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Question 1
Correct
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A 27-year-old woman who has never given birth presents to your clinic seeking contraception. She complains of experiencing extremely heavy menstrual periods and desires a long-term contraceptive option that can alleviate her heavy bleeding. What is the most appropriate contraceptive method for this patient?
Your Answer: Intrauterine system
Explanation:The Mirena coil is a contraceptive method that reduces the duration and intensity of periods and can be used for an extended period.
Intrauterine contraceptive devices include copper IUDs and levonorgestrel-releasing IUS. Both are over 99% effective. The IUD prevents fertilization by decreasing sperm motility, while the IUS prevents endometrial proliferation and thickens cervical mucus. Potential problems include heavier periods with IUDs and initial bleeding with the IUS. There is a small risk of uterine perforation, ectopic pregnancy, and infection. New IUS systems, such as Jaydess® and Kyleena®, have smaller frames and less levonorgestrel, resulting in lower serum levels and different rates of amenorrhea.
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This question is part of the following fields:
- Reproductive Medicine
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Question 2
Incorrect
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A 30-year-old woman visits her doctor with worries about a genetic disorder. Her granddaughter, who is three years old, has been diagnosed with sickle cell anemia. She reports that no one else in the family has the condition.
What is the likelihood of her being a carrier of the sickle cell allele?Your Answer: 1 in 16
Correct Answer: 1 in 2
Explanation:Understanding the Probability of Cystic Fibrosis Inheritance
Cystic fibrosis is a genetic condition that is inherited in an autosomal recessive pattern. This means that for a child to be affected, they must inherit two mutated alleles – one from each parent. If one grandparent is a carrier, there is a 1 in 2 chance that they passed the gene on to their offspring, who is the parent of the affected child.
When both parents are carriers, there is a 1 in 4 chance that their child will be affected by cystic fibrosis. However, the chance of inheriting the condition is always 1 in 2 for boys and girls.
Diagnosis of cystic fibrosis often occurs before the age of two, with up to 75% of patients being diagnosed at this age. It is important to note that carriers of cystic fibrosis are relatively common, with an estimated 1 in 25 people in the UK being carriers.
Understanding the probability of cystic fibrosis inheritance is crucial for families with a history of the condition, as it can help them make informed decisions about family planning and genetic testing.
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This question is part of the following fields:
- Genetics
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Question 3
Correct
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A 65-year-old man comes to the General Practitioner with his daughter. She reports that her father’s behavior has changed over the past year. He used to be a very sociable and outgoing man but recently he has become withdrawn and uninterested in his hobbies. He has also become forgetful and has difficulty completing tasks that he used to do easily. The patient tells you that he does not think there is anything wrong with him and he is just getting older.
Which of the following is the most likely diagnosis?Your Answer: Frontotemporal dementia
Explanation:Differentiating Types of Dementia: A Brief Overview
Dementia is a broad term used to describe a decline in cognitive function that interferes with daily activities. However, there are different types of dementia, each with unique characteristics. Here are some key features to help differentiate between frontotemporal dementia, Alzheimer’s disease, Huntington’s disease, normal-pressure hydrocephalus (NPH), and Parkinson’s disease.
Frontotemporal Dementia
This type of dementia is rare and typically affects individuals between the ages of 55 and 65. Early personality and behavior changes are core symptoms, while memory impairment is not typical. Other key features include a gradual progression, decline in social conduct, emotional blunting, and loss of insight.Alzheimer’s Disease
Alzheimer’s disease is the most common form of dementia, affecting individuals over the age of 65. Memory loss is a key early symptom, followed by agitation and obsessive behavior later in the disease course.Huntington’s Disease
Huntington’s disease is a neurodegenerative condition that is often inherited. Symptoms include memory impairment, depression, clumsiness, mood swings, and difficulty concentrating. However, this patient’s symptoms are more consistent with early frontotemporal dementia.Normal-Pressure Hydrocephalus (NPH)
NPH is a reversible cause of dementia characterized by gait abnormality, memory impairment, and incontinence. It may be mistaken for Parkinson’s disease, but symptoms will not improve with levodopa.Parkinson’s Disease
While dementia and hallucinations may develop during the course of Parkinson’s disease, it is primarily a movement disorder characterized by tremors, rigidity, and bradykinesia. -
This question is part of the following fields:
- Neurology
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Question 4
Correct
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A 50-year-old woman with known ovarian cancer presented to the emergency department complaining of severe right leg pain since yesterday. She had a hysterectomy 1 month ago.
Which of the following is the most likely cause of her symptoms?
Your Answer: DVT (deep-vein thrombosis)
Explanation:After undergoing surgery, a woman presents with leg pain. Several potential causes are considered, including deep-vein thrombosis (DVT), acute limb ischaemia, air embolus, lumbar disc herniation, and paradoxical embolus. Based on the patient’s risk factors and symptoms, DVT is deemed the most likely diagnosis. Other causes are ruled out due to lack of relevant history or low probability. Understanding the possible causes of leg pain after urological surgery can help healthcare providers make an accurate diagnosis and provide timely treatment.
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This question is part of the following fields:
- Haematology/Oncology
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Question 5
Correct
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A 75-year-old patient presents for a follow-up appointment after undergoing private health screening. The patient has been advised to seek medical attention regarding her thyroid function tests (TFTs).
TSH levels are at 9.2 mU/L and free thyroxine levels are at 14 pmol/L. Despite her age, the patient is currently in good health and shows no symptoms. What is the best course of action for managing her condition?Your Answer: Repeat TFTs in a few months time
Explanation:According to the guidelines recommended by NICE Clinical Knowledge Summaries, this patient with subclinical hypothyroidism should be monitored at present based on both TSH and age criteria.
Understanding Subclinical Hypothyroidism
Subclinical hypothyroidism is a condition where the thyroid-stimulating hormone (TSH) is elevated, but the levels of T3 and T4 are normal, and there are no obvious symptoms. However, there is a risk of the condition progressing to overt hypothyroidism, especially in men, with a 2-5% chance per year. This risk is further increased if thyroid autoantibodies are present.
Not all patients with subclinical hypothyroidism require treatment, and guidelines have been produced by NICE Clinical Knowledge Summaries (CKS) to help determine when treatment is necessary. If the TSH level is above 10mU/L and the free thyroxine level is within the normal range, levothyroxine may be offered. If the TSH level is between 5.5 – 10mU/L and the free thyroxine level is within the normal range, a 6-month trial of levothyroxine may be considered if the patient is under 65 years old and experiencing symptoms of hypothyroidism. For older patients, a ‘watch and wait’ strategy is often used, and asymptomatic patients may simply have their thyroid function monitored every 6 months.
In summary, subclinical hypothyroidism is a condition that requires careful monitoring and consideration of treatment options based on individual patient factors.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 6
Incorrect
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Which of the following skin conditions is not linked to diabetes mellitus?
Your Answer: Vitiligo
Correct Answer: Sweet's syndrome
Explanation:Sweet’s syndrome is a condition associated with acute myeloid leukemia, also known as acute febrile neutrophilic dermatosis, but not with diabetes mellitus.
Skin Disorders Linked to Diabetes
Diabetes mellitus is a chronic metabolic disorder that affects various organs in the body, including the skin. Several skin disorders are associated with diabetes, including necrobiosis lipoidica, infections such as candidiasis and staphylococcal, neuropathic ulcers, vitiligo, lipoatrophy, and granuloma annulare. Necrobiosis lipoidica is characterized by shiny, painless areas of yellow, red, or brown skin, typically on the shin, and is often associated with surrounding telangiectasia. Infections such as candidiasis and staphylococcal can also occur in individuals with diabetes. Neuropathic ulcers are a common complication of diabetes, and vitiligo and lipoatrophy are also associated with the condition. Granuloma annulare is a papular lesion that is often slightly hyperpigmented and depressed centrally, but recent studies have not confirmed a significant association between diabetes mellitus and this skin disorder. It is important for individuals with diabetes to be aware of these potential skin complications and to seek medical attention if they notice any changes in their skin.
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This question is part of the following fields:
- Dermatology
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Question 7
Correct
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What is the most frequent cause of hypothyroidism in children in the United Kingdom?
Your Answer: Autoimmune thyroiditis
Explanation:Causes of Hypothyroidism in Children
Hypothyroidism in children, also known as juvenile hypothyroidism, is most commonly caused by autoimmune thyroiditis. This occurs when the body’s immune system attacks the thyroid gland, leading to decreased production of thyroid hormones. However, there are other causes of hypothyroidism in children as well. For example, children who have undergone total-body irradiation as part of treatment for acute lymphoblastic leukemia may develop hypothyroidism as a side effect. Additionally, iodine deficiency is a common cause of hypothyroidism in children in developing countries. It is important for parents and healthcare providers to be aware of these potential causes in order to properly diagnose and treat hypothyroidism in children.
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This question is part of the following fields:
- Paediatrics
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Question 8
Correct
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A 49-year-old homeless man has been admitted to the emergency department after collapsing with sudden onset left side hemiparesis and facial droop. A CT scan has revealed a large intracerebral haemorrhage, which is likely to have occurred spontaneously. The patient's medical and family history is unknown, but you suspect that coagulopathy may be the cause of the spontaneous bleed. The clotting profile and specific clotting factor levels are as follows:
- PT prolonged
- APTT prolonged
- Factor VIII high
- Factor II low
- Factor V low
- Factor VII low
- Factor IX low
- Von Willebrand factor high
What is the most probable reason for the coagulopathy?Your Answer: Liver failure
Explanation:It is highly probable that the individual is suffering from liver failure as all clotting factors, except for factor VIII, are below normal levels. In cases of liver failure, both PT and APTT may be prolonged. Haemophilia A and B are unlikely as they result in deficiencies of specific clotting factors, whereas Von Willebrand disease may have low levels of Von Willebrand factor but the other factors remain unaffected. Disseminated intravascular coagulation, on the other hand, leads to depletion of all clotting factors.
Coagulopathy in Liver Disease: Paradoxical Supra-normal Factor VIII and Increased Thrombosis Risk
In liver failure, the levels of all clotting factors decrease except for factor VIII, which paradoxically increases. This is because factor VIII is synthesized not only in hepatic endothelial cells but also in endothelial cells throughout the body. Moreover, good hepatic function is required for the rapid clearance of activated factor VIII from the bloodstream, leading to further increases in circulating factor VIII. Despite conventional coagulation studies suggesting an increased risk of bleeding, patients with chronic liver disease are paradoxically at an increased risk of thrombosis formation. This is due to several factors, including reduced synthesis of natural anticoagulants such as protein C, protein S, and anti-thrombin, which are all essential for preventing thrombosis.
