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Question 1
Incorrect
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A 32-year-old man with a history of migraine and asthma seeks medical attention for worsening migraine symptoms. He is experiencing one debilitating migraine attack every two weeks, lasting approximately 24 hours, and only partially relieved by zolmitriptan. This has resulted in frequent work absences. His current medication regimen includes zolmitriptan, salbutamol, and Clenil. What is the most suitable medication to prescribe for reducing the frequency of his migraine attacks?
Your Answer: Amitriptyline
Correct Answer: Topiramate
Explanation:For the prophylaxis of migraines, NICE recommends either topiramate or propranolol. However, propranolol is not suitable for this patient due to his asthma. As for acute treatment, a combination of triptan and NSAID or triptan and paracetamol is recommended.
Managing Migraines: Guidelines and Treatment Options
Migraines can be debilitating and affect a significant portion of the population. To manage migraines, it is important to understand the different treatment options available. The National Institute for Health and Care Excellence (NICE) has provided guidelines for the management of migraines.
For acute treatment, a combination of an oral triptan and an NSAID or paracetamol is recommended as first-line therapy. For young people aged 12-17 years, a nasal triptan may be preferred. If these measures are not effective or not tolerated, a non-oral preparation of metoclopramide or prochlorperazine may be offered, along with a non-oral NSAID or triptan.
Prophylaxis should be considered if patients are experiencing two or more attacks per month. NICE recommends either topiramate or propranolol, depending on the patient’s preference, comorbidities, and risk of adverse events. Propranolol is preferred in women of childbearing age as topiramate may be teratogenic and reduce the effectiveness of hormonal contraceptives. Acupuncture and riboflavin may also be effective in reducing migraine frequency and intensity.
For women with predictable menstrual migraines, frovatriptan or zolmitriptan may be used as a type of mini-prophylaxis. Specialists may also consider candesartan or monoclonal antibodies directed against the calcitonin gene-related peptide (CGRP) receptor, such as erenumab. However, pizotifen is no longer recommended due to common adverse effects such as weight gain and drowsiness.
It is important to exercise caution with young patients as acute dystonic reactions may develop. By following these guidelines and considering the various treatment options available, migraines can be effectively managed and their impact on daily life reduced.
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This question is part of the following fields:
- Neurology
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Question 2
Incorrect
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A 32-year-old woman visits her doctor complaining of excessive morning sickness during her third month of pregnancy. Her routine blood tests show an ALT level of 64 IU (normal range: < 40 IU/l) and a bilirubin of 55 µmol/l (normal range: < 21 µmol/l). What is the most probable diagnosis?
Your Answer: Acute fatty liver of pregnancy (AFLP)
Correct Answer: Hyperemesis gravidarum (HG)
Explanation:Hyperemesis gravidarum (HG) is a severe form of nausea and vomiting that occurs during pregnancy and can lead to fluid and electrolyte imbalances, ketosis, and weight loss. It often affects the liver, with abnormal ALT levels in about half of patients. Jaundice may also occur in severe cases. While HG typically resolves by the end of the third trimester, it can persist throughout pregnancy in some cases.
Acute fatty liver of pregnancy (AFLP) is a rare condition that occurs in about 5 out of 100,000 pregnancies. It often presents in the third trimester with symptoms such as nausea, vomiting, abdominal pain, fever, headache, and pruritus. Jaundice may also occur and can become severe. AFLP is typically managed by prompt delivery and supportive care, but it is unlikely to be the diagnosis for a patient in the first trimester.
HELLP syndrome is a condition that can occur in patients with severe pre-eclampsia, with symptoms including abnormal pain and elevated AST levels. It is most likely to occur close to delivery, but it can occur as early as 20 weeks. However, this patient is only 13 weeks pregnant, making HELLP syndrome an unlikely diagnosis.
Intrahepatic cholestasis of pregnancy (ICP) is a common condition that should be considered in cases of abnormal liver function tests in the second trimester. It is characterized by itching, and severe cases may lead to jaundice. Affected pregnancies are at an increased risk of prematurity and stillbirth, so early delivery may be necessary.
Pre-eclampsia is a condition that typically occurs in the second half of pregnancy and is characterized by high blood pressure and proteinuria. It may also cause peripheral edema, abdominal pain, headache, and visual problems. Treatment involves delivery.
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This question is part of the following fields:
- Gastroenterology
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Question 3
Incorrect
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A 45-year-old woman comes to the clinic with complaints of tremors and weight loss. Upon further inquiry, she reveals feeling more irritable than usual and intolerant of heat. During the examination, her heart rate is found to be 113 beats per minute, and she has a significant tremor in her outstretched hands. Blood tests reveal elevated thyrotropin receptor levels, but her thyroid peroxidase antibodies are normal.
