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Question 1
Incorrect
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A 27-year-old man comes to his General Practitioner with complaints of lower back pain and pain and weakness in his lower limbs. He reports that his symptoms have been getting worse for the past five days. About three weeks ago, he had Campylobacter gastroenteritis.
During the examination, the doctor observes diminished or absent reflexes in the legs and hypotonia. The patient's pain and light-touch sensations are also reduced.
What is the most probable diagnosis?Your Answer: Spinal cord compression
Correct Answer: Guillain-Barré syndrome (GBS)
Explanation:Neurological Disorders: Guillain-Barré Syndrome, Myasthenia Gravis, Multiple Sclerosis, Polymyositis, and Spinal Cord Compression
Guillain-Barré syndrome (GBS) is a neurological disorder that causes demyelination and axonal degeneration, resulting in acute, ascending, and progressive neuropathy. It typically presents with symmetrical weakness starting in the lower extremities and may progress to respiratory failure in severe cases. Treatment involves plasma exchange or immunoglobulins and intravenous methylprednisolone, but approximately 20% of patients may experience residual disability and 10% may die from complications.
Myasthenia gravis (MG) is another neurological disorder that causes weakness, but it is characterized by fatigability and doesn’t involve sensory changes. Symptoms range from mild weakness of limited muscle groups to severe weakness of multiple muscle groups.
Multiple sclerosis (MS) is a disorder that classically presents with symptoms and signs separated by time and space. Transverse myelitis can occur, resulting in acute weakness or paralysis of both legs, sensory loss, and loss of control of the bowels and bladder.
Polymyositis is a disorder characterized by muscle weakness that starts proximally and progresses over a period of weeks to months. While it may cause muscle aches, it would not normally cause sensory changes.
Symptoms suggestive of spinal cord compression include back pain, paralysis, decreased sensation below the level of compression, and urinary and fecal incontinence or retention.
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This question is part of the following fields:
- Neurology
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Question 2
Incorrect
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You are conducting a review of your repeat prescribing system due to a recent complaint following a prescribing error involving a pediatric patient.
What are the recommended best practices for repeat prescribing in order to reduce the occurrence of prescribing or monitoring errors in pediatric patients?Your Answer: Update medication from discharge summaries within 4 weeks of receipt
Correct Answer: Request repeat prescriptions from any staff member by telephone
Explanation:Practice-wide Defences Against Prescribing Errors
A study conducted by GMC has identified several practice-wide defences against prescribing errors. These defences include strongly discouraging verbal repeat requests, performing face to face medication reviews, having blood tests one week before scheduled reviews, and updating records within 48 hours with hospital correspondence.
To prevent prescribing errors, it is important to discourage verbal repeat requests as they can lead to confusion and mistakes. Face to face medication reviews can also help identify any potential errors and ensure that the patient is receiving the correct medication. Having blood tests one week before scheduled reviews can help monitor the patient’s health and ensure that the medication is working effectively. Finally, updating records within 48 hours with hospital correspondence can help ensure that all healthcare providers are aware of any changes in the patient’s medication or health status.
By implementing these practice-wide defences, healthcare providers can help prevent prescribing errors and ensure that patients receive safe and effective care.
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This question is part of the following fields:
- Improving Quality, Safety And Prescribing
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Question 3
Incorrect
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A 25-year-old female presents with a history of weight loss and diarrhoea. During a colonoscopy to investigate her symptoms, a biopsy is taken and the report indicates the presence of pigment-laden macrophages suggestive of melanosis coli. What is the probable diagnosis?
Your Answer: Ulcerative colitis
Correct Answer: Laxative abuse
Explanation:Understanding Melanosis Coli: A Pigmentation Disorder of the Bowel Wall
Melanosis coli is a condition that affects the pigmentation of the bowel wall. This disorder is characterized by the presence of pigment-laden macrophages, which can be observed through histology. One of the primary causes of melanosis coli is laxative abuse, particularly the use of anthraquinone compounds like senna.
This condition is a result of the accumulation of melanin in the macrophages of the colon. The pigmentation can be seen as dark brown or black spots on the lining of the colon. While melanosis coli is not typically a serious condition, it can be a sign of underlying issues such as chronic constipation or other gastrointestinal disorders.
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This question is part of the following fields:
- Gastroenterology
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Question 4
Incorrect
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A 68-year-old man with osteoarthritis is evaluated. He has been taking regular paracetamol and a topical NSAID for symptom control, but due to insufficient pain relief, an oral NSAID was recently added. He has been taking ibuprofen 400 mg as needed up to three times a day, but upon further discussion, he is using it at least once daily. He has no significant gastrointestinal medical history, particularly no prior issues with gastroesophageal reflux or peptic ulceration. What is the most appropriate management strategy for gastroprotection?
Your Answer: Co-prescribe a proton pump inhibitor (e.g. omeprazole)
Correct Answer: Co-prescribe an alginate preparation to use on a PRN basis (e.g. Gaviscon)
Explanation:Co-prescription of Proton Pump Inhibitors with NSAIDs
When prescribing oral NSAIDs or COX-2 inhibitors for the treatment of osteoarthritis, it is important to co-prescribe a proton pump inhibitor with the lowest acquisition cost. This is recommended by NICE guidance to prevent gastrointestinal, liver, or cardio-renal side effects.
To minimize the risk of these side effects, anti-inflammatories should be used at the lowest effective dose for the shortest possible time period. Even if a patient has no history of gastrointestinal problems, a proton pump inhibitor should still be co-prescribed.
It is also important to consider other medications that may increase the risk of gastrointestinal problems when used in combination with NSAIDs, such as steroids, aspirin, and certain antidepressants. By taking these precautions, healthcare professionals can help ensure the safe and effective use of NSAIDs in the treatment of osteoarthritis.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 5
Incorrect
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A mother brings her 4-year-old girl who is known to have Down's syndrome to surgery, as she is worried about her vision. Which of the following eye issues is the least commonly linked with Down's syndrome?