Reference
Tripodi et al. An imbalance of pro- vs anti-coagulation factors in plasma from patients with cirrhosis. Gastroenterology. 2009 Dec;137(6):2105-11. -
This question is part of the following fields:
- Haematology/Oncology
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Question 9
Correct
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A teenage boy presents with bizarre delusions, a blunted affect and tangential thought processes.
Which one of the following characteristics would indicate an unfavourable prognosis?
Your Answer: A prolonged premorbid history of social withdrawal
Explanation:Understanding Prognostic Factors in Schizophrenia
Schizophrenia is a complex mental illness that can have a significant impact on a person’s life. While there is no cure for schizophrenia, early diagnosis and treatment can help manage symptoms and improve outcomes. Understanding prognostic factors can also be helpful in predicting the course of the illness and developing appropriate treatment plans.
One important factor to consider is the premorbid history of the patient. A prolonged history of social withdrawal is predictive of more severe and long-lasting psychopathology. Additionally, a family history of schizophrenia in first-degree relatives can have a negative impact on prognosis, while a history in second-degree relatives has little significance.
The onset of illness is also an important factor to consider. In schizophrenia, a sudden onset of illness has a more favourable prognosis than an insidious one. However, if the patient presents with catatonic symptoms, this is actually an indicator of a relatively good prognosis.
Finally, MRI changes are associated with more severe symptoms and clinical course in people with schizophrenia. While it is not fully clear whether these changes are fixed or progress over time, they can be an important factor to consider in developing a treatment plan.
Overall, understanding these prognostic factors can help clinicians develop appropriate treatment plans and provide better support for patients with schizophrenia.
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This question is part of the following fields:
- Psychiatry
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Question 10
Incorrect
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Which one of the following statements regarding elderly advanced life support is accurate?
Your Answer: Ratio of chest compressions to ventilation is 15:2
Correct Answer: Chest compressions should continue whilst the defibrillator is charged
Explanation:The 2015 Resus Council guidelines for adult advanced life support outline the steps to be taken when dealing with patients with shockable and non-shockable rhythms. For both types of patients, chest compressions are a crucial part of the process, with a ratio of 30 compressions to 2 ventilations. Defibrillation is recommended for shockable rhythms, with a single shock for VF/pulseless VT followed by 2 minutes of CPR. Adrenaline and amiodarone are the drugs of choice for non-shockable rhythms, with adrenaline given as soon as possible and amiodarone administered after 3 shocks for VF/pulseless VT. Thrombolytic drugs should be considered if a pulmonary embolus is suspected. Atropine is no longer recommended for routine use in asystole or PEA. Oxygen should be titrated to achieve saturations of 94-98% following successful resuscitation. The Hs and Ts should be considered as potential reversible causes of cardiac arrest.
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This question is part of the following fields:
- Respiratory Medicine
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Question 11
Correct
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A 28-year-old patient complains of a painful bump on their eyelid. The lump has been there for about four days and is gradually getting bigger.
During the examination, a tender, smooth lump is observed, measuring roughly 2 mm in size, emerging from the outer edge of the left upper eyelid. The eye is not inflamed, and there is no periorbital or orbital redness, and the patient's visual acuity is normal.
What is the best course of action for managing this condition?Your Answer: Provide advice on application of hot compresses and simple analgesia
Explanation:Management of Stye or Hordeolum
A stye or hordeolum is an acute and painful swelling of the eyelid caused by inflammation in an eyelash follicle. It usually presents unilaterally and can take a few days to develop. While it does not affect visual acuity, it can cause watery eyes. The first-line management for a stye is the application of warm compresses a few times a day, which can help the stye resolve or drain. However, if symptoms do not improve, referral to Eye Casualty for incision and drainage may be necessary. Topical antibiotics are not recommended in the absence of conjunctivitis, and systemic antibiotics are not indicated unless there are signs of cellulitis over the eyelid. Therefore, simple analgesia and warm compresses are the recommended management for a stye or hordeolum.
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This question is part of the following fields:
- Ophthalmology
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Question 12
Correct
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A 32-year-old woman comes to her General Practitioner complaining of dysuria and lower abdominal pain for the past three days. She has also noticed an unusual vaginal discharge since yesterday. She has been in a committed relationship for the past year and is sexually active. The urine dipstick is normal and her pregnancy test is negative.
What is the most suitable investigation to be performed next, given the most probable diagnosis?
Choose the SINGLE most appropriate investigation from the options below.
Your Answer: High vaginal swab for nucleic acid amplification test (NAAT)
Explanation:Investigations for Suspected Sexually Transmitted Infection in Women
When a woman presents with lower abdominal pain, dysuria, and vaginal discharge, it is important to consider the possibility of a sexually transmitted infection (STI), particularly if she is under 25 years old, has had a new sexual partner or multiple partners in the past year, or has a history of STIs. A high vaginal swab for nucleic acid amplification test (NAAT) is the investigation of choice in women suspected of having an STI, such as chlamydia or gonorrhoea. If the NAAT is positive for gonorrhoea, swabs are collected for culture to test for antibiotic susceptibility. Blood tests for inflammatory markers may be useful if an acute abdomen is suspected. HIV serology is not the next investigation in this case, but those diagnosed with STIs are offered screening for HIV. An ultrasound scan of the abdomen and pelvis may be done if a complicated pelvic inflammatory disease is suspected, but it is unlikely to be helpful in this case. Urine culture would not be useful in the absence of urinary symptoms.
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This question is part of the following fields:
- Infectious Diseases
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Question 13
Incorrect
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A 65-year-old man presents to his GP for a hypertension review. His home readings indicate an average blood pressure of 162/96 mmHg. He reports feeling generally well, and physical examination is unremarkable. Previous investigations have not revealed an underlying cause for his hypertension. Recent blood tests show normal electrolyte levels and kidney function. He is currently on ramipril, amlodipine, and bendroflumethiazide. What would be the most appropriate medication to add for the management of this patient's hypertension?
Your Answer: Furosemide
Correct Answer: Alpha-blocker or beta-blocker
Explanation:If a patient has poorly controlled hypertension and is already taking an ACE inhibitor, calcium channel blocker, and a standard-dose thiazide diuretic, and their potassium level is above 4.5mmol/l, the best option is to add an alpha- or beta-blocker. According to NICE guidelines, this patient has resistant hypertension, which is stage 4 of the NICE flowchart for hypertension management. Spironolactone can also be introduced at this stage, but only if the patient’s serum potassium is less than 4.5mmol/l, as spironolactone is a potassium-sparing diuretic. Indapamide is not suitable for someone who is already taking a thiazide diuretic like bendroflumethiazide. Furosemide is typically used for hypertension management in patients with heart failure or kidney disease, which is not present in this case. Hydralazine is primarily used for emergency hypertension management or hypertension during pregnancy, not for long-term management.
NICE Guidelines for Managing Hypertension
Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of a calcium channel blocker or thiazide-like diuretic in addition to an ACE inhibitor or angiotensin receptor blocker.
The guidelines also provide a flow chart for the diagnosis and management of hypertension. Lifestyle advice, such as reducing salt intake, caffeine intake, and alcohol consumption, as well as exercising more and losing weight, should not be forgotten and is frequently tested in exams. Treatment options depend on the patient’s age, ethnicity, and other factors, and may involve a combination of drugs.
NICE recommends treating stage 1 hypertension in patients under 80 years old if they have target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For patients with stage 2 hypertension, drug treatment should be offered regardless of age. The guidelines also provide step-by-step treatment options, including adding a third or fourth drug if necessary.
New drugs, such as direct renin inhibitors like Aliskiren, may have a role in patients who are intolerant of more established antihypertensive drugs. However, trials have only investigated the fall in blood pressure and no mortality data is available yet. Patients who fail to respond to step 4 measures should be referred to a specialist. The guidelines also provide blood pressure targets for different age groups.
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This question is part of the following fields:
- Cardiovascular
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Question 14
Correct
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A 68-year-old female with a history of osteoporosis is prescribed alendronate. What is the most crucial side-effect to caution her about?
Your Answer: Heartburn
Explanation:Patients starting bisphosphonates should be warned about potential oesophageal problems, particularly with alendronate. Any new symptoms following the introduction of this drug should be reviewed by a medical professional.
Bisphosphonates: Uses and Adverse Effects
Bisphosphonates are drugs that mimic the action of pyrophosphate, a molecule that helps prevent bone demineralization. They work by inhibiting osteoclasts, which are cells that break down bone tissue. This reduces the risk of bone fractures and can be used to treat conditions such as osteoporosis, hypercalcemia, Paget’s disease, and pain from bone metastases.
However, bisphosphonates can have adverse effects, including oesophageal reactions such as oesophagitis and ulcers, osteonecrosis of the jaw, and an increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate. Patients may also experience an acute phase response, which can cause fever, myalgia, and arthralgia. Hypocalcemia, or low calcium levels, can also occur due to reduced calcium efflux from bone, but this is usually not clinically significant.
To minimize the risk of adverse effects, patients taking oral bisphosphonates should swallow the tablets whole with plenty of water while sitting or standing. They should take the medication on an empty stomach at least 30 minutes before breakfast or other oral medications and remain upright for at least 30 minutes after taking the tablet. Hypocalcemia and vitamin D deficiency should be corrected before starting bisphosphonate treatment, and calcium supplements should only be prescribed if dietary intake is inadequate. The duration of bisphosphonate treatment varies depending on the patient’s level of risk, and some authorities recommend stopping treatment after five years for low-risk patients with a femoral neck T-score of > -2.5.
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This question is part of the following fields:
- Musculoskeletal
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Question 15
Correct
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A 42-year-old woman presents to her General Practitioner with a 4-month history of nasal congestion and coughing. Over the previous few days, she has also been experiencing a persistent headache which seems to be worse when she leans forward.
Which of the following is the most probable diagnosis?
Your Answer: Chronic rhinosinusitis
Explanation:Differentiating Chronic Rhinosinusitis from Other Headache Disorders
Chronic rhinosinusitis is a condition characterized by inflammation of the paranasal sinuses and nasal passages that lasts for 12 weeks or longer. Patients with chronic rhinosinusitis typically present with symptoms such as nasal congestion, coughing, persistent headache that worsens on bending forwards, facial pain, nasal discharge, and postnasal drip. Predisposing factors for chronic rhinosinusitis include atopy, nasal obstruction, recent local infection, swimming or diving, and smoking. Management of chronic rhinosinusitis involves avoidance of allergens, intranasal corticosteroids, and nasal irrigation with saline.
