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Question 1
Correct
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A 67-year-old man presents to the memory clinic with a history of cognitive decline over the past 10 months. His wife reports that he is struggling with basic tasks and becoming increasingly forgetful and confused. She has also noticed a change in his personality, including more frequent swearing and inappropriate behavior such as answering the door naked. Interestingly, his mother had a similar reputation in her later years. The patient reports smoking 20 cigarettes per day and drinking one glass of wine each evening. What is the most probable diagnosis?
Your Answer: Frontotemporal dementia
Explanation:The patient is likely suffering from frontotemporal dementia, which is also known as Pick’s disease. This type of dementia is characterized by a change in personality and social disinhibition, and it often has a positive family history. In contrast, Alzheimer’s disease typically presents with a decline in episodic memory and visuospatial awareness, while Lewy body dementia is characterized by fluctuating confusion and hallucinations. Creutzfeldt-Jakob disease is a rare condition that causes rapid neurodegeneration and may present with cognitive decline and personality changes, as well as additional symptoms such as abnormal movements and loss of coordination.
Understanding Frontotemporal Lobar Degeneration
Frontotemporal lobar degeneration (FTLD) is a type of cortical dementia that is the third most common after Alzheimer’s and Lewy body dementia. There are three recognized types of FTLD: Frontotemporal dementia (Pick’s disease), Progressive non-fluent aphasia (chronic progressive aphasia, CPA), and Semantic dementia. Common features of frontotemporal lobar dementias include onset before 65, insidious onset, relatively preserved memory and visuospatial skills, personality change, and social conduct problems.
Pick’s disease is the most common type of FTLD and is characterized by personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviors. Focal gyral atrophy with a knife-blade appearance is characteristic of Pick’s disease. Macroscopic changes seen in Pick’s disease include atrophy of the frontal and temporal lobes. Microscopic changes include Pick bodies, spherical aggregations of tau protein (silver-staining), gliosis, neurofibrillary tangles, and senile plaques.
In contrast, CPA is characterized by non-fluent speech, with short utterances that are agrammatic. Comprehension is relatively preserved. Semantic dementia, on the other hand, is characterized by fluent progressive aphasia. The speech is fluent but empty and conveys little meaning. Unlike in Alzheimer’s, memory is better for recent rather than remote events.
In terms of management, NICE does not recommend the use of AChE inhibitors or memantine in people with frontotemporal dementia. Understanding the different types of FTLD and their characteristics can aid in early diagnosis and appropriate management.
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This question is part of the following fields:
- Neurology
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Question 2
Correct
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A 82-year-old man comes to the clinic complaining of sudden loss of vision in his left eye since this morning. He denies any associated eye pain or headaches and is otherwise feeling well. His medical history includes ischaemic heart disease. Upon examination, the patient has no vision in his left eye. The left pupil shows poor response to light, but the consensual light reaction is normal. Fundoscopy reveals a red spot over a pale and opaque retina. What is the most probable diagnosis?
Your Answer: Central retinal artery occlusion
Explanation:Central Retinal Artery Occlusion: A Rare Cause of Sudden Vision Loss
Central retinal artery occlusion is a rare condition that can cause sudden, painless loss of vision in one eye. It is typically caused by a blood clot or inflammation in the artery that supplies blood to the retina. This can be due to atherosclerosis or arteritis, such as temporal arteritis. Symptoms may include a relative afferent pupillary defect and a cherry red spot on a pale retina. Unfortunately, the prognosis for this condition is poor, and management can be difficult. Treatment may involve identifying and addressing any underlying conditions, such as intravenous steroids for temporal arteritis. In some cases, intraarterial thrombolysis may be attempted, but the results of this treatment are mixed. Overall, central retinal artery occlusion is a serious condition that requires prompt medical attention.
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This question is part of the following fields:
- Ophthalmology
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Question 3
Correct
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A 42-year-old woman presented with complaints of constant fatigue and underwent blood tests. All results were within normal limits except for her thyroid function test (TFT) which revealed:
TSH 12.5 mU/l
Free T4 7.5 pmol/l
What would be the most suitable course of action?Your Answer: Levothyroxine
Explanation:The TFTs indicate a diagnosis of hypothyroidism, which can be treated with levothyroxine. Carbimazole is not suitable for this condition as it is used to treat hyperthyroidism. To ensure proper absorption, levothyroxine should be taken 30 minutes before consuming food, caffeine, or other medications.
Managing Hypothyroidism: Dosage, Monitoring, and Side-Effects
Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone. The main treatment for hypothyroidism is levothyroxine, a synthetic form of thyroid hormone. When managing hypothyroidism, it is important to consider the patient’s age, cardiac history, and initial starting dose. Elderly patients and those with ischaemic heart disease should start with a lower dose of 25mcg od, while other patients can start with 50-100mcg od. After a change in dosage, thyroid function tests should be checked after 8-12 weeks to ensure the therapeutic goal of normalising the thyroid stimulating hormone (TSH) level is achieved. The target TSH range is 0.5-2.5 mU/l.
Women with hypothyroidism who become pregnant should have their dose increased by at least 25-50 micrograms levothyroxine due to the increased demands of pregnancy. The TSH should be monitored carefully, aiming for a low-normal value. It is important to note that there is no evidence to support combination therapy with levothyroxine and liothyronine.
While levothyroxine is generally well-tolerated, there are some potential side-effects to be aware of. Over-treatment can lead to hyperthyroidism, while long-term use can reduce bone mineral density. In patients with cardiac disease, levothyroxine can worsen angina and lead to atrial fibrillation. It is also important to be aware of drug interactions, particularly with iron and calcium carbonate, which can reduce the absorption of levothyroxine. These medications should be given at least 4 hours apart.
In summary, managing hypothyroidism involves careful consideration of dosage, monitoring of TSH levels, and awareness of potential side-effects and drug interactions. With appropriate management, patients with hypothyroidism can achieve normal thyroid function and improve their overall health.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 4
Correct
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A 32-year-old male patient comes in for mole removal. Which areas of the body are more prone to developing keloid scars?
Your Answer: Sternum
Explanation:Understanding Keloid Scars
Keloid scars are abnormal growths that develop from the connective tissue of a scar and extend beyond the boundaries of the original wound. They are more common in people with dark skin and tend to occur in young adults. Keloids are most frequently found on the sternum, shoulder, neck, face, extensor surface of limbs, and trunk.
To prevent keloid scars, incisions should be made along relaxed skin tension lines. However, if keloids do develop, early treatment with intra-lesional steroids such as triamcinolone may be effective. In some cases, excision may be necessary, but this should be approached with caution as it can potentially lead to further keloid scarring.
It is important to note that the historical use of Langer lines to determine optimal incision lines has been shown to produce worse cosmetic results than following skin tension lines. Understanding the predisposing factors and treatment options for keloid scars can help individuals make informed decisions about their care.
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This question is part of the following fields:
- Dermatology
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Question 5
Correct
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A 35-year-old woman presents with a 3-day history of a painful and swollen right ankle. She is pyrexial with a temperature of 38.2 °C. Examination of her cardiovascular and respiratory systems is normal, and an abdominal examination is also normal. She mentions that she developed a painful left ear and saw another doctor 4 days ago, who told her that she had an infected ear and prescribed antibiotics. Her right ankle is swollen, red, tender and slightly flexed. A diagnosis of septic arthritis is made.
Which of the following is the most likely causative organism?
Select the SINGLE most likely causative organism.Your Answer: Staphylococcus aureus (S. aureus)
Explanation:Common Bacterial Infections and their Causes
Septic arthritis is a joint infection caused by pyogenic organisms, with S. aureus being the most common culprit. Other organisms responsible include streptococci, Neisseria species, and Gram-negative bacilli. The infection typically spreads to the joint via the bloodstream or from adjacent osteomyelitis or trauma. Symptoms include pain, redness, warmth, and swelling in the affected joint. Diagnosis is established by aspirating and culturing the joint fluid. Immediate treatment with appropriate antibiotics is crucial to prevent cartilage destruction, and needle aspiration or surgical drainage may be necessary.
N. meningitidis is a Gram-negative bacterium that causes meningococcaemia and meningococcal meningitis, particularly in children and young adults. It is spread via respiratory secretions and can be carried asymptomatically by 5-10% of adults, with higher rates in close communities. The disease carries significant morbidity and mortality.
S. viridans is commonly found in the mouth and can cause endocarditis if introduced into the bloodstream. It is the most common cause of subacute bacterial endocarditis.
S. epidermidis is a Gram-positive staphylococcus that normally resides on human skin and mucosa. It commonly causes infections on catheters and implants, and is a frequent cause of nosocomial infections, particularly in TPN and bone marrow transplant patients.
E. coli is commonly found in the large intestine and is a major cause of urinary tract infections, cholecystitis and cholangitis, and neonatal meningitis.
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This question is part of the following fields:
- Musculoskeletal
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Question 6
Incorrect
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A 54-year-old man with a history of epilepsy presents with a complaint of numbness in his hands and feet after a recent change in medication. Upon examination, he exhibits reduced sensation in a glove-and-stocking distribution and a decreased ankle reflex. Additionally, he has lymphadenopathy in the cervical and inguinal region and bleeding gums. Which medication is most likely responsible for these symptoms?
Your Answer: Topiramate
Correct Answer: Phenytoin
Explanation:Phenytoin: Mechanism of Action and Adverse Effects
Phenytoin is a medication used to manage seizures. Its mechanism of action involves binding to sodium channels, which increases their refractory period. However, the drug is associated with a large number of adverse effects, which can be categorized as acute, chronic, idiosyncratic, and teratogenic. Acute effects include dizziness, diplopia, nystagmus, slurred speech, ataxia, confusion, and seizures. Chronic effects include gingival hyperplasia, hirsutism, coarsening of facial features, drowsiness, megaloblastic anemia, peripheral neuropathy, enhanced vitamin D metabolism causing osteomalacia, lymphadenopathy, and dyskinesia. Idiosyncratic effects include fever, rashes, hepatitis, Dupuytren’s contracture, aplastic anemia, and drug-induced lupus. Teratogenic effects are associated with cleft palate and congenital heart disease. Although routine monitoring of phenytoin levels is not necessary, trough levels should be checked before dosing in cases of dose adjustment, suspected toxicity, or non-adherence to the prescribed medication.
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This question is part of the following fields:
- Neurology
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Question 7
Incorrect
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In a patient with parkinsonian features, what is the single most appropriate feature that supports the diagnosis of progressive supranuclear palsy (PSP) over idiopathic Parkinson's disease (PD)?
Your Answer: Response to levodopa
Correct Answer: Early postural instability
Explanation:Differentiating Progressive Supranuclear Palsy from Other Movement Disorders
Progressive Supranuclear Palsy (PSP) is a neurodegenerative condition that typically affects individuals over the age of 50, with a higher incidence in men. Early postural instability is a hallmark feature of PSP, often leading to falls within the first year of onset. The Clinical Criteria for the Diagnosis of Progressive Supranuclear Palsy developed by the National Institute for Neurological Disorders and Society for PSP (NINDS-SPSP) suggests that a poor or absent response to levodopa is indicative of PSP.
Unlike Parkinson’s disease (PD), PSP is not associated with Internuclear Ophthalmoplegia (INO) and does not typically present with marked tremors. Instead, PSP is characterized by supranuclear gaze dysfunction, rigidity, bradykinesia, dysarthria, and dysphagia. Symptoms are usually symmetrical, and unilateral onset is more suggestive of idiopathic PD.
In summary, early postural instability, poor response to levodopa, absence of INO, and lack of marked tremors are key features that can help differentiate PSP from other movement disorders.
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This question is part of the following fields:
- Neurology
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Question 8
Incorrect
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A 32-year-old man with a past medical history of polyarthralgia, back pain, and diarrhea presents with a 3 cm red lesion on his shin that is beginning to ulcerate. What is the probable diagnosis?
Your Answer: Metastatic colon cancer
Correct Answer: Pyoderma gangrenosum
Explanation:It is probable that this individual is suffering from ulcerative colitis, a condition that is commonly linked to arthritis in large joints, sacroiliitis, and pyoderma gangrenosum.
Understanding Pyoderma Gangrenosum
Pyoderma gangrenosum is a rare inflammatory disorder that causes painful skin ulceration. While it can affect any part of the skin, it is most commonly found on the lower legs. This condition is classified as a neutrophilic dermatosis, which means that it is characterized by the infiltration of neutrophils in the affected tissue. The exact cause of pyoderma gangrenosum is unknown in 50% of cases, but it can be associated with inflammatory bowel disease, rheumatological conditions, haematological disorders, and other diseases.
