/l 150–400 × 109/l
      Sodium (Na+) 129 mmol/l 135–145 mmol/l
      Potassium (K+) 6.0 mmol/l 3.5–5.0 mmol/l
      Creatinine (Cr) 93 μmol/l 50–120 µmol/l
      Glucose 2.7 mmol/l < 11.1 mmol/l (random)
      What is the most likely diagnosis?

      Your Answer: Addisonian crisis

      Explanation:

      Differential Diagnosis: Addisonian Crisis and Other Conditions

      Addisonian Crisis: A Brief Overview

      Addison’s disease, or adrenal insufficiency, is a condition that results from the destruction of the adrenal cortex, leading to a deficiency in glucocorticoid and mineralocorticoid hormones. The majority of cases in the UK are due to autoimmune disease, while tuberculosis is the most common cause worldwide. Patients with Addison’s disease may present with vague symptoms such as anorexia, weight loss, and gastrointestinal upset, as well as hyperpigmentation of the skin. Basic investigations may reveal hyponatremia, hyperkalemia, and hypoglycemia. A short ACTH stimulation test is used to confirm the diagnosis. Emergency treatment involves IV or IM hydrocortisone and fluids, while long-term treatment is based on oral cortisol and mineralocorticoid replacement.

      Differential Diagnosis

      Insulin Overdose: While hypoglycemia is a common feature of insulin overdose, the clinical information provided suggests that the low glucose level is due to the loss of the anti-insulin effect of cortisol, which is a hallmark of Addison’s disease.

      Meningococcal Septicaemia: Although hypotension and tachycardia may be present in meningococcal septicaemia, the other features described do not support this diagnosis.

      Paracetamol Overdose: Paracetamol overdose can cause liver toxicity, but the clinical features described are not typical of this condition and are more suggestive of an Addisonian crisis.

      Salicylate Overdose: Salicylate overdose can cause a range of symptoms, including nausea, vomiting, and abdominal pain, but the clinical features described do not support this diagnosis.

      Conclusion

      Based on the information provided, an Addisonian crisis is the most likely diagnosis. However, further investigations may be necessary to rule out other conditions. Prompt recognition and treatment of an Addisonian crisis are essential to prevent life-threatening complications.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      54.6
      Seconds
  • Question 16 - A 68-year-old man presents to his GP clinic complaining of confusion and difficulty...

    Incorrect

    • A 68-year-old man presents to his GP clinic complaining of confusion and difficulty sleeping for the past 5 months. According to his wife, his confusion varies in severity from day to day, and he has been experiencing visual hallucinations of people and animals in their home. The patient is currently taking apixaban 5 mg, amlodipine 5mg, and atorvastatin 20 mg, and there is no recent history of infection. Physical examination reveals normal vital signs and no motor or speech impairment, but the patient struggles to draw a clock face and count down from 20 to 1 correctly. A urine dip test is unremarkable. What is the most likely diagnosis?

      Your Answer: Vascular dementia

      Correct Answer: Lewy body dementia

      Explanation:

      Based on the information provided, Lewy body dementia is the most probable diagnosis. Unlike other forms of dementia, it is characterized by fluctuating cognitive abilities, particularly in attention and executive functioning. The patient may also experience sleep disturbances, visual hallucinations, and parkinsonism. To confirm the diagnosis, the patient will need to undergo cognitive testing, blood tests, and a CT head scan to rule out other conditions. SPECT imaging may also be considered if there is still uncertainty, as it is highly sensitive and specific for Lewy body dementia.

      Alzheimer’s disease is less likely as memory impairment is typically the first cognitive domain affected, and confusion is not as fluctuating. Visual hallucinations are also less common than in Lewy body dementia.

      Chronic subdural hematoma is unlikely as it typically presents with reduced consciousness or neurological deficits rather than cognitive deficits alone. Given the patient’s age and anticoagulation therapy, CT imaging should be performed to rule out any intracranial hemorrhage.

      Frontotemporal dementia is unlikely as it typically presents before the age of 65 with personality changes and social conduct problems, while memory and visuospatial skills are relatively preserved.

      Understanding Lewy Body Dementia

      Lewy body dementia is a type of dementia that is becoming more recognized as a cause of cognitive impairment, accounting for up to 20% of cases. It is characterized by the presence of alpha-synuclein cytoplasmic inclusions, known as Lewy bodies, in certain areas of the brain. While there is a complicated relationship between Parkinson’s disease and Lewy body dementia, with dementia often seen in Parkinson’s disease, the two conditions are distinct. Additionally, up to 40% of patients with Alzheimer’s disease have Lewy bodies.

      The features of Lewy body dementia include progressive cognitive impairment, which typically occurs before parkinsonism, but both features usually occur within a year of each other. Unlike other forms of dementia, cognition may fluctuate, and early impairments in attention and executive function are more common than memory loss. Other features include parkinsonism, visual hallucinations, and sometimes delusions and non-visual hallucinations.

      Diagnosis of Lewy body dementia is usually clinical, but single-photon emission computed tomography (SPECT) can be used to confirm the diagnosis. Management of Lewy body dementia involves the use of acetylcholinesterase inhibitors and memantine, similar to Alzheimer’s disease. However, neuroleptics should be avoided as patients with Lewy body dementia are extremely sensitive and may develop irreversible parkinsonism. It is important to carefully consider the use of medication in these patients to avoid worsening their condition.

    • This question is part of the following fields:

      • Neurology
      58.1
      Seconds
  • Question 17 - A 26-year-old male patient complains of severe pain during defecation for the last...

    Correct

    • A 26-year-old male patient complains of severe pain during defecation for the last two weeks. He has also noticed occasional blood on the toilet paper while wiping. During the examination, a tear is observed on the posterior midline of the anal verge. Which of the following treatment options should not be suggested?

      Your Answer: Topical steroids

      Explanation:

      Studies have demonstrated that topical steroids are not very effective in the treatment of anal fissures.

      Understanding Anal Fissures: Causes, Symptoms, and Treatment

      Anal fissures are tears in the lining of the distal anal canal that can be either acute or chronic. Acute fissures last for less than six weeks, while chronic fissures persist for more than six weeks. The most common risk factors for anal fissures include constipation, inflammatory bowel disease, and sexually transmitted infections such as HIV, syphilis, and herpes.

      Symptoms of anal fissures include painful, bright red rectal bleeding, with around 90% of fissures occurring on the posterior midline. If fissures are found in other locations, underlying causes such as Crohn’s disease should be considered.

      Management of acute anal fissures involves softening stool, dietary advice, bulk-forming laxatives, lubricants, topical anaesthetics, and analgesia. For chronic anal fissures, the same techniques should be continued, and topical glyceryl trinitrate (GTN) is the first-line treatment. If GTN is not effective after eight weeks, surgery (sphincterotomy) or botulinum toxin may be considered, and referral to secondary care is recommended.

      In summary, anal fissures can be a painful and uncomfortable condition, but with proper management, they can be effectively treated. It is important to identify and address underlying risk factors to prevent the development of chronic fissures.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      20.9
      Seconds
  • Question 18 - A 59 year old man with a history of aortic stenosis presents to...

    Incorrect

    • A 59 year old man with a history of aortic stenosis presents to his cardiology clinic with complaints of worsening shortness of breath and fainting episodes. His recent ECHO reveals a mean gradient of 45 mmHg and mild aortic regurgitation, while his ECG shows left ventricular hypertrophy, left bundle branch block, and a prolonged PR interval. What factor is most indicative of the need for valve replacement surgery?

      Your Answer: Left bundle branch block

      Correct Answer: Presence of symptoms

      Explanation:

      Aortic valve replacement is typically recommended for patients with severe aortic stenosis who are experiencing symptoms such as dyspnea, chest pain, and syncope. Without treatment, these symptoms can lead to a mortality rate of 2-3 years. However, the decision to perform valve replacement on asymptomatic patients is a topic of debate.

      Aortic Stenosis: Symptoms, Causes, and Management

      Aortic stenosis is a condition characterized by the narrowing of the aortic valve, which can lead to various symptoms. These symptoms include chest pain, dyspnea, syncope, and a characteristic ejection systolic murmur that radiates to the carotids. Severe aortic stenosis can also cause a narrow pulse pressure, slow rising pulse, delayed ESM, soft/absent S2, S4, thrill, and left ventricular hypertrophy or failure. The most common causes of aortic stenosis are degenerative calcification in older patients and bicuspid aortic valve in younger patients.