Acute sinusitis shares many features with chronic rhinosinusitis, but the history of symptoms is much shorter. Treatment for acute sinusitis includes analgesia, intranasal decongestants or nasal saline, and intranasal corticosteroids if symptoms persist for more than ten days. Oral antibiotics may be given for severe presentations.
Cluster headaches are characterized by intense, sharp, stabbing pain around one eye, accompanied by eye redness, lacrimation, lid swelling, nasal stuffiness, skin erythema, miosis or ptosis. Cluster headaches occur in clusters lasting between four and 12 weeks, with patients feeling completely fine in between clusters. Tension headaches are described as a band-like headache that does not impair activities of daily living.
Postnasal drip (PND) typically presents with a chronic cough and bad breath, unlike the presentation in chronic rhinosinusitis. It is important to differentiate chronic rhinosinusitis from other headache disorders to ensure appropriate management and treatment.
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This question is part of the following fields:
- ENT
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Question 16
Correct
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You see a 4-year-old child in surgery with his mother. He has been diagnosed with molluscum contagiosum and she is keen to have him treated.
Which of the following statements about molluscum contagiosum is true?Your Answer: The condition resolves spontaneously
Explanation:Molluscum Contagiosum: Myths and Facts
Molluscum contagiosum is a common skin infection caused by a poxvirus. However, there are several myths surrounding this condition that need to be debunked. Firstly, it is not true that the condition resolves spontaneously. While most cases do clear up on their own within 6-9 months, some can last up to 4 years. Secondly, molluscum contagiosum is highly infectious and can be transmitted through contact with infected persons or objects, including swimming pools. Sexual transmission is also possible.
Another myth is that patients can treat themselves by squeezing the spots. This is not recommended as it can lead to scarring. Additionally, molluscum contagiosum is not limited to children. While it does present mainly in young children, there is also a later peak in young adults, some of which is attributable to sexual transmission.
Finally, piercing the lesions with an orange stick dipped in phenol is not the treatment of choice. In fact, the condition usually requires no treatment and resolves on its own. Treatment may be recommended for adults or older children with particularly unsightly spots or in the immunosuppressed, where it can take several years to resolve. Topical applications such as benzyl peroxide or potassium hydroxide, as well as curettage and cryotherapy, can be used to treat the condition.
In conclusion, it is important to separate fact from fiction when it comes to molluscum contagiosum. While it is a common and often harmless condition, it is important to seek medical advice if you have concerns or if the spots are causing discomfort or affecting your quality of life.
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This question is part of the following fields:
- Dermatology
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Question 17
Incorrect
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A 32-year-old man presents with a burning sensation and unusual appearance to his tongue. Upon examination, small bumps are observed on the surface of the tongue, along with red patches and white lines that resemble a map.
What is the most probable cause?Your Answer: Lichen planus
Correct Answer: Geographic tongue
Explanation:Understanding Geographic Tongue: Symptoms, Causes, and Treatment
Geographic tongue, also known as benign migratory glossitis, is a common condition that affects the tongue. It is characterized by irregularly shaped, red, smooth, and swollen patches on the tongue, often with a white border, giving rise to a map-like appearance. The exact cause of geographic tongue is unknown, but it has been associated with fissured tongue and has an inverse association with cigarette smoking.
Symptoms of geographic tongue include a burning sensation on the tongue, and eating acidic foods can worsen the pain. While the condition is usually self-limiting, symptomatic treatment can include topical anaesthetic preparations and/or soluble corticosteroids used as a ‘mouth rinse’.
It is important to note that geographic tongue is not a pre-malignant condition and is not associated with an increased risk of oral cancer. However, it is important to seek medical attention if you experience any unusual symptoms or changes in your oral health.
Overall, understanding the symptoms, causes, and treatment options for geographic tongue can help individuals manage their condition and maintain good oral health.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 18
Incorrect
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A 72-year-old man presents to the Haematology Clinic with symptoms of bone pain and anaemia. The medical team suspects multiple myeloma (MM) and orders a set of blood tests, including a full blood count, urea, serum creatinine and electrolytes, serum calcium, albumin, serum protein electrophoresis, serum-free light-chain assay, and serum beta-2 microglobulin. The team also plans to perform an imaging investigation to look for osteolytic lesions. What initial scan should be ordered?
Your Answer: Skeletal survey (X-ray)
Correct Answer: Whole-body low-dose CT (WBLD-CT)
Explanation:When investigating suspected multiple myeloma (MM), it is crucial to use whole-body low-dose CT (WBLD-CT) imaging. This method is more effective than traditional radiology in detecting lytic lesions and should be the first option if available. Lesions with a diameter of 5mm or more are considered positive. If WBLD-CT and MRI fail to show lesions with a strong clinical indication, an FDG-PET or FDG-PET-CT can be used to detect bone lesions. During treatment follow-up, an FDG-PET-CT can detect active lesions and provide prognostic information. While a skeletal survey (X-ray) is less sensitive than WBLD-CT, it can still be useful. If suspicion remains high for MM despite negative WBLD-CT or skeletal survey results, a whole-body MRI should be performed. This method can detect focal lesions and bone marrow infiltration and may also be of prognostic value in asymptomatic patients. The presence of focal lesions is a strong predictor of progression to symptomatic MM.
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This question is part of the following fields:
- Haematology/Oncology
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Question 19
Incorrect
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A 35-year-old woman presents with a 7-day history of mucopurulent anal discharge, bloody stool and pain during defecation. She denies any recent travel and has not experienced any vomiting episodes.
Which of the following is the most probable diagnosis?
Your Answer: Salmonella infection
Correct Answer: Gonorrhoea
Explanation:Sexually Transmitted Infections: Differential Diagnosis
Sexually transmitted infections (STIs) are a common cause of morbidity worldwide. When evaluating a patient with symptoms suggestive of an STI, it is important to consider a broad differential diagnosis. Here are some common STIs and their clinical presentations:
Gonorrhoea: This is a purulent infection of the mucous membranes caused by Neisseria gonorrhoeae. In men, symptoms include urethritis, acute epididymitis, and rectal infection. A diagnosis can be made by identifying typical Gram-negative intracellular diplococci after a Gram stain.
Crohn’s disease: This is an inflammatory bowel disease that presents with prolonged diarrhea, abdominal pain, anorexia, and weight loss. It is not consistent with a typical STI presentation.
Candidiasis: This is a fungal infection caused by yeasts from the genus Candida. It is associated with balanitis, presenting with penile pruritus and whitish patches on the penis.
Salmonella infection: This is often transmitted orally via contaminated food or beverages. Symptoms include a severe non-specific febrile illness, which can be confused with typhoid fever. There is nothing in this clinical scenario to suggest Salmonella infection.
Chancroid: This is a bacterial STI caused by Haemophilus ducreyi. It is characterised by painful necrotising genital ulcers and inguinal lymphadenopathy.
In summary, a thorough differential diagnosis is important when evaluating patients with symptoms suggestive of an STI.
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This question is part of the following fields:
- Infectious Diseases
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Question 20
Incorrect
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A 28-year-old woman visits her doctor after missing her progestogen-only pill, Noriday, this morning. She usually takes it at 9am, but it's now 12:30 pm. What guidance should the doctor provide?
Your Answer: Take missed pill as soon as possible and no further action needed
Correct Answer: Take missed pill as soon as possible and advise condom use until pill taking re-established for 48 hours
Explanation:Progestogen Only Pill: What to Do When You Miss a Pill
The progestogen only pill (POP) has simpler rules for missed pills compared to the combined oral contraceptive pill. It is important to note that the rules for the two types of pills should not be confused. The traditional POPs (Micronor, Noriday, Nogeston, Femulen) and Cerazette (desogestrel) have the following guidelines for missed pills:
– If the pill is less than 3 hours late, no action is required, and you can continue taking the pill as normal.
– If the pill is more than 3 hours late (i.e., more than 27 hours since the last pill was taken), action is needed.
– If the pill is less than 12 hours late, no action is required, and you can continue taking the pill as normal.
– If the pill is more than 12 hours late (i.e., more than 36 hours since the last pill was taken), action is needed. -
This question is part of the following fields:
- Reproductive Medicine
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Question 21
Incorrect
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A 35-year-old woman experiences a significant postpartum bleeding following the birth of her twins. The obstetrician in charge examines her and suspects that uterine atony is the underlying cause. The standard protocol for managing major PPH is initiated, but bimanual uterine compression proves ineffective in controlling the bleeding. What medication would be a suitable next step in treating uterine atony?
Your Answer: None - proceed immediately to balloon tamponade
Correct Answer: Intravenous oxytocin
Explanation:Postpartum haemorrhage caused by uterine atony can be treated with various medical options such as oxytocin, ergometrine, carboprost and misoprostol.
Uterine atony is the primary cause of postpartum haemorrhage, which occurs when the uterus fails to contract fully after the delivery of the placenta, leading to difficulty in achieving haemostasis. This condition is often associated with overdistension, which can be caused by multiple gestation, macrosomia, polyhydramnios or other factors.
In addition to the standard approach for managing PPH, including an ABC approach for unstable patients, the following steps should be taken in sequence:
1. Bimanual uterine compression to stimulate contraction manually
2. Intravenous oxytocin and/or ergometrine
3. Intramuscular carboprost
4. Intramyometrial carboprost
5. Rectal misoprostol
6. Surgical intervention such as balloon tamponade(RCOG Green-top Guideline No. 52)
Understanding Postpartum Haemorrhage
Postpartum haemorrhage (PPH) is a condition where a woman experiences blood loss of more than 500 ml after giving birth vaginally. It can be classified as primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia.
In managing PPH, it is important to involve senior staff immediately and follow the ABC approach. This includes two peripheral cannulae, lying the woman flat, blood tests, and commencing a warmed crystalloid infusion. Mechanical interventions such as rubbing up the fundus and catheterisation are also done. Medical interventions include IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options such as intrauterine balloon tamponade, B-Lynch suture, ligation of uterine arteries, and hysterectomy may be considered if medical options fail to control the bleeding.
Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to understand the causes and risk factors of PPH to prevent and manage this life-threatening emergency effectively.