The initial symptoms of pyoderma gangrenosum may start suddenly with a small pustule, red bump, or blood-blister. The skin then breaks down, resulting in an ulcer that is often painful. The edge of the ulcer is typically described as purple, violaceous, and undermined. In some cases, systemic symptoms such as fever and myalgia may also be present. Diagnosis is often made by the characteristic appearance, associations with other diseases, the presence of pathergy, histology results, and ruling out other potential causes.
Management of pyoderma gangrenosum typically involves oral steroids as first-line treatment due to the potential for rapid progression. Other immunosuppressive therapies such as ciclosporin and infliximab may also be used in difficult cases. It is important to note that any surgery should be postponed until the disease process is controlled on immunosuppression to avoid worsening the condition. Understanding pyoderma gangrenosum and seeking prompt medical attention can help manage this rare and painful condition.
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This question is part of the following fields:
- Dermatology
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Question 9
Correct
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A 55-year-old woman has been prescribed simvastatin for primary prevention of cardiovascular disease (CVD).
Which of the following should be the NEXT step?Your Answer: Check LFTs and lipid profiles at 3 months
Explanation:Monitoring Statin Therapy: Recommended Blood Tests and Timing
Statin therapy is a common treatment for patients with high cholesterol levels, both for primary and secondary prevention of cardiovascular disease. However, regular monitoring is necessary to ensure the treatment is effective and safe. Here are some recommended blood tests and their timing for monitoring statin therapy:
Recommended Blood Tests and Timing for Monitoring Statin Therapy
Check LFTs and lipid profiles at 3 months
Within three months of starting high-intensity statin treatment, it is recommended to measure total cholesterol, HDL-cholesterol, and non-HDL cholesterol. The aim is to achieve a >40% reduction in non-HDL-cholesterol. LFTs should also be checked at this time and again at 12 months, unless clinically indicated.
Check LFTs and lipid profiles at 12 months
Both LFTs and the lipid profile should be checked at 12 months, but it is important to assess whether a suitable cholesterol level reduction has been achieved earlier in the process. This allows for discussion of adherence to medication, diet, and lifestyle measures, and consideration of increasing the dose.
Check LFTs at 1 week
Checking LFTs within a week of starting treatment is not necessary, as any liver abnormalities would be unlikely to develop so soon without the patient experiencing symptoms of acute liver disease.
Check the lipid profiles at 1 month
It takes approximately 6-8 weeks for a stable result in lipid reduction to be seen after starting a statin, so checking the lipid profile at 1 month is not appropriate.
Check TFTs at 3 months
There is no need to check thyroid function tests during statin therapy for monitoring purposes. However, patients with other conditions that justify TFTs should have them done as clinically appropriate.
Regular monitoring of statin therapy through blood tests is crucial for ensuring the treatment is effective and safe for patients with high cholesterol levels.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 10
Incorrect
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Sophie is a premature baby (28 weeks) who was born 3 weeks ago. During the past week, she has been experiencing bloody stools, abdominal distension, and poor feeding. Upon physical examination, there is an increase in abdominal size with decreased bowel sounds. An abdominal X-ray reveals asymmetrical bowel loops that are dilated and have bowel wall oedema. What is the probable diagnosis?
Your Answer: Hirschsprung's disease
Correct Answer: Necrotising enterocolitis
Explanation:Understanding Necrotising Enterocolitis
Necrotising enterocolitis is a serious condition that is responsible for a significant number of premature infant deaths. The condition is characterized by symptoms such as feeding intolerance, abdominal distension, and bloody stools. If left untreated, these symptoms can quickly progress to more severe symptoms such as abdominal discolouration, perforation, and peritonitis.
To diagnose necrotising enterocolitis, doctors often use abdominal x-rays. These x-rays can reveal a number of important indicators of the condition, including dilated bowel loops, bowel wall oedema, and intramural gas. Other signs that may be visible on an x-ray include portal venous gas, pneumoperitoneum resulting from perforation, and air both inside and outside of the bowel wall. In some cases, an x-ray may also reveal air outlining the falciform ligament, which is known as the football sign.
Overall, understanding the symptoms and diagnostic indicators of necrotising enterocolitis is crucial for early detection and treatment of this serious condition. By working closely with healthcare professionals and following recommended screening protocols, parents and caregivers can help ensure the best possible outcomes for premature infants at risk for this condition.
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This question is part of the following fields:
- Paediatrics
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Question 11
Incorrect
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A 35-year-old woman came to your GP clinic with a cold sore and left eye discomfort. She reported experiencing a red, painful eye with watering and sensitivity to light for the past 3 days. During fluorescein examination, you observed a dendritic ulcer on the cornea that was stained with fluorescein.
What is the primary treatment for this condition?Your Answer: Topical chloramphenicol drops
Correct Answer: Topical aciclovir drops
Explanation:The appropriate treatment for herpes simplex keratitis is the use of topical aciclovir. Antibiotics are ineffective against viral infections and should not be used. The use of steroids can worsen the condition and should be avoided. If the patient is already using topical steroids for another eye condition, the dosage should be decreased.
Understanding Herpes Simplex Keratitis
Herpes simplex keratitis is a condition that affects the cornea of the eye and is caused by the herpes simplex virus. The most common symptom of this condition is a dendritic corneal ulcer, which can cause a red, painful eye, photophobia, and epiphora. In some cases, visual acuity may also be decreased. Fluorescein staining may show an epithelial ulcer, which can help with diagnosis. One common treatment for this condition is topical aciclovir, which can help to reduce the severity of symptoms and prevent further damage to the cornea.
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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 72-year-old man who smokes visits your GP clinic and inquires about potential complications associated with surgical resection of his malignant parotid gland tumour. What is the classic complication linked to parotid gland surgery?
Your Answer: Lower motor neurone facial palsy
Explanation:A lower motor neurone facial palsy can be caused by parotid pathology.
After exiting the stylomastoid foramen, the facial nerve passes through the parotid gland and divides into five branches: temporal, zygomatic, buccal, marginal mandibular, and cervical. If there is any pathology within the parotid gland, it can lead to a lower motor neurone facial palsy. Additionally, surgery to the parotid gland can also result in this complication.
Facial Nerve Palsy: Causes and Path
Facial nerve palsy is a condition that affects the facial nerve, which supplies the muscles of facial expression, digastric muscle, and glandular structures. It can be caused by various factors, including sarcoidosis, Guillain-Barre syndrome, Lyme disease, acoustic neuromas, and Bell’s palsy. Bilateral facial nerve palsy is less common and can be caused by the same factors as unilateral palsy, but it can also be a result of neurofibromatosis type 2.
The facial nerve has two paths: the subarachnoid path and the facial canal path. The subarachnoid path originates from the pons and passes through the petrous temporal bone into the internal auditory meatus with the vestibulocochlear nerve. The facial canal path passes superior to the vestibule of the inner ear and contains the geniculate ganglion at the medial aspect of the middle ear. It has three branches: the greater petrosal nerve, the nerve to stapedius, and the chorda tympani. The facial nerve then passes through the stylomastoid foramen and gives rise to the posterior auricular nerve and a branch to the posterior belly of the digastric and stylohyoid muscle.
It is important to differentiate between lower motor neuron and upper motor neuron lesions in facial nerve palsy. An upper motor neuron lesion spares the upper face, while a lower motor neuron lesion affects all facial muscles. Multiple sclerosis and diabetes mellitus can also cause an upper motor neuron palsy. Understanding the causes and path of facial nerve palsy can aid in its diagnosis and treatment.
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This question is part of the following fields:
- ENT
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Question 13
Correct
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A 55-year-old woman presents to a walk-in clinic with complaints of fatigue and feeling cold for the past two months. She has become increasingly distressed by these symptoms and reports a recent weight gain of approximately 5kg. Which of her regular medications could potentially be causing these symptoms?
Your Answer: Lithium
Explanation:Hypothyroidism can be caused by long-term use of lithium.
The patient’s symptoms suggest hypothyroidism, and the only medication on the list that can lead to this condition is lithium. While the other drugs listed may cause individual side effects that could contribute to the patient’s presentation, none of them would produce all of the symptoms described.
Amlodipine may cause weight gain due to fluid retention, but it is unlikely to cause as much as 5 kg, and it would not cause mood changes or fatigue to the extent described. Bisoprolol can cause significant fatigue, but it would not cause weight gain. Citalopram may cause significant weight gain and mood changes, but it is unlikely to cause the patient to feel cold. Atorvastatin can also cause weight gain, but this is rare.
Understanding the Causes of Hypothyroidism
Hypothyroidism is a condition that affects a small percentage of women in the UK, with females being more susceptible than males. The most common cause of hypothyroidism is Hashimoto’s thyroiditis, an autoimmune disease that may be associated with other conditions such as IDDM, Addison’s or pernicious anaemia. Other causes of hypothyroidism include subacute thyroiditis, Riedel thyroiditis, thyroidectomy or radioiodine treatment, drug therapy, and dietary iodine deficiency. It is important to note that some of these causes may have an initial thyrotoxic phase.
In rare cases, hypothyroidism may also be caused by pituitary failure, which is known as secondary hypothyroidism. Additionally, there are certain conditions that may be associated with hypothyroidism, such as Down’s syndrome, Turner’s syndrome, and coeliac disease.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 14
Correct
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A 65-year-old woman is admitted to hospital with community-acquired pneumonia. She has developed acute kidney injury. Her blood results show the following:
Test Result Reference range
Potassium (K) (mmol/l) 6.0 3.5-5.3
Creatine (Cr) (μmol/l) 220
Male: 80-110
Female: 70-100
Which of the following of her medications should be stopped immediately?
Your Answer: Ramipril
Explanation:Medication and Renal Impairment: Considerations and Dose Adjustments
When prescribing medication for patients with renal impairment, it is important to consider the potential for inducing or worsening kidney damage. Here are some considerations and dose adjustments for commonly prescribed medications:
Ramipril: This ACE inhibitor has the potential to cause hypotension, which can lead to impaired kidney function. In patients with stable renal impairment, a maximum daily dose of 5 mg can be considered. The initial dose should not exceed 1.25 mg daily if eGFR is <30 ml/min per 1.73 m2. Bisoprolol: This medication is not associated with inducing or worsening kidney damage. However, the dose should be reduced if eGFR is lower than 20 ml/min per 1.73 m2 (maximum 10 mg daily). Paracetamol: At therapeutic doses, paracetamol is not associated with kidney damage. However, in overdose, it can cause renal damage. The minimum interval between doses should be six hours if eGFR is <30 ml/min per 1.73 m2. Fluticasone with salmeterol: Neither component of this inhaler is associated with kidney damage and does not require dose adjustment in patients with renal disease. Simvastatin: Statins should be used with caution in patients with renal impairment, as the likelihood of muscle toxicity increases with higher doses. Doses >10 mg daily should be used with caution if eGFR is lower than 30 ml/min per 1.73 m2.
In summary, medication dosing and selection should be carefully considered in patients with renal impairment to avoid potential kidney damage and ensure optimal therapeutic outcomes.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 15
Correct
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A 45-year-old businessman presents to the Emergency Department with his second episode of epistaxis in a 24 hour period. On each occasion, the nosebleeds stopped with pressure applied just below the nasal bridge, but the most recent bleed went on for 30 minutes. He has hypertension, for which he takes medication regularly. He also admits to smoking a pack of cigarettes per day and drinking 10-15 units of alcohol each week. There is no history of trauma. He is worried about the problem affecting his work, as he has an important meeting the following day.
On examination, he looks well and is not pale, and his blood pressure and pulse are within normal limits. He is peripherally well perfused. On inspection of the nasal vestibule, there are prominent blood vessels visible on the right side of the nasal septum, with a small amount of clotted blood also present.
What is the most appropriate management plan for this patient?Your Answer: Cauterise the bleeding point using silver nitrate
Explanation:Treatment Options for Epistaxis: From Simple First-Aid Measures to Invasive Procedures
Epistaxis, or nosebleed, is a common condition that can be treated through simple first-aid measures. However, in cases of repeated or prolonged nosebleeds, more invasive treatment may be necessary. Here are some treatment options for epistaxis:
Cauterization: If an anterior bleeding point is seen, cautery can be attempted. This is usually achieved by the application of a silver nitrate stick to the area for around 10 seconds after giving topical local anesthesia.
