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  • Question 1 - A 28-year-old female presents to the ENT specialists with a 1-month-history of severe...

    Incorrect

    • A 28-year-old female presents to the ENT specialists with a 1-month-history of severe otalgia, temporal headaches, and purulent otorrhoea. She has a medical history of type one diabetes mellitus and no allergies. On examination, the left external auditory canal and periauricular soft tissue are erythematous and tender. What is the most suitable antibiotic treatment for this patient?

      Your Answer: No antibiotics required

      Correct Answer: Ciprofloxacin

      Explanation:

      For patients with diabetes who present with otitis externa, it is important to consider the possibility of malignant otitis externa, which is a severe bacterial infection that can spread to the bony ear canal and cause osteomyelitis. Pseudomonas aeruginosa is the most common cause of this condition, so treatment should involve coverage for this bacteria. Intravenous ciprofloxacin is the preferred antibiotic for this purpose. It is also important to note that diabetic patients with non-malignant otitis externa should also be treated with ciprofloxacin due to their increased risk of developing malignant otitis externa. Clarithromycin and flucloxacillin are not appropriate choices for this condition, and leaving the infection untreated can lead to serious complications.

      Malignant Otitis Externa: A Rare but Serious Infection

      Malignant otitis externa is a type of ear infection that is uncommon but can be serious. It is typically found in individuals who are immunocompromised, with 90% of cases occurring in diabetics. The infection starts in the soft tissues of the external auditory meatus and can progress to involve the soft tissues and bony ear canal, eventually leading to temporal bone osteomyelitis.

      When diagnosing malignant otitis externa, doctors will typically perform a CT scan. Key features in a patient’s medical history include diabetes or immunosuppression, severe and unrelenting ear pain, temporal headaches, and purulent otorrhea. In some cases, patients may also experience dysphagia, hoarseness, and/or facial nerve dysfunction.

      If a patient presents with non-resolving otitis externa and worsening pain, they should be referred urgently to an ear, nose, and throat specialist. Treatment typically involves intravenous antibiotics that cover pseudomonal infections.

      Overall, while malignant otitis externa is rare, it is important to be aware of its symptoms and risk factors, particularly in immunocompromised individuals. Early diagnosis and treatment can help prevent the infection from progressing and causing more serious complications.

    • This question is part of the following fields:

      • ENT
      86.3
      Seconds
  • Question 2 - A 68-year-old female with a history of osteoporosis is prescribed alendronate. What is...

    Incorrect

    • A 68-year-old female with a history of osteoporosis is prescribed alendronate. What is the most crucial side-effect to caution her about?

      Your Answer: Diarrhoea

      Correct Answer: Heartburn

      Explanation:

      Patients starting bisphosphonates should be warned about potential oesophageal problems, particularly with alendronate. Any new symptoms following the introduction of this drug should be reviewed by a medical professional.

      Bisphosphonates: Uses and Adverse Effects

      Bisphosphonates are drugs that mimic the action of pyrophosphate, a molecule that helps prevent bone demineralization. They work by inhibiting osteoclasts, which are cells that break down bone tissue. This reduces the risk of bone fractures and can be used to treat conditions such as osteoporosis, hypercalcemia, Paget’s disease, and pain from bone metastases.

      However, bisphosphonates can have adverse effects, including oesophageal reactions such as oesophagitis and ulcers, osteonecrosis of the jaw, and an increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate. Patients may also experience an acute phase response, which can cause fever, myalgia, and arthralgia. Hypocalcemia, or low calcium levels, can also occur due to reduced calcium efflux from bone, but this is usually not clinically significant.

      To minimize the risk of adverse effects, patients taking oral bisphosphonates should swallow the tablets whole with plenty of water while sitting or standing. They should take the medication on an empty stomach at least 30 minutes before breakfast or other oral medications and remain upright for at least 30 minutes after taking the tablet. Hypocalcemia and vitamin D deficiency should be corrected before starting bisphosphonate treatment, and calcium supplements should only be prescribed if dietary intake is inadequate. The duration of bisphosphonate treatment varies depending on the patient’s level of risk, and some authorities recommend stopping treatment after five years for low-risk patients with a femoral neck T-score of > -2.5.