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This question is part of the following fields:
- Reproductive Medicine
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Question 22
Incorrect
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A 52-year-old woman presents with lethargy and pruritus. She reports having a normal appetite and no weight loss. Upon examination, there is no clinical jaundice or organomegaly. The following blood test results are obtained:
- Hb: 12.8 g/dl
- Platelets: 188 * 109/l
- WBC: 6.7 * 109/l
- Na+: 140 mmol/l
- K+: 3.9 mmol/l
- Urea: 6.2 mmol/l
- Creatinine: 68 µmol/l
- Bilirubin: 30 µmol/l
- ALP: 231 u/l
- ALT: 38 u/l
- γGT: 367 u/l
- Albumin: 39 g/l
What additional test is most likely to lead to a diagnosis?Your Answer: Liver ultrasound
Correct Answer: Anti-mitochondrial antibodies
Explanation:Primary Biliary Cholangitis: A Chronic Liver Disorder
Primary biliary cholangitis, previously known as primary biliary cirrhosis, is a chronic liver disorder that is commonly observed in middle-aged women. The exact cause of this condition is not yet fully understood, but it is believed to be an autoimmune disease. The disease is characterized by the progressive damage of interlobular bile ducts due to chronic inflammation, leading to cholestasis and eventually cirrhosis. The most common symptom of primary biliary cholangitis is itching in middle-aged women.
This condition is often associated with other autoimmune diseases such as Sjogren’s syndrome, rheumatoid arthritis, systemic sclerosis, and thyroid disease. Early symptoms of primary biliary cholangitis may be asymptomatic or may include fatigue, pruritus, and cholestatic jaundice. Late symptoms may progress to liver failure. Diagnosis of primary biliary cholangitis involves immunology tests such as anti-mitochondrial antibodies (AMA) M2 subtype and smooth muscle antibodies, as well as imaging tests to exclude an extrahepatic biliary obstruction.
The first-line treatment for primary biliary cholangitis is ursodeoxycholic acid, which slows down the progression of the disease and improves symptoms. Cholestyramine is used to alleviate pruritus, and fat-soluble vitamin supplementation is recommended. In severe cases, liver transplantation may be necessary, especially if bilirubin levels exceed 100. However, recurrence in the graft can occur, but it is not usually a problem. Complications of primary biliary cholangitis include cirrhosis, portal hypertension, ascites, variceal hemorrhage, osteomalacia, osteoporosis, and an increased risk of hepatocellular carcinoma.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 23
Correct
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Which of the following statements best describes bladder cancer?
Your Answer: Survival correlates well with TNM staging at diagnosis.
Explanation:Bladder Cancer: Prognostic Factors, Staging, and Treatment Options
Bladder cancer is a common malignancy that affects the urinary system. Survival rates are closely linked to the TNM staging at diagnosis, with non-muscle invasive bladder cancer having a good prognosis and decreasing survival rates with increasing stage. The most significant prognostic factors for bladder cancer are grade, depth of invasion, and the presence of carcinoma in situ. Chemotherapy for metastatic disease is seldom used and has limited effectiveness. Cisplatin-based chemotherapy regimens are the standard treatment for metastatic bladder cancer, with a median overall patient survival of 13-15 months and a 2-year survival rate of 15-20%. Careful follow-up is necessary for non-muscle invasive bladder cancer due to the high rate of disease recurrence and progression.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 24
Correct
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An 80-year-old man presents with right-sided facial droop, dysphasia, and right-sided hemianopia. He has a medical history of gout, recurrent UTIs, dementia, and diabetes mellitus. A CT head is unremarkable, and an MRI head reveals a left-sided infarct. Which of the patient's pre-existing conditions elevate his chances of experiencing an ischemic stroke?
Your Answer: Diabetes mellitus
Explanation:The following factors increase the risk of ischaemic stroke: age, hypertension, smoking, hyperlipidaemia, diabetes mellitus, and atrial fibrillation. However, gout, recurrent UTIs, and dementia do not have an impact on stroke risk. Taking aspirin can lower the risk of stroke.
Understanding Stroke: A Basic Overview
Stroke is a significant cause of morbidity and mortality, with over 150,000 cases reported annually in the UK alone. It is the fourth leading cause of death in the country, killing twice as many women as breast cancer each year. However, the prevention and treatment of strokes have undergone significant changes in the past decade. What was once considered an untreatable condition is now viewed as a brain attack that requires emergency assessment to determine if patients can benefit from new treatments such as thrombolysis.
A stroke, also known as a cerebrovascular accident (CVA), occurs when there is a sudden interruption in the vascular supply of the brain. This interruption can lead to irreversible damage as neural tissue is entirely dependent on aerobic metabolism. There are two main types of strokes: ischaemic and haemorrhagic. Ischaemic strokes occur when there is a blockage in the blood vessel that stops blood flow, while haemorrhagic strokes happen when a blood vessel bursts, leading to a reduction in blood flow.
Symptoms of a stroke include motor weakness, speech problems, swallowing difficulties, visual field defects, and balance problems. The Oxford Stroke Classification is a formal system used to classify strokes based on initial symptoms. Patients with suspected stroke require emergency neuroimaging to determine if they are suitable for thrombolytic therapy to treat early ischaemic strokes. If the stroke is haemorrhagic, neurosurgical consultation should be considered for advice on further management.
In conclusion, understanding the basics of stroke is crucial in identifying and managing the condition. Early intervention and treatment can significantly improve outcomes for patients.
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This question is part of the following fields:
- Neurology
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Question 25
Incorrect
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You have just received a 70-year-old man into the resuscitation room who had a witnessed collapse after complaining of chest pain. There was no pulse, and cardiopulmonary resuscitation (CPR) was performed at the scene. CPR is ongoing upon patient arrival in the Emergency Department. Pulse check demonstrates no palpable central pulse, and there is no respiratory effort. A 3-lead electrocardiogram (ECG) demonstrates no coordinated electrical activity or recognisable complexes, looking very much like a wandering flat line.
What is the most appropriate management of this patient?Your Answer: 1 mg of adrenaline 1 : 1000 intramuscularly (IM), and continue CPR
Correct Answer: 1 mg of adrenaline 1 : 10 000 intravenously (IV), and continue CPR
Explanation:Managing Cardiac Arrest: Correct and Incorrect Approaches
When dealing with a patient in cardiac arrest, it is crucial to follow the correct management protocol. In the case of a patient in asystole, CPR 30:2 (compressions: ventilations) should be initiated, along with 1 mg of adrenaline 10 ml of 1:10 000 IV every other cycle of CPR. Direct current (DC) shock is not indicated for asystole. Adrenaline 1:1000 IM is not appropriate for cardiac arrest situations, as it is used in anaphylaxis. External pacing is unlikely to be successful in the absence of P-wave asystole. Atropine is indicated in severe bradycardia, not asystole. It is essential to follow the correct approach to manage cardiac arrest effectively.
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This question is part of the following fields:
- Cardiovascular
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Question 26
Incorrect
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A 62-year-old female presents to the Emergency Department complaining of central chest pain that has been radiating to her left arm for the past 30 minutes. Upon examination, an ECG reveals ST elevation in leads II, III, and aVF. Which coronary artery is the most probable culprit?
Your Answer: Left anterior descending
Correct Answer: Right coronary
Explanation:Anteroseptal changes in V1-V4 indicate involvement of the left anterior descending artery.
Inferior changes in II, III, and aVF suggest the right coronary artery is affected.
Anterolateral changes in V1-6, I, and aVL indicate the proximal left anterior descending artery is involved.
Lateral changes in I, aVL, and possibly V5-6 suggest the left circumflex artery is affected.
Posterior changes in V1-3 may indicate a posterior infarction, which is confirmed by ST elevation and Q waves in posterior leads (V7-9). This type of infarction is usually caused by the left circumflex artery, but can also be caused by the right coronary artery.
Reciprocal changes of STEMI are typically seen as horizontal ST depression, tall and broad R waves, upright T waves, and a dominant R wave in V2. It is important to note that a new left bundle branch block (LBBB) may indicate acute coronary syndrome.Overall, understanding the correlation between ECG changes and coronary artery territories is crucial in diagnosing acute coronary syndrome. By identifying the specific changes in the ECG, medical professionals can determine which artery is affected and provide appropriate treatment. Additionally, recognizing the reciprocal changes of STEMI and the significance of a new LBBB can aid in making an accurate diagnosis.
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This question is part of the following fields:
- Cardiovascular
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Question 27
Correct
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A 50-year-old man comes to see his GP complaining of chest tightness and shortness of breath on exertion for the past month. He reports that the symptoms subside after resting for 5 minutes. The patient has a medical history of asthma, hypertension, and obesity.
During the examination, the patient's temperature is 37.2ºC, heart rate is 86 bpm, blood pressure is 132/75 mmHg, and the ECG is normal.
What is the most appropriate prophylactic medication for this likely diagnosis?Your Answer: Prescribe sublingual glyceryl trinitrate
Explanation:To prevent angina attacks, the first-line treatment is either a beta-blocker or a calcium channel blocker. This patient is displaying symptoms of stable angina, which includes shortness of breath and chest tightness that occurs during exercise and is relieved by rest. The ECG results are normal, ruling out any serious conditions like myocardial infarction. According to NICE guidelines, all patients with stable angina should receive aspirin and a statin, unless there are contraindications. Additionally, sublingual glyceryl trinitrate spray (GTN) should be given to stop acute angina attacks. However, GTN spray does not prevent future attacks, so prophylactic medication should also be prescribed.
Angina pectoris is a condition that can be managed through various methods, including lifestyle changes, medication, percutaneous coronary intervention, and surgery. In 2011, NICE released guidelines for the management of stable angina. Medication is an important aspect of treatment, and all patients should receive aspirin and a statin unless there are contraindications. Sublingual glyceryl trinitrate can be used to abort angina attacks. The first-line medication should be either a beta-blocker or a calcium channel blocker, depending on the patient’s comorbidities, contraindications, and preferences. If a calcium channel blocker is used as monotherapy, a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be used. Beta-blockers should not be prescribed concurrently with verapamil due to the risk of complete heart block. If the initial treatment is not effective, medication should be increased to the maximum tolerated dose. If a patient is still symptomatic after monotherapy with a beta-blocker, a calcium channel blocker can be added, and vice versa. If a patient cannot tolerate the addition of a calcium channel blocker or a beta-blocker, other drugs such as long-acting nitrates, ivabradine, nicorandil, or ranolazine can be considered. Nitrate tolerance is a common issue, and patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize the development of nitrate tolerance. This effect is not seen in patients who take once-daily modified-release isosorbide mononitrate. If a patient is taking both a beta-blocker and a calcium-channel blocker, a third drug should only be added while awaiting assessment for PCI or CABG.