      If a patient is asymptomatic, observation is usually recommended. However, if the patient is symptomatic or has a valvular gradient greater than 40 mmHg with features such as left ventricular systolic dysfunction, valve replacement is necessary. Surgical AVR is the preferred treatment for young, low/medium operative risk patients, while TAVR is used for those with a high operative risk. Balloon valvuloplasty may be used in children without aortic valve calcification and in adults with critical aortic stenosis who are not fit for valve replacement.

      In summary, aortic stenosis is a condition that can cause various symptoms and requires prompt management to prevent complications. The causes of aortic stenosis vary, and treatment options depend on the patient’s age, operative risk, and overall health.

    • This question is part of the following fields:

      • Cardiovascular
      24.9
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  • Question 19 - You are urgently requested to assess a 62-year-old female patient admitted to the...

    Correct

    • You are urgently requested to assess a 62-year-old female patient admitted to the cardiology ward with complaints of breathing difficulty. During the examination, you observe a raised JVP and bilateral fine crackles to the mid zones. The patient's blood pressure is 100/60 mmHg, and the pulse is irregular and ranges between 140-150. An ECG confirms atrial fibrillation, and there is no prior history of the condition in the patient's notes or previous ECGs. What is the most appropriate course of action for managing this patient?

      Your Answer: Urgent synchronised DC cardioversion

      Explanation:

      Urgent synchronised DC cardioversion is necessary when heart failure is observed as an adverse sign.

      Management of Peri-Arrest Tachycardias

      The Resuscitation Council (UK) guidelines for the management of peri-arrest tachycardias have been simplified in the 2015 update. The previous separate algorithms for broad-complex tachycardia, narrow complex tachycardia, and atrial fibrillation have been replaced by a unified treatment algorithm. After basic ABC assessment, patients are classified as stable or unstable based on the presence of adverse signs such as hypotension, pallor, sweating, confusion, or impaired consciousness. If any of these signs are present, synchronised DC shocks should be given, up to a maximum of three shocks.

      The treatment following this is based on whether the QRS complex is narrow or broad and whether the rhythm is regular or irregular. For broad-complex tachycardia, a loading dose of amiodarone followed by a 24-hour infusion is given if the rhythm is regular. If the rhythm is irregular, expert help should be sought as it could be due to atrial fibrillation with bundle branch block, atrial fibrillation with ventricular pre-excitation, or torsade de pointes.

      For narrow-complex tachycardia, vagal manoeuvres followed by IV adenosine are given if the rhythm is regular. If unsuccessful, atrial flutter is considered, and rate control is achieved with beta-blockers. If the rhythm is irregular, it is likely due to atrial fibrillation, and electrical or chemical cardioversion is considered if the onset is less than 48 hours. Beta-blockers are usually the first-line treatment for rate control unless contraindicated. The full treatment algorithm can be found on the Resuscitation Council website.

    • This question is part of the following fields:

      • Cardiovascular
      13.5
      Seconds
  • Question 20 - Which one of the following is not a first-rank symptom of schizophrenia for...

    Correct

    • Which one of the following is not a first-rank symptom of schizophrenia for individuals?

      Your Answer: Catatonia

      Explanation:

      Schizophrenia is a mental disorder that is characterized by various symptoms. Schneider’s first rank symptoms are divided into four categories: auditory hallucinations, thought disorders, passivity phenomena, and delusional perceptions. Auditory hallucinations can include hearing two or more voices discussing the patient in the third person, thought echo, or voices commenting on the patient’s behavior. Thought disorders can involve thought insertion, thought withdrawal, or thought broadcasting. Passivity phenomena can include bodily sensations being controlled by external influence or actions/impulses/feelings that are imposed on the individual or influenced by others. Delusional perceptions involve a two-stage process where a normal object is perceived, and then there is a sudden intense delusional insight into the object’s meaning for the patient.

      Other features of schizophrenia include impaired insight, incongruity/blunting of affect (inappropriate emotion for circumstances), decreased speech, neologisms (made-up words), catatonia, and negative symptoms such as incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), and avolition (poor motivation). It is important to note that schizophrenia can manifest differently in each individual, and not all symptoms may be present.

    • This question is part of the following fields:

      • Psychiatry
      12.1
      Seconds
  • Question 21 - A 21-year-old is brought unconscious to the Emergency Department. An alert ambulance attendant...

    Incorrect

    • A 21-year-old is brought unconscious to the Emergency Department. An alert ambulance attendant notes that the patient's breath smells like fruit punch. The patient was found holding a glass containing a clear liquid, and the ambulance attendant had noted a syringe on the patient's coffee table and a pool of vomit near the patient.
      With which of the following would this presentation be most consistent?

      Your Answer: Heroin overdose

      Correct Answer: Diabetic ketoacidosis (DKA)

      Explanation:

      Differentiating between medical conditions based on breath scent

      When a comatose patient presents with a distinct scent on their breath, it can be a helpful clue in determining the underlying medical condition. The smell of acetone is strongly indicative of diabetic ketoacidosis (DKA), which is commonly seen in patients with poorly controlled type I diabetes. In contrast, alcohol intoxication produces a scent of alcohol rather than a fruity odor. Diabetic hyperosmolar coma, typically seen in older patients with type II diabetes, does not produce a specific scent as there is no acetone production. Heroin overdose and profound hypoglycemia also do not result in a distinct breath scent. Understanding the different scents associated with various medical conditions can aid in prompt and accurate diagnosis.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      35.4
      Seconds
  • Question 22 - A 48-year-old man presents to the emergency department with his spouse. He is...

    Incorrect

    • A 48-year-old man presents to the emergency department with his spouse. He is experiencing significant swelling of his tongue and lips, rendering him unable to speak. His wife reports that his symptoms have worsened during their wait, and she is unsure of the cause as he has no known allergies. However, she does mention that he was recently prescribed a new medication by his primary care physician.
      Which of the following medications is the most probable culprit?

      Your Answer: Omeprazole

      Correct Answer: Ramipril

      Explanation:

      Although it is possible for the man to have been prescribed any of the medications listed, it is evident that he is experiencing angioedema, as indicated by the swelling of his tongue and lips. Ramipril, an ACE inhibitor, is the medication most commonly associated with this side effect. Even if the patient has no history of allergies or negative reactions to ACE inhibitors, angioedema can still occur. While the likelihood of this happening is low, it is important to keep in mind due to the large number of patients taking this type of medication and the potential complications associated with angioedema.

      Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. These inhibitors are also used to treat diabetic nephropathy and for secondary prevention of ischaemic heart disease. The mechanism of action of ACE inhibitors is to inhibit the conversion of angiotensin I to angiotensin II. They are metabolized in the liver through phase 1 metabolism.

      ACE inhibitors may cause side effects such as cough, which occurs in around 15% of patients and may occur up to a year after starting treatment. This is thought to be due to increased bradykinin levels. Angioedema may also occur up to a year after starting treatment. Hyperkalaemia and first-dose hypotension are other potential side effects, especially in patients taking diuretics. ACE inhibitors should be avoided during pregnancy and breastfeeding, and caution should be exercised in patients with renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema.

      Patients receiving high-dose diuretic therapy (more than 80 mg of furosemide a day) are at an increased risk of hypotension when taking ACE inhibitors. Before initiating treatment, urea and electrolytes should be checked, and after increasing the dose, a rise in creatinine and potassium may be expected. Acceptable changes include an increase in serum creatinine up to 30% from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment. The current NICE guidelines provide a flow chart for the management of hypertension.

    • This question is part of the following fields:

      • Immunology/Allergy
      18
      Seconds
  • Question 23 - A father brings his 4-year-old daughter to see her General Practitioner with a...

    Correct

    • A father brings his 4-year-old daughter to see her General Practitioner with a rash covering her face, trunk, arms and legs. She had a fever for a couple of days with a runny nose before the rash appears but is now well and afebrile. The rash is mainly vesicular with small fluid-filled blisters and there are a few scabbed lesions. Her father is concerned as she is scratching the lesions, especially at night. She is otherwise fit and well and is up-to-date with her vaccinations.
      Which of the following is the most appropriate treatment?

      Your Answer: Chlorphenamine

      Explanation:

      Treatment Options for chickenpox in Children

      chickenpox is a common viral infection in children that presents with a characteristic vesicular rash. While there is no specific treatment for chickenpox, symptomatic relief can be provided to alleviate itching and fever. Here are some treatment options for chickenpox in children:

      1. Chlorphenamine: This sedating antihistamine can be used at night-time to help with itching.

      2. Aciclovir: This antiviral medication is recommended for patients who are immunosuppressed or have risk factors for developing complications from infection, such as adults or newborns.