Blood tests and investigations: Blood tests and other investigations are of little use, as an underlying cause is highly unlikely in a young and otherwise well patient.
First-aid measures: Epistaxis is mainly treated through simple first-aid measures. It is important to reassure the patient that the problem is normally self-limiting.
Nasal tampon: Bleeds that do not settle with cautery, or significant bleeds where a bleeding point cannot be seen, require the application of a nasal tampon and referral to ENT.
Admission: This patient does not require admission. Blood tests are unlikely to be helpful, and she is haemodynamically stable.
In summary, treatment options for epistaxis range from simple first-aid measures to invasive procedures. The choice of treatment depends on the severity and frequency of the nosebleeds.
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This question is part of the following fields:
- ENT
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Question 16
Incorrect
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A 75 year-old woman visits her doctor complaining of a 1.5cm ulcerated lesion on her left labium majus. She has been experiencing vulval itching and soreness for the past three years, despite using topical steroid treatment. What is the probable diagnosis?
Your Answer: Vulval intraepithelial neoplasia
Correct Answer: Vulval carcinoma
Explanation:Understanding Vulval Carcinoma
Vulval carcinoma is a type of cancer that affects the vulva, which is the external female genitalia. It is a relatively rare condition, with only around 1,200 cases diagnosed in the UK each year. The majority of cases occur in women over the age of 65 years, and around 80% of cases are squamous cell carcinomas.
There are several risk factors associated with vulval carcinoma, including human papilloma virus (HPV) infection, vulval intraepithelial neoplasia (VIN), immunosuppression, and lichen sclerosus. Symptoms of vulval carcinoma may include a lump or ulcer on the labia majora, inguinal lymphadenopathy, and itching or irritation.
It is important for women to be aware of the risk factors and symptoms of vulval carcinoma, and to seek medical attention if they experience any concerning symptoms. Early detection and treatment can improve outcomes and increase the chances of a full recovery.
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This question is part of the following fields:
- Reproductive Medicine
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Question 17
Correct
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A 16-year-old girl comes to see her doctor because she has not yet begun menstruating. During the physical examination, you observe that she has a short stature and a webbed neck. What would you anticipate hearing when listening to her heart?
Your Answer: Ejection systolic murmur
Explanation:The ejection systolic murmur present in this patient is likely due to her Turner’s syndrome, which is associated with a bicuspid aortic valve. A continuous machinery murmur, late systolic murmur, and mid-late diastolic murmur are less likely causes, as they are associated with different conditions that are not commonly seen in patients with Turner’s syndrome.
Understanding Turner’s Syndrome
Turner’s syndrome is a genetic disorder that affects approximately 1 in 2,500 females. It is caused by the absence of one sex chromosome (X) or a deletion of the short arm of one of the X chromosomes. This condition is denoted as 45,XO or 45,X.
The features of Turner’s syndrome include short stature, a shield chest with widely spaced nipples, a webbed neck, a bicuspid aortic valve (15%), coarctation of the aorta (5-10%), primary amenorrhea, cystic hygroma (often diagnosed prenatally), a high-arched palate, a short fourth metacarpal, multiple pigmented naevi, lymphoedema in neonates (especially feet), and elevated gonadotrophin levels. Hypothyroidism is much more common in Turner’s syndrome, and there is also an increased incidence of autoimmune disease (especially autoimmune thyroiditis) and Crohn’s disease.
In summary, Turner’s syndrome is a chromosomal disorder that affects females and can cause a range of physical features and health issues. Early diagnosis and management can help individuals with Turner’s syndrome lead healthy and fulfilling lives.
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This question is part of the following fields:
- Paediatrics
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Question 18
Correct
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When visiting a 60-year-old patient at home to do a wound dressing, the District Nurse wants to confirm if the patient has received complete tetanus vaccination. What is the number of tetanus vaccine doses required for life-long protection?
Your Answer: 5
Explanation:Tetanus Vaccination and Management of Wounds
The tetanus vaccine is a purified toxin that is given as part of a combined vaccine. In the UK, it is given as part of the routine immunisation schedule at 2, 3, and 4 months, 3-5 years, and 13-18 years, providing a total of 5 doses for long-term protection against tetanus.
When managing wounds, the first step is to classify them as clean, tetanus-prone, or high-risk tetanus-prone. Clean wounds are less than 6 hours old and have negligible tissue damage, while tetanus-prone wounds include puncture-type injuries acquired in a contaminated environment or wounds containing foreign bodies. High-risk tetanus-prone wounds include wounds or burns with systemic sepsis, certain animal bites and scratches, heavy contamination with material likely to contain tetanus spores, wounds or burns with extensive devitalised tissue, and wounds or burns that require surgical intervention.
If the patient has had a full course of tetanus vaccines with the last dose less than 10 years ago, no vaccine or tetanus immunoglobulin is required regardless of the wound severity. If the patient has had a full course of tetanus vaccines with the last dose more than 10 years ago, a reinforcing dose of vaccine is required for tetanus-prone wounds, and a reinforcing dose of vaccine plus tetanus immunoglobulin is required for high-risk wounds. If the vaccination history is incomplete or unknown, a reinforcing dose of vaccine is required regardless of the wound severity, and a reinforcing dose of vaccine plus tetanus immunoglobulin is required for tetanus-prone and high-risk wounds.
Overall, proper vaccination and wound management are crucial in preventing tetanus infection.
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This question is part of the following fields:
- Infectious Diseases
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Question 19
Correct
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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: 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 20
Correct
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An 80-year-old male has been diagnosed with upper rectal cancer. The cancer is confined to the area and the medical team has decided to perform an anterior resection to remove it. The surgeon believes that to achieve the best long-term outcome, it is necessary to temporarily divert the colon to safeguard the colorectal anastomosis. What type of stoma would be most suitable?
Your Answer: Loop ileostomy
Explanation:A loop ileostomy is the appropriate procedure for defunctioning the colon to protect an anastomosis. This involves taking a loop of ileum, making a horizontal incision, and bringing it up to the skin. It is commonly used after rectal cancer surgery and can be reversed at a later time.
An end colostomy is performed when an anastomosis is not possible or desirable, and the colon needs to be diverted or resected. The distal part of the colon is brought up to the skin in this procedure.
An end ileostomy is typically done after the complete removal of the colon or when an ileocolic anastomosis is not planned. While it can be used to defunction the colon, it is more challenging to reverse.
A gastrostomy is used for gastric decompression or feeding.
A loop jejunostomy is used as a high-output stoma and may be performed after an emergency laparotomy with planned early closure.
Abdominal stomas are created during various abdominal procedures to bring the lumen or contents of organs onto the skin. Typically, this involves the bowel, but other organs may also be diverted if necessary. The type and method of construction of the stoma will depend on the contents of the bowel. Small bowel stomas should be spouted to prevent irritant contents from coming into contact with the skin, while colonic stomas do not require spouting. Proper siting of the stoma is crucial to reduce the risk of leakage and subsequent maceration of the surrounding skin. The type and location of the stoma will vary depending on the purpose, such as defunctioning the colon or providing feeding access. Overall, abdominal stomas are a necessary medical intervention that requires careful consideration and planning.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 21
Incorrect
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As a foundation doctor on the neonatal ward, you are updating a prescription chart for a premature baby born at twenty-seven weeks who is in poor condition. While reviewing the chart, you come across caffeine as one of the medications prescribed. Can you explain the purpose of caffeine in neonatal care?
Your Answer:
Correct Answer: Aiding weaning off a ventilator
Explanation:Newborn babies can benefit from caffeine as it acts as a respiratory stimulant. It is also used to help neonates transition off a ventilator. Sildenafil, known as Viagra, is typically used to treat erectile dysfunction in adults, but it can also be used to treat pulmonary hypertension in neonates. The approach to addressing distress in newborns depends on the underlying cause, which is often related to respiratory or pain issues. Gaviscon and ranitidine are sometimes used to treat gastro-oesophageal reflux, although this is not an approved use. Necrotising enterocolitis is more prevalent in premature babies and can be treated through medical interventions, such as resting the gut, or surgical interventions, such as resection.
Surfactant Deficient Lung Disease in Premature Infants
Surfactant deficient lung disease (SDLD), previously known as hyaline membrane disease, is a condition that affects premature infants. It occurs due to the underproduction of surfactant and the immaturity of the lungs’ structure. The risk of SDLD decreases with gestation, with 50% of infants born at 26-28 weeks and 25% of infants born at 30-31 weeks being affected. Other risk factors include male sex, diabetic mothers, Caesarean section, and being the second born of premature twins.
The clinical features of SDLD are similar to those of respiratory distress in newborns, including tachypnea, intercostal recession, expiratory grunting, and cyanosis. Chest x-rays typically show a ground-glass appearance with an indistinct heart border.
Prevention during pregnancy involves administering maternal corticosteroids to induce fetal lung maturation. Management of SDLD includes oxygen therapy, assisted ventilation, and exogenous surfactant given via an endotracheal tube. With proper management, the prognosis for infants with SDLD is generally good.
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This question is part of the following fields:
- Paediatrics
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Question 22
Incorrect
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A 65-year-old male with a history of COPD and hypertension complains of pain while swallowing. The patient is currently taking a salbutamol and beclomethasone inhaler, bendroflumethiazide, and amlodipine. What could be the possible reason for this symptom?
Your Answer:
Correct Answer: Oesophageal candidiasis
Explanation:Oesophageal candidiasis, a known complication of inhaled steroid therapy, often presents with pain while swallowing (odynophagia).
Understanding Dysphagia and its Causes
Dysphagia, or difficulty in swallowing, can be caused by various conditions affecting the esophagus, such as oesophageal cancer, oesophagitis, oesophageal candidiasis, achalasia, pharyngeal pouch, systemic sclerosis, and myasthenia gravis. Each condition has its own characteristic features, which can help in identifying the underlying cause of dysphagia. For instance, dysphagia associated with weight loss, anorexia, or vomiting during eating may indicate oesophageal cancer, while dysphagia of both liquids and solids from the start may suggest achalasia.
To determine the cause of dysphagia, patients usually undergo an upper GI endoscopy, which allows doctors to examine the esophagus and detect any abnormalities. Fluoroscopic swallowing studies may also be done to evaluate motility disorders. Additionally, a full blood count and ambulatory oesophageal pH and manometry studies may be required for certain conditions.
It’s important to note that new-onset dysphagia is a red flag symptom that requires urgent endoscopy, regardless of age or other symptoms. Therefore, understanding the different causes of dysphagia and their characteristic features can aid in prompt diagnosis and treatment.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 23
Incorrect
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A 56-year-old man is recuperating after experiencing his initial bout of gout. He continues to experience some persistent discomfort in his big toe. He has no predisposing factors for gout and no signs of gouty tophi upon examination. At what point would it be appropriate to initiate uric acid-lowering treatment?
Your Answer:
Correct Answer: Once his symptoms of acute gout have resolved
Explanation:It is now recommended to offer allopurinol to all patients after their first gout attack, without delay. However, it is advised to wait until the inflammation has subsided before discussing urate-lowering therapy with the patient. If the attacks are too frequent, allopurinol can be considered even before the inflammation has completely settled. These recommendations are provided by the 2017 British Society for Rheumatology and NICE Clinical Knowledge Summaries.
Gout is caused by chronic hyperuricaemia and is managed acutely with NSAIDs or colchicine. Urate-lowering therapy (ULT) is recommended for patients with >= 2 attacks in 12 months, tophi, renal disease, uric acid renal stones, or prophylaxis if on cytotoxics or diuretics. Allopurinol is first-line ULT, with an initial dose of 100 mg od and titrated to aim for a serum uric acid of < 300 µmol/l. Lifestyle modifications include reducing alcohol intake, losing weight if obese, and avoiding high-purine foods. Consideration should be given to stopping precipitating drugs and losartan may be suitable for patients with coexistent hypertension.
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This question is part of the following fields:
- Musculoskeletal
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Question 24
Incorrect
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A 48-year-old woman is contemplating hormone replacement therapy but is concerned about the potential risk of developing breast cancer. She began menstruating at the age of 11 and experienced premature menopause at 45. She has three children, all of whom she breastfed, and has never used oral contraceptives. Apart from hormone replacement therapy, which of the following factors is most strongly linked to an elevated risk of breast cancer?
Your Answer:
Correct Answer: Early menarche
Explanation:Breast cancer risk is increased by HRT, early menarche, late menopause, and COCP, while it is reduced by multiple pregnancy and breastfeeding.