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This question is part of the following fields:
- Respiratory Medicine
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Question 28
Incorrect
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A 38-year-old homeless man presents to the emergency department after collapsing on the street. He reports feeling increasingly lethargic over the past week and has been coughing up green sputum. He has a history of alcoholic pancreatitis.
His vital signs are as follows:
- Temperature: 38.4ºC
- Heart rate: 122 bpm
- Blood pressure: 106/54 mmHg
- Respiratory rate: 22 breaths/min
- Oxygen saturations: 94% on 2L nasal cannulae
Upon examination, coarse crackles are heard in the left upper lobe. His heart sounds are normal and his abdomen is soft and nontender.
What is the most likely causative organism?Your Answer: Mycoplasma pneumoniae
Correct Answer: Klebsiella pneumoniae
Explanation:Klebsiella pneumoniae is a gram-negative rod that commonly causes a cavitating pneumonia in the upper lobes, particularly in individuals with a history of diabetes and alcoholism. The presence of upper zone crackles is a sign of Klebsiella pneumoniae infection, while a history of alcoholic pancreatitis suggests chronic alcohol use.
Legionella pneumophila causes Legionnaire’s disease, an atypical pneumonia that typically spreads through contaminated water sources, such as air conditioner vents. Symptoms include fever, cough, and myalgia, with bilateral chest symptoms being more common. Other extra-pulmonary symptoms, such as hyponatremia and hepatitis, may also be present.
Mycoplasma pneumoniae is another cause of atypical pneumonia, with symptoms including coryza and a dry cough. This form of pneumonia is associated with extra-pulmonary symptoms such as haemolytic anaemia and erythema multiforme, which are not present in this case.
Staphylococcus aureus is the most likely cause of pneumonia following influenza virus infection. However, since there is no history of preceding coryza and the patient has upper zone crackles and alcoholism, Staphylococcus aureus is less likely to be the cause of this patient’s pneumonia.
Klebsiella Pneumoniae: A Gram-Negative Rod Causing Infections in Humans
Klebsiella pneumoniae is a type of Gram-negative rod that is typically found in the gut flora of humans. Although it is a normal part of the body’s microbiome, it can also cause a variety of infections in humans, including pneumonia and urinary tract infections. This bacterium is more commonly found in individuals who have diabetes or who consume alcohol regularly. In some cases, Klebsiella pneumoniae infections can occur following aspiration.
One of the distinctive features of Klebsiella pneumoniae infections is the presence of red-currant jelly sputum. This type of sputum is often seen in patients with pneumonia caused by this bacterium. Additionally, Klebsiella pneumoniae infections tend to affect the upper lobes of the lungs.
Unfortunately, Klebsiella pneumoniae infections can be quite serious and even life-threatening. They commonly lead to the formation of lung abscesses and empyema, and the mortality rate for these infections is between 30-50%. It is important for healthcare providers to be aware of the potential for Klebsiella pneumoniae infections, particularly in patients who are at higher risk due to underlying health conditions.
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This question is part of the following fields:
- Respiratory Medicine
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Question 29
Correct
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What is the recommended next step in managing the blood pressure of a 42 year old woman with a history of depression and a recent paracetamol overdose who has a manual blood pressure reading of 165/85 mmHg?
Your Answer: Offer ambulatory blood pressure monitoring
Explanation:The National Institute for Clinical Excellence updated its guideline for hypertension management in 2011, placing emphasis on the use of ambulatory blood pressure monitoring (ABPM) to confirm hypertension in individuals with elevated clinic readings. ABPM involves taking two measurements per hour during waking hours and using the average of at least 14 measurements to confirm a diagnosis of hypertension. Secondary causes of hypertension should be investigated in patients under 40 without traditional risk factors, those with other symptoms of secondary causes, and those with resistant hypertension. Hyperaldosteronism is the most common cause of secondary hypertension, and a trial of spironolactone may be used for both therapeutic and diagnostic purposes. Drug treatment for essential hypertension involves ACE inhibitors for those under 55 and calcium channel blockers for those over 55 or of black African or Caribbean origin. Step 2 involves using both ACE inhibitors and calcium channel blockers, while step 3 adds a thiazide-like diuretic. Further diuretics, beta-blockers, or alpha blockers may be considered in step 4, with expert advice sought. For a more detailed explanation, refer to the provided link.
NICE released updated guidelines in 2019 for the management of hypertension, building on previous guidelines from 2011. These guidelines aimed to classify hypertension into stages and recommend the use of ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) to accurately diagnose hypertension. This is important because some patients experience white coat hypertension, where their blood pressure rises in a clinical setting, leading to potential overdiagnosis of hypertension. ABPM and HBPM allow for a more accurate assessment of a patient’s overall blood pressure and can prevent overdiagnosis.
NICE recommends measuring blood pressure in both arms when considering a diagnosis of hypertension and repeating measurements if there is a difference of more than 20 mmHg between arms. If the blood pressure is >= 140/90 mmHg, NICE suggests offering ABPM or HBPM to confirm the diagnosis. If the blood pressure is >= 180/120 mmHg, referral for specialist assessment is recommended if there are signs of retinal haemorrhage or papilloedema or life-threatening symptoms. If target organ damage is identified, antihypertensive drug treatment may be started immediately.
ABPM involves taking at least 2 measurements per hour during the person’s usual waking hours and using the average value of at least 14 measurements. If ABPM is not tolerated, HBPM should be offered. HBPM involves taking two consecutive measurements at least 1 minute apart, twice daily for at least 4 days, and using the average value of all remaining measurements.
Interpreting the results of ABPM/HBPM is important for determining treatment. If the average blood pressure is >= 135/85 mmHg (stage 1 hypertension), treatment may be considered for patients under 80 years of age with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. In 2019, NICE also recommended considering antihypertensive drug treatment for adults under 60 with stage 1 hypertension and an estimated 10-year risk below 10%. If the average blood pressure is >= 150/95 mmHg (stage 2 hypertension), drug treatment should be offered regardless of age.
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This question is part of the following fields:
- Cardiovascular
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Question 30
Incorrect
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Which one of the following statement regarding the 1977 Abortion Act is true?
Your Answer: It requires the opinion of one psychiatrist and one general medical practitioner before an abortion can be performed
Correct Answer: It states that an abortion may be performed if the pregnancy presents a risk to the physical or mental health of any existing children
Explanation:Termination of Pregnancy in the UK
The UK’s current abortion law is based on the 1967 Abortion Act, which was amended in 1990 to reduce the upper limit for termination from 28 weeks to 24 weeks gestation. To perform an abortion, two registered medical practitioners must sign a legal document, except in emergencies where only one is needed. The procedure must be carried out by a registered medical practitioner in an NHS hospital or licensed premise.
The method used to terminate a pregnancy depends on the gestation period. For pregnancies less than nine weeks, mifepristone (an anti-progestogen) is administered, followed by prostaglandins 48 hours later to stimulate uterine contractions. For pregnancies less than 13 weeks, surgical dilation and suction of uterine contents is used. For pregnancies more than 15 weeks, surgical dilation and evacuation of uterine contents or late medical abortion (inducing ‘mini-labour’) is used.
The 1967 Abortion Act outlines the circumstances under which a person shall not be guilty of an offence under the law relating to abortion. These include if two registered medical practitioners are of the opinion, formed in good faith, that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family. The limits do not apply in cases where it is necessary to save the life of the woman, there is evidence of extreme fetal abnormality, or there is a risk of serious physical or mental injury to the woman.
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This question is part of the following fields:
- Reproductive Medicine
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Question 31
Correct
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A 12-year-old girl presents to the clinic with complaints of anterior knee pain for a few weeks, which worsens while walking downstairs. During the examination, a positive shrug test is observed, and she has a valgus knee deformity.
What is the most probable diagnosis?Your Answer: Chondromalacia patellae
Explanation:Common Causes of Knee Pain in Adolescents and Young Adults
Knee pain is a common complaint among adolescents and young adults. There are several conditions that can cause knee pain, including chondromalacia patellae, osteoarthritis, Osgood-Schlatter disease, osteochondritis dissecans, and patellar subluxation.
Chondromalacia patellae is characterized by abnormal softening of the cartilage on the underside of the patella. It is more common in females, those with valgus knee deformity, and those who are flat-footed. Patients may experience anterior knee pain that worsens with prolonged sitting or activities such as walking down stairs, jumping, running, or climbing. Treatment involves physiotherapy to alter patella-femoral alignment, along with analgesics and ice for symptom relief.
Osteoarthritis is a disease of older patients caused by cartilage breakdown in weight-bearing joints. Osgood-Schlatter disease is a common cause of knee pain in young adolescents, particularly sporty boys, and is caused by overuse of quadriceps. Osteochondritis dissecans is caused by separation of subchondral bone articular cartilage from the joint surface and tends to present in teenagers and young adults with vague and achy joint pain. Patellar subluxation describes the temporary but recurring lateral subluxation of the patella, which can cause anterior patellar pain and joint stiffness.
It is important to note that knee pain in children could be due to hip pathology, such as slipped upper femoral epiphysis. Diagnosis and treatment for these conditions may involve clinical examination, radiographs, and MRI. Treatment may include physiotherapy, analgesics, ice packs, knee braces, and in some cases, surgery.
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This question is part of the following fields:
- Musculoskeletal
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Question 32
Incorrect
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A 45-year-old woman presents to her General Practitioner with a 3-day history of increased urinary frequency, urgency, nocturia and mild, lower abdominal discomfort.
On examination, she looks well. She is afebrile, while her abdomen is soft and nontender. A urine dipstick is performed. Her estimated glomerular filtration rate was normal: > 90 ml/minute per 1.73 m2 three months ago.