What is the most effective treatment option for managing symptoms while awaiting more definitive treatment?Your Answer: Ivabradine
Correct Answer: Propranolol
Explanation:Propranolol is a beta-blocker that can help manage symptoms in new cases of Graves’ disease. It is particularly effective in reducing tremors and palpitations associated with thyrotoxicosis.
Carbimazole is the primary treatment for inducing remission in most cases of Graves’ disease. However, it may take some time to take effect, and patients may require short-term symptomatic relief with a beta-blocker like propranolol.
Bisoprolol is a beta-blocker used to treat hypertension, angina, and heart failure, but it is not typically used for Graves’ disease.
Ivabradine is a cardiac medication that targets the sino-atrial node to regulate heart rate. It is commonly used to treat angina and heart failure.
Management of Graves’ Disease
Despite numerous trials, there is no clear consensus on the optimal management of Graves’ disease. Treatment options include anti-thyroid drugs (ATDs), radioiodine treatment, and surgery. In recent years, ATDs have become the most popular first-line therapy for Graves’ disease. This is particularly true for patients with significant symptoms of thyrotoxicosis or those at risk of hyperthyroid complications, such as elderly patients or those with cardiovascular disease.
To control symptoms, propranolol is often used to block the adrenergic effects. NICE Clinical Knowledge Summaries recommend that patients with Graves’ disease be referred to secondary care for ongoing treatment. If symptoms are not controlled with propranolol, carbimazole should be considered in primary care.
ATD therapy involves starting carbimazole at 40 mg and gradually reducing it to maintain euthyroidism. This treatment is typically continued for 12-18 months. The major complication of carbimazole therapy is agranulocytosis. An alternative regime, called block-and-replace, involves starting carbimazole at 40 mg and adding thyroxine when the patient is euthyroid. This treatment typically lasts for 6-9 months. Patients following an ATD titration regime have been shown to suffer fewer side-effects than those on a block-and-replace regime.
Radioiodine treatment is often used in patients who relapse following ATD therapy or are resistant to primary ATD treatment. Contraindications include pregnancy (should be avoided for 4-6 months following treatment) and age < 16 years. Thyroid eye disease is a relative contraindication, as it may worsen the condition. The proportion of patients who become hypothyroid depends on the dose given, but as a rule, the majority of patients will require thyroxine supplementation after 5 years.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 4
Incorrect
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Oliver is an 8-year-old boy brought in by his mother with a 2 day history of fever and sore throat. Today he has developed a rash on his torso. He is eating and drinking well, but has not been to school for the last 2 days and has been feeling tired.
On examination, Oliver is alert, smiling and playful. He has a temperature of 37.8°C. His throat appears red with petechiae on the hard and soft palate and his tongue is covered with a white coat through which red papillae are visible. There is a blanching rash present on his trunk which is red and punctate with a rough, sandpaper-like texture.
What is the appropriate time for Oliver to return to school based on the most likely diagnosis?Your Answer: 48 hours after commencing antibiotics
Correct Answer: 24 hours after commencing antibiotics
Explanation:If a child has scarlet fever, they can go back to school after 24 hours of starting antibiotics. The symptoms described are typical of scarlet fever, including a strawberry tongue and a rough-textured rash with small red spots on the palate called Forchheimer spots. Charlotte doesn’t need to be hospitalized but should take a 10-day course of phenoxymethylpenicillin. According to NICE, the child should stay away from school, nursery, or work for at least 24 hours after starting antibiotics. It is also important to advise parents to take measures to prevent cross-infection, such as frequent handwashing, avoiding sharing utensils and towels, and disposing of tissues promptly.
Scarlet fever is a condition caused by erythrogenic toxins produced by Group A haemolytic streptococci, usually Streptococcus pyogenes. It is more common in children aged 2-6 years, with the highest incidence at 4 years. The disease is spread through respiratory droplets or direct contact with nose and throat discharges. The incubation period is 2-4 days, and symptoms include fever, malaise, headache, sore throat, ‘strawberry’ tongue, and a rash that appears first on the torso and spares the palms and soles. Scarlet fever is usually a mild illness, but it may be complicated by otitis media, rheumatic fever, acute glomerulonephritis, or rare invasive complications.