Breast Cancer Risk Factors: Understanding the Predisposing Factors
Breast cancer is a complex disease that can be influenced by various factors. Some of these factors are considered predisposing factors, which means they increase the likelihood of developing breast cancer. One of the most well-known predisposing factors is the presence of BRCA1 and BRCA2 genes, which can increase a person’s lifetime risk of breast and ovarian cancer by 40%. Other predisposing factors include having a first-degree relative with premenopausal breast cancer, nulliparity, having a first pregnancy after the age of 30, early menarche, late menopause, combined hormone replacement therapy, combined oral contraceptive use, past breast cancer, not breastfeeding, ionizing radiation, p53 gene mutations, obesity, and previous surgery for benign disease.
To reduce the risk of developing breast cancer, it is important to understand these predisposing factors and take steps to minimize their impact. For example, women with a family history of breast cancer may choose to undergo genetic testing to determine if they carry the BRCA1 or BRCA2 genes. Women who have not yet had children may consider having their first child before the age of 30, while those who have already had children may choose to breastfeed. Additionally, women who are considering hormone replacement therapy or oral contraceptives should discuss the potential risks and benefits with their healthcare provider. By understanding these predisposing factors and taking proactive steps to reduce their impact, women can help protect themselves against breast cancer.
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This question is part of the following fields:
- Reproductive Medicine
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Question 25
Incorrect
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Sophie, 16, has come to her doctor's office to ask for the combined oral contraceptive pill (COCP). As per the guidelines of the Faculty of Sexual and Reproductive Healthcare (FSRH), what is an absolute contraindication for the COCP?
Your Answer:
Correct Answer: Migraine with aura
Explanation:The FSRH uses a scale of 1 to 4 to categorize risk factors for contraceptive methods. A rating of 1 indicates no restrictions on use, while a rating of 4 indicates a condition that poses an unacceptable risk if the contraceptive method is used. Migraine with aura is the only absolute contraindication among the answer options. Ratings of 2 and 3 indicate that the advantages and risks of the contraceptive method should be carefully considered and evaluated by a clinical expert.
The decision to prescribe the combined oral contraceptive pill is now based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential contraindications and cautions on a four-point scale. UKMEC 1 indicates no restrictions for use, while UKMEC 2 suggests that the benefits outweigh the risks. UKMEC 3 indicates that the disadvantages may outweigh the advantages, and UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, a family history of thromboembolic disease in first-degree relatives under 45 years old, and current gallbladder disease. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. In 2016, breast feeding between 6 weeks and 6 months postpartum was changed from UKMEC 3 to UKMEC 2.
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This question is part of the following fields:
- Reproductive Medicine
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Question 26
Incorrect
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A 10-year-old girl presents to the general practice clinic with a sore throat and fever that have been present for 3 days. What clinical sign would indicate that the patient may have a bacterial throat infection and could benefit from antibiotics? Choose ONE positive indicator from the options provided.
Your Answer:
Correct Answer: Tender cervical lymphadenopathy
Explanation:Assessing the Need for Antibiotics in Acute Sore Throat: Understanding the Centor Criteria and Other Indicators
When a patient presents with a sore throat, it is important to determine whether antibiotics are necessary for treatment. The Centor criteria and FeverPAIN score are two approved scoring systems used to predict the likelihood of a bacterial cause for the sore throat.
Tender cervical lymphadenopathy is one of the parameters in the Centor criteria and scores 1 point. Other parameters include age, exudate on tonsils, absence of cough, and fever. A score of 3 or more suggests a high probability of bacterial infection and the need for antibiotic treatment.
Cough present is not an indicator for antibiotic therapy, but its absence is one of the factors in the Centor criteria. Sore throat alone is also not an indicator for antibiotics, but a score of 4-5 on the FeverPAIN score or a Centor criteria score above 3 may indicate the need for antibiotics.
Vomiting and nasal congestion are not included in either scoring system for determining the need for antibiotics. However, vomiting may be a sign of severe illness and dehydration, and any patient presenting with vomiting and a sore throat should be assessed for signs of sepsis and dehydration. Nasal congestion may suggest a viral cause for the sore throat, but alternative causes should still be assessed.
In summary, understanding the Centor criteria and other indicators can help healthcare providers determine whether antibiotics are necessary for treating acute sore throat.
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This question is part of the following fields:
- ENT
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Question 27
Incorrect
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A 50-year-old man presents to the emergency department with right upper quadrant pain, fatigue, and anorexia that has been going on for a few weeks and is getting gradually worse. His past medical history includes heavy alcohol intake, gastroesophageal reflux disease (GORD) and a hiatus hernia. He only takes omeprazole and has no known allergies.
On examination, he looks jaundiced.
A liver function test is done which shows:
Bilirubin 50 µmol/L (3 - 17)
ALT 150 u/L (3 - 40)
AST 300 u/L (8 - 33)
Albumin 35 g/L (35 - 50)
What is the most likely diagnosis?Your Answer:
Correct Answer: Alcoholic hepatitis
Explanation:Understanding Alcoholic Liver Disease and its Management
Alcoholic liver disease is a range of conditions that includes alcoholic fatty liver disease, alcoholic hepatitis, and cirrhosis. One of the characteristic findings in this disease is an elevated gamma-GT level. Additionally, a ratio of AST:ALT greater than 2, and especially greater than 3, strongly suggests acute alcoholic hepatitis.
When it comes to managing alcoholic hepatitis, glucocorticoids such as prednisolone are often used during acute episodes. The Maddrey’s discriminant function (DF) is used to determine who would benefit from glucocorticoid therapy. This function is calculated using prothrombin time and bilirubin concentration. Pentoxyphylline is also sometimes used as a treatment option.
A study called STOPAH compared the two common treatments for alcoholic hepatitis, pentoxyphylline and prednisolone. The study showed that prednisolone improved survival at 28 days, while pentoxyphylline did not improve outcomes. Understanding the different types of alcoholic liver disease and their management options is crucial for healthcare professionals in providing effective care for patients.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 28
Incorrect
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A 56-year-old male with no previous medical history presents with a sprained ankle and is incidentally found to be in atrial fibrillation. He denies any symptoms of palpitations or shortness of breath. Despite discussing treatment options, he declines cardioversion. Cardiovascular examination is otherwise normal, with a blood pressure of 118/76 mmHg. As per the most recent NICE guidelines, what is the recommended treatment for this patient if he remains in chronic atrial fibrillation?
Your Answer:
Correct Answer: No treatment
Explanation:NICE recommends using the CHA2DS2-VASc score to determine the need for anticoagulation in patients with any history of AF. The ORBIT scoring system should be used to assess bleeding risk, but anticoagulation should not be withheld solely on the grounds of age or risk of falls. DOACs are now recommended as the first-line anticoagulant for patients with AF, with warfarin used second-line if a DOAC is contraindicated or not tolerated. Aspirin is not recommended for reducing stroke risk in patients with AF.
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This question is part of the following fields:
- Cardiovascular
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Question 29
Incorrect
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A 38-year-old, overweight woman presents to the clinic with complaints of occasional abdominal pain for the past few months. She experienced a constant pain episode two days ago that started in the epigastric region and then moved to the right upper quadrant, accompanied by vomiting.
What is the most probable diagnosis?Your Answer:
Correct Answer: Biliary colic
Explanation:Biliary Colic and Other Abdominal Conditions: A Brief Overview
Biliary colic, diverticulitis, chronic pancreatitis, ulcerative colitis, and coeliac disease are all conditions that can cause abdominal pain and discomfort. Understanding the risk factors, symptoms, and diagnostic criteria for each can help healthcare professionals make accurate diagnoses and provide appropriate treatment. Biliary colic, for example, is characterized by severe, constant pain in the epigastrium or right upper quadrant, often accompanied by nausea and vomiting. Diverticulitis, on the other hand, typically presents with left lower quadrant pain and changes in bowel habits. Chronic pancreatitis is associated with intermittent attacks of severe pain in the mid-abdomen or left upper abdomen, while ulcerative colitis is characterized by rectal bleeding, frequent stools, and mucus discharge. Coeliac disease, the most common food intolerance worldwide, can present with a range of gastrointestinal and extraintestinal symptoms. By understanding the unique features of each condition, healthcare professionals can provide effective care and improve patient outcomes.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 30
Incorrect
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A 25-year-old woman visits her doctor complaining of diarrhoea and vomiting after spending Christmas with her family. Her sister has just informed her that she too is experiencing the same symptoms. The doctor suspects norovirus. What is the best way to prevent the spread of this virus?
Your Answer:
Correct Answer: Wash hands with soap and water
Explanation:Handwashing is more effective than alcohol gels in preventing the spread of norovirus.
Norovirus, also known as the winter vomiting bug, is a common cause of gastroenteritis in the UK. It is a type of RNA virus that can cause symptoms such as nausea, vomiting, and diarrhea, as well as headaches, low-grade fevers, and myalgia. The virus is highly contagious and can be transmitted through the fecal-oral route, as well as through aerosolized particles from vomit or contaminated bodily fluids. Good hand hygiene and isolation of infected individuals are important measures to limit transmission. Diagnosis is typically made through clinical history and stool culture viral PCR. While the infection is self-limiting in most cases, dehydration and electrolyte imbalances can occur and require supportive management.
Norovirus is a genus of non-encapsulated RNA virus species that can cause gastroenteritis. The CDC estimates that 1 in 5 cases of infectious gastroenteritis are caused by norovirus, with 685 million cases per year worldwide. Symptoms typically develop within 15-50 hours of infection and can include vomiting, diarrhea, headaches, low-grade fevers, and myalgia. The virus is highly contagious and can be transmitted through direct physical contact, contact with contaminated food, or through aerosolized particles from vomit or contaminated bodily fluids. Good hand hygiene and isolation of infected individuals are important measures to limit transmission. Diagnosis is typically made through clinical history and stool culture viral PCR. While the infection is self-limiting in most cases, dehydration and electrolyte imbalances can occur and require supportive management.
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This question is part of the following fields:
- Infectious Diseases
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Question 31
Incorrect
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A 56-year-old woman visits the emergency GP service with a red and painful eye that has been bothering her for a few hours. Upon examination, the doctor notices a dilated pupil and a significant decrease in vision.
What is the most probable diagnosis?Your Answer:
Correct Answer: Acute angle-closure glaucoma
Explanation:Common Eye Conditions: Symptoms and Characteristics
Acute angle-closure glaucoma, Conjunctivitis, Foreign body, Optic neuritis, and Uveitis are some of the most common eye conditions that individuals may experience. Each condition has its own set of symptoms and characteristics that can help in identifying the underlying cause.
Acute angle-closure glaucoma is characterized by sudden onset symptoms such as blurred vision, seeing haloes around lights, red eye, pain, headache, and nausea and vomiting. It is an ophthalmic emergency that requires urgent specialist assessment to prevent blindness.
Conjunctivitis is one of the most common non-traumatic eye complaints resulting in presentation to A&E. It is characterized by redness, profuse discharge, irritation, and rarely photophobia. Most causes are benign, with a self-limited process.
Foreign body in the cornea is characterized by pain, foreign body sensation, photophobia, tearing, and red eye. A visible foreign body may be present on physical examination.
Optic neuritis is characterized by rapidly developing impairment of vision in one eye, dyschromatopsia, retro-orbital or ocular pain, Uhthoff’s phenomenon, and Pulfrich’s phenomenon. It often occurs in association with multiple sclerosis (MS) and neuromyelitis optica (NMO).
Uveitis is characterized by inflammation of the uveal tract or adjacent ocular structures. It is often autoimmune in nature, and the aetiology remains elusive in most cases. Symptoms vary depending on the location of the inflammation, with acute anterior uveitis being the most common form of intraocular inflammation, causing a painful red eye.
Understanding the symptoms and characteristics of these common eye conditions can help in identifying the underlying cause and seeking appropriate treatment.
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This question is part of the following fields:
- Ophthalmology
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Question 32
Incorrect
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A 72-year-old diabetic man presents to his General Practitioner complaining of poor vision, particularly while driving at night. He reports that his vision has been progressively worsening and he struggles with glare from oncoming vehicles. He also finds watching TV difficult and struggles to recognise his neighbour waving at him from across the street. He has had to have his glasses prescription changed three times in the past 18 months.
What is the most likely diagnosis?Your Answer:
Correct Answer: Cataracts
Explanation:Common Eye Conditions and Their Symptoms
Cataracts: Gradual, painless reduced visual acuity, blurred vision, difficulty seeing at night-time, sensitivity to light due to glare and halos around light, inability to watch TV or recognise faces. Risk factors include increasing age, steroid use, alcohol excess, myotonic dystrophy, and diabetes. Treatment is with surgical replacement of the lens.