Urinalysis reveals the following:
Investigation Result
Leukocytes +++
Nitrates +
Blood +
What is the most appropriate initial treatment option?Your Answer: Trimethoprim 200 mg twice a day for three days
Correct Answer: Nitrofurantoin 100 mg twice a day for seven days
Explanation:The recommended first-line treatment for uncomplicated UTIs is nitrofurantoin, with trimethoprim as an alternative if resistance is low. Painless haematuria warrants investigation of the renal tract, and this should also be considered in men with confirmed UTIs. Amoxicillin is not typically recommended for UTIs due to its inactivation by penicillinase produced by E. coli, but it may be appropriate if the causative organism is sensitive to it. While waiting for MSU results, empirical antibiotic treatment should be started immediately if a UTI is suspected. Ciprofloxacin is indicated for acute prostatitis or pyelonephritis, not uncomplicated lower UTIs, and caution is needed when prescribing quinolones to the elderly due to the risk of tendon rupture. Trimethoprim is an appropriate first-line antibiotic for lower UTIs in men, with a 7-day course recommended, while a 3-day course is suitable for non-pregnant women under 65.
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This question is part of the following fields:
- Infectious Diseases
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Question 33
Correct
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A 30-year-old woman presents with a productive cough, weight loss, and night sweats, four months after returning from India. She is diagnosed with pulmonary tuberculosis and started on appropriate antibiotics. However, six weeks into her treatment, she experiences numbness and tingling in her distal extremities, a known side effect of isoniazid. What medication should have been prescribed alongside her antibiotic regimen to minimize this side effect?
Your Answer: Pyridoxine
Explanation:To treat active tuberculosis, isoniazid is often prescribed alongside other antibiotics such as rifampicin, ethambutol, or pyrazinamide. However, it is important to note that isoniazid alone does not protect against peripheral neuropathy, a potential side effect of tuberculosis treatment.
Rifampicin is an antibiotic that can increase the rate of B6 excretion, which may lead to a deficiency in some individuals.
Ethambutol is another antibiotic used to treat tuberculosis, but it can cause a loss of visual acuity and color blindness.
Prednisolone is typically only prescribed for meningeal or pericardial tuberculosis and can cause side effects such as mood changes, weight gain, and immunosuppression.
Pyrazinamide is another antibiotic used to treat tuberculosis, but it can cause liver toxicity.
Side-Effects and Mechanism of Action of Tuberculosis Drugs
Rifampicin is a drug that inhibits bacterial DNA dependent RNA polymerase, which prevents the transcription of DNA into mRNA. However, it is a potent liver enzyme inducer and can cause hepatitis, orange secretions, and flu-like symptoms.
Isoniazid, on the other hand, inhibits mycolic acid synthesis. It can cause peripheral neuropathy, which can be prevented with pyridoxine (Vitamin B6). It can also cause hepatitis and agranulocytosis. Additionally, it is a liver enzyme inhibitor.
Pyrazinamide is converted by pyrazinamidase into pyrazinoic acid, which in turn inhibits fatty acid synthase (FAS) I. However, it can cause hyperuricaemia, leading to gout, as well as arthralgia, myalgia, and hepatitis.
Lastly, Ethambutol inhibits the enzyme arabinosyl transferase, which polymerizes arabinose into arabinan. It can cause optic neuritis, so it is important to check visual acuity before and during treatment. Additionally, the dose needs adjusting in patients with renal impairment.
In summary, these tuberculosis drugs have different mechanisms of action and can cause various side-effects. It is important to monitor patients closely and adjust treatment accordingly to ensure the best possible outcomes.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 34
Incorrect
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An elderly man, aged 74, with metastatic small cell lung cancer has been admitted to the hospice for symptom management. He is currently experiencing persistent hiccups that are difficult to control. What is the best course of action for managing this symptom?
Your Answer: Codeine phosphate
Correct Answer: Chlorpromazine
Explanation:Palliative Care Prescribing for Hiccups
Hiccups can be a distressing symptom for patients receiving palliative care. To manage this symptom, healthcare professionals may prescribe medications such as chlorpromazine, which is licensed for the treatment of intractable hiccups. Other medications that may be used include haloperidol and gabapentin. In cases where there are hepatic lesions, dexamethasone may also be prescribed. It is important to note that the choice of medication will depend on the individual patient’s needs and medical history. Proper management of hiccups can improve the patient’s quality of life and provide relief from discomfort.
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This question is part of the following fields:
- Respiratory Medicine
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Question 35
Incorrect
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A 45-year-old woman has been using diphenhydramine (Benadryl) for allergy relief. She reports using it frequently and her doctor suspects she may be experiencing symptoms of the anticholinergic syndrome (ACS).
Which of the following statements accurately describes the anticholinergic syndrome?Your Answer: Constricted pupils occur
Correct Answer: Hot, dry skin occurs
Explanation:Understanding Anticholinergic Syndrome: Symptoms and Treatment
Anticholinergic syndrome is a condition that occurs when there is an inhibition of cholinergic neurotransmission at muscarinic receptor sites. It can be caused by the ingestion of various medications, intentional overdose, inadvertent ingestion, medical non-compliance, or geriatric polypharmacy. The syndrome produces central nervous system effects, peripheral nervous system effects, or both, resulting in a range of symptoms.
Symptoms of anticholinergic syndrome include flushing, dry skin and mucous membranes, mydriasis with loss of accommodation, altered mental status, fever, sinus tachycardia, decreased bowel sounds, functional ileus, urinary retention, hypertension, tremulousness, and myoclonic jerking. Hot, dry skin and constricted pupils are also common manifestations.
Treatment for anticholinergic syndrome involves stabilizing the patient in A&E and removing the toxin from the gastrointestinal tract. This can be done with a single dose of activated charcoal by mouth or nasogastric tube. Gastric lavage, followed by activated charcoal administration, is acceptable for patients presenting with altered mental state and within 1 hour of ingestion.
Physostigmine salicylate is the classic antidote for anticholinergic toxicity. While most patients can be safely treated without it, it is recommended when tachydysrhythmia is present. However, physostigmine is contraindicated in patients with cardiac conduction disturbances on ECG.
In conclusion, understanding the symptoms and treatment of anticholinergic syndrome is crucial for healthcare professionals to provide appropriate care for patients who may present with this condition.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 36
Incorrect
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A 56-year-old man undergoes a routine medical check-up for his job. He shows no symptoms and his clinical examination is normal. What test would confirm a diagnosis of impaired fasting glucose?
Your Answer: 75g oral glucose tolerance test 2 hour value of 8.4 mmol/L
Correct Answer: Fasting glucose 6.8 mmol/L on two occasions
Explanation:An oral glucose tolerance test result of 8.4 mmol/L after 2 hours with a 75g glucose load suggests impaired glucose tolerance instead of impaired fasting glucose.
Type 2 diabetes mellitus can be diagnosed through a plasma glucose or HbA1c sample. The diagnostic criteria vary depending on whether the patient is experiencing symptoms or not. If the patient is symptomatic, a fasting glucose level of 7.0 mmol/l or higher or a random glucose level of 11.1 mmol/l or higher (or after a 75g oral glucose tolerance test) indicates diabetes. If the patient is asymptomatic, the same criteria apply but must be demonstrated on two separate occasions.
In 2011, the World Health Organization released supplementary guidance on the use of HbA1c for diagnosing diabetes. A HbA1c level of 48 mmol/mol (6.5%) or higher is diagnostic of diabetes mellitus. However, a HbA1c value of less than 48 mmol/mol (6.5%) does not exclude diabetes and may not be as sensitive as fasting samples for detecting diabetes. For patients without symptoms, the test must be repeated to confirm the diagnosis. It is important to note that increased red cell turnover can cause misleading HbA1c results.
There are certain conditions where HbA1c cannot be used for diagnosis, such as haemoglobinopathies, haemolytic anaemia, untreated iron deficiency anaemia, suspected gestational diabetes, children, HIV, chronic kidney disease, and people taking medication that may cause hyperglycaemia (such as corticosteroids).
Impaired fasting glucose (IFG) is defined as a fasting glucose level of 6.1 mmol/l or higher but less than 7.0 mmol/l. Impaired glucose tolerance (IGT) is defined as a fasting plasma glucose level less than 7.0 mmol/l and an OGTT 2-hour value of 7.8 mmol/l or higher but less than 11.1 mmol/l. People with IFG should be offered an oral glucose tolerance test to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person does not have diabetes but does have IGT.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 37
Incorrect
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A 27-year-old woman arrives at the emergency department complaining of sudden abdominal pain and vaginal bleeding. She had her last period 6 weeks ago and is sexually active without using any hormonal contraception. She has no significant medical history. Upon examination, she has a heart rate of 84 bpm and a blood pressure of 128/78 mmHg. There is tenderness in the left iliac fossa. A pregnancy test confirms that she is pregnant, and further investigations reveal a 40 mm left adnexal mass with no heartbeat. The serum b-hCG level is 6200 IU/L. What is the most appropriate course of action for her management?
Your Answer: Laparoscopic salpingotomy and monitoring
Correct Answer: Laparoscopic salpingectomy and monitoring
Explanation:For women with no other risk factors for infertility, salpingectomy is the first-line treatment for ectopic pregnancy requiring surgical management, rather than salpingotomy. In the case of a patient with acute-onset abdominal pain and vaginal bleeding after 6-8 weeks following her last period, a positive pregnancy test, and ultrasound findings confirming an ectopic pregnancy, laparoscopic salpingectomy and monitoring is the correct course of action. This is especially true if the size of the ectopic pregnancy is greater than 35 mm and the beta-hCG levels are higher than 5000 IU/L. Salpingotomy may require further treatment with methotrexate and may not remove the ectopic pregnancy entirely, making salpingectomy the preferred method. Expectant management and monitoring, laparoscopic salpingotomy and monitoring, and methotrexate and monitoring are all inappropriate 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.
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This question is part of the following fields:
- Reproductive Medicine
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Question 38
Correct
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A 70-year-old man arrives at the emergency department complaining of feeling generally unwell and lethargic for the past 2 weeks. He reports a yellow-green tinge to his vision as his only other symptom. The patient has a medical history of atrial fibrillation, depression, and a myocardial infarction 3 years ago. He takes multiple medications that come in a blister pack, but he is unsure of their names. Upon blood testing, his Digoxin concentration is 3 mcg/l (<1 mcg/l). What medication could have caused this clinical presentation?
Your Answer: Bendroflumethiazide
Explanation:Thiazides like bendroflumethiazide can cause digoxin toxicity by causing hypokalaemia, which allows digoxin to have more of an effect on Na+/K+ ATPase. Symptoms of digoxin toxicity are vague but may include gastrointestinal upset, weakness, fatigue, and xanthopsia. Citalopram, isosorbide mononitrate, and ramipril do not appear to have any significant effect on digoxin toxicity.