Your Answer: Recurrent blepharitis
Correct Answer: Retinal detachment
Explanation:Vision and Hearing Issues in Down’s Syndrome
Individuals with Down’s syndrome are at a higher risk of experiencing vision and hearing problems. When it comes to vision, they are more likely to have refractive errors, which can cause blurred vision. Strabismus, a condition where the eyes do not align properly, is also common in 20-40% of individuals with Down’s syndrome. Cataracts, which can cause cloudiness in the eye lens, are more prevalent in those with Down’s syndrome, both congenital and acquired. Recurrent blepharitis, an inflammation of the eyelids, and glaucoma, a condition that damages the optic nerve, are also potential issues.
In terms of hearing, otitis media and glue ear are very common in individuals with Down’s syndrome. These conditions can lead to hearing problems, which can affect speech and language development. It is important for individuals with Down’s syndrome to receive regular vision and hearing screenings to detect and address any issues early on.
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This question is part of the following fields:
- Children And Young People
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Question 6
Incorrect
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A 7-year-old boy has developed involuntary movements of his arms and face over the last few days. Some of these he converts into apparently purposeful movement by pushing back his hair or scratching his nose. There is reduced tone in the limbs, and he is unsteady. He seems unconcerned and intermittently giggles. His mother tells you that he had a sore throat four weeks previously.
What is the most likely diagnosis?Your Answer: Huntington’s chorea
Correct Answer: Sydenham’s chorea
Explanation:Understanding Sydenham’s Chorea: A Common Cause of Acute Chorea Worldwide
Sydenham’s chorea, also known as St Vitus’ dance, is a neurological manifestation of rheumatic fever and remains the most common cause of acute chorea worldwide. While it was commonly seen in the 1930s, it occurs less frequently in the UK today. This condition can occur with or without symptoms of rheumatic fever and is usually self-limiting. Improvement occurs over about two weeks, but total recovery can take up to nine months, and may recur in some patients.
In this scenario, the short time course of the chorea and the girl’s age are useful diagnostically. It is important to note that psychological changes may precede or accompany the choreiform movements, as demonstrated by the girl’s emotional lability.
It is important to consider other potential causes of chorea, such as cerebral tumour, cerebrovascular accident, Guillain–Barré syndrome, and Huntington’s chorea. However, in this case, these conditions are unlikely as they do not fit with the girl’s symptoms and age.
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This question is part of the following fields:
- Children And Young People
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Question 7
Correct
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A 12-year-old boy with cystic fibrosis comes to the clinic with abrupt onset of intense pleuritic chest pain. There is no record of hemoptysis. During the examination, he has a normal body temperature but an elevated respiratory rate and reports sharp chest pain with every inhalation. The pain is localized to the right side of his chest. Auscultation reveals breath sounds on both sides. What is the most probable diagnosis?
Your Answer: Spontaneous pneumothorax
Explanation:Pneumothorax in Children with Cystic Fibrosis
Pneumothorax is a known complication of cystic fibrosis, and sudden onset of severe pleuritic chest pain is a common symptom. However, only large pneumothoraces give the classic reduced breath sounds and hyperresonant percussion note. Children with congenital lung disease like cystic fibrosis may develop small pneumothoraces, which can be difficult to diagnose due to airflow limitation.
If a child with cystic fibrosis presents with sudden onset of severe pleuritic chest pain, they should be referred to the hospital for a chest X-ray to confirm the diagnosis and assess the need for drainage. Pneumothoraces can also occur due to chest trauma or pneumonia infection.
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This question is part of the following fields:
- Children And Young People
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Question 8
Correct
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What interventions can be used to identify asthma when there is diagnostic uncertainty or coexistence of COPD and asthma?
Your Answer: Inhaled beclomethasone (BDP) 200 mcg twice daily for 10 days
Explanation:Diagnosis and Treatment of Asthma in Adults
In adults, the diagnosis of asthma can be challenging, especially when there is diagnostic uncertainty or when both asthma and chronic obstructive pulmonary disease (COPD) are present. The British Thoracic Society recommends a 6-8 week treatment trial of inhaled beclomethasone (or equivalent) twice daily for patients with significant airflow obstruction. However, in patients with suspected inhaled corticosteroid resistance, a two-week treatment trial of oral prednisolone 30 mg daily is preferred.
To help identify asthma, clinicians should assess FEV1 (or PEF) and/or symptoms before and after 400mcg inhaled salbutamol. A >400ml improvement in FEV1 to either b2 agonists or corticosteroid treatment strongly suggests underlying asthma. Serial peak flow measurements showing 20% or greater diurnal or day-to-day variability can also be used to help diagnose asthma.
NICE NG115 further clarifies that a large response to bronchodilators or oral prednisolone (over 400 ml) can also help identify asthma. Clinically significant COPD is not present if the FEV1 and FEV1/FVC ratio return to normal with drug therapy. In cases of diagnostic uncertainty, a combination of these findings can be used to help diagnose asthma and guide treatment decisions.
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This question is part of the following fields:
- Respiratory Health
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Question 9
Incorrect
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The following blood result is reported for an 85-year-old woman with a medical history of hypertension, diverticulitis, and hypothyroidism. She is currently taking amlodipine, ramipril, and levothyroxine. The result shows a TSH level of 0.01 mU/L (0.5-5.5) and a free T4 level of 22 pmol/L (9.0 - 18). What potential complication could she face if this condition remains untreated?
Your Answer: Confusion
Correct Answer: Osteoporosis
Explanation:The risk of osteoporosis increases with over-replacement of thyroxine. Elevated T4 and suppressed TSH levels in blood tests indicate over-replacement with levothyroxine, which can cause confusion in biochemistry abnormalities, although this is more commonly observed in hypothyroidism. Constipation is a symptom of hypothyroidism, not over-replacement with levothyroxine. Muscle weakness and reduced reflexes are also associated with hypothyroidism, not hyperthyroidism. Over-replacement with thyroxine would result in weight loss rather than weight gain.