      3. Flucloxacillin: This antibiotic is used to treat secondary bacterial infections that can occur with chickenpox. However, it is not necessary for a child who is well and afebrile.

      4. Ibuprofen: While ibuprofen and paracetamol are both used as antipyretics in children with febrile illnesses, the use of ibuprofen in children with chickenpox is linked to an increased risk of severe skin infection. Paracetamol is recommended instead.

      5. Malathion: This treatment is for scabies, not chickenpox. Scabies presents with a different type of rash and does not have a prodromal illness.

      In summary, treatment for chickenpox in children is mainly symptomatic. Antihistamines and calamine lotion can help with itching, while paracetamol can be used for fever. Antibiotics and antivirals are only necessary in certain cases.

    • This question is part of the following fields:

      • Dermatology
      24.9
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  • Question 24 - A 50-year-old man with a persistent chest infection visits the clinic for evaluation....

    Correct

    • A 50-year-old man with a persistent chest infection visits the clinic for evaluation. Despite two rounds of antibiotics, there has been no significant improvement. The medical team decides to conduct a chest x-ray and screening blood tests. When analyzing the blood tests, which of the following markers is typically not elevated in response to an acute infection?

      Your Answer: Albumin

      Explanation:

      A decrease in albumin levels is frequently observed after an acute phase response.

      Acute phase proteins are a group of proteins that are produced by the liver in response to inflammation or infection. These proteins are involved in various physiological processes such as immune response, blood clotting, and iron metabolism. Examples of acute phase proteins include CRP, procalcitonin, ferritin, fibrinogen, alpha-1 antitrypsin, caeruloplasmin, serum amyloid A, serum amyloid P component, haptoglobin, and complement.

      During the acute phase response, the liver decreases the production of other proteins known as negative acute phase proteins. These proteins include albumin, transthyretin, transferrin, retinol binding protein, and cortisol binding protein. The levels of acute phase proteins, particularly CRP, are commonly measured in acutely unwell patients. Elevated levels of CRP are indicative of inflammation or infection, and levels greater than 150 at 48 hours post-surgery suggest the development of complications.

      It is important to note that while acute phase proteins play a significant role in humans, some of these proteins, such as serum amyloid P component, have a more significant role in other mammals like mice. Overall, the production of acute phase proteins is a crucial part of the body’s response to inflammation or infection, and monitoring their levels can aid in the diagnosis and management of various medical conditions.

    • This question is part of the following fields:

      • Infectious Diseases
      16.6
      Seconds
  • Question 25 - A 50-year-old man comes to the Emergency Department complaining of right upper quadrant...

    Correct

    • A 50-year-old man comes to the Emergency Department complaining of right upper quadrant pain, dark urine, and pale stools that have been present for the past 24 hours. He reports being a part-time teacher and smoking 10 cigarettes daily. He has no significant medical history and is not taking any medications. Upon examination, his sclera are yellow, and his BMI is 29 kg/m². What investigation would be the most useful in this case?

      Your Answer: Ultrasound of abdomen

      Explanation:

      Gallstones: Symptoms, Diagnosis, and Treatment

      Gallstones are a common condition, with up to 24% of women and 12% of men affected. Local infection and cholecystitis may develop in up to 30% of cases, and 12% of patients undergoing surgery will have stones in the common bile duct. The majority of gallstones are of mixed composition, with pure cholesterol stones accounting for 20% of cases. Symptoms typically include colicky right upper quadrant pain that worsens after fatty meals. Diagnosis involves abdominal ultrasound and liver function tests, with magnetic resonance cholangiography or intraoperative imaging used to confirm the presence of stones in the bile duct. Treatment options include expectant management for asymptomatic gallstones, laparoscopic cholecystectomy for symptomatic gallstones, and early ERCP or surgical exploration for stones in the bile duct. Intraoperative cholangiography or laparoscopic ultrasound may be used to confirm anatomy or exclude CBD stones during surgery. ERCP carries risks such as bleeding, duodenal perforation, cholangitis, and pancreatitis.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      48.7
      Seconds
  • Question 26 - A 28-year-old man with Crohn's disease visits his primary care physician complaining of...

    Incorrect

    • A 28-year-old man with Crohn's disease visits his primary care physician complaining of discomfort in the area around his anus. He mentions the presence of malodorous pus when he cleans himself. During the examination, a draining opening is observed on his perineum. A digital rectal exam confirms the diagnosis of a perianal fistula. What imaging modality is the best option for this condition?

      Your Answer: Endo-anal ultrasound

      Correct Answer: MRI pelvis

      Explanation:

      When investigating suspected perianal fistulae in patients with Crohn’s disease, MRI is the preferred imaging modality. This is because an MRI can accurately map out the extent and track of the fistula, as well as identify any associated abscesses or other fistulas. As perianal fistulas are a soft tissue pathology, an MRI pelvis is the most effective way to visualize them. Barium enema is not reliable for imaging small structures like fistulas, while CT pelvis may potentially identify fistulas but is less sensitive and accurate than MRI. Endo-anal ultrasound may be used for some perianal fistulas, but given the likelihood of complex fistulas in Crohn’s disease, MRI is the preferred option. Additionally, MRI is preferable in adults of reproductive age to avoid unnecessary radiation exposure to the reproductive organs.

      Managing Crohn’s Disease: Guidelines and Treatment Options

      Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract. To manage this condition, the National Institute for Health and Care Excellence (NICE) has published guidelines that provide recommendations for inducing and maintaining remission, as well as treating complications. One of the most important steps in managing Crohn’s disease is to advise patients to quit smoking, as this can worsen the condition. Additionally, some medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and the combined oral contraceptive pill, may increase the risk of relapse, although the evidence is not conclusive.

      To induce remission, glucocorticoids are often used, either orally, topically, or intravenously. Budesonide is an alternative for some patients. Enteral feeding with an elemental diet may also be used, especially in young children or when there are concerns about the side effects of steroids. Second-line treatments for inducing remission include 5-ASA drugs like mesalazine, as well as azathioprine or mercaptopurine, which may be used in combination with other medications. Methotrexate is another option. Infliximab is useful for refractory disease and fistulating Crohn’s, and patients may continue on azathioprine or methotrexate.

      To maintain remission, stopping smoking is a priority, and azathioprine or mercaptopurine is used first-line. TPMT activity should be assessed before starting these medications. Methotrexate is used second-line. Surgery may be necessary for around 80% of patients with Crohn’s disease, depending on the location and severity of the disease. Complications of Crohn’s disease include small bowel cancer, colorectal cancer, and osteoporosis. Perianal fistulae and abscesses require specific treatments, such as oral metronidazole, anti-TNF agents like infliximab, or a draining seton. By following these guidelines and treatment options, patients with Crohn’s disease can better manage their condition and improve their quality of life.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      23.4
      Seconds
  • Question 27 - A 25-year-old gymnast complains of experiencing pain in her lateral forearm that worsens...

    Correct

    • A 25-year-old gymnast complains of experiencing pain in her lateral forearm that worsens when she straightens her wrist or fingers. Additionally, she occasionally feels a peculiar sensation in her hand similar to pins and needles. During the examination, she displays tenderness below the common extensor origin, with no pain over the lateral epicondyle itself. What is the probable reason for her forearm pain?

      Your Answer: Radial tunnel syndrome

      Explanation:

      Radial tunnel syndrome and lateral epicondylitis have similar presentations, but radial tunnel syndrome causes pain distal to the epicondyle and worsens with elbow extension and forearm pronation. This can make it challenging to differentiate between the two conditions. Radial tunnel syndrome is more common in athletes who frequently hyperextend their wrists or perform supination/pronation movements, such as gymnasts, racquet players, and golfers. Patients may also experience hand paraesthesia or wrist aching. Cubital tunnel syndrome, on the other hand, causes tingling and numbness in the 4th and 5th fingers, while olecranon bursitis results in swelling over the posterior elbow.

      Understanding Lateral Epicondylitis

      Lateral epicondylitis, commonly known as tennis elbow, is a condition that often occurs after engaging in activities that the body is not accustomed to, such as painting or playing tennis. It is most prevalent in individuals aged 45-55 years and typically affects the dominant arm. The primary symptom of this condition is pain and tenderness localized to the lateral epicondyle. The pain is often exacerbated by wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended. Episodes of lateral epicondylitis can last between 6 months and 2 years, with patients experiencing acute pain for 6-12 weeks.