Open Angle Glaucoma: Increased intraocular pressure resulting in visual field defects, loss of peripheral vision, seeing halos around lights, and tunnel vision. Patients may report bumping into things or not seeing cars in their periphery.
Acute Closed Angle Glaucoma: Ophthalmological emergency presenting as a painful red eye, vomiting, headache, and reduced visual acuity. On examination, patients have a tender, hard eye with a semi-dilated, fixed pupil.
Presbyopia: Age-related condition causing trouble focusing on close-up vision, often requiring reading glasses.
Retinal Detachment: New-onset floaters and flashes, sudden-onset, painless visual field loss that may progress over hours to days, and a dark curtain or shadow over the field of vision in one eye only.
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This question is part of the following fields:
- Ophthalmology
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Question 33
Incorrect
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A 26-year-old woman in her first pregnancy visits her GP at 12 weeks gestation complaining of dysuria. Apart from this, she is healthy and her pregnancy has been uneventful so far. Upon urine dip, leucocytes, nitrates, blood, and protein are detected. What is the most suitable course of treatment?
Your Answer:
Correct Answer: Nitrofurantoin
Explanation:Although UTI in pregnancy may not show any symptoms, it still needs to be treated promptly to prevent the development of pyelonephritis. The common medications used to treat UTIs are nitrofurantoin and trimethoprim. Nitrofurantoin can be used during pregnancy, but it should be avoided at term as it can cause neonatal haemolysis. Trimethoprim should be avoided in the first trimester of pregnancy. Penicillins and cephalosporins are safe to use during pregnancy, but sulfonamides (such as sulfasalazine) and quinolones (such as ciprofloxacin) should be avoided.
Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is teratogenic in the first trimester. Asymptomatic bacteriuria in pregnant women should also be treated to prevent progression to acute pyelonephritis. Men with UTIs should be offered a seven-day course of trimethoprim or nitrofurantoin unless prostatitis is suspected. A urine culture should be sent before antibiotics are started. Catheterised patients should not be treated for asymptomatic bacteria, but if symptomatic, a seven-day course of antibiotics should be given. Acute pyelonephritis requires hospital admission and treatment with a broad-spectrum cephalosporin or quinolone for 10-14 days. Referral to urology is not routinely required for men who have had one uncomplicated lower UTI.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 34
Incorrect
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A 28-year-old woman complains of lumpy breasts. She notices the lumps are more prominent before her period. There is no family history of breast cancer.
Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Diffuse cystic mastopathy
Explanation:Breast Masses: Differential Diagnosis and Clinical Features
Breast masses are a common concern for women, and it is important to differentiate between benign and malignant causes. Here, we discuss the clinical features and differential diagnosis of various breast masses.
Diffuse cystic mastopathy is a benign condition that affects a significant proportion of women. It is characterized by the formation of cysts in the breast lobules due to hormonal changes in the menstrual cycle. The lumps are smooth, mobile, and tend to peak in size before each period. Diagnosis is primarily based on clinical examination, but a biopsy may be needed to confirm the diagnosis.
Fat necrosis is another benign condition that can occur due to direct trauma or surgery. It is characterized by the formation of firm, round, and painless masses in the breast. The skin around the lump may be red or bruised, and a biopsy may be needed to differentiate it from breast cancer.
Breast abscesses are characterized by local inflammation, pain, and fever. They may be associated with previous breast infections and may require drainage. However, there is no evidence of an infectious process in this patient.
Breast cancer is a concern in any patient with a breast mass, but early breast cancer is often asymptomatic. Physical findings that may indicate the possible presence of breast cancer include changes in breast size or shape, skin dimpling or changes, nipple abnormalities, and axillary lumps. However, none of these symptoms are present in this patient.
Fibroadenoma is the most common cause of breast mass in women under 35 years of age. It is characterized by a singular, firm, rubbery, smooth, and mobile mass. However, this patient reports multiple lumps, making a diagnosis of fibroadenoma less likely.
In conclusion, the cyclic nature of this patient’s breast masses makes diffuse cystic mastopathy the most likely diagnosis. However, a biopsy may be needed to confirm the diagnosis and rule out other causes.
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This question is part of the following fields:
- Reproductive Medicine
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Question 35
Incorrect
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A 35-year-old woman with a dichorionic twin pregnancy is concerned about the possibility of her twins having Down's syndrome. What is the most suitable investigation to perform in this case?
Your Answer:
Correct Answer: Nuchal translucency ultrasonography on each twin
Explanation:There are several methods for screening and diagnosing Down’s syndrome in pregnancy. The nuchal translucency scan, which measures fluid in the fetal neck, is best done between 11 and 14 weeks and can detect an increased risk of genetic syndromes. The triple screen, which measures levels of certain hormones in the mother’s blood, is done in the second trimester and can detect up to 69% of cases in singleton pregnancies, but may have a higher false positive or false negative in twin pregnancies. Amniocentesis and chorionic villous sampling are invasive diagnostic tests that can detect chromosomal disorders with high accuracy, but carry a small risk of pregnancy loss. The routine anomaly scan should not be used for Down’s syndrome screening. Cell-free fetal DNA screening is a newer method that can detect about 99% of Down’s syndrome pregnancies, but is currently only offered by private clinics at a high cost. A positive screening result suggests an increased risk for Down’s syndrome, and definitive testing with chorionic villous sampling or amniocentesis is indicated.
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This question is part of the following fields:
- Reproductive Medicine
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Question 36
Incorrect
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Which one of the following regarding the FAST questionnaire for alcohol misuse is correct?
Your Answer:
Correct Answer: May be stopped after first question depending on the answer
Explanation:Alcohol Problem Drinking: Detection and Assessment
Alcohol problem drinking can have serious consequences on an individual’s health and well-being. Therefore, it is important to detect and assess problem drinking early on. Screening tools such as AUDIT, FAST, and CAGE can be used to identify individuals who may have hazardous or harmful alcohol consumption or alcohol dependence.
AUDIT is a 10-item questionnaire that takes about 2-3 minutes to complete. It has been shown to be superior to CAGE and biochemical markers for predicting alcohol problems. A score of 8 or more in men, and 7 or more in women, indicates a strong likelihood of hazardous or harmful alcohol consumption. A score of 15 or more in men, and 13 or more in women, is likely to indicate alcohol dependence. AUDIT-C is an abbreviated form consisting of 3 questions.
FAST is a 4-item questionnaire with a minimum score of 0 and a maximum score of 16. The score for hazardous drinking is 3 or more. Over 50% of people will be classified using just the first question, which asks how often the individual has had eight or more drinks on one occasion (or six or more drinks for women).
CAGE is a well-known screening test, but recent research has questioned its value. Two or more positive answers are generally considered a ‘positive’ result. The questions ask if the individual has ever felt the need to cut down on their drinking, if people have annoyed them by criticizing their drinking, if they have ever felt guilty about their drinking, and if they have ever had a drink in the morning to get rid of a hangover.
To diagnose alcohol dependence, the ICD-10 definition requires three or more of the following: compulsion to drink, difficulties controlling alcohol consumption, physiological withdrawal, tolerance to alcohol, neglect of alternative activities to drinking, and persistent use of alcohol despite evidence of harm.
Overall, using screening tools and diagnostic criteria can help healthcare professionals identify individuals with alcohol problem drinking and provide appropriate interventions and support.
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This question is part of the following fields:
- Psychiatry
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Question 37
Incorrect
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A 28-year-old woman presents with a recurring, intensely itchy rash on the palms of her hands. She reports that these rashes tend to occur every summer. Despite trying over-the-counter emollients and antihistamines, there has been only marginal improvement. The patient is otherwise healthy with no other medical conditions and does not smoke.
During examination, bilateral vesicles are observed on the palms and sides of the fingers. The palms appear dry with areas of skin peeling, while the rest of her body is unaffected.
What is the most probable diagnosis?Your Answer:
Correct Answer: Pompholyx eczema
Explanation:Palmoplantar pustulosis is often accompanied by psoriasis on other areas of the body and is strongly linked to smoking. Unlike pompholyx eczema, the connection to high temperatures and humidity is not as significant. Scabies, which is caused by the parasite Sarcoptes scabiei, results in severe itching of the hands and web spaces but is typically not a recurring issue. Symptoms include linear burrows and erythematous papules rather than vesicles.
Understanding Pompholyx Eczema
Pompholyx eczema, also known as dyshidrotic eczema, is a type of skin condition that affects both the hands and feet. It is often triggered by high temperatures and humidity, such as sweating. The main symptom of pompholyx eczema is the appearance of small blisters on the palms and soles, which can be intensely itchy and sometimes accompanied by a burning sensation. Once the blisters burst, the skin may become dry and crack.
To manage pompholyx eczema, cool compresses and emollients can be used to soothe the affected areas. Topical steroids may also be prescribed to reduce inflammation and itching. It is important to avoid further irritation by wearing gloves or protective footwear and avoiding exposure to irritants. With proper management, the symptoms of pompholyx eczema can be controlled and minimized.
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This question is part of the following fields:
- Dermatology
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Question 38
Incorrect
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Which of the following is not an absolute contraindication to using combined oral contraceptive pills for women?
Your Answer:
Correct Answer: Breast feeding a 10-week-old baby
Explanation:Breastfeeding is classified as UKMEC category 4 if done for less than 6 weeks after giving birth, but it is categorized as UKMEC category 2 if done after this period.
The decision to prescribe the combined oral contraceptive pill is now based on the UK Medical Eligibility Criteria (UKMEC), which categorizes potential contraindications and cautions on a four-point scale. UKMEC 1 indicates no restrictions for use, while UKMEC 2 suggests that the benefits outweigh the risks. UKMEC 3 indicates that the disadvantages may outweigh the advantages, and UKMEC 4 represents an unacceptable health risk. Examples of UKMEC 3 conditions include controlled hypertension, a family history of thromboembolic disease in first-degree relatives under 45 years old, and current gallbladder disease. Examples of UKMEC 4 conditions include a history of thromboembolic disease or thrombogenic mutation, breast cancer, and uncontrolled hypertension. Diabetes mellitus diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity. In 2016, breast feeding between 6 weeks and 6 months postpartum was changed from UKMEC 3 to UKMEC 2.
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This question is part of the following fields:
- Reproductive Medicine
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Question 39
Incorrect
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A 28-year-old professional basketball player presents with complaints of feeling lightheaded during exercise. Upon physical examination, a laterally displaced apical impulse is noted. Auscultation reveals a 2/6 mid-systolic murmur in the mitral area that increases upon sudden standing. The ECG shows LVH and Q waves in V1–4 leads.
What is the most probable diagnosis?Your Answer:
Correct Answer: Hypertrophic cardiomyopathy
Explanation:Differential Diagnosis for a Patient with Dyspnoea and a Murmur: Hypertrophic Cardiomyopathy
Hypertrophic cardiomyopathy is a condition that can lead to sudden death in young athletes and is characterized by dyspnoea, LVH, and a loud S4. The systolic murmur associated with hypertrophic cardiomyopathy does not radiate to the carotids and can be differentiated from aortic stenosis, which causes a crescendo-decrescendo murmur that does radiate to the carotids. Young-onset hypertension is unlikely to cause a murmur, and acute myocardial infarction would show ST elevation or depression on ECG, but not LVH. Atrial septal defect is usually picked up in newborn checks and presents with a brief murmur in early systole and early diastole, while hypertrophic cardiomyopathy presents with a double or triple apical impulse and a characteristic jerky carotid pulse. It is important to recognize the symptoms and signs of hypertrophic cardiomyopathy to prevent sudden death in young athletes.
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This question is part of the following fields:
- Cardiovascular
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Question 40
Incorrect
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A 49-year-old man comes to the emergency department complaining of dizziness and shortness of breath on exertion for the past 3 days. He reports experiencing palpitations during this time but denies any chest pain or cough. The patient has a history of hypertension and angina, for which he takes amlodipine and GTN spray, respectively. Upon examination, he appears alert and oriented, but his vital signs reveal a heart rate of 170 BPM, respiratory rate of 25 breaths/min, and blood pressure of 72/50 mmHg. An ECG shows a narrow complex irregular tachycardia without P waves. What is the most crucial next step in management?