Managing Hypothyroidism: Dosage, Goals, and Side-Effects
Hypothyroidism is a condition where the thyroid gland doesn’t produce enough thyroid hormone. The management of hypothyroidism involves the use of levothyroxine, a synthetic form of thyroid hormone. The initial starting dose of levothyroxine should be lower in elderly patients and those with ischaemic heart disease. For patients with cardiac disease, severe hypothyroidism, or patients over 50 years, the initial starting dose should be 25mcg od with dose slowly titrated. Other patients should be started on a dose of 50-100 mcg od. After a change in thyroxine dose, thyroid function tests should be checked after 8-12 weeks. The therapeutic goal is to achieve a ‘normalisation’ of the thyroid stimulating hormone (TSH) level, with a TSH value of 0.5-2.5 mU/l being the preferred range.
Women with established 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. There is no evidence to support combination therapy with levothyroxine and liothyronine.
Levothyroxine therapy may cause side-effects such as hyperthyroidism due to over-treatment, reduced bone mineral density, worsening of angina, and atrial fibrillation. Interactions with iron and calcium carbonate may reduce the absorption of levothyroxine, so they should be given at least 4 hours apart.
In summary, the management of hypothyroidism involves careful dosage adjustment, regular monitoring of thyroid function tests, and aiming for a TSH value in the normal range. Women who become pregnant should have their dose increased, and combination therapy with levothyroxine and liothyronine is not recommended. Patients should also be aware of potential side-effects and interactions with other medications.
*source: NICE Clinical Knowledge Summaries
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 10
Incorrect
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A 25-year-old woman has a significantly reduced ability to understand new or complex information, and a reduced ability to cope independently. There is evidence that she has had such problems since an early age.
Which term is currently used in the UK to describe this patient’s impairment?Your Answer: Intellectual disability
Correct Answer: Learning disability
Explanation:Understanding Different Terms for Cognitive Impairments
There are various terms used to describe cognitive impairments, but it is important to use the correct terminology to avoid confusion and stigma.
A learning disability refers to a long-term reduced ability to cope independently or process new or complex information. It is important to seek specialist input for assessment and support if a learning disability is suspected.
An intellectual disability is a general impairment that affects a person’s overall functioning. However, the correct term to use is still learning disability.
A learning difficulty, such as dyslexia, doesn’t impair a person’s general functioning.
The terms mental handicap and mental sub normality are outdated and no longer used in clinical practice. It is important to use respectful and accurate language when discussing cognitive impairments.
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This question is part of the following fields:
- Neurodevelopmental Disorders, Intellectual And Social Disability
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Question 11
Incorrect
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A study looks at the risk of myocardial infarction in 2 groups of patients with different ages. There are 1000 patients in the group aged 50 and above, and 1000 in the group aged below 50. In the group aged below 50, there were 20 myocardial infarctions, while in the group aged 50 and above there were 80 myocardial infarctions.
Select from the list the risk of a myocardial infarction in the group aged below 50.Your Answer: 2
Correct Answer: 0.2
Explanation:Understanding Risk: Calculating the Proportion of Patients Developing a Condition
Risk is a term used to describe the likelihood of an event occurring. In the context of healthcare, risk is often used to calculate the proportion of patients who develop a specific condition. For example, if 200 out of 1000 patients develop a certain condition, the risk of that condition is 0.2 or 20%. Understanding risk is important in healthcare as it helps healthcare professionals make informed decisions about treatment options and preventative measures. By calculating the risk of a particular condition, healthcare providers can identify patients who may be at higher risk and take steps to mitigate that risk.
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This question is part of the following fields:
- Population Health
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Question 12
Incorrect
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A 56-year-old man presents with a persistent cough. He reports no other health concerns and is not taking any regular medications. During the consultation, he requests a brief examination of his toenail, which has recently changed in appearance without any known cause. Specifically, the nail on his right big toe is thickened and yellowed at the outer edge. Although he experiences no discomfort or other symptoms, he is curious about the cause of this change.
What initial management approach would you recommend in this scenario?Your Answer: Check liver function tests and prescribe an oral antifungal such as terbinafine if normal
Correct Answer: No treatment necessary if he is happy to leave it; give self-care advice
Explanation:If a patient has a fungal nail infection that is asymptomatic and doesn’t bother them in terms of appearance, treatment may not be necessary according to NICE CKS guidelines. However, if treatment is desired, topical antifungal treatment for 9-12 months may be appropriate for minor involvement of a single nail. Liver function tests should be checked before prescribing oral antifungal medication such as terbinafine. Self-care advice can be given to the patient, including keeping feet clean and dry, wearing breathable socks and footwear, and avoiding going barefoot in changing rooms. Referral to podiatry is not necessary unless the patient is unable to perform their own foot-care. Swabbing the skin for microscopy and culture may not be useful in cases where the skin is not involved.
Fungal Nail Infections: Causes, Symptoms, and Treatment
Fungal nail infections, also known as onychomycosis, can affect any part of the nail or the entire nail unit. However, toenails are more susceptible to infection than fingernails. The primary cause of fungal nail infections is dermatophytes, with Trichophyton rubrum being the most common. Yeasts, such as Candida, and non-dermatophyte molds can also cause fungal nail infections. Risk factors for developing a fungal nail infection include increasing age, diabetes mellitus, psoriasis, and repeated nail trauma.
The most common symptom of a fungal nail infection is thickened, rough, and opaque nails. Patients may present with unsightly nails, which can be a source of embarrassment. Differential diagnoses include psoriasis, repeated trauma, lichen planus, and yellow nail syndrome. To confirm a fungal nail infection, nail clippings or scrapings of the affected nail should be examined under a microscope and cultured. However, the false-negative rate for cultures is around 30%, so repeat samples may be necessary if clinical suspicion is high.