      To manage lateral epicondylitis, it is essential to avoid muscle overload and engage in simple analgesia. Steroid injections and physiotherapy are also viable options for managing the condition. By understanding the symptoms and management options for lateral epicondylitis, individuals can take the necessary steps to alleviate pain and discomfort associated with this condition.

    • This question is part of the following fields:

      • Musculoskeletal
      29.8
      Seconds
  • Question 28 - A 65-year-old patient visits her GP with complaints of heat intolerance, palpitations, anxiety,...

    Correct

    • A 65-year-old patient visits her GP with complaints of heat intolerance, palpitations, anxiety, and weight loss that have been progressively worsening for the past three months. She has also noticed that her eyes feel dry and appear wider than they did in photographs taken a few years ago. The patient has a medical history of hypertension and suffered a heart attack six years ago. She is currently taking ramipril, simvastatin, aspirin, clopidogrel, and atenolol. What is the most appropriate management plan for her likely diagnosis?

      Your Answer: Carbimazole

      Explanation:

      Carbimazole is the preferred initial treatment for Graves’ disease, especially in elderly patients or those with underlying cardiovascular disease and significant thyrotoxicosis, as evidenced by this patient’s symptoms and peripheral signs of Graves’ disease such as ophthalmopathy. Radioiodine treatment is not recommended as first-line therapy in these cases due to the increased risk of Graves’ ophthalmopathy. Adrenalectomy is the primary treatment for pheochromocytoma, while ketoconazole is used to manage excess cortisol production in conditions like Cushing’s. Hydrocortisone is part of the treatment plan for Addison’s Disease.

      Management of Graves’ Disease

      Despite numerous attempts, there is no clear consensus on the best way to manage Graves’ disease. The available treatment options include anti-thyroid drugs (ATDs), radioiodine treatment, and surgery. In recent years, ATDs have become the most popular first-line therapy for Graves’ disease. This is particularly true for patients who have significant symptoms of thyrotoxicosis or those who are at a high risk of hyperthyroid complications, such as elderly patients or those with cardiovascular disease.

      To control symptoms, propranolol is often used to block the adrenergic effects. NICE Clinical Knowledge Summaries recommend that patients with Graves’ disease be referred to secondary care for ongoing treatment. If a patient’s symptoms are not controlled with propranolol, carbimazole should be considered in primary care.

      ATD therapy involves starting carbimazole at 40mg and gradually reducing it to maintain euthyroidism. This treatment is typically continued for 12-18 months. The major complication of carbimazole therapy is agranulocytosis. An alternative regime, known as block-and-replace, involves starting carbimazole at 40mg and adding thyroxine when the patient is euthyroid. This treatment typically lasts for 6-9 months. Patients following an ATD titration regime have been shown to suffer fewer side-effects than those on a block-and-replace regime.

      Radioiodine treatment is often used in patients who relapse following ATD therapy or are resistant to primary ATD treatment. However, it is contraindicated in pregnancy (should be avoided for 4-6 months following treatment) and in patients under the age of 16. Thyroid eye disease is a relative contraindication, as it may worsen the condition. The proportion of patients who become hypothyroid depends on the dose given, but as a rule, the majority of patients will require thyroxine supplementation after 5 years.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      28.2
      Seconds
  • Question 29 - A 28-year-old female presents to the GP office with a complaint of unusual...

    Correct

    • A 28-year-old female presents to the GP office with a complaint of unusual vaginal discharge. The discharge is described as frothy and green-yellow in color. She is sexually active and does not use any form of birth control. Her most recent sexual encounter was with a new partner two weeks ago. During speculum examination, a strawberry cervix is observed. She is in good health and not taking any medications. A pregnancy test came back negative. What is the recommended course of action for the most probable diagnosis?

      Your Answer: Oral metronidazole

      Explanation:

      The recommended treatment for the patient’s likely diagnosis of trichomoniasis is oral metronidazole, either as a 7-day course of 200mg or a one-time dose of 2g. Intramuscular ceftriaxone, benzathine benzylpenicillin, and oral doxycycline are not indicated for the treatment of trichomoniasis. Oral azithromycin is also not effective for this condition.

      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.

    • This question is part of the following fields:

      • Reproductive Medicine
      34.8
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  • Question 30 - A 64-year-old woman presents to her GP complaining of worsening dyspnea. Upon taking...

    Correct

    • A 64-year-old woman presents to her GP complaining of worsening dyspnea. Upon taking a detailed medical history and conducting a thorough physical examination, the GP orders an outpatient chest CT scan. The results reveal lung fibrosis as the likely cause of the patient's symptoms. The patient has a medical history of gout and rheumatoid arthritis. Which medication prescribed to the patient is most likely responsible for causing lung fibrosis?

      Your Answer: Sulfasalazine

      Explanation:

      Drugs that can lead to lung fibrosis

      Lung fibrosis is a condition where the lung tissue becomes scarred and thickened, making it difficult for the lungs to function properly. There are several drugs that can cause lung fibrosis as a side effect. These drugs include amiodarone, which is used to treat heart rhythm problems, cytotoxic agents such as busulphan and bleomycin, which are used to treat cancer, and anti-rheumatoid drugs like methotrexate and sulfasalazine. Nitrofurantoin, an antibiotic used to treat urinary tract infections, and ergot-derived dopamine receptor agonists like bromocriptine, cabergoline, and pergolide, which are used to treat Parkinson’s disease, can also cause lung fibrosis. It is important to be aware of the potential side effects of these drugs and to discuss any concerns with a healthcare provider. Proper monitoring and management can help prevent or minimize the risk of lung fibrosis.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      30.2
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  • Question 31 - A father brings his 18-month-old son in for review. He started walking five...

    Correct

    • A father brings his 18-month-old son in for review. He started walking five months ago. The father has noticed that his son seems to be 'bow-legged' when he walks.

      Examination of the knees and hips is unremarkable with a full range of movement. Leg length is equal. On standing the intercondylar distance is around 7cm.

      What is the most appropriate action?

      Your Answer: Reassure that it is a normal variant and likely to resolve by the age of 4 years

      Explanation:

      It is common for children under the age of 3 to have bow legs, which is considered a normal variation. Typically, this condition resolves on its own by the time the child reaches 4 years old.

      Common Lower Limb Variants in Children

      Parents often become concerned when they notice apparent abnormalities in their child’s lower limbs. This can lead to a visit to their primary care physician and a referral to secondary care. However, many of these presentations are actually normal variants that will resolve on their own.

      One common variant is flat feet, where the child’s medial arch is absent when standing. This typically resolves between the ages of 4-8 years and does not require orthotics. In-toeing is another common presentation, which can be caused by metatarsus adductus, internal tibial torsion, or femoral anteversion. Most cases resolve spontaneously, but severe or persistent cases may require intervention. Out-toeing is also common in early infancy and usually resolves by the age of 2 years.

      Bow legs, or genu varum, is another normal variant that presents in the first or second year of life. This is characterized by an increased intercondylar distance and typically resolves by the age of 4-5 years. Knock knees, or genu valgum, presents in the third or fourth year of life and is characterized by an increased intermalleolar distance. This also typically resolves spontaneously.

      Overall, it is important for parents to be aware of these common lower limb variants in children and to seek medical advice if they have concerns. However, in many cases, parental reassurance and monitoring is all that is needed.

    • This question is part of the following fields:

      • Paediatrics
      27.5
      Seconds
  • Question 32 - An 85-year-old man complains of increasing back pain and overall weakness. An X-ray...

    Correct

    • An 85-year-old man complains of increasing back pain and overall weakness. An X-ray of his back reveals multiple vertebral collapses and lytic lesions.
      What is the most probable diagnosis?

      Your Answer: Multiple myeloma

      Explanation:

      Understanding Multiple Myeloma: A Malignant Disease of Plasma Cells

      Multiple myeloma is a malignant disease of plasma cells that commonly affects adults aged over 60 years. It is characterized by the production of paraproteinaemia in the blood, which can affect multiple organs including the blood, bone, kidneys, and immune system. The most common symptoms of multiple myeloma include unexplained bone pain, hypercalcaemia, weight loss, hyperviscosity symptoms, spinal cord compression, and fever.

      On the other hand, osteoporosis is a condition characterized by low bone mass and deterioration of the structure of the bone tissue, resulting in bone fragility and susceptibility to fracture. Multiple vertebral collapses and lytic lesions are more sinister in nature and are commonly associated with multiple myeloma.

      Osteosarcoma, bone metastases, and chronic myeloblastic leukaemia (CML) are not related to multiple myeloma. Osteosarcoma is characterized by cortical destruction and the presence of a soft-tissue mass, while bone metastases usually lead to destruction of the cortex on plain radiographs. Symptoms of CML include fatigue, night sweats, weight loss, abdominal fullness, and left upper quadrant pain.