Your Answer:
Correct Answer: Electrical cardioversion
Explanation:In the case of an acute presentation of atrial fibrillation with signs of haemodynamic instability such as hypotension or heart failure, the correct treatment is electrical cardioversion. This is because the patient is at risk of going into cardiac arrest and needs to be returned to normal sinus rhythm immediately to prevent end organ damage. Giving a bolus of IV saline is not recommended as it will not push more blood into the ventricles and could even be harmful. Starting high dose aspirin or bisoprolol is not appropriate in this situation. Digoxin is only considered as a second line treatment for stable patients, so pharmacologic therapies are not considered until after cardioversion has been attempted and blood pressure returns to normal.
Atrial fibrillation (AF) is a condition that requires careful management to prevent complications. The latest guidelines from NICE recommend that patients presenting with AF should be assessed for haemodynamic instability, and if present, electrically cardioverted. For haemodynamically stable patients, the management depends on how acute the AF is. If the AF has been present for less than 48 hours, rate or rhythm control may be considered. However, if it has been present for 48 hours or more, or the onset is uncertain, rate control is recommended. If long-term rhythm control is being considered, cardioversion should be delayed until the patient has been maintained on therapeutic anticoagulation for at least 3 weeks.
Rate control is the first-line treatment strategy for AF, except in certain cases. Medications such as beta-blockers, calcium channel blockers, and digoxin can be used to control the heart rate. However, digoxin is no longer considered first-line as it is less effective at controlling the heart rate during exercise. Rhythm control agents such as beta-blockers, dronedarone, and amiodarone can be used to maintain sinus rhythm in patients with a history of AF. Catheter ablation is recommended for those who have not responded to or wish to avoid antiarrhythmic medication.
The aim of catheter ablation is to ablate the faulty electrical pathways that are causing AF. The procedure is performed percutaneously, typically via the groin, and can use radiofrequency or cryotherapy to ablate the tissue. Anticoagulation should be used 4 weeks before and during the procedure. It is important to note that catheter ablation controls the rhythm but does not reduce the stroke risk, so patients still require anticoagulation as per their CHA2DS2-VASc score. Complications of catheter ablation can include cardiac tamponade, stroke, and pulmonary vein stenosis. The success rate of the procedure is around 50% for early recurrence within 3 months, and around 55% of patients who’ve had a single procedure remain in sinus rhythm after 3 years. Of patients who’ve undergone multiple procedures, around 80% are in sinus rhythm.
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This question is part of the following fields:
- Cardiovascular
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Question 41
Incorrect
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Which of the following complications is most commonly associated with PUVA therapy in elderly patients?
Your Answer:
Correct Answer: Squamous cell cancer
Explanation:Squamous cell skin cancer is the most notable adverse effect of PUVA therapy in treating psoriasis.
NICE recommends a step-wise approach for chronic plaque psoriasis, starting with regular emollients and then using a potent corticosteroid and vitamin D analogue separately, followed by a vitamin D analogue twice daily, and then a potent corticosteroid or coal tar preparation if there is no improvement. Phototherapy, systemic therapy, and topical treatments are also options for management. Topical steroids should be used cautiously and vitamin D analogues may be used long-term. Dithranol and coal tar have adverse effects but can be effective.
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This question is part of the following fields:
- Dermatology
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Question 42
Incorrect
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A 25-year-old woman who is 14 weeks pregnant complains of worsening acne that is causing her distress. Despite using topical benzyl peroxide, she has noticed limited improvement. During examination, non-inflammatory lesions and pustules are observed on her face. What would be the most suitable next course of action?
Your Answer:
Correct Answer: Oral erythromycin
Explanation:If treatment for acne is required during pregnancy, oral erythromycin is a suitable option, as the other medications are not recommended.
Acne vulgaris is a common skin condition that typically affects adolescents, with the face, neck, and upper trunk being the most commonly affected areas. It is characterized by the obstruction of hair follicles with keratin plugs, leading to the formation of comedones, inflammation, and pustules. The severity of acne can be classified as mild, moderate, or severe, depending on the presence and extent of inflammatory lesions, papules, and pustules.
The management of acne vulgaris typically involves a step-up approach, starting with single topical therapy such as topical retinoids or benzoyl peroxide. If this is not effective, topical combination therapy may be used, which includes a topical antibiotic, benzoyl peroxide, and topical retinoid. Oral antibiotics such as tetracyclines may also be prescribed, but they should be avoided in pregnant or breastfeeding women and children under 12 years of age. Erythromycin may be used in pregnancy, while minocycline is now considered less appropriate due to the possibility of irreversible pigmentation. Oral antibiotics should be used for a maximum of three months and always co-prescribed with a topical retinoid or benzoyl peroxide to reduce the risk of antibiotic resistance.
Combined oral contraceptives (COCP) are an alternative to oral antibiotics in women, and Dianette (co-cyrindiol) may be used as it has anti-androgen properties. However, it has an increased risk of venous thromboembolism compared to other COCPs, so it should generally be used second-line and for only three months. Oral isotretinoin is a potent medication that should only be used under specialist supervision, and it is contraindicated in pregnancy. Finally, there is no evidence to support dietary modification in the management of acne vulgaris.
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This question is part of the following fields:
- Dermatology
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Question 43
Incorrect
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A 29-year-old pregnant woman presents to the GP clinic for a review. She is currently 8 weeks pregnant and has undergone urine microscopy, culture, and sensitivity tests. Despite having no fever or dysuria, the following results were obtained:
- Red blood cells < 106/L
- White blood cells 100 x 106/L
- Culture Escherichia coli > 106/L colonies
- Sensitivity trimethoprim sensitive, cefalexin sensitive, nitrofurantoin resistant
What would be the most appropriate course of action for management?Your Answer:
Correct Answer: Cefalexin for 7 days
Explanation:Pregnant women with asymptomatic bacteriuria should receive immediate antibiotic treatment. In this case, cefalexin for 7 days is the appropriate choice based on the sensitivity results of the culture. Amoxicillin is another option, but without sensitivity data, it cannot be recommended. Nitrofurantoin should be avoided as the bacteria are resistant, and a 5-day course is insufficient. No treatment is not an option for pregnant women as it increases the risk of pyelonephritis. Trimethoprim should also be avoided due to its potential impact on fetal development as a folate antagonist.
Urinary tract infections (UTIs) are common in adults and can affect different parts of the urinary tract. The management of UTIs depends on various factors such as the patient’s age, gender, and pregnancy status. For non-pregnant women, local antibiotic guidelines should be followed if available. Trimethoprim or nitrofurantoin for three days are recommended by NICE Clinical Knowledge Summaries. However, if the patient is aged over 65 years or has visible or non-visible haematuria, a urine culture should be sent. Pregnant women with UTIs should be treated with nitrofurantoin, amoxicillin, or cefalexin for seven days. Trimethoprim should be avoided during pregnancy as it is teratogenic in the first trimester. Asymptomatic bacteriuria in pregnant women should also be treated to prevent progression to acute pyelonephritis. Men with UTIs should be offered a seven-day course of trimethoprim or nitrofurantoin unless prostatitis is suspected. A urine culture should be sent before antibiotics are started. Catheterised patients should not be treated for asymptomatic bacteria, but if symptomatic, a seven-day course of antibiotics should be given. Acute pyelonephritis requires hospital admission and treatment with a broad-spectrum cephalosporin or quinolone for 10-14 days. Referral to urology is not routinely required for men who have had one uncomplicated lower UTI.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 44
Incorrect
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Which of the following causes of diarrhea has the briefest incubation period?
Your Answer:
Correct Answer: Bacillus cereus
Explanation:Gastroenteritis can occur either at home or while traveling, known as travelers’ diarrhea. This condition is characterized by at least three loose to watery stools in 24 hours, accompanied by abdominal cramps, fever, nausea, vomiting, or blood in the stool. The most common cause of travelers’ diarrhea is Escherichia coli. Acute food poisoning is another pattern of illness that results in sudden onset of nausea, vomiting, and diarrhea after ingesting a toxin. Staphylococcus aureus, Bacillus cereus, or Clostridium perfringens are typically responsible for acute food poisoning.
There are several types of infections that can cause gastroenteritis, each with its own typical presentation. Escherichia coli is common among travelers and causes watery stools, abdominal cramps, and nausea. Giardiasis results in prolonged, non-bloody diarrhea, while cholera causes profuse, watery diarrhea and severe dehydration leading to weight loss. Shigella causes bloody diarrhea, vomiting, and abdominal pain, while Staphylococcus aureus results in severe vomiting with a short incubation period. Campylobacter typically starts with a flu-like prodrome and progresses to crampy abdominal pains, fever, and diarrhea, which may be bloody and mimic appendicitis. Bacillus cereus can cause two types of illness, vomiting within six hours, typically due to rice, or diarrheal illness occurring after six hours. Amoebiasis has a gradual onset of bloody diarrhea, abdominal pain, and tenderness that may last for several weeks.
The incubation period for gastroenteritis varies depending on the type of infection. Staphylococcus aureus and Bacillus cereus have an incubation period of 1-6 hours, while Salmonella and Escherichia coli have an incubation period of 12-48 hours. Shigella and Campylobacter have an incubation period of 48-72 hours, while Giardiasis and Amoebiasis have an incubation period of more than seven days.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 45
Incorrect
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At the 4-month check, you observe bilateral hydroceles in a male infant. The swelling is limited to the scrotum and the testis can be felt in the scrotal sac. The infant is otherwise healthy and thriving. The mother expresses concern about the potential impact of the swelling on her son's fertility.
What is the best course of action for managing this situation?Your Answer:
Correct Answer: Reassure mum that hydroceles are common in infants and often self resolve
Explanation:It is common for newborn males to have communicating hydroceles, which usually resolve on their own. This is due to the processus vaginalis remaining open. Parents should be reassured that the hydroceles typically disappear within a few months. However, if the hydrocele persists beyond one year, it is recommended to refer the child to a urologist for possible repair. Ultrasound is not necessary to confirm the diagnosis. It is important to note that hydroceles do not impact fertility, but undescended testes can affect fertility if not treated.
Common Scrotal Problems and Their Features
Epididymal cysts, hydroceles, and varicoceles are the most common scrotal problems seen in primary care. Epididymal cysts are usually found posterior to the testicle and are separate from the body of the testicle. They may be associated with conditions such as polycystic kidney disease, cystic fibrosis, and von Hippel-Lindau syndrome. Diagnosis is confirmed by ultrasound, and management is usually supportive, although surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts.
Hydroceles, on the other hand, describe the accumulation of fluid within the tunica vaginalis. They may be communicating or non-communicating, and may develop secondary to conditions such as epididymo-orchitis, testicular torsion, or testicular tumors. Hydroceles are usually soft, non-tender swellings of the hemi-scrotum that transilluminate with a pen torch. Diagnosis may be clinical, but ultrasound is required if there is any doubt about the diagnosis or if the underlying testis cannot be palpated. Management depends on the severity of the presentation, with infantile hydroceles generally repaired if they do not resolve spontaneously by the age of 1-2 years.
Varicoceles, on the other hand, are abnormal enlargements of the testicular veins that are usually asymptomatic but may be associated with subfertility. They are much more common on the left side and are classically described as a bag of worms. Diagnosis is confirmed by ultrasound with Doppler studies, and management is usually conservative, although surgery may be required if the patient is troubled by pain. There is ongoing debate regarding the effectiveness of surgery to treat infertility.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 46
Incorrect
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A 55-year-old woman presents to your clinic with complaints of hot flashes that are disrupting her sleep. She is experiencing irregular and lighter periods. She has not undergone a hysterectomy and is interested in hormone replacement therapy (HRT). What would be the most suitable HRT regimen for her?
Your Answer:
Correct Answer: Systemic combined cyclical HRT
Explanation:What are the main factors to consider when determining the appropriate HRT regime? How would you classify a patient who is still having periods? What is the recommended HRT regime for this patient?
To determine the correct HRT regime, it is important to consider whether the patient has a uterus, whether they are perimenopausal or menopausal, and whether a systemic or local effect is needed. A patient who is still having periods is considered perimenopausal, as menopause is defined as 12 months after the last menstrual period. For this patient, the recommended HRT regime would be combined oestrogen and progestogen cyclical HRT. Cyclical HRT is preferred in perimenopausal women as it produces predictable withdrawal bleeding, while continuous regimens can cause unpredictable bleeding. Systemic oestrogen-only HRT is not appropriate for a woman with a uterus as it increases the risk of endometrial cancer. Oestrogen cream or pessary would only provide a local effect and would be useful for urogenital symptoms such as vaginal dryness or dyspareunia.