Asymptomatic fungal nail infections do not require treatment unless the patient is bothered by the appearance. Topical treatment with amorolfine 5% nail lacquer is recommended for limited involvement, while oral terbinafine is the first-line treatment for more extensive involvement due to a dermatophyte infection. Fingernail infections require 6 weeks to 3 months of therapy, while toenails should be treated for 3 to 6 months. Oral itraconazole is recommended for more extensive involvement due to a Candida infection, with pulsed weekly therapy being the preferred method.
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This question is part of the following fields:
- Dermatology
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Question 13
Incorrect
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Sophie is 25 years old and has come to you seeking contraception. She is currently using condoms and doesn't believe she is at risk of pregnancy. She smokes 4 cigarettes a day, has a body mass index of 22 kg/m², and a blood pressure of 120/65 mmHg. She has no personal or family history of blood clots, heart disease, strokes, or migraines. Sophie has a regular 30-day menstrual cycle and is on day 3 of her cycle. She wants to start contraception immediately and you decide to prescribe Yasmin. Which of the following statements is true?
Your Answer: She can start the combined oral contraceptive pill today but she needs to use barrier protection for 2 days
Correct Answer: She can start the combined oral contraceptive pill today but she needs to use barrier protection for 7 days
Explanation:Extra precautions should be taken during the first 7 days of starting the combined oral contraceptive pill as it doesn’t provide immediate protection when initiated on day 6 of the menstrual cycle. Women over the age of 35 who smoke should not use this form of contraception.
Women who are considering taking the combined oral contraceptive pill (COC) should receive counselling on various aspects. This includes the potential benefits and harms of the COC, such as its high effectiveness rate of over 99% when taken correctly, but also the small risk of blood clots, heart attacks, strokes, and increased risk of breast and cervical cancer. Additionally, advice on taking the pill should be provided, such as starting it within the first 5 days of the cycle to avoid the need for additional contraception, taking it at the same time every day, and considering tailored regimens that eliminate the pill-free interval. It is also important to discuss situations where efficacy may be reduced, such as vomiting or taking liver enzyme-inducing drugs. Finally, counselling should include information on STIs and the use of concurrent antibiotics, which may no longer require extra precautions except for enzyme-inducing antibiotics like rifampicin.
Overall, women should receive comprehensive counselling on the COC to make informed decisions about their reproductive health. This includes discussing the potential benefits and harms, advice on taking the pill, and situations where efficacy may be reduced. By providing this information, women can make informed decisions about their contraceptive options and reduce the risk of unintended pregnancies.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 14
Incorrect
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Which of the following is the least commonly associated with antiphospholipid syndrome during pregnancy?
Your Answer: Intra-uterine growth retardation
Correct Answer: Placenta praevia
Explanation:Antiphospholipid Syndrome and Pregnancy: Risks and Management
Antiphospholipid syndrome is a condition that increases the risk of both venous and arterial blood clots, recurrent miscarriage, and low platelet count. It can occur as a primary disorder or as a secondary condition to other illnesses, such as systemic lupus erythematosus. When a woman with antiphospholipid syndrome becomes pregnant, there are several potential complications that may arise, including pre-eclampsia, placental abruption, and preterm delivery.
To manage these risks, low-dose aspirin is typically prescribed as soon as the pregnancy is confirmed through a urine test. Once a fetal heartbeat is detected on ultrasound, low molecular weight heparin is added to the treatment plan. This medication is usually discontinued at 34 weeks gestation. These interventions have been shown to increase the live birth rate by seven-fold. It is important for women with antiphospholipid syndrome to work closely with their healthcare provider to ensure the best possible outcome for both mother and baby.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 15
Correct
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A 63-year-old man comes to the clinic with his wife for evaluation. He has been experiencing a change in his voice with constant hoarseness and a chronic dry cough for the past six weeks. He attributes this to a previous cold and chest infection and believes it will improve over time.
He is a heavy smoker, consuming 25 cigarettes per day for the past 50 years. He has a history of COPD and is currently taking a high dose Seretide inhaler. On examination, his BP is 145/85 mmHg, pulse is 75 and regular, and chest auscultation reveals scattered wheezing.
Investigations reveal:
Hb 134 g/L (135-180)
WCC 8.0 ×109/L (4.5-10)
PLT 179 ×109/L (150-450)
Na 137 mmol/L (135-145)
K 4.7 mmol/L (3.5-5.5)
Cr 122 µmol/L (70-110)
ECG shows sinus rhythm.
CXR (arranged by another GP partner) shows no mass lesion identified.
What is the most appropriate course of action?Your Answer: Urgent ENT referral
Explanation:Urgent Investigation for Hoarseness
Under NICE guidance, patients who present with hoarseness for more than three weeks require urgent investigation for possible cancer. In this case, a chest x-ray did not show an underlying cancer, but an ENT referral for laryngoscopy is warranted.
While inadequate oral hygiene after inhaler use leading to candida infection is a possibility, the absence of oral candida makes it unlikely. Speech therapy is an option to maximize vocal effectiveness, and it is effective for hoarseness related to organic pathology such as nodules or polyps, and non-organic laryngeal dysfunction (for example, muscle tension dysphonia).
Stopping the use of Seretide is inappropriate because it is likely to worsen symptoms of COPD and is unlikely to elucidate the underlying cause of the hoarseness. It is important to investigate the cause of hoarseness to ensure prompt and appropriate treatment.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 16
Correct
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A 38-year-old man who was diagnosed with epilepsy around 25 years ago is seeking information about driving regulations for individuals with epilepsy. He is currently on sodium valproate monotherapy and had his last seizure 2 years ago. What is the minimum duration of seizure freedom required before he can drive a car?