To diagnose scarlet fever, a throat swab is usually taken, but antibiotic treatment should be started immediately, rather than waiting for the results. Management involves oral penicillin V for ten days, while patients with a penicillin allergy should be given azithromycin. Children can return to school 24 hours after starting antibiotics, and scarlet fever is a notifiable disease. Desquamation occurs later in the course of the illness, particularly around the fingers and toes. The rash is often described as having a rough ‘sandpaper’ texture, and children often have a flushed appearance with circumoral pallor. Invasive complications such as bacteraemia, meningitis, and necrotizing fasciitis are rare but may present acutely with life-threatening illness.
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This question is part of the following fields:
- Children And Young People
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Question 5
Incorrect
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Which of the following individuals doesn't need the pneumococcal vaccine?
Your Answer: 41-year-old diabetic man on metformin
Correct Answer: 40-year-old asthmatic using salbutamol and beclomethasone
Explanation:According to the Green Book guidelines, only asthmatic patients who use oral steroids at a level that significantly weakens their immune system require the pneumococcal vaccine. However, since the angina patient is on beta-blockers, they should be given the vaccination. For more information, please refer to the provided link.
The pneumococcal vaccine comes in two types: the pneumococcal conjugate vaccine (PCV) and the pneumococcal polysaccharide vaccine (PPV). The PCV is given to children as part of their routine immunizations at 3 and 12-13 months. On the other hand, the PPV is offered to adults over 65 years old, patients with chronic conditions such as COPD, and those who have had a splenectomy.
The vaccine is recommended for individuals with asplenia or splenic dysfunction, chronic respiratory disease, chronic heart disease, chronic kidney disease, chronic liver disease, diabetes mellitus, immunosuppression, cochlear implants, and patients with cerebrospinal fluid leaks. However, controlled hypertension is not an indication for vaccination. Patients with any stage of HIV infection are also included in the list of those who should be vaccinated.
Adults usually require only one dose of the vaccine, but those with asplenia, splenic dysfunction, or chronic kidney disease need a booster every five years. It is important to note that asthma is only included if it requires the use of oral steroids at a dose sufficient to act as a significant immunosuppressant.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 6
Incorrect
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A 25-year-old man presents to the clinic with symptoms of acute sinusitis. He had a severe cold 10 days ago and thought he was recovering, but now has pain over his left cheek and a purulent nasal discharge, more pronounced from the left nostril. On examination, he is febrile with a temperature of 38.5°C and is tender when pressure is applied over the left maxilla. As he is feeling unwell, you decide to prescribe antibiotics, but he has a penicillin allergy. What would be your approach to treating this patient?
Your Answer:
Correct Answer: Doxycycline for 5 days
Explanation:Antibiotic Treatment for Acute Sinusitis
Some important points to consider when treating acute sinusitis with antibiotics include the choice and duration of treatment. It is important to note that NICE CKS doesn’t recommend antibiotic treatment for uncomplicated acute sinusitis lasting 10 days or less. However, if antibiotic treatment is deemed appropriate, it is crucial to be familiar with the options available.
For patients who are not allergic to penicillin, a 5-day course of Phenoxymethylpenicillin is the first choice. However, if the patient is allergic to penicillin, the options are limited to a 5-day course of doxycycline or a 7-day course of Clarithromycin. It is important to read the question carefully and take note of any allergies mentioned in the vignette.
In summary, when considering antibiotic treatment for acute sinusitis, it is important to follow NICE CKS guidelines and be aware of the appropriate choice and duration of treatment based on the patient’s allergy status.
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This question is part of the following fields:
- Evidence Based Practice, Research And Sharing Knowledge
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Question 7
Incorrect
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A 50-year-old woman presents with a tremor. This mainly affects her hands but she has also noticed that her head has a tendency to nod, especially when she is under stress or embarrassed. The hand tremor is worse when she is carrying things such as a cup and saucer. She has noticed that the symptoms are improved when she drinks alcohol. Her mother had a similar tremor. Examination reveals a 4-6-Hz tremor, most marked when her arms are outstretched, and nodding movements of the head. She has difficulty in neatly copying a spiral diagram. Other neurological examination is normal. Thyroid function is normal.
Select the single most appropriate first-line therapy.Your Answer:
Correct Answer: Propranolol
Explanation:Treatment Options for Essential Tremor: A Comprehensive Guide
Essential tremor is a common neurological disorder that causes involuntary shaking of the hands, head, and voice. While there is no cure for essential tremor, there are several treatment options available to manage the symptoms.
Before starting any treatment, it is important to rule out any underlying peripheral or central nervous system disease and exclude possible causes of physiological tremor such as hyperthyroidism, drug-related tremor, or alcohol withdrawal.
The most appropriate first-line therapy for essential tremor is β blockade. If this is not tolerated, primidone is an alternative. Other medications that have shown effectiveness include alprazolam, atenolol, topiramate, and clonazepam. However, gabapentin has only been found to be effective when used as monotherapy and not as adjunct therapy.