      In summary, understanding the symptoms and characteristics of multiple myeloma is crucial in diagnosing and treating this malignant disease of plasma cells.

    • This question is part of the following fields:

      • Haematology/Oncology
      16.1
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  • Question 33 - A 45-year-old man with a chronic history of back pain visits his GP...

    Correct

    • A 45-year-old man with a chronic history of back pain visits his GP with complaints of left eye pain and sensitivity to light. Upon examination, the pupil appears small and oval-shaped, accompanied by ciliary congestion. What is the probable diagnosis?

      Your Answer: Anterior uveitis

      Explanation:

      It is possible that his chronic back pain is related to HLA-B27, which is often associated with anterior uveitis. As for his red eye, it could be indicative of either glaucoma or uveitis. Glaucoma typically presents with severe pain, haloes, and a semi-dilated pupil, while uveitis is characterized by a small, fixed oval pupil and ciliary flush.

      Understanding the Causes of Red Eye

      Red eye is a common condition that can be caused by various factors. It is important to identify the underlying cause of red eye to determine the appropriate treatment. In some cases, urgent referral to an ophthalmologist may be necessary. Here are some of the key distinguishing features of the different causes of red eye:

      Acute angle closure glaucoma is characterized by severe pain, decreased visual acuity, and haloes. The pupil may also be semi-dilated and the cornea hazy.

      Anterior uveitis presents with acute onset, pain, blurred vision, and photophobia. The pupil is small and fixed, and there may be ciliary flush.

      Scleritis is characterized by severe pain and tenderness, which may worsen with movement. It may also be associated with underlying autoimmune diseases such as rheumatoid arthritis.

      Conjunctivitis may be bacterial or viral, with purulent or clear discharge, respectively.

      Subconjunctival haemorrhage may be caused by trauma or coughing bouts.

      Endophthalmitis typically occurs after intraocular surgery and presents with red eye, pain, and visual loss.

      By understanding the different causes of red eye and their distinguishing features, healthcare professionals can provide appropriate management and referral when necessary.

    • This question is part of the following fields:

      • Ophthalmology
      23.9
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  • Question 34 - A 65-year-old man presents to the ophthalmology clinic with a complaint of gradual...

    Incorrect

    • A 65-year-old man presents to the ophthalmology clinic with a complaint of gradual vision loss. During tonometry, his intraocular pressure is found to be 26mmHg and optic disc cupping is observed on fundoscopy. Visual field examination reveals peripheral visual loss. The physician prescribes timolol eye drops to be used twice daily. What is the mechanism of action of this medication?

      Your Answer: Decrease production of aqueous fluid and increase uveoscleral outflow

      Correct Answer: Decrease production of aqueous fluid

      Explanation:

      Timolol, a beta blocker, is effective in treating primary open-angle glaucoma by reducing the production of aqueous fluid. This condition is characterized by increased intraocular pressure due to inefficient drainage of fluid in the eye’s trabecular meshwork. Symptoms include gradual loss of vision, particularly in the peripheral fields. Brimonidine, an alpha-adrenergic agonist, also reduces aqueous fluid production and increases uveoscleral outflow. However, drugs that decrease uveoscleral outflow or increase aqueous fluid production would worsen the patient’s condition. Glucocorticoids can cause reduced drainage of aqueous humour and are implicated in causing open-angle glaucoma. Latanoprost, a prostaglandin analogue, increases uveoscleral outflow.

      Glaucoma is a condition where the optic nerve is damaged due to increased pressure in the eye. Primary open-angle glaucoma is a type where the iris is clear of the trabecular meshwork, which is responsible for draining aqueous humour from the eye. This results in increased resistance to outflow and raised intraocular pressure. The condition affects 0.5% of people over 40 years old and increases with age. Genetics also play a role, with first-degree relatives having a 16% chance of developing the disease. Symptoms are usually absent, and diagnosis is made through routine eye examinations. Investigations include visual field tests, tonometry, and slit lamp examinations. Treatment involves eye drops to lower intraocular pressure, with prostaglandin analogues being the first line of treatment. Surgery may be considered in refractory cases. Regular reassessment is necessary to monitor progression and prevent visual field loss.

    • This question is part of the following fields:

      • Ophthalmology
      25.5
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  • Question 35 - A 56-year-old man with a history of type 2 diabetes mellitus and benign...

    Incorrect

    • A 56-year-old man with a history of type 2 diabetes mellitus and benign prostatic hyperplasia presents to dermatology with multiple lesions on his shin. Upon examination, symmetrical, tender, erythematous nodules are observed. The lesions are healing without scarring. What is the probable diagnosis?

      Your Answer: Pretibial myxoedema

      Correct Answer: Erythema nodosum

      Explanation:

      The relevant diagnosis for this question relies solely on the description of the lesions, as the patient’s medical history is not a factor. Specifically, the tender shin lesions are indicative of erythema nodosum.

      Understanding Shin Lesions: Differential Diagnosis and Characteristic Features

      Shin lesions can be caused by a variety of conditions, and it is important to differentiate between them in order to provide appropriate treatment. The four most common conditions that can cause shin lesions are erythema nodosum, pretibial myxoedema, pyoderma gangrenosum, and necrobiosis lipoidica diabeticorum.

      Erythema nodosum is characterized by symmetrical, tender, erythematous nodules that heal without scarring. It is often caused by streptococcal infections, sarcoidosis, inflammatory bowel disease, or certain medications such as penicillins, sulphonamides, or oral contraceptive pills.

      Pretibial myxoedema, on the other hand, is seen in Graves’ disease and is characterized by symmetrical, erythematous lesions that give the skin a shiny, orange peel appearance.

      Pyoderma gangrenosum initially presents as a small red papule, which later develops into deep, red, necrotic ulcers with a violaceous border. It is idiopathic in 50% of cases, but may also be seen in inflammatory bowel disease, connective tissue disorders, and myeloproliferative disorders.

      Finally, necrobiosis lipoidica diabeticorum is characterized by shiny, painless areas of yellow/red skin typically found on the shin of diabetics. It is often associated with telangiectasia.

      In summary, understanding the differential diagnosis and characteristic features of shin lesions can help healthcare professionals provide appropriate treatment and improve patient outcomes.

    • This question is part of the following fields:

      • Dermatology
      65.4
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  • Question 36 - Fragile X is commonly associated with all of the following symptoms except? ...

    Incorrect

    • Fragile X is commonly associated with all of the following symptoms except?

      Your Answer: Long thin face

      Correct Answer: Small, firm testes

      Explanation:

      Fragile X Syndrome: A Genetic Disorder

      Fragile X syndrome is a genetic disorder caused by a trinucleotide repeat. It affects both males and females, but males are more severely affected. Common features in males include learning difficulties, large low set ears, long thin face, high arched palate, macroorchidism, hypotonia, and a higher likelihood of autism. Mitral valve prolapse is also a common feature. Females, who have one fragile chromosome and one normal X chromosome, may have a range of symptoms from normal to mild.

      Diagnosis of Fragile X syndrome can be made antenatally by chorionic villus sampling or amniocentesis. The number of CGG repeats can be analyzed using restriction endonuclease digestion and Southern blot analysis. Early diagnosis and intervention can help manage the symptoms of Fragile X syndrome and improve the quality of life for those affected.

    • This question is part of the following fields:

      • Paediatrics
      11.8
      Seconds
  • Question 37 - A new mother in her early thirties, who has asthma, has just given...

    Correct

    • A new mother in her early thirties, who has asthma, has just given birth to her first child. She experienced a sudden worsening of her asthma symptoms and was prescribed 30mg of oral prednisolone. She is now concerned about the safety of taking prednisolone while breastfeeding and wonders if she should switch to a different medication.

      Your Answer: It is safe to continue 30mg prednisolone and breastfeed

      Explanation:

      When a mother who is breastfeeding takes prednisolone, the amount of the drug that is transferred to the breast milk is minimal. Therefore, it is unlikely to have any negative impact on the baby.

      Management of Acute Asthma

      Acute asthma is classified by the British Thoracic Society (BTS) into three categories: moderate, severe, and life-threatening. Patients with any of the life-threatening features should be treated as having a life-threatening attack. A fourth category, Near-fatal asthma, is also recognized. Further assessment may include arterial blood gases for patients with oxygen saturation levels below 92%. A chest x-ray is not routinely recommended unless the patient has life-threatening asthma, suspected pneumothorax, or failure to respond to treatment.