Hormone replacement therapy (HRT) involves a small dose of oestrogen and progestogen to alleviate menopausal symptoms. The indications for HRT have changed due to the long-term risks, and it is primarily used for vasomotor symptoms and preventing osteoporosis in younger women. HRT consists of natural oestrogens and synthetic progestogens, and can be taken orally or transdermally. Transdermal is preferred for women at risk of venous thromboembolism.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 47
Incorrect
-
A 10-year-old boy who plays rugby complains of pain to his knee; he says his kneecap feels as though it is out of place at these times.
Which of the following is the likely diagnosis?
Your Answer:
Correct Answer: Patellar subluxation
Explanation:Common Causes of Knee Pain in Adolescents and Young Adults
Knee pain is a common complaint among adolescents and young adults, and can be caused by a variety of conditions. Here are some of the most common causes:
1. Patellar subluxation: This is a temporary but recurring lateral subluxation of the patella, which can cause the knee to give way or feel like it’s moving out of place. Conservative treatment with physiotherapy and knee braces is usually effective, but surgery may be necessary in some cases.
2. Chondromalacia patellae: This condition is caused by abnormal softening of the cartilage on the underside of the patella, and is a common cause of chronic knee pain in teenagers and young adults. Physiotherapy to alter patella-femoral alignment is the main treatment, along with analgesics and ice packs.
3. Osgood-Schlatter disease: This is a common cause of knee pain in young adolescents, particularly sporty boys. It is caused by overuse of quadriceps, and is characterized by pain inferior to the patella. Treatment is with simple analgesics and ice packs.
4. Osteochondritis dissecans: This condition is caused by separation of subchondral bone articular cartilage from the joint surface, and affects the knee in 75% of cases. It tends to present in teenagers and young adults, with vague and achy joint pain that is made worse by activity. Treatment depends on the severity of the condition, and may include surgery.
Overall, knee pain in adolescents and young adults can be caused by a variety of conditions, and treatment depends on the underlying cause and severity of the condition.
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This question is part of the following fields:
- Musculoskeletal
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Question 48
Incorrect
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A 42-year-old woman presents to the Emergency Department with dizziness and headache. On examination, her blood pressure is found to be 190/120 mmHg. She said that she had been diagnosed with hypertension on two previous occasions but discontinued drugs both times. She is a computer analyst and drinks 3–5 units of alcohol every day. Blood tests reveal:
Investigation Result Normal Value
Potassium (K+) 3.8 mmol/l 3.5–5.0 mmol/l
Corrected calcium (Ca2+) 3.03 mmol/l 2.20-2.60 mmol/l
Sodium (Na+) 140 mmol/l 135–145 mmol/l
Albumin 38 g/l 35–55 g/l
Magnesium (Mg2+) 0.60 mmol/l 0.75–1.00 mmol/l
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Sipple syndrome or MEN 2a
Explanation:Possible Causes of Hypertension, Hypercalcemia, and Low Magnesium in a Patient
One possible diagnosis for a patient with severe hypertension, hypercalcemia, and low magnesium is MEN 2a, also known as Sipple syndrome. This is because these symptoms can be explained by the presence of a phaeochromocytoma and hyperparathyroidism, which are both associated with MEN 2a.
Conn syndrome, which is characterized by asymptomatic hypertension and hypokalemia, is not the most likely diagnosis in this case since the patient is normokalemic and has high calcium levels. Phaeochromocytoma could explain the hypertension, but not the hypercalcemia and low magnesium.
MEN 1, also known as Wermer syndrome, is associated with hyperparathyroidism, pancreatic endocrine tumors, and pituitary tumors, but rarely with phaeochromocytoma. Wagenmann-Froboese syndrome, or MEN 2b, is associated with medullary thyroid carcinoma and phaeochromocytoma, but hyperparathyroidism is rarely present.
Therefore, based on the patient’s symptoms, MEN 2a or Sipple syndrome is the most likely diagnosis.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 49
Incorrect
-
A 72-year-old man has recently been diagnosed with heart failure. He is currently taking ramipril for his high blood pressure. What is the most appropriate medication to help manage his heart failure?
Your Answer:
Correct Answer: Bisoprolol
Explanation:Comparing Beta Blockers for Heart Failure: Efficacy and Evidence
Beta blockers are a class of medications commonly used in the treatment of heart failure. Among them, bisoprolol and carvedilol have the strongest evidence of efficacy in reducing mortality rates in heart failure patients, according to data from the CIBIS and CASA-2 trials. Atenolol, although cardioselective, has less evidence to support its use in heart failure. Labetalol is primarily used for hypertension in pregnancy, while propranolol has the most evidence of benefit after a myocardial infarction but is not always preferred due to its twice-daily dosing. Sotalol, a first-generation beta blocker, is not cardioselective and is not recommended for heart failure. Overall, the choice of beta blocker for heart failure should be based on the available evidence and individual patient factors.
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This question is part of the following fields:
- Cardiovascular
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Question 50
Incorrect
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A 45-year-old woman returns to her General Practitioner for the results of a human immunodeficiency virus (HIV) test; the result is positive. Which of the following investigations will be most useful in estimating her risk of developing an opportunistic infection (OI)?
Your Answer:
Correct Answer: CD4 count
Explanation:The CD4 count is a reliable way to measure the immune system’s response to HIV infection. In HIV-negative individuals, the CD4 count is usually maintained above 600-800 cells/µl. However, without antiretroviral therapy, HIV-positive individuals will experience a gradual decline in CD4 count over time. A CD4 count of less than 350 cells/µl increases the risk of opportunistic infections, while a count of less than 200 cells/µl indicates an 80% risk of developing an OI within three years. Some patients may remain well despite having a low CD4 count, depending on viral load and host immunity factors. Different OIs are more likely at different CD4 counts. The World Health Organization now recommends starting ART in every HIV-positive individual, regardless of CD4 count.
A CXR is usually normal in HIV-positive individuals without chronic respiratory disorders. Blood cultures may help diagnose an OI, but do not estimate the risk of developing OIs. HIV-positive individuals often have an abnormal FBC, but this does not help with risk assessment for OIs. TST is used to check for immunity to TB and diagnose LTBI. HIV-positive individuals are at higher risk of TB disease, but may have a muted response to TST due to their compromised immunity. TST can be useful in assessing eligibility for isoniazid preventive therapy, but not in assessing disease stage and risk of OIs in general.
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This question is part of the following fields:
- Infectious Diseases
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Question 51
Incorrect
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A 68-year-old man presents with lower back pain. He has a medical history of prostate cancer, asthma, diabetes, and hypertension. The pain is radiating down his right leg and he is experiencing reduced power in that leg. Additionally, he has a decreased anal tone. Although the lumbar spine x-ray shows no apparent fracture, what would be the most appropriate next investigation to perform?
Your Answer:
Correct Answer: MRI lumbosacral spine
Explanation:Lower back pain accompanied by lower limb pain, limb weakness, numbness or tingling, and decreased perianal tone are red flags that suggest spinal cord compression. In this case, the patient has a history of prostate cancer, which further raises suspicion. Urgent MRI is necessary to rule out spinal cord compression, and the results should be discussed with the on-call neurosurgical team. Additional x-rays or ultrasound would not be helpful, as MRI is the preferred diagnostic tool.
Neoplastic Spinal Cord Compression: An Oncological Emergency
Neoplastic spinal cord compression is a medical emergency that affects around 5% of cancer patients. The majority of cases are due to vertebral body metastases, resulting in extradural compression. This condition is more common in patients with lung, breast, and prostate cancer.
The earliest and most common symptom of neoplastic spinal cord compression is back pain, which may worsen when lying down or coughing. Other symptoms include lower limb weakness and sensory changes such as numbness and sensory loss. The neurological signs depend on the level of the lesion, with lesions above L1 resulting in upper motor neuron signs in the legs and a sensory level. Lesions below L1 usually cause lower motor neuron signs in the legs and perianal numbness. Tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion.
An urgent MRI is recommended within 24 hours of presentation, according to the 2019 NICE guidelines. High-dose oral dexamethasone is used for management, and urgent oncological assessment is necessary for consideration of radiotherapy or surgery.
In summary, neoplastic spinal cord compression is a serious condition that requires prompt diagnosis and management to prevent further neurological damage.
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This question is part of the following fields:
- Neurology
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Question 52
Incorrect
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A 47-year-old man is seen by his General Practitioner for his annual hypertension review. He agrees to be referred to the local smoking cessation service, as he is currently experiencing chest pain.
Which of the following medications will need to be monitored closely on cessation of smoking?Your Answer:
Correct Answer: Theophylline
Explanation:The Effect of Smoking Cessation on Asthma Medications
Smoking cessation can have a significant impact on the management of asthma and the use of certain medications. Here is a breakdown of how smoking cessation affects different asthma medications:
Theophylline: Smoking induces the hepatic enzyme CYP1A2, which plays a major role in metabolizing theophylline. Therefore, quitting smoking can lead to higher plasma levels of theophylline and potentially fatal arrhythmias. Patients need to have their plasma theophylline concentration levels monitored closely and may require a reduced dose after quitting smoking.
Budesonide/formoterol: Neither budesonide nor formoterol are metabolized by CYP1A2, so there is no need for close monitoring following smoking cessation. Asthma control should improve after quitting smoking, and the inhaler dose should be reviewed as part of stepwise management.
Montelukast: Montelukast is metabolized by the cytochrome P450 system but not CYP1A2, so smoking cessation does not affect its level.
Prednisolone: Prednisolone is metabolized by the cytochrome P450 system, but CYP1A2 is not involved. Therefore, smoking cessation does not affect its metabolism.
Salbutamol: Smoking cessation can improve asthma control, leading to less frequent use of salbutamol or other reliever inhalers. There is no need to monitor this closely as reducing the as-required use of this medication poses no risk.
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This question is part of the following fields:
- Haematology/Oncology
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Question 53
Incorrect
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A 39-year-old male patient comes to the clinic complaining of scrotal swelling and discomfort that has been going on for three months. Upon examination, there is swelling on one side of the scrotum that illuminates when light is shone on it. The swelling is soft and painless, and the testis cannot be fully felt due to the presence of fluid. What is the best next step to take?
Your Answer:
Correct Answer: Refer urgently for testicular ultrasound
Explanation:An ultrasound is necessary for adult patients with a hydrocele to rule out any underlying causes, such as a tumor. Although the most common cause of a non-acute hydrocele is unknown, it is crucial to exclude malignancy first. Therefore, providing reassurance or reevaluating the patient at a later time would only be appropriate after a testicular ultrasound has ruled out cancer. Testicular biopsy should not be used to investigate suspected testicular cancer as it may spread the malignancy through seeding along the needle’s track. While a unilateral hydrocele may be an uncommon presentation of a renal carcinoma invading the renal vein, a CTAP would not be the initial investigation in this case. If malignancy is confirmed, CT may be useful in staging the malignancy.
A hydrocele is a condition where fluid accumulates within the tunica vaginalis. There are two types of hydroceles: communicating and non-communicating. Communicating hydroceles occur when the processus vaginalis remains open, allowing peritoneal fluid to drain into the scrotum. This type of hydrocele is common in newborn males and usually resolves within a few months. Non-communicating hydroceles occur when there is excessive fluid production within the tunica vaginalis. Hydroceles can develop secondary to conditions such as epididymo-orchitis, testicular torsion, or testicular tumors.
The main feature of a hydrocele is a soft, non-tender swelling of the hemi-scrotum that is usually located anterior to and below the testicle. The swelling is confined to the scrotum and can be transilluminated with a pen torch. If the hydrocele is large, the testis may be difficult to palpate. Diagnosis can be made clinically, but ultrasound is necessary if there is any doubt about the diagnosis or if the underlying testis cannot be palpated.
Management of hydroceles depends on the severity of the presentation. Infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years. In adults, a conservative approach may be taken, but further investigation, such as an ultrasound, is usually warranted to exclude any underlying cause, such as a tumor.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 54
Incorrect
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A 26-year-old female patient arrives with a sudden onset of pain at the back of her ankle while jogging, accompanied by a cracking sound. Which medication from the following list could have played a role in causing this injury?
Your Answer:
Correct Answer: Ciprofloxacin
Explanation:The patient is displaying typical symptoms of a ruptured Achilles tendon, which can be caused by ciprofloxacin. Tendon damage is a known potential side effect of quinolone antibiotics, and it seems to be a rare reaction that can occur after just 8 days of treatment.