Understanding Digoxin and Its Toxicity
Digoxin is a medication used for rate control in atrial fibrillation and for improving symptoms in heart failure patients. It works by decreasing conduction through the atrioventricular node and increasing the force of cardiac muscle contraction. However, it has a narrow therapeutic index and requires monitoring for toxicity.
Toxicity may occur even when the digoxin concentration is within the therapeutic range. Symptoms of toxicity include lethargy, nausea, vomiting, anorexia, confusion, yellow-green vision, arrhythmias, and gynaecomastia. Hypokalaemia is a classic precipitating factor, as it allows digoxin to more easily bind to the ATPase pump and increase its inhibitory effects. Other factors that may contribute to toxicity include increasing age, renal failure, myocardial ischaemia, electrolyte imbalances, hypoalbuminaemia, hypothermia, hypothyroidism, and certain medications such as amiodarone, quinidine, and verapamil.
Management of digoxin toxicity involves the use of Digibind, correction of arrhythmias, and monitoring of potassium levels. It is important to recognize the potential for toxicity and monitor patients accordingly to prevent adverse outcomes.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 39
Incorrect
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A 56-year-old construction worker comes in for evaluation. He has a history of osteoarthritis in his hands but no other significant medical history. Despite taking paracetamol regularly, he is still experiencing significant pain, particularly in the base of his thumbs. What would be the most appropriate next step in his management?
Your Answer: Add oral ibuprofen
Correct Answer: Add topical ibuprofen
Explanation:According to the 2008 NICE guidelines, the initial treatment for osteoarthritis should involve the administration of paracetamol and topical NSAIDs, particularly for knee and hand joints.
The Role of Glucosamine in Osteoarthritis Management
Osteoarthritis (OA) is a common condition that affects the joints, causing pain and stiffness. The National Institute for Health and Care Excellence (NICE) published guidelines in 2014 on the management of OA, which includes non-pharmacological and pharmacological treatments. Glucosamine, a normal constituent of glycosaminoglycans in cartilage and synovial fluid, has been studied for its potential benefits in OA management.
Several double-blind randomized controlled trials (RCTs) have reported significant short-term symptomatic benefits of glucosamine in knee OA, including reduced joint space narrowing and improved pain scores. However, more recent studies have produced mixed results. The 2008 NICE guidelines do not recommend the use of glucosamine, and a 2008 Drug and Therapeutics Bulletin review advised against prescribing it on the NHS due to limited evidence of cost-effectiveness.
Despite the conflicting evidence, some patients may still choose to use glucosamine as a complementary therapy for OA management. It is important for healthcare professionals to discuss the potential benefits and risks of glucosamine with their patients and to consider individual patient preferences and circumstances.
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This question is part of the following fields:
- Musculoskeletal
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Question 40
Incorrect
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A 67-year-old woman comes to the clinic complaining of experiencing electric shock-like pains on the right side of her face for the past two months. She reports having 10-20 episodes per day, each lasting for 30-60 seconds. She recently had a dental check-up, which was normal. Upon neurological examination, no abnormalities were found. What is the most appropriate initial treatment?
Your Answer: Amitriptyline
Correct Answer: Carbamazepine
Explanation:Carbamazepine is the first-line treatment for trigeminal neuralgia.
Understanding Trigeminal Neuralgia
Trigeminal neuralgia is a type of pain syndrome that is characterized by severe pain on one side of the face. While most cases are idiopathic, some may be caused by compression of the trigeminal roots due to tumors or vascular problems. According to the International Headache Society, trigeminal neuralgia is defined as a disorder that causes brief electric shock-like pains that are limited to one or more divisions of the trigeminal nerve. The pain is often triggered by light touch, such as washing, shaving, or brushing teeth, and can occur spontaneously. Certain areas of the face, such as the nasolabial fold or chin, may be more susceptible to pain. The pain may also remit for varying periods.
Red flag symptoms and signs that suggest a serious underlying cause include sensory changes, ear problems, a history of skin or oral lesions that could spread perineurally, pain only in the ophthalmic division of the trigeminal nerve, optic neuritis, a family history of multiple sclerosis, and onset before the age of 40.
The first-line treatment for trigeminal neuralgia is carbamazepine. If there is a failure to respond to treatment or atypical features are present, such as onset before the age of 50, referral to neurology is recommended. Understanding the symptoms and management of trigeminal neuralgia is important for proper diagnosis and treatment.
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This question is part of the following fields:
- Neurology
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Question 41
Incorrect
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A 65-year-old patient with a history of migraines presents to you after being discharged from the stroke unit following a posterior circulation stroke. She is distressed as she believes there was a considerable delay in her diagnosis. Initially diagnosed with a severe migraine, she was not referred to the hospital until her symptoms persisted for several days.
What is the primary symptom that typically presents in a posterior circulation stroke?Your Answer: Coordination difficulties
Correct Answer: Dizziness
Explanation:Dizziness is the most prevalent indication of a posterior circulation stroke, although other symptoms such as double vision, disorientation, visual disturbance, confusion, and memory loss are also significant. Roughly 33% of posterior circulation strokes are misdiagnosed as migraines, which can cause temporary neurological deficits even without a headache. Additionally, individuals who suffer from migraines are more likely to experience a headache as a result of brain ischemia, which can further complicate the diagnosis. Patients who experience new vertigo or headaches, dizziness, or a change in the nature of their migraines should be evaluated for a posterior circulation stroke.
Understanding Stroke: A Basic Overview
Stroke is a significant cause of morbidity and mortality, with over 150,000 cases reported annually in the UK alone. It is the fourth leading cause of death in the country, killing twice as many women as breast cancer each year. However, the prevention and treatment of strokes have undergone significant changes in the past decade. What was once considered an untreatable condition is now viewed as a brain attack that requires emergency assessment to determine if patients can benefit from new treatments such as thrombolysis.
A stroke, also known as a cerebrovascular accident (CVA), occurs when there is a sudden interruption in the vascular supply of the brain. This interruption can lead to irreversible damage as neural tissue is entirely dependent on aerobic metabolism. There are two main types of strokes: ischaemic and haemorrhagic. Ischaemic strokes occur when there is a blockage in the blood vessel that stops blood flow, while haemorrhagic strokes happen when a blood vessel bursts, leading to a reduction in blood flow.
Symptoms of a stroke include motor weakness, speech problems, swallowing difficulties, visual field defects, and balance problems. The Oxford Stroke Classification is a formal system used to classify strokes based on initial symptoms. Patients with suspected stroke require emergency neuroimaging to determine if they are suitable for thrombolytic therapy to treat early ischaemic strokes. If the stroke is haemorrhagic, neurosurgical consultation should be considered for advice on further management.
In conclusion, understanding the basics of stroke is crucial in identifying and managing the condition. Early intervention and treatment can significantly improve outcomes for patients.
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This question is part of the following fields:
- Neurology
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Question 42
Incorrect
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For what has the National Institute for Health and Care Excellence (NICE) recommended the use of varenicline?
Your Answer: Cannabis cessation
Correct Answer: Smoking cessation (cigarettes)
Explanation:The Use of Varenicline in Smoking Cessation and Other Substance Withdrawals
Varenicline, marketed as Champix®, is a medication used in combination with motivational support to aid smoking cessation. The National Institute for Health and Care Excellence (NICE) recommends offering varenicline or nicotine replacement therapy (NRT) to all smokers, along with advice and encouragement to quit. The choice of therapy depends on factors such as the smoker’s compliance, availability of counseling and support, previous experience with cessation aids, contraindications, and personal preference. However, varenicline use has been associated with changes in behavior and thinking, anxiety, psychosis, mood swings, depression, and suicidal ideation, so monitoring is advised.
While varenicline is not currently indicated for cannabis cessation, some studies suggest that it may reduce the enjoyment reported from using cannabis, which could lead to further investigation in this area. However, varenicline has no role in the treatment of alcohol withdrawal, and the FDA has warned that people taking varenicline should reduce their alcohol intake due to the potential for unusual behavior, including aggression. The use of varenicline for opioid withdrawal in patients with chronic pain is also under investigation but is not currently recommended. Finally, varenicline is not indicated for cocaine cessation.
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This question is part of the following fields:
- Psychiatry
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Question 43
Incorrect
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A 60-year-old man came to your GP clinic complaining of blurred vision for the past month. He has a history of type 2 diabetes mellitus. During direct ophthalmoscopy, you observed a ring of hard exudates at the fovea, but the rest of the retina appeared normal. What is the probable diagnosis for his vision blurring?
Your Answer: Proliferative diabetic retinopathy
Correct Answer: Diabetic maculopathy
Explanation:Diabetic maculopathy refers to any structural anomaly in the macula caused by diabetes. The patient in this case had hard exudates in the macula, which resulted in blurred vision. As there were no abnormalities in the rest of the retina, options 1-3 (background, pre-proliferative and proliferative diabetic retinopathies) are incorrect. Although vitreous hemorrhage can cause blurred vision in cases of proliferative retinopathy, there is no indication of it in the given history.
Understanding Diabetic Retinopathy
Diabetic retinopathy is a leading cause of blindness among adults aged 35-65 years old. The condition is caused by hyperglycemia, which leads to abnormal metabolism in the retinal vessel walls and damage to endothelial cells and pericytes. This damage causes increased vascular permeability, resulting in exudates seen on fundoscopy. Pericyte dysfunction predisposes to the formation of microaneurysms, while neovascularization is caused by the production of growth factors in response to retinal ischemia.
Patients with diabetic retinopathy are classified into those with non-proliferative diabetic retinopathy (NPDR), proliferative retinopathy (PDR), and maculopathy. NPDR is further classified into mild, moderate, and severe, depending on the presence of microaneurysms, blot hemorrhages, hard exudates, cotton wool spots, venous beading/looping, and intraretinal microvascular abnormalities. PDR is characterized by retinal neovascularization, which may lead to vitreous hemorrhage, and fibrous tissue forming anterior to the retinal disc. Maculopathy is based on location rather than severity and is more common in Type II DM.
Management of diabetic retinopathy involves optimizing glycaemic control, blood pressure, and hyperlipidemia, as well as regular review by ophthalmology. Treatment options include intravitreal vascular endothelial growth factor (VEGF) inhibitors for maculopathy, regular observation for non-proliferative retinopathy, and panretinal laser photocoagulation and intravitreal VEGF inhibitors for proliferative retinopathy. Vitreoretinal surgery may be necessary in cases of severe or vitreous hemorrhage.