      Admission criteria include a previous near-fatal asthma attack, pregnancy, an attack occurring despite already using oral corticosteroid, and presentation at night. All patients with life-threatening asthma should be admitted to the hospital, and patients with features of severe acute asthma should also be admitted if they fail to respond to initial treatment. Oxygen therapy should be started for hypoxaemic patients. Bronchodilation with short-acting betaâ‚‚-agonists (SABA) is recommended, and all patients should be given 40-50mg of prednisolone orally daily. Ipratropium bromide and IV magnesium sulphate may also be considered for severe or life-threatening asthma. Patients who fail to respond require senior critical care support and should be treated in an appropriate ITU/HDU setting. Criteria for discharge include stability on discharge medication, checked and recorded inhaler technique, and PEF levels above 75% of best or predicted.

    • This question is part of the following fields:

      • Respiratory Medicine
      20.9
      Seconds
  • Question 38 - At what age is it likely that the refugee's hip condition began to...

    Incorrect

    • At what age is it likely that the refugee's hip condition began to develop, given the severe flattening and fragmentation of the right femoral head and widened joint space in the left hip joint seen on the hip radiograph during his first routine check-up at the age of 30?

      Your Answer: 12-16 years old

      Correct Answer: 4 - 8 years old

      Explanation:

      Perthes’ disease is commonly seen in children aged between 4 and 8 years, as is the case with this untreated patient. The other age ranges mentioned are not typical for this condition.

      Understanding Perthes’ Disease

      Perthes’ disease is a degenerative condition that affects the hip joints of children, typically between the ages of 4-8 years. It is caused by a lack of blood supply to the femoral head, which leads to bone infarction and avascular necrosis. This condition is more common in boys, with around 10% of cases being bilateral. The symptoms of Perthes’ disease include hip pain, stiffness, reduced range of hip movement, and a limp. Early changes can be seen on an x-ray, such as widening of the joint space, while later changes include decreased femoral head size and flattening.

      To diagnose Perthes’ disease, a plain x-ray is usually sufficient. However, if symptoms persist and the x-ray is normal, a technetium bone scan or magnetic resonance imaging may be necessary. If left untreated, Perthes’ disease can lead to complications such as osteoarthritis and premature fusion of the growth plates.

      The severity of Perthes’ disease is classified using the Catterall staging system, which ranges from stage 1 (clinical and histological features only) to stage 4 (loss of acetabular integrity). Treatment options include keeping the femoral head within the acetabulum using a cast or braces, observation for children under 6 years old, and surgical management for older children with severe deformities. The prognosis for Perthes’ disease is generally good, with most cases resolving with conservative management. Early diagnosis is key to improving outcomes.

    • This question is part of the following fields:

      • Paediatrics
      60.2
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  • Question 39 - A 36-year-old woman arrives at the emergency department complaining of sudden abdominal pain...

    Incorrect

    • A 36-year-old woman arrives at the emergency department complaining of sudden abdominal pain and vaginal bleeding. She has a medical history of complicated pelvic inflammatory disease that resulted in scarring of her right fallopian tube. Her last menstrual period was six weeks ago. Upon examination, her heart rate is 93 bpm, and her blood pressure is 136/76 mmHg. Palpation of the left iliac fossa causes pain. A urinary pregnancy test confirms her pregnancy, and further investigations reveal a 45 mm left adnexal mass with no heartbeat detected. Her serum b-hCG level is 5200 IU/L. What is the most appropriate course of action for her treatment?

      Your Answer: Expectant management and monitoring

      Correct Answer: Laparoscopic salpingotomy and monitoring

      Explanation:

      For women with risk factors for infertility, such as contralateral tube damage, salpingotomy should be considered as the preferred surgical management for ectopic pregnancy. In the case of this patient, who presented with acute-onset abdominal pain and vaginal bleeding 6-8 weeks after her last period, a positive pregnancy test, and ultrasound findings confirming ectopic pregnancy, surgical intervention is necessary. Given the size of the ectopic pregnancy and beta-hCG levels, either laparoscopic salpingectomy or salpingotomy is appropriate. However, since the patient has a history of PID and scarring of the contralateral tube, salpingotomy is the preferred option as it preserves the affected tube and her fertility. Expectant management, laparoscopic salpingectomy, and medical management with methotrexate are not appropriate for this patient’s case.

      Ectopic pregnancy is a serious condition that requires prompt investigation and management. Women who are stable are typically investigated and managed in an early pregnancy assessment unit, while those who are unstable should be referred to the emergency department. The investigation of choice for ectopic pregnancy is a transvaginal ultrasound, which will confirm the presence of a positive pregnancy test.

      There are three ways to manage ectopic pregnancies: expectant management, medical management, and surgical management. The choice of management will depend on various criteria, such as the size of the ectopic pregnancy, whether it is ruptured or not, and the patient’s symptoms and hCG levels. Expectant management involves closely monitoring the patient over 48 hours, while medical management involves giving the patient methotrexate and requires follow-up. Surgical management can involve salpingectomy or salpingotomy, depending on the patient’s risk factors for infertility.

      Salpingectomy is the first-line treatment for women with no other risk factors for infertility, while salpingotomy should be considered for women with contralateral tube damage. However, around 1 in 5 women who undergo a salpingotomy require further treatment, such as methotrexate and/or a salpingectomy. It is important to carefully consider the patient’s individual circumstances and make a decision that will provide the best possible outcome.

    • This question is part of the following fields:

      • Reproductive Medicine
      42.7
      Seconds
  • Question 40 - A 28-year-old woman comes to her GP complaining of pelvic pain and deep...

    Incorrect

    • A 28-year-old woman comes to her GP complaining of pelvic pain and deep dyspareunia that has been ongoing for four days. During the examination, the GP notes a temperature of 37.9 degrees Celsius, lower abdominal tenderness, and cervical motion tenderness. The GP suspects that the woman may have pelvic inflammatory disease. What criteria should the GP use to determine whether antibiotics should be prescribed?

      Your Answer: Endocervical swab microscopy

      Correct Answer: Clinical evidence - history and examination

      Explanation:

      According to NICE guidelines, clinicians should diagnose pelvic inflammatory disease based on clinical symptoms and start antibiotic treatment promptly. While investigations such as endocervical and high vaginal swabs for microscopy and culture should be performed, they should not delay treatment. Negative swab results do not exclude the possibility of the disease. Blood cultures are not necessary unless the patient shows signs of systemic illness. Transvaginal ultrasound is not the first choice but may be necessary if an abscess is suspected.
      (NICE CKS – Pelvic Inflammatory Disease)

      Understanding Pelvic Inflammatory Disease

      Pelvic inflammatory disease (PID) is a condition that occurs when the female pelvic organs, including the uterus, fallopian tubes, ovaries, and surrounding peritoneum, become infected and inflamed. The most common cause of PID is an ascending infection from the endocervix, often caused by Chlamydia trachomatis. Other causative organisms include Neisseria gonorrhoeae, Mycoplasma genitalium, and Mycoplasma hominis. Symptoms of PID include lower abdominal pain, fever, dyspareunia, dysuria, menstrual irregularities, vaginal or cervical discharge, and cervical excitation.

      To diagnose PID, a pregnancy test should be done to rule out an ectopic pregnancy, and a high vaginal swab should be taken to screen for Chlamydia and Gonorrhoea. However, these tests are often negative, so consensus guidelines recommend having a low threshold for treatment due to the potential complications of untreated PID. Management typically involves a combination of antibiotics, such as oral ofloxacin and oral metronidazole or intramuscular ceftriaxone, oral doxycycline, and oral metronidazole.

      Complications of PID include perihepatitis (Fitz-Hugh Curtis Syndrome), which occurs in around 10% of cases and is characterized by right upper quadrant pain that may be confused with cholecystitis. PID can also lead to infertility, with the risk as high as 10-20% after a single episode, chronic pelvic pain, and ectopic pregnancy. In mild cases of PID, intrauterine contraceptive devices may be left in, but recent guidelines suggest that removal of the IUD should be considered for better short-term clinical outcomes. Understanding PID and its potential complications is crucial for early diagnosis and effective management.

    • This question is part of the following fields:

      • Reproductive Medicine
      31.2
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  • Question 41 - When is the infant blood spot screening test typically performed in the United...

    Correct

    • When is the infant blood spot screening test typically performed in the United Kingdom?