Understanding Quinolones: Antibiotics that Inhibit DNA Synthesis
Quinolones are a type of antibiotics that are known for their bactericidal properties. They work by inhibiting DNA synthesis, which makes them effective in treating bacterial infections. Some examples of quinolones include ciprofloxacin and levofloxacin.
The mechanism of action of quinolones involves inhibiting topoisomerase II (DNA gyrase) and topoisomerase IV. However, bacteria can develop resistance to quinolones through mutations to DNA gyrase or by using efflux pumps that reduce the concentration of quinolones inside the cell.
While quinolones are generally safe, they can have adverse effects. For instance, they can lower the seizure threshold in patients with epilepsy and cause tendon damage, including rupture, especially in patients taking steroids. Additionally, animal models have shown that quinolones can damage cartilage, which is why they are generally avoided in children. Quinolones can also lengthen the QT interval, which can be dangerous for patients with heart conditions.
Quinolones should be avoided in pregnant or breastfeeding women and in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Overall, understanding the mechanism of action, mechanism of resistance, adverse effects, and contraindications of quinolones is important for their safe and effective use in treating bacterial infections.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 55
Incorrect
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A 32-year-old man presents to the Neurology Clinic. He has been recently diagnosed with idiopathic intracranial hypertension (IIH) and wants to know what lifestyle changes and medical treatments he needs to adopt to help reduce symptoms, and which to avoid.
Which of the following should be avoided in patients with IIH?
Your Answer:
Correct Answer: Maintaining a high-sodium diet
Explanation:Managing Idiopathic Intracranial Hypertension: Strategies and Interventions
Idiopathic intracranial hypertension (IIH) is a condition characterized by increased pressure within the skull, which can lead to vision loss and other neurological symptoms. Effective management of IIH involves a combination of lifestyle modifications, medication, and, in some cases, surgery. Here are some key strategies and interventions for managing IIH:
Low-sodium diet with acetazolamide: A low-sodium diet with acetazolamide has been shown to improve vision in patients with IIH. A high-sodium diet should be avoided as it can increase fluid retention and decrease the effectiveness of acetazolamide.
Weight loss: Weight loss can induce remission of papilledema in patients with IIH. A strict diet and pharmacological therapy may be necessary to achieve weight loss and prevent vision loss.
Surgical treatment: If patients are losing their vision despite maximal medical therapy, surgical treatment by optic-nerve-sheath fenestration or CSF shunting should be considered.
Discontinuing excessive vitamin A intake: Excessive vitamin A intake can increase CSF volume and pressure, so it is important to eliminate this risk factor in patients with IIH.
Discontinuing retinoid treatment: Retinoid, a metabolite of vitamin A, has been linked to the development of IIH. Therefore, discontinuing retinoid treatment is crucial when suspecting IIH.
Starting acetazolamide: Acetazolamide is a medication that decreases CSF production in humans and is often used in the initial management of IIH.
By implementing these strategies and interventions, patients with IIH can effectively manage their condition and prevent vision loss.
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This question is part of the following fields:
- Neurology
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Question 56
Incorrect
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A 65-year-old woman presents to the Emergency Department with a cough, fever, diarrhoea and myalgia. The cough is non-productive and has been getting gradually worse since she returned from holiday in Italy one week ago. Her daughter is concerned because over the past 24 hours she has become more drowsy and febrile. She is normally fit and well but drinks around 15 units of alcohol per week.
On examination, pulse is 80/min, blood pressure 110/70 mmHg, oxygen saturations are 95% on room air and temperature is 38.2ºC. Bilateral coarse crackles are heard in the chest.
Initial blood tests show the following:
Hb 13.8 g/dl
Platelets 300 * 109/l
WBC 14.5 * 109/l
Na+ 132 mmol/l
K+ 4.1 mmol/l
Urea 8.9 mmol/l
Creatinine 89 µmol/l
Bilirubin 11 µmol/l
ALP 35 u/l
ALT 62 u/l
A chest x-ray shows patchy consolidation in the right lower zone with an associated pleural effusion.
What is the most likely causative organism?Your Answer:
Correct Answer: Legionella pneumophila
Explanation:Legionella is often characterized by symptoms resembling the flu, such as a dry cough, confusion, and a slower than normal heart rate. Additionally, hyponatremia may be detected through blood tests. A history of recent travel abroad and the presence of pleural effusion are also indicative of Legionella.
Legionnaire’s Disease: Symptoms, Diagnosis, and Management
Legionnaire’s disease is a type of pneumonia caused by the Legionella pneumophilia bacterium, which is commonly found in water tanks. It is not transmitted from person to person. Symptoms of the disease include flu-like symptoms such as fever, dry cough, confusion, and lymphopaenia. Other features include relative bradycardia, hyponatraemia, and deranged liver function tests. Pleural effusion is seen in around 30% of patients.
Diagnosis of Legionnaire’s disease can be done through a urinary antigen test. Treatment involves the use of erythromycin or clarithromycin. Chest x-ray features of the disease are non-specific but may include patchy consolidation with a mid-to-lower zone predominance.
Compared to Mycoplasma pneumonia, Legionnaire’s disease has distinct differences in symptoms and diagnostic methods. It is important to be aware of the potential for Legionnaire’s disease in cases where water tanks or air-conditioning systems may be involved, as early diagnosis and treatment can lead to better outcomes.
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This question is part of the following fields:
- Infectious Diseases
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Question 57
Incorrect
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What is the most frequent cause of hypothyroidism in children in the United Kingdom?
Your Answer:
Correct 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 58
Incorrect
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A 10-year-old girl comes in for a check-up. She was diagnosed with asthma two years ago by her pediatrician. She is currently taking a salbutamol inhaler, using 2 puffs 3 times a day, and a low-dose beclomethasone inhaler. She also takes oral montelukast. However, she still experiences a night time cough and has to use her blue inhaler most days. Unfortunately, the addition of montelukast has not provided much relief. On examination today, her chest is clear with no wheeze and a near-normal peak flow. What should be the next step in her management?
Your Answer:
Correct Answer: Stop montelukast and add salmeterol
Explanation:For children between the ages of 5 and 16 with asthma that is not being effectively managed with a combination of a short-acting beta agonist (SABA), low-dose inhaled corticosteroids (ICS), and a leukotriene receptor antagonist, it is recommended to add a long-acting beta agonist (LABA) to the treatment plan and discontinue the use of the leukotriene receptor antagonist.
Managing Asthma in Children: NICE Guidelines
Asthma management in children has been updated by NICE in 2017, following the 2016 BTS guidelines. The new guidelines for children aged 5-16 are similar to those for adults, with a stepwise approach for treatment. For newly-diagnosed asthma, short-acting beta agonist (SABA) is recommended. If symptoms persist, a combination of SABA and paediatric low-dose inhaled corticosteroid (ICS) is used. Leukotriene receptor antagonist (LTRA) is added if symptoms still persist, followed by long-acting beta agonist (LABA) if necessary. Maintenance and reliever therapy (MART) is used as a combination of ICS and LABA for daily maintenance therapy and symptom relief. For children under 5 years old, clinical judgement plays a greater role in diagnosis. The stepwise approach is similar to that for older children, with an 8-week trial of paediatric moderate-dose ICS before adding LTRA. If symptoms persist, referral to a paediatric asthma specialist is recommended.
It should be noted that NICE does not recommend changing treatment for well-controlled asthma patients simply to adhere to the latest guidelines. The definitions of low, moderate, and high-dose ICS have also changed, with different definitions for adults and children. For children, <= 200 micrograms budesonide or equivalent is considered a paediatric low dose, 200-400 micrograms is a moderate dose, and > 400 micrograms is a high dose. Overall, the new NICE guidelines provide a clear and concise approach to managing asthma in children.
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This question is part of the following fields:
- Paediatrics
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Question 59
Incorrect
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As a junior doctor in a community mental health team, you are attending to a 35-year-old woman who is suffering from moderate-severe depression. She often voices out intense suicidal ideations and has a history of intentional overdose. Which category of antidepressants is currently less utilized due to their high toxicity in overdose?
Your Answer:
Correct Answer: Tricyclic antidepressants
Explanation:Tricyclic antidepressants are not commonly used for depression anymore due to their high risk of causing dangerous overdose. Therefore, when selecting an antidepressant for a patient who is at high risk of overdose, it is important to choose a class of antidepressants that are less toxic if taken in excess. TCAs have a narrow therapeutic index, which means that even moderate doses can lead to severe cardiovascular and CNS toxicity. Complications of TCA overdose include prolonged hypotension, cardiac arrhythmias, and seizures, which can ultimately result in death due to cardiovascular collapse.
Diagnosis of TCA overdose is typically made based on clinical presentation, and classic ECG changes may be observed, such as sinus tachycardia progressing to wide complex tachycardia and ventricular arrhythmias as the severity of intoxication increases. Treatment involves correcting acidosis, hypoxia, and electrolyte imbalances, as well as administering hypertonic sodium bicarbonate to improve conduction abnormalities and hypotension. Anti-arrhythmic drugs should generally be avoided, and benzodiazepines are the preferred treatment for seizures.
Tricyclic Antidepressants for Neuropathic Pain
Tricyclic antidepressants (TCAs) were once commonly used for depression, but their side-effects and toxicity in overdose have led to a decrease in their use. However, they are still widely used in the treatment of neuropathic pain, where smaller doses are typically required. TCAs such as low-dose amitriptyline are commonly used for the management of neuropathic pain and the prophylaxis of headache, while lofepramine has a lower incidence of toxicity in overdose. It is important to note that some TCAs, such as amitriptyline and dosulepin, are considered more dangerous in overdose than others.
Common side-effects of TCAs include drowsiness, dry mouth, blurred vision, constipation, urinary retention, and lengthening of the QT interval. When choosing a TCA for neuropathic pain, the level of sedation may also be a consideration. Amitriptyline, clomipramine, dosulepin, and trazodone are more sedative, while imipramine, lofepramine, and nortriptyline are less sedative. It is important to work with a healthcare provider to determine the appropriate TCA and dosage for the individual’s specific needs.
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This question is part of the following fields:
- Psychiatry
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Question 60
Incorrect
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A 40-year-old woman presents to your clinic with concerns about her heavy periods. She has been trying to conceive for the past 10 months without success. She has noticed that her periods have been getting progressively heavier over the past year, and she has experienced episodes of flooding. She initially attributed this to getting older, but now it has become unmanageable. During the examination, you palpate a supra-pubic mass. What is the most probable diagnosis?
Your Answer:
Correct Answer: Fibroids
Explanation:The patient’s symptoms of menorrhagia, subfertility, and an abdominal mass strongly suggest the presence of fibroids. While ectopic pregnancy should be ruled out, it is less likely due to the absence of severe pain. Endometriosis and endometrial cancer are also unlikely causes of an abdominal mass. Although ovarian cancer cannot be completely ruled out, it is not the most probable diagnosis. Fibroids are benign tumors that commonly occur in the myometrium. Symptoms include heavy menstrual bleeding, pain (if the fibroid twists), and subfertility. As fibroids grow larger, they can cause additional symptoms such as dysuria, hydronephrosis, constipation, and sciatica. Initial treatment typically involves medications such as tranexamic acid, NSAIDs, or progesterones to manage menorrhagia, but surgery is often necessary for persistent fibroids.
Understanding Uterine Fibroids
Uterine fibroids are non-cancerous growths that develop in the uterus. They are more common in black women and are thought to occur in around 20% of white women in their later reproductive years. Fibroids are usually asymptomatic, but they can cause menorrhagia, which can lead to iron-deficiency anaemia. Other symptoms include lower abdominal pain, bloating, and urinary symptoms. Fibroids may also cause subfertility.
Diagnosis is usually made through transvaginal ultrasound. Asymptomatic fibroids do not require treatment, but periodic monitoring is recommended. Menorrhagia secondary to fibroids can be managed with various treatments, including the levonorgestrel intrauterine system, NSAIDs, tranexamic acid, and hormonal therapies.
Medical treatment to shrink or remove fibroids may include GnRH agonists or ulipristal acetate, although the latter is not currently recommended due to concerns about liver toxicity. Surgical options include myomectomy, hysteroscopic endometrial ablation, hysterectomy, and uterine artery embolization.
Fibroids generally regress after menopause, but complications such as subfertility and iron-deficiency anaemia can occur. Red degeneration, which is haemorrhage into the tumour, is a common complication during pregnancy.
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This question is part of the following fields:
- Reproductive Medicine
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