For head tremors, botulinum toxin A can be used. In rare cases, surgery may be considered, such as deep brain stimulation or thalamotomy.
It is important to note that mild tremors may not require any treatment or only intermittent treatment for difficult social situations.
In conclusion, essential tremor can be managed with various treatment options. It is important to consult with a healthcare professional to determine the best course of action for each individual case.
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This question is part of the following fields:
- Neurology
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Question 8
Incorrect
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You see a 26-year-old male patient with erectile dysfunction. He is typically healthy and doesn't take any regular medications. He is a non-smoker and drinks alcohol in moderation.
You proceed to gather a more comprehensive history of his issue and conduct a thorough psychosexual evaluation.
Which of the following history findings would indicate a psychogenic origin rather than an organic cause for his condition?Your Answer:
Correct Answer: A history of premature ejaculation
Explanation:Erectile dysfunction (ED) is a condition where a person is unable to achieve or maintain an erection that is sufficient for satisfactory sexual performance. The causes of ED can be categorized into organic, psychogenic, or mixed, and can also be caused by certain medications.
Symptoms that indicate a psychogenic cause of ED include a sudden onset, early loss of erection, self-stimulated or waking erections, premature ejaculation or inability to ejaculate, relationship problems or changes, major life events, and psychological issues.
On the other hand, symptoms that suggest an organic cause of ED include a gradual onset and normal ejaculation.
Erectile dysfunction (ED) is a condition where a man is unable to achieve or maintain an erection that is sufficient for sexual performance. It is not a disease but a symptom that can be caused by organic, psychogenic, or mixed factors. It is important to differentiate between the causes of ED, with factors such as a gradual onset of symptoms and lack of tumescence favoring an organic cause, while sudden onset of symptoms and decreased libido favoring a psychogenic cause. Risk factors for ED include cardiovascular disease, alcohol use, and certain medications.
To assess for ED, it is recommended to measure lipid and fasting glucose serum levels to calculate cardiovascular risk. Free testosterone should also be measured in the morning, and if low or borderline, further assessment may be needed. PDE-5 inhibitors, such as sildenafil, are the first-line treatment for ED and should be prescribed to all patients regardless of the cause. Vacuum erection devices can be used as an alternative for those who cannot or will not take PDE-5 inhibitors. Referral to urology may be appropriate for young men who have always had difficulty achieving an erection, and those who cycle for more than three hours per week should be advised to stop.
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This question is part of the following fields:
- Mental Health
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Question 9
Incorrect
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A 28-year-old female presents with weight loss and irritability.
Thyroid function tests reveal:
Free T4 32.9 pmol/L (9.8-23.1)
TSH <0.02 mU/L (0.35-5.50)
Free T3 11.1 pmol/L (3.5-6.5)
Examination reveals a fine tremor, pulse of 95 beats per minute, a smooth goitre with a bruit and lid lag only without any other eye signs.
What is the most likely cause for these thyroid function test results?Your Answer:
Correct Answer: Hashitoxicosis
Explanation:TFTs and Hyperthyroidism
Thyroid function tests (TFTs) can reveal hyperthyroidism, which can be caused by Graves’ disease, Hashitoxicosis, and Multinodular goitre. However, the distinguishing feature in this case is the presence of a thyroid bruit, which suggests increased vascularity due to stimulation by a thyroid-stimulating hormone (TSH) receptor antibody, specifically in Graves’ disease. It is important to note that eye signs such as proptosis, chemosis, and exophthalmos are common features of Graves’ disease but may not always be present. Proper diagnosis and management of hyperthyroidism require careful evaluation and monitoring of thyroid function and associated symptoms.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 10
Incorrect
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A 56-year-old man comes to you with concerns about his erectile dysfunction. He has a clean medical history except for a bout of depression that occurred six years ago. What is the accurate statement regarding prescribing sildenafil for him?
Your Answer:
Correct Answer: It may be freely prescribed on the NHS
Explanation:In 2014, sildenafil was removed from the list of restricted medications and can now be prescribed without limitations.
Phosphodiesterase type V inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. They work by increasing cGMP, which leads to relaxation of smooth muscles in blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which is taken about an hour before sexual activity. Other examples include tadalafil (Cialis) and vardenafil (Levitra), which have longer-lasting effects and can be taken regularly. However, these medications have contraindications, such as not being safe for patients taking nitrates or those with hypotension. They can also cause side effects such as visual disturbances, blue discolouration, and headaches. It is important to consult with a healthcare provider before taking PDE5 inhibitors.
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This question is part of the following fields:
- Sexual Health
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