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This question is part of the following fields:
- Ophthalmology
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Question 44
Incorrect
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A 14-year-old adolescent complains of recurring reactions to his nose ring. He remembers experiencing a similar reaction on his wrist when wearing a nickel bracelet. What test is used to confirm a nickel allergy?
Your Answer: Skin prick testing
Correct Answer: Patch test
Explanation:Medical Testing Techniques
Patch Test, Flow Cytometry, HLA Typing, Polymerase Chain Reaction, and Skin Prick Testing are all medical testing techniques used for different purposes.
Patch Test is used to diagnose delayed type IV hypersensitivity reactions. It involves applying various test substances to the skin and examining it for any inflammatory response.
Flow Cytometry is used to differentiate between cell populations and count the number of cells in a given sample. It works by channelling cells through a laser beam one at a time and identifying the size and granularity of the cell.
HLA Typing is used to match patients and donors for cord blood or bone marrow transplants. It tests for proteins or markers used by the immune system to differentiate ‘self’ from ‘non-self’.
Polymerase Chain Reaction is used to amplify a single or multiple copies of a DNA segment. It has medical uses such as functional analysis of genes, diagnosis of hereditary diseases, and detection of infectious diseases.
Skin Prick Testing is used to diagnose type I hypersensitivity reactions, which are mediated by immunoglobulin E. It involves immediate degranulation of mast cells and the release of histamine. Examples of type I hypersensitivity reactions include allergic rhinitis, systemic anaphylaxis, and allergic asthma.
Medical Testing Techniques for Different Purposes
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This question is part of the following fields:
- Immunology/Allergy
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Question 45
Correct
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A 50-year-old man presents with intermittent leg pain that worsens with movement and improves with rest. He reports no recent illness or injury. The patient has a history of hypertension and takes amlodipine 5mg daily. He is a smoker with a BMI of 30 kg/m². On examination, there is no visible deformity in his lower limbs, and his calves are soft and nontender bilaterally with no edema. The ankle-brachial pressure index is 0.8. The patient is started on atorvastatin 80 mg daily. What other treatment should be prescribed for this patient?
Your Answer: Clopidogrel
Explanation:NICE guidelines recommend that patients with peripheral arterial disease should be treated with clopidogrel and atorvastatin. This patient is experiencing intermittent claudication, which is a symptom of peripheral vascular disease caused by atherosclerosis. It is important to differentiate this from critical limb ischaemia, which is characterised by pain at rest. An ankle-brachial pressure index of < 0.9 suggests PAD, with an index < 0.5 suggesting critical limb ischaemia. This patient has several risk factors, including smoking, hypertension and obesity. Aspirin is not the first-line antiplatelet for PAD and should only be used if clopidogrel is not tolerated. Low molecular weight heparin is indicated for deep vein thrombosis, which is characterised by unilateral calf pain and swelling with tenderness along the deep venous system. Metformin is indicated for diabetes mellitus, which cannot be diagnosed without a HbA1c or blood glucose reading. Regular glucose checks are recommended for patients with vascular risk factors. Peripheral arterial disease (PAD) is a condition that is strongly associated with smoking. Therefore, patients who still smoke should be provided with assistance to quit smoking. It is also important to treat any comorbidities that the patient may have, such as hypertension, diabetes mellitus, and obesity. All patients with established cardiovascular disease, including PAD, should be taking a statin, with Atorvastatin 80 mg being the recommended dosage. In 2010, NICE published guidance recommending the use of clopidogrel as the first-line treatment for PAD patients instead of aspirin. Exercise training has also been shown to have significant benefits, and NICE recommends a supervised exercise program for all PAD patients before other interventions. For severe PAD or critical limb ischaemia, there are several treatment options available. Endovascular revascularization and percutaneous transluminal angioplasty with or without stent placement are typically used for short segment stenosis, aortic iliac disease, and high-risk patients. On the other hand, surgical revascularization, surgical bypass with an autologous vein or prosthetic material, and endarterectomy are typically used for long segment lesions, multifocal lesions, lesions of the common femoral artery, and purely infrapopliteal disease. Amputation should only be considered for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty or bypass surgery. There are also drugs licensed for use in PAD, including naftidrofuryl oxalate, a vasodilator sometimes used for patients with a poor quality of life. Cilostazol, a phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects, is not recommended by NICE.
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This question is part of the following fields:
- Cardiovascular
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Question 46
Correct
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A 26-year-old man came to the clinic complaining of fevers, sore throat, and cervical lymphadenopathy that had been going on for 8 days. A positive monospot test was obtained. What is the most appropriate management plan?
Your Answer: Reassurance
Explanation:Infectious mononucleosis caused by the Epstein bar virus (EBV) is usually a self-limiting condition that lasts for approximately 2 weeks in individuals with a healthy immune system. Treatment options such as aciclovir, penicillin V, clarithromycin, and valganciclovir are not effective for treating EBV.
Understanding Infectious Mononucleosis
Infectious mononucleosis, also known as glandular fever, is a viral infection caused by the Epstein-Barr virus (EBV) in 90% of cases. It is most commonly seen in adolescents and young adults. The classic triad of symptoms includes sore throat, pyrexia, and lymphadenopathy, which are present in around 98% of patients. Other symptoms include malaise, anorexia, headache, palatal petechiae, splenomegaly, hepatitis, lymphocytosis, haemolytic anaemia, and a maculopapular rash. The symptoms typically resolve after 2-4 weeks.
The diagnosis of infectious mononucleosis is confirmed through a heterophil antibody test (Monospot test) in the second week of the illness. Management is supportive and includes rest, drinking plenty of fluids, avoiding alcohol, and taking simple analgesia for any aches or pains. It is recommended to avoid playing contact sports for 4 weeks after having glandular fever to reduce the risk of splenic rupture.
Interestingly, there is a correlation between EBV and socioeconomic groups. Lower socioeconomic groups have high rates of EBV seropositivity, having frequently acquired EBV in early childhood when the primary infection is often subclinical. However, higher socioeconomic groups show a higher incidence of infectious mononucleosis, as acquiring EBV in adolescence or early adulthood results in symptomatic disease.
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This question is part of the following fields:
- Infectious Diseases
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Question 47
Incorrect
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A 45-year-old woman with multiple sclerosis comes in for evaluation. She reports experiencing worsening issues with painful spasms in her leg muscles. What is the initial treatment option that should be considered?
Your Answer: Referral for relaxation therapy
Correct Answer: Baclofen
Explanation:The recommended initial treatments for spasticity in multiple sclerosis are baclofen and gabapentin.
Multiple sclerosis is a condition that cannot be cured, but its treatment aims to reduce the frequency and duration of relapses. In the case of an acute relapse, high-dose steroids may be administered for five days to shorten its length. However, it is important to note that steroids do not affect the degree of recovery. Disease-modifying drugs are used to reduce the risk of relapse in patients with MS. These drugs are typically indicated for patients with relapsing-remitting disease or secondary progressive disease who have had two relapses in the past two years and are able to walk a certain distance unaided. Natalizumab, ocrelizumab, fingolimod, beta-interferon, and glatiramer acetate are some of the drugs used to reduce the risk of relapse in MS.
Fatigue is a common problem in MS patients, and amantadine is recommended by NICE after excluding other potential causes such as anaemia, thyroid problems, or depression. Mindfulness training and CBT are other options for managing fatigue. Spasticity is another issue that can be addressed with first-line drugs such as baclofen and gabapentin, as well as physiotherapy. Cannabis and botox are currently being evaluated for their effectiveness in managing spasticity. Bladder dysfunction is also a common problem in MS patients, and anticholinergics may worsen symptoms in some patients. Ultrasound is recommended to assess bladder emptying, and intermittent self-catheterisation may be necessary if there is significant residual volume. Gabapentin is the first-line treatment for oscillopsia, which is a condition where visual fields appear to oscillate.
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This question is part of the following fields:
- Neurology
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Question 48
Correct
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A 4-year-old boy is brought to the doctor's office because of a rash on his upper arm. During the examination, the doctor observes several raised lesions that are approximately 2 mm in diameter. Upon closer inspection, a central dimple is visible in most of the lesions. What is the probable diagnosis?
Your Answer: Molluscum contagiosum
Explanation:Understanding Molluscum Contagiosum
Molluscum contagiosum is a viral skin infection that is commonly seen in children, particularly those with atopic eczema. It is caused by the molluscum contagiosum virus and can be transmitted through direct contact or contaminated surfaces. The infection presents as pinkish or pearly white papules with a central umbilication, which can appear anywhere on the body except for the palms of the hands and soles of the feet. In children, lesions are commonly seen on the trunk and in flexures, while in adults, sexual contact may lead to lesions developing on the genitalia, pubis, thighs, and lower abdomen.
While molluscum contagiosum is a self-limiting condition that usually resolves within 18 months, it is important to avoid sharing towels, clothing, and baths with uninfected individuals to prevent transmission. Scratching the lesions should also be avoided, and treatment may be considered if the itch is problematic. However, treatment is not usually recommended, and if necessary, simple trauma or cryotherapy may be used. In some cases, referral may be necessary, such as for individuals who are HIV-positive with extensive lesions or those with eyelid-margin or ocular lesions and associated red eye.
Overall, understanding molluscum contagiosum and taking appropriate precautions can help prevent transmission and alleviate symptoms.
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This question is part of the following fields:
- Dermatology
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Question 49
Correct
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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.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 50
Correct
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A 45-year-old teacher who was previously healthy was discovered unconscious on the ground. Upon admission, assessment showed weakness on the right side of their body, with their leg more affected than their arm and face, and significant difficulty with speech. What is the most probable diagnosis?
Your Answer: An occlusion of the left middle cerebral artery (MCA)
Explanation:A blockage in the left middle cerebral artery (MCA) is a common cause of cerebral infarction. The symptoms experienced will depend on the extent of the infarct and which hemisphere of the brain is dominant. In right-handed individuals, over 95% have left-sided dominance. Symptoms may include weakness on the opposite side of the body, particularly in the face and arm, as well as sensory loss and homonymous hemianopia. If the left MCA is affected, the patient may experience expressive dysphasia in the anterior MCA territory (Broca’s area) if it is their dominant side, or neglect if it is their non-dominant side. A tumour in the left cerebral hemisphere or thalamus would have a more gradual onset of symptoms, while an occlusion of the right anterior cerebral artery would produce left-sided weakness. The region affected and presentation of each type of artery involvement is summarized in a table.
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This question is part of the following fields:
- Neurology
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