      Your Answer: Between fifth and ninth day of life

      Explanation:

      Neonatal Blood Spot Screening: Identifying Potential Health Risks in Newborns

      Neonatal blood spot screening, also known as the Guthrie test or heel-prick test, is a routine procedure performed on newborns between 5-9 days of life. The test involves collecting a small sample of blood from the baby’s heel and analyzing it for potential health risks. Currently, there are nine conditions that are screened for, including congenital hypothyroidism, cystic fibrosis, sickle cell disease, phenylketonuria, medium chain acyl-CoA dehydrogenase deficiency (MCADD), maple syrup urine disease (MSUD), isovaleric acidaemia (IVA), glutaric aciduria type 1 (GA1), and homocystinuria (pyridoxine unresponsive) (HCU).

    • This question is part of the following fields:

      • Paediatrics
      9.7
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  • Question 42 - A 33-year-old pregnant woman arrives with preterm labor at 32 weeks gestation. What...

    Correct

    • A 33-year-old pregnant woman arrives with preterm labor at 32 weeks gestation. What is the primary intervention to prevent neonatal respiratory distress syndrome?

      Your Answer: Administer dexamethasone to the mother

      Explanation:

      Neonatal respiratory distress syndrome (NRDS) is a condition that primarily affects premature newborns due to a lack of surfactant. This deficiency causes an increase in alveolar surface tension, leading to reduced compliance and increased breathing effort. The production of surfactant in the fetus is aided by natural maternal glucocorticosteroids, and synthetic steroids are the first-line treatment for preventing NRDS in high-risk pregnancies. Tocolytics, which can delay preterm labor, are not typically used, but may be considered in certain cases to allow time for maternal steroids to take effect. While curosurf, continuous positive airway pressure, and extracorporeal membrane oxygenation can be effective treatments for NRDS, they are not used as preventative measures.

      Surfactant Deficient Lung Disease in Premature Infants

      Surfactant deficient lung disease (SDLD), previously known as hyaline membrane disease, is a condition that affects premature infants. It occurs due to the underproduction of surfactant and the immaturity of the lungs’ structure. The risk of SDLD decreases with gestation, with 50% of infants born at 26-28 weeks and 25% of infants born at 30-31 weeks being affected. Other risk factors include male sex, diabetic mothers, Caesarean section, and being the second born of premature twins.

      The clinical features of SDLD are similar to those of respiratory distress in newborns, including tachypnea, intercostal recession, expiratory grunting, and cyanosis. Chest x-rays typically show a ground-glass appearance with an indistinct heart border.

      Prevention during pregnancy involves administering maternal corticosteroids to induce fetal lung maturation. Management of SDLD includes oxygen therapy, assisted ventilation, and exogenous surfactant given via an endotracheal tube. With proper management, the prognosis for infants with SDLD is generally good.

    • This question is part of the following fields:

      • Paediatrics
      39.2
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  • Question 43 - A 68-year-old man comes to the clinic complaining of intermittent swallowing difficulties for...

    Correct

    • A 68-year-old man comes to the clinic complaining of intermittent swallowing difficulties for the past two years. His wife has noticed that he has bad breath and coughs at night. He has a history of type 2 diabetes mellitus but reports that he is generally healthy. Despite having a good appetite, his weight has remained stable. Upon clinical examination, no abnormalities are found. What is the probable diagnosis?

      Your Answer: Pharyngeal pouch

      Explanation:

      Esophageal cancer is unlikely due to the individual’s good health and two-year history.

      Understanding Pharyngeal Pouch or Zenker’s Diverticulum

      A pharyngeal pouch, also known as Zenker’s diverticulum, is a condition where there is a posteromedial diverticulum through Killian’s dehiscence. This triangular area is found in the wall of the pharynx between the thyropharyngeus and cricopharyngeus muscles. It is more common in older patients and is five times more common in men.

      The symptoms of pharyngeal pouch include dysphagia, regurgitation, aspiration, neck swelling that gurgles on palpation, and halitosis. To diagnose this condition, a barium swallow combined with dynamic video fluoroscopy is usually done.

      Surgery is the most common management for pharyngeal pouch. It is important to address this condition promptly to prevent complications such as aspiration pneumonia. Understanding the symptoms and seeking medical attention early can help in the proper management of pharyngeal pouch.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      43.2
      Seconds
  • Question 44 - As a foundation doctor on the neonatal ward, you consult with your supervisor...

    Incorrect

    • As a foundation doctor on the neonatal ward, you consult with your supervisor regarding a patient who is five days old and displaying symptoms of cyanosis, tachypnoea, and weak peripheral pulses. Your suspicion is that the patient has a duct dependent cardiac lesion. Once this is confirmed, what would be the most suitable course of treatment?

      Your Answer: Indomethacin

      Correct Answer: Prostaglandins

      Explanation:

      Prostaglandins can maintain the patency of a patent ductus arteriosus, which can be beneficial in cases of duct dependent cardiac lesions such as tetralogy of Fallot, Ebstein’s anomaly, pulmonary atresia, and pulmonary stenosis. These conditions may be diagnosed before birth or present with symptoms such as cyanosis, tachypnea, and weak peripheral pulses at birth. While surgery is often the definitive treatment, keeping the duct open with prostaglandins can provide time for appropriate management planning. Aspirin is not recommended for children due to the risk of Reyes syndrome, which can cause liver and brain edema and be fatal. Indomethacin and other medications may also be used to close the duct.

      Patent ductus arteriosus is a type of congenital heart defect that is typically classified as ‘acyanotic’. However, if left untreated, it can eventually lead to late cyanosis in the lower extremities, which is known as differential cyanosis. This condition is caused by a connection between the pulmonary trunk and descending aorta that fails to close with the first breaths due to increased pulmonary flow that enhances prostaglandins clearance. Patent ductus arteriosus is more common in premature babies, those born at high altitude, or those whose mothers had rubella infection during the first trimester of pregnancy.

      The features of patent ductus arteriosus include a left subclavicular thrill, a continuous ‘machinery’ murmur, a large volume, bounding, collapsing pulse, a wide pulse pressure, and a heaving apex beat. To manage this condition, indomethacin or ibuprofen is given to the neonate, which inhibits prostaglandin synthesis and closes the connection in the majority of cases. If patent ductus arteriosus is associated with another congenital heart defect that is amenable to surgery, then prostaglandin E1 is useful to keep the duct open until after surgical repair.

    • This question is part of the following fields:

      • Paediatrics
      36.2
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  • Question 45 - A 24-year-old woman presents urgently to the hospital. She is 35 weeks pregnant...

    Incorrect

    • A 24-year-old woman presents urgently to the hospital. She is 35 weeks pregnant and reports sudden onset of right-sided numbness and dysphasia. Initially, she experienced tingling in the right side of her face, which then spread to her right hand over a few minutes. Shortly after, she noticed difficulty finding words and her right arm felt clumsy. The entire episode resolved completely within 20-30 minutes. Upon arrival at the hospital, her neurological exam was normal.
      What is the most likely diagnosis?

      Your Answer: Cerebral venous thrombosis

      Correct Answer: Migraine aura without headache

      Explanation:

      Migraine aura without headache is a condition where a person experiences the typical symptoms of a migraine aura, but without the accompanying headache. In some cases, a person may have multiple attacks with only an aura, while in rare cases, they may only experience the aura without a headache. To diagnose this condition, the International Headache Society requires the presence of one or more fully reversible aura symptoms, such as visual, sensory, speech and/or language, motor, brain stem, or retinal symptoms, along with at least two of the following characteristics: gradual spread of symptoms over more than 5 minutes, each symptom lasting between 5-60 minutes, and at least one symptom being unilateral. It can be difficult to distinguish an aura from a transient ischemic attack (TIA) in patients without a history of migraines, but the characteristic slow progression of symptoms is suggestive of migraine aura without headache. This condition is more commonly seen in patients with a previous history of migraines or a positive family history of migraines.

    • This question is part of the following fields:

      • Neurology
      30.4
      Seconds
  • Question 46 - An 80-year-old man comes to his General Practitioner complaining of loin pain, haematuria...

    Incorrect

    • An 80-year-old man comes to his General Practitioner complaining of loin pain, haematuria and a palpable abdominal mass. He is diagnosed with renal clear cell carcinoma. Upon staging, it is discovered that the tumour has spread to the adrenal gland. What would be the primary management option for this patient?

      Your Answer: Radical nephrectomy

      Correct Answer: Immunomodulatory drugs

      Explanation:

      Treatment Options for Stage 4 Renal Cancer with Metastases

      Loin pain, haematuria, and a palpable abdominal mass are the classic symptoms of renal cancer, which is not very common. When the cancer has metastasized to the adrenal gland, it becomes a stage 4 tumor. Targeted molecular therapy is the first-line treatment for stage 4 renal cancer with metastases. Immunomodulatory drugs such as sunitinib, temsirolimus, and nivolumab are commonly used for this purpose.