Your Answer: 12 months
Explanation:It is common for people to have questions about the DVLA rules regarding epilepsy, given the high number of individuals affected by this condition and the potential risks associated with having a seizure while driving. In this case, the patient has a history of epilepsy and has not experienced a seizure in the past four years. According to the DVLA guidelines, individuals with epilepsy may be eligible for a driving license if they have been seizure-free for at least one year, including minor seizures and other signs of epilepsy such as limb jerking, auras, and absences. This also includes episodes that do not involve a loss of consciousness.
The DVLA has guidelines for individuals with neurological disorders who wish to drive cars or motorcycles. However, the rules for drivers of heavy goods vehicles are much stricter. For individuals with epilepsy or seizures, they must not drive and must inform the DVLA. If an individual has had a first unprovoked or isolated seizure, they must take six months off driving if there are no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG. If these conditions are not met, the time off driving is increased to 12 months. Individuals with established epilepsy or those with multiple unprovoked seizures may qualify for a driving license if they have been free from any seizure for 12 months. If there have been no seizures for five years (with medication if necessary), a ’til 70 license is usually restored. Individuals should not drive while anti-epilepsy medication is being withdrawn and for six months after the last dose.
For individuals with syncope, a simple faint has no restriction on driving. A single episode that is explained and treated requires four weeks off driving. A single unexplained episode requires six months off driving, while two or more episodes require 12 months off. For individuals with other conditions such as stroke or TIA, they must take one month off driving. They may not need to inform the DVLA if there is no residual neurological deficit. If an individual has had multiple TIAs over a short period of time, they must take three months off driving and inform the DVLA. For individuals who have had a craniotomy, such as for meningioma, they must take one year off driving. If an individual has had a pituitary tumor, a craniotomy requires six months off driving, while trans-sphenoidal surgery allows driving when there is no debarring residual impairment likely to affect safe driving. Individuals with narcolepsy/cataplexy must cease driving on diagnosis but can restart once there is satisfactory control of symptoms. For individuals with chronic neurological disorders such as multiple sclerosis or motor neuron disease, they should inform the DVLA and complete the PK1 form (application for driving license holders’ state of health). If the tumor is a benign meningioma and there is no seizure history, the license can be reconsidered six months after surgery if the individual remains seizure-free.
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This question is part of the following fields:
- Neurology
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Question 17
Incorrect
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A 56-year-old gentleman presents to you with a recent diagnosis of mild obstructive sleep apnoea (AHI<15). He holds a group 1 driving licence and is seeking advice regarding driving. Upon reviewing the specialist's letter, you note that the patient has been prescribed night time continuous positive airway pressure (CPAP) ventilation. What recommendations should you provide to the patient regarding driving?
Your Answer: If he requires CPAP as treatment he cannot hold a valid licence
Correct Answer: He can only drive once satisfactory control of his symptoms has been attained
Explanation:Driving Restrictions for Obstructive Sleep Apnoea
Obstructive sleep apnoea (OSA) is a condition that is often overlooked, but it can have serious consequences for driving safety. Excessive daytime sleepiness caused by OSA has been linked to numerous road traffic accidents. Both group 1 and group 2 license holders have restrictions on driving if OSA continues to cause excessive awake time sleepiness. For group 1 drivers, they can resume driving once their symptoms are under control.
The main issue is not treatment compliance, but rather the control of symptoms to eliminate excessive awake time sleepiness. Group 1 license holders do not require specialist approval to drive, and the method of treatment is not a determining factor. The DVLA uses the Apnea Hypopnea Index (AHI) to assess OSA, which may be unfamiliar to some. However, it is important to be familiar with it and interpret the latest DVLA guidance accordingly.
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This question is part of the following fields:
- Consulting In General Practice
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Question 18
Correct
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You refer a 50-year-old patient with suspected dementia to the Memory clinic after a mini-mental state exam indicates mild cognitive impairment. A dementia blood screen performed by yourself is normal. What is the most appropriate role of neuroimaging in the evaluation of patients with suspected dementia?
Your Answer: Neuroimaging is required in all cases
Explanation:According to the NICE guidelines, neuroimaging is necessary for the diagnosis of dementia. Structural imaging, such as magnetic resonance imaging (MRI) or computed tomography (CT) scanning, should be used to rule out other cerebral pathologies and to aid in determining the subtype diagnosis. MRI is preferred for early diagnosis and detecting subcortical vascular changes. However, in cases where the diagnosis is already clear in individuals with moderate to severe dementia, imaging may not be necessary. It is important to seek specialist advice when interpreting scans in individuals with learning disabilities.
Dementia is a condition that affects a significant number of people in the UK, with Alzheimer’s disease being the most common cause followed by vascular and Lewy body dementia. Diagnosis can be challenging and often delayed, but assessment tools such as the 10-point cognitive screener and 6-Item cognitive impairment test are recommended by NICE for non-specialist settings. However, tools like the abbreviated mental test score, General practitioner assessment of cognition, and mini-mental state examination are not recommended. A score of 24 or less out of 30 on the MMSE suggests dementia.
In primary care, a blood screen is usually conducted to exclude reversible causes like hypothyroidism. NICE recommends tests such as FBC, U&E, LFTs, calcium, glucose, ESR/CRP, TFTs, vitamin B12, and folate levels. Patients are often referred to old-age psychiatrists working in memory clinics. In secondary care, neuroimaging is performed to exclude other reversible conditions like subdural haematoma and normal pressure hydrocephalus and provide information on aetiology to guide prognosis and management. The 2011 NICE guidelines state that structural imaging is essential in investigating dementia.
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This question is part of the following fields:
- Older Adults
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Question 19
Incorrect
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A 35-year-old woman presents to her GP with a complaint of feeling constantly fatigued for the past 3 months. She has a history of intravenous drug use and routine testing reveals abnormal liver enzyme tests, including a significant increase in alanine aminotransferase (ALT). Although she is not jaundiced, the GP suspects that she may be suffering from acute hepatitis. Which of the following tests is most likely to be positive in this patient if this suspicion is correct?
Your Answer: Hepatitis B surface antigen
Correct Answer: Hepatitis C antibody
Explanation:Diagnosing Hepatitis C: Understanding the Clinical Features and Testing Methods
Hepatitis C (HCV) is a viral infection that often goes undetected due to the lack of specific symptoms. Fatigue, a common symptom, is not enough to suspect hepatitis C unless other risk factors are present. Abnormal liver function tests may indicate HCV, but a positive serology test is needed to confirm the diagnosis. This test is usually positive three months after exposure, but may take up to nine months. HCV RNA testing is used to confirm ongoing infection, and negative results should be repeated after six months. Chronic infection is common in HCV, affecting about 80% of those infected.
Other viral infections, such as hepatitis B and Epstein-Barr virus (EBV), may also cause liver abnormalities. Jaundice is more common in hepatitis B, while EBV typically causes mild elevation of serum transaminases. Testing for IgM and IgG antibodies can help diagnose acute or past infections. Enzyme levels, such as alkaline phosphatase and gamma-glutamyl transpeptidase, may also be used to differentiate between viral infections.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 20
Incorrect
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You come across a 16-year-old student who has been experiencing vertigo for the past 2 days. She complains of feeling like the room is spinning and experiencing nausea. She has been suffering from a severe cold for the last 10 days but denies any other symptoms. Upon examination and hearing tests, you suspect that she has vestibular neuronitis.
What is a correct statement about vestibular neuronitis?Your Answer: Tinnitus is often associated with vestibular neuronitis
Correct Answer: Hearing is normal in vestibular neuronitis
Explanation:Understanding Vestibular Neuronitis
Vestibular neuronitis is a type of vertigo that typically occurs after a viral infection. It is characterized by recurrent episodes of vertigo that can last for hours or days, accompanied by nausea and vomiting. Horizontal nystagmus is also a common symptom, but there is no hearing loss or tinnitus.
It is important to differentiate vestibular neuronitis from other conditions such as viral labyrinthitis and posterior circulation stroke. The HiNTs exam can be used to distinguish between these conditions.
Treatment for vestibular neuronitis typically involves medication to alleviate symptoms, such as buccal or intramuscular prochlorperazine for severe cases, or a short course of oral medication for less severe cases. Vestibular rehabilitation exercises are also recommended for patients who experience chronic symptoms.
Understanding the symptoms and treatment options for vestibular neuronitis can help individuals manage this condition and improve their quality of life.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 21
Incorrect
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A 70-year-old man presents to your clinic with a complaint of recurrent nosebleeds from his right nostril over the past week. The bleeding lasts for about 30 minutes but is not severe. The patient has a history of ischemic heart disease and is on regular medication of aspirin 75 mg and atorvastatin 40 mg. He denies any allergies and has no other significant medical history. On examination, there is no visible bleeding point, and all vital signs are normal. What is the most appropriate management for this patient, in addition to general epistaxis advice?
Your Answer: Refer to ENT routine outpatients for consideration of superior palatine artery (SPA) ligation
Correct Answer: Prescribe topical Naseptin (chlorhexidine/neomycin) cream
Explanation:Recurrent nosebleeds without any concerning symptoms can be effectively treated with Naseptin cream, which contains chlorhexidine and neomycin. While severe cases may require emergency care, mild cases can be managed in primary care. According to NICE guidelines, topical treatment with Naseptin cream is a suitable first-line approach.
If the nosebleeds are heavy but not currently active, persist despite topical treatment, or the patient is taking anticoagulant medication, referral to an ENT ‘hot clinic’ may be necessary. If the nosebleeds continue to recur despite treatment, referral to an ENT outpatient clinic for SPA ligation may be considered.
In primary care, silver nitrate cautery may be attempted if a clear bleeding point can be identified and the healthcare provider has the appropriate skills and experience. However, patients should not stop taking antiplatelet medication without consulting their healthcare provider.
Understanding Epistaxis: Causes and Management
Epistaxis, commonly known as nosebleeds, can be categorized into anterior and posterior bleeds. Anterior bleeds usually have a visible source of bleeding and occur due to an injury to the network of capillaries that form Kiesselbach’s plexus. On the other hand, posterior haemorrhages tend to be more severe and originate from deeper structures. They are more common in older patients and pose a higher risk of aspiration and airway obstruction.
Most cases of epistaxis are benign and self-limiting. However, exacerbation factors such as nose picking, nose blowing, trauma to the nose, insertion of foreign bodies, bleeding disorders, and immune thrombocytopenia can trigger nosebleeds. Other causes include hereditary haemorrhagic telangiectasia, granulomatosis with polyangiitis, and cocaine use.
If the patient is haemodynamically stable, bleeding can be controlled with first aid measures such as sitting with their torso forward and their mouth open, pinching the cartilaginous area of the nose firmly for at least 20 minutes, and using a topical antiseptic to reduce crusting and the risk of vestibulitis. If bleeding persists, cautery or packing may be necessary. Cautery should be used initially if the source of the bleed is visible, while packing may be used if cautery is not viable or the bleeding point cannot be visualized.
Patients that are haemodynamically unstable or compromised should be admitted to the emergency department, while those with a bleed from an unknown or posterior source should be admitted to the hospital. Epistaxis that has failed all emergency management may require sphenopalatine ligation in theatre. Overall, understanding the causes and management of epistaxis is crucial in providing effective care for patients experiencing nosebleeds.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 22
Incorrect
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A 65-year-old male is referred with episodes of severe vertigo which may last up to four hours and are associated with vomiting and uncomfortable pressure in the right ear.
On examination during an attack he is noted to have right horizontal nystagmus together with mild right-sided sensorineural deafness.