      Other treatment options for renal cancer include cryotherapy, partial nephrectomy, radiofrequency ablation, and radical nephrectomy. Cryotherapy uses liquid nitrogen to freeze cancerous cells, but it is usually only used for early-stage disease and is not first-line here. Partial nephrectomy is reserved for patients with small renal masses, usually stage 1. Radiofrequency ablation can be used for non-surgical candidates with small renal masses without metastasis, usually stage 1 or 2. Radical nephrectomy involves removal of the entire kidney, which is primarily done for stage 2 and 3 renal cell cancers.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      24.9
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  • Question 47 - A 50-year-old male is taking oral antibiotics for mild diverticulitis. He goes to...

    Incorrect

    • A 50-year-old male is taking oral antibiotics for mild diverticulitis. He goes to a wedding and later complains of palpitations, vomiting, headache, and flushing. His heart rate is 110 beats/min. He has no significant medical history and no known allergies to any medication or food. He denies using recreational drugs but admits to having one beer at the wedding. What antibiotic is he likely taking?

      Your Answer: Ciprofloxacin

      Correct Answer: Metronidazole

      Explanation:

      When metronidazole and ethanol are taken together, it can result in a disulfiram-like reaction, which can cause symptoms such as flushing in the head and neck, nausea, vomiting, sweating, headaches, and palpitations. Additionally, alcohol consumption should be avoided when taking cefoperazone, a cephalosporin, as it can also lead to a disulfiram-like reaction.

      Metronidazole is an antibiotic that functions by producing reactive cytotoxic metabolites within bacteria. This medication can cause adverse effects such as a disulfiram-like reaction when combined with alcohol and an increased anticoagulant effect when taken with warfarin.

    • This question is part of the following fields:

      • Infectious Diseases
      32.1
      Seconds
  • Question 48 - You are evaluating a patient who is experiencing hip discomfort. Do you suspect...

    Correct

    • You are evaluating a patient who is experiencing hip discomfort. Do you suspect osteoarthritis as the diagnosis? If so, what signs or symptoms would warrant additional testing for a different diagnosis?

      Your Answer: Morning stiffness lasting 4 hours

      Explanation:

      If morning stiffness persists for more than 2 hours, it could be a sign of inflammatory arthritis and should be investigated further.

      Osteoarthritis (OA) of the hip is a prevalent condition, with the knee being the only joint more commonly affected. It is particularly prevalent in older individuals, and women are twice as likely to develop it. Obesity and developmental dysplasia of the hip are also risk factors. The condition is characterized by chronic groin pain that is exacerbated by exercise and relieved by rest. However, if the pain is present at rest, at night, or in the morning for more than two hours, it may indicate an alternative cause. The Oxford Hip Score is a widely used tool to assess the severity of the condition.

      If the symptoms are typical, a clinical diagnosis can be made. Otherwise, plain x-rays are the first-line investigation. Management of OA of the hip includes oral analgesia and intra-articular injections, which provide short-term relief. However, total hip replacement is the definitive treatment.

      Total hip replacement is a common operation in the developed world, but it is not without risks. Perioperative complications include venous thromboembolism, intraoperative fracture, nerve injury, surgical site infection, and leg length discrepancy. Postoperatively, posterior dislocation may occur during extremes of hip flexion, presenting with a clunk, pain, and inability to weight bear. Aseptic loosening is the most common reason for revision, and prosthetic joint infection is also a potential complication.

    • This question is part of the following fields:

      • Musculoskeletal
      29
      Seconds
  • Question 49 - A 72-year-old man who smokes visits your GP clinic and inquires about potential...

    Correct

    • A 72-year-old man who smokes visits your GP clinic and inquires about potential complications associated with surgical resection of his malignant parotid gland tumour. What is the classic complication linked to parotid gland surgery?

      Your Answer: Lower motor neurone facial palsy

      Explanation:

      A lower motor neurone facial palsy can be caused by parotid pathology.

      After exiting the stylomastoid foramen, the facial nerve passes through the parotid gland and divides into five branches: temporal, zygomatic, buccal, marginal mandibular, and cervical. If there is any pathology within the parotid gland, it can lead to a lower motor neurone facial palsy. Additionally, surgery to the parotid gland can also result in this complication.

      Facial Nerve Palsy: Causes and Path

      Facial nerve palsy is a condition that affects the facial nerve, which supplies the muscles of facial expression, digastric muscle, and glandular structures. It can be caused by various factors, including sarcoidosis, Guillain-Barre syndrome, Lyme disease, acoustic neuromas, and Bell’s palsy. Bilateral facial nerve palsy is less common and can be caused by the same factors as unilateral palsy, but it can also be a result of neurofibromatosis type 2.

      The facial nerve has two paths: the subarachnoid path and the facial canal path. The subarachnoid path originates from the pons and passes through the petrous temporal bone into the internal auditory meatus with the vestibulocochlear nerve. The facial canal path passes superior to the vestibule of the inner ear and contains the geniculate ganglion at the medial aspect of the middle ear. It has three branches: the greater petrosal nerve, the nerve to stapedius, and the chorda tympani. The facial nerve then passes through the stylomastoid foramen and gives rise to the posterior auricular nerve and a branch to the posterior belly of the digastric and stylohyoid muscle.

      It is important to differentiate between lower motor neuron and upper motor neuron lesions in facial nerve palsy. An upper motor neuron lesion spares the upper face, while a lower motor neuron lesion affects all facial muscles. Multiple sclerosis and diabetes mellitus can also cause an upper motor neuron palsy. Understanding the causes and path of facial nerve palsy can aid in its diagnosis and treatment.

    • This question is part of the following fields:

      • ENT
      16.4
      Seconds
  • Question 50 - A 42-year-old woman presents to the Ear, Nose and Throat Clinic with a...

    Correct

    • A 42-year-old woman presents to the Ear, Nose and Throat Clinic with a 4-month history of right-sided hearing loss. She reports occasional buzzing in her right ear and feeling unsteady. She has no significant medical history and denies any recent infections. On examination, Rinne's test is positive in both ears, with Weber's test lateralizing to her left ear. There is no evidence of nystagmus, and her coordination remains intact. Apart from an absent right-sided corneal reflex, the rest of her cranial-nerve examination is unremarkable. What is the most appropriate investigation to confirm the diagnosis?

      Your Answer: Magnetic resonance imaging (MRI) of the cerebellopontine angle with contrast

      Explanation:

      Diagnostic Tests for Acoustic Tumours: Importance of MRI with Contrast

      Acoustic tumours require accurate diagnosis for effective treatment. The most definitive diagnostic test is gadolinium-enhanced magnetic resonance imaging (MRI) of the cerebellopontine angle. This test can detect tumours as small as 1-2 mm in diameter, while fine-cut computed tomography (CT) scanning may miss tumours as large as 1.5 cm even with intravenous contrast enhancement.

      Audiometry is also important, but only 5% of patients with acoustic tumours will have a normal audiogram. If MRI is contraindicated, air-contrast cisternography can detect relatively small intracanalicular tumours with high sensitivity.

      Fine-cut CT scanning of the internal auditory canal with contrast can rule out medium to large tumours, but cannot reliably detect tumours smaller than 1-1.5 cm. CT scanning without contrast can rule out medium-sized tumours, but is not reliable for detecting smaller tumours.

      It is critical to use gadolinium contrast in MRI of the cerebellopontine angle, as non-enhanced MRI may miss small tumours. Therefore, MRI with contrast is the most important diagnostic test for acoustic tumours.

    • This question is part of the following fields:

      • Neurology
      76.6
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Endocrinology/Metabolic Disease (3/4) 75%
Cardiovascular (2/4) 50%
Reproductive Medicine (2/5) 40%
Neurology (4/7) 57%
Paediatrics (5/9) 56%
Musculoskeletal (3/3) 100%
Renal Medicine/Urology (1/2) 50%
Gastroenterology/Nutrition (3/4) 75%
Psychiatry (1/1) 100%
Immunology/Allergy (0/1) 0%
Dermatology (1/2) 50%
Infectious Diseases (1/2) 50%
Pharmacology/Therapeutics (1/1) 100%
Haematology/Oncology (1/1) 100%
Ophthalmology (1/2) 50%
Respiratory Medicine (1/1) 100%
ENT (1/1) 100%
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