Which one of the following is the most likely diagnosis?Your Answer: Labyrinthitis
Correct Answer: Ménière's disease
Explanation:Ménière’s Disease: A History of Paroxysmal Attacks
Ménière’s disease is characterized by paroxysmal attacks that can last for hours and consist of vertigo, vomiting, pressure within the ear, and deafness. These attacks can lead to irreversible sensorineural deafness of low frequency. Tinnitus is often present but may not occur in the early stages, making the classic triad of tinnitus, vertigo, and deafness unreliable for diagnosis.
Prochlorperazine or cinnarizine can help with vomiting, and restricting salt and fluid intake may hasten resolution. Diuretics may also be used, but there is little evidence for their efficacy. Unilateral hearing loss caused by acoustic neuroma is uncommonly associated with vertigo.
Benign positional vertigo is characterized by brief episodes of vertigo that are triggered by movement. Labyrinthitis is characterized by acute disabling vertigo, usually preceded by an upper respiratory tract infection, and is rarely episodic. Vertebrobasilar ischaemic attacks last only a few minutes and typically cause a mild swaying or swimming sensation.
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This question is part of the following fields:
- Neurology
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Question 23
Incorrect
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A 38-year-old female presents with an acute illness. She reports experiencing a fever, malaise, and a sore throat. She has a medical history of asthma, hyperthyroidism, and migraines. Her current medications include salbutamol inhaled as needed, sumatriptan 50 mg as needed, carbimazole 40 mg daily, and Cerazette 75 mcg daily. What blood tests should be ordered?
Your Answer: Full blood count
Correct Answer: Liver function
Explanation:Carbimazole and Infection Risk
Carbimazole is a medication used to treat thyrotoxicosis by blocking the iodination of thyroid hormone. However, patients taking carbimazole should be aware of the potential risk of infection, particularly sore throat, and report any symptoms or signs of infection to their healthcare provider. This is because carbimazole can cause bone marrow suppression, which can lead to agranulocytosis, a rare but serious adverse effect.
If a patient on carbimazole presents with an acute illness consisting of fever, malaise, and sore throat, a full blood count should be performed to assess the white blood cell count and differential. If neutropenia is found, carbimazole should be stopped immediately. It is important for healthcare providers to monitor patients taking carbimazole for signs of infection and to take appropriate action if necessary to prevent serious complications.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 24
Correct
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You assess a 48-year-old woman who was diagnosed with breast cancer two years ago. She has been experiencing difficulty walking since yesterday and can only take a few steps. What is the earliest and most common sign of spinal cord compression?
Your Answer: Back pain
Explanation:The earliest and most common symptom of spinal cord compression is back pain.
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, which are more common in patients with lung, breast, and prostate cancer. The earliest and most common symptom 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, while lesions below L1 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.
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. Proper management is crucial to prevent further damage to the spinal cord and improve the patient’s quality of life.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 25
Incorrect
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A 23-year-old female contacts you seeking guidance. She missed taking her Microgynon 30 pill yesterday. For the past 14 days, she has been sexually active with her partner. She is currently on her fifth day of a new pill packet and has not missed any other pills.
What advice would you provide?Your Answer: Take the missed pill as soon as possible, use condoms for the next 7 days
Correct Answer: Take the missed pill as soon as possible, no additional measures needed
Explanation:If one COCP pill is missed, the patient should take the last pill as soon as possible, but no additional action is required.
The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their advice for women taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol. If one pill is missed at any time during the cycle, the woman should take the last pill, even if it means taking two pills in one day, and then continue taking pills daily, one each day. No additional contraceptive protection is needed. However, if two or more pills are missed, the woman should take the last pill, leave any earlier missed pills, and then continue taking pills daily, one each day. She should use condoms or abstain from sex until she has taken pills for seven days in a row. If pills are missed in week one, emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week one. If pills are missed in week two, after seven consecutive days of taking the COC, there is no need for emergency contraception. If pills are missed in week three, she should finish the pills in her current pack and start a new pack the next day, thus omitting the pill-free interval. Theoretically, women would be protected if they took the COC in a pattern of seven days on, seven days off.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 26
Correct
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A 65-year-old man complains of increasing stiffness and pain in his right knee and seeks medical attention. He denies any history of trauma, locking, or giving way. Upon examination, an x-ray reveals the following findings:
Plain film: right knee
Moderate degenerative changes indicative of osteoarthritis. Intra-articular calcification, possibly a loose body.
What is the best course of action for managing this patient's condition?Your Answer: Continue to manage as per osteoarthritis guidelines
Explanation:According to the recent guidelines by NICE, there is no requirement to refer a patient with x-ray evidence of a loose body if they are asymptomatic and not experiencing locking.
The Role of Glucosamine in Osteoarthritis Management
Glucosamine is a natural component found in cartilage and synovial fluid. Several double-blind randomized controlled trials have reported significant short-term symptomatic benefits of glucosamine in knee osteoarthritis, including reduced joint space narrowing and improved pain scores. However, more recent studies have produced mixed results. The 2008 NICE guidelines do not recommend the use of glucosamine, and a Drug and Therapeutics Bulletin review advised against prescribing it on the NHS due to limited evidence of cost-effectiveness. Despite this, some patients may still choose to use glucosamine as a complementary therapy for osteoarthritis management. It is important for healthcare professionals to discuss the potential benefits and risks of glucosamine with their patients and to consider individual patient preferences and circumstances.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 27
Incorrect
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What is a metabolic effect of exenatide?
Your Answer: Promotes gluconeogenesis by the liver
Correct Answer: Accelerates gastric emptying
Explanation:Exenatide and its Metabolic Effects
Exenatide is a medication that imitates the effects of GLP-1, a hormone produced in the gut. It has been found to have beneficial effects on the metabolism of individuals with diabetes mellitus. This medication has several metabolic effects, including the suppression of appetite, inhibition of glucose production in the liver, slowing of gastric emptying, and stimulation of insulin release. However, it doesn’t increase insulin sensitivity, which is achieved by other drugs such as metformin and the glitazones. Overall, exenatide has been shown to have a positive impact on the management of diabetes by regulating various metabolic processes.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 28
Incorrect
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A 58-year-old man is discharged from hospital after suffering an acute coronary syndrome. He has type 2 diabetes and takes metformin. Diabetic control had previously been good.
What is the most appropriate statement to make regarding this patient's management?Your Answer: Blood pressure should be 150/80 mmHg or less
Correct Answer: Statins should always be started unless they are contraindicated
Explanation:Correct Management of Type 2 Diabetes and Cardiovascular Disease: Common Misconceptions
There are several misconceptions regarding the management of type 2 diabetes and cardiovascular disease that need to be addressed. One common misconception is that statins should only be started if a formal risk assessment is conducted. However, the National Institute for Health and Care Excellence recommends that statin treatment with atorvastatin 80 mg should always be started for secondary prevention of cardiovascular disease, unless contraindicated.
Another misconception is that blood pressure should be 150/80 mmHg or less. The target for blood pressure in type 2 diabetes is actually 140/90 mmHg, and following a myocardial infarction, it may be prudent to aim even lower.
It is also incorrect to assume that insulin should be started for all patients with type 2 diabetes and cardiovascular disease. Insulin should only be used if clinically indicated due to poor diabetic control.
Contrary to popular belief, the usual cardiac rehabilitation program is not contraindicated for patients with type 2 diabetes and cardiovascular disease. All patients should be given advice about and offered a cardiac rehabilitation program with an exercise component.
Finally, the use of angiotensin-converting-enzyme (ACE) inhibition is not contraindicated in the first six weeks after a myocardial infarction. In fact, people who have had a myocardial infarction with or without diabetes should normally be discharged from the hospital with ACE inhibitor treatment, provided there are no contraindications.
In summary, it is important to dispel these common misconceptions and ensure that patients with type 2 diabetes and cardiovascular disease receive appropriate and evidence-based management.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 29
Correct
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At the age of 35, Mary recently gave birth to her first child, a son named Tom, who has Down syndrome. His parents have come to terms with the diagnosis, Tom seems to be thriving in all other respects, and there is no reported family history, although Mary's husband Peter was adopted.
At the three month immunisation visit, Mary tells you that she wants to try for another child and wonders what the risk is of having another affected child. You have the option of referring your patients to the genetic clinic for chromosome analysis, if deemed suitable.
Which of the following is the single best answer to her question?Your Answer: Chromosome analysis from Tom may help answer her question
Explanation:Recurrence Risk for Down Syndrome
There is a small chance of recurrence (about 1%) for Down syndrome if it is caused by non-disjunction of chromosome 21. However, if the individual has inherited a translocation from either parent, the risk of recurrence is higher. To determine the risk, a chromosome analysis of the individual’s blood is necessary.
If the individual has a translocation between chromosomes 21 and 13 or 14 (which occurs in 3-4% of Down syndrome cases), the risk of recurrence increases to 2-3% if carried by the father and 10% if carried by the mother. If the individual has a translocation of chromosome 21 onto another chromosome 21 (known as isochromosome 21, found in 1% of cases), and it is found in either parent, then the recurrence risk is practically 100%.
Therefore, if an individual with Down syndrome has a translocation, both parents should be tested to clarify the risk. However, if the individual has a simple trisomy, the parents can be reassured that the recurrence risk is normal (1%).
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This question is part of the following fields:
- Genomic Medicine
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Question 30
Correct
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A 28-year-old woman presents with a 2-year history of mild persistent erythema on her cheeks and nose, which worsens with spicy foods and hot drinks. She has noticed a recent worsening of her symptoms and is now 12 weeks pregnant. On examination, you note a centrofacial erythematous rash with papules, pustules, and a bulbous nose. The patient has no known medication allergies. What is the most appropriate course of action?
Your Answer: Refer to dermatology
Explanation:Patients who have developed rhinophyma as a result of rosacea should be referred to a dermatologist for further evaluation and treatment. Rhinophyma is a severe form of rosacea that affects the nasal soft tissues, causing nasal obstruction, disfigurement, and significant psychological distress. Only specialized care in secondary settings can provide the necessary assessment and management, which may include laser therapy, scalpel excision, electrocautery, or surgery.
Continuing with self-management measures is not recommended as the patient requires an escalation in treatment. However, lifestyle modifications remain an essential aspect of her management.
Prescribing oral doxycycline is not appropriate in this case as the patient is pregnant, and the medication is contraindicated.
Topical brimonidine is also not recommended as the manufacturer advises against its use during pregnancy due to limited information available. While it can provide temporary relief of flushing and erythema symptoms, it is not a suitable treatment option for rhinophyma.
Rosacea, also known as acne rosacea, is a skin condition that is chronic in nature and its cause is unknown. It typically affects the nose, cheeks, and forehead, and the first symptom is often flushing. Telangiectasia, which are small blood vessels that are visible on the skin, are common, and the condition can progress to persistent erythema with papules and pustules. Rhinophyma, a condition where the nose becomes enlarged and bulbous, can also occur. Ocular involvement, such as blepharitis, can also be present, and sunlight can exacerbate symptoms.
Management of rosacea depends on the severity of the symptoms. For mild symptoms, topical metronidazole may be used, while topical brimonidine gel may be considered for patients with predominant flushing but limited telangiectasia. More severe cases may require systemic antibiotics such as oxytetracycline. It is recommended that patients apply a high-factor sunscreen daily and use camouflage creams to conceal redness. Laser therapy may be appropriate for patients with prominent telangiectasia, and those with rhinophyma should be referred to a dermatologist for further management.
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This question is part of the following fields:
- Dermatology
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