    • This question is part of the following fields:

      • Musculoskeletal
      36.4
      Seconds
  • Question 3 - A 5-year-old girl is discovered collapsed and unresponsive. Upon examination, there are no...

    Correct

    • A 5-year-old girl is discovered collapsed and unresponsive. Upon examination, there are no apparent obstructions in her airway. There are no signs of life and no indication of any respiratory efforts being made. Emergency assistance has been summoned and is en route.
      What is the most suitable course of action to take next in her treatment?

      Your Answer: Give 5 rescue breaths

      Explanation:

      The correct initial step for paediatric basic life support (BLS) is to give 5 rescue breaths immediately, even before checking for a pulse. This is because respiratory causes are the most common in children. Checking for a femoral pulse is not necessary to determine the need for chest compressions, as palpation of the pulse is not a reliable indicator of effective circulation. Giving 2 rescue breaths is incorrect for children, as they require 5 rescue breaths to mitigate hypoxia. The correct ratio of chest compressions to rescue breaths is 15:2, but the first step in paediatric BLS is always to give 5 rescue breaths.

      Paediatric Basic Life Support Guidelines

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

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

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

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

    • This question is part of the following fields:

      • Paediatrics
      21
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  • Question 4 - A 67-year-old woman presents to the Memory Clinic with a 9-month history of...

    Incorrect

    • A 67-year-old woman presents to the Memory Clinic with a 9-month history of cognitive decline. Her daughter mentions that she has difficulty remembering basic tasks and is becoming more confused and forgetful than usual. Her daughter noticed a change in her personality and has caught her leaving the stove on and wandering outside alone on multiple occasions.
      Given the likely diagnosis, which of the following is the most appropriate initial step in this patient’s management?
      Select the SINGLE most appropriate management from the list below.

      Your Answer: Start treatment with an acetylcholinesterase (AChE) inhibitor agent

      Correct Answer: Stop drugs that may be exacerbating memory problems or confusion (anticholinergics, central nervous system drugs)

      Explanation:

      Managing Frontotemporal Dementia: Treatment Options and Referrals

      Frontotemporal dementia (FTD) is a progressive neurodegenerative disorder that affects behavior, language, and executive function. While there is no cure for FTD, management strategies can help alleviate symptoms and provide support for patients and their families.

      One important step in managing FTD is to stop any drugs that may be exacerbating memory problems or confusion, such as anticholinergics or central nervous system drugs. Multidisciplinary health and social care is also crucial, involving referrals to geriatric medicine, psychiatry, psychology, social work, occupational therapy, speech and language therapy, physiotherapy, and community nursing.

      However, certain treatment options should be avoided or used with caution in FTD patients. Benzodiazepines, for example, are associated with cognitive worsening and fall-related injuries. Anticholinesterase inhibitors, typically used in mild to moderate Alzheimer’s disease, have shown disappointing results in FTD patients who do not have cholinergic loss. Memantine, used in moderate to severe Alzheimer’s disease, has not been shown to be effective in FTD and may even have a detrimental effect on cognition in some individuals.

      Antipsychotics should only be used cautiously and when other options have failed, as FTD patients are at higher risk of extrapyramidal side effects. Overall, a personalized and coordinated approach to FTD management is essential for optimizing patient outcomes.

    • This question is part of the following fields:

      • Neurology
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  • Question 5 - A 65-year-old man with chronic kidney failure has been instructed by his nephrologist...

    Incorrect

    • A 65-year-old man with chronic kidney failure has been instructed by his nephrologist to adhere to a 'renal diet'. He visits you to gain further knowledge about this. What is typically recommended to individuals with chronic kidney disease?

      Your Answer: High calcium diet

      Correct Answer: Low potassium diet

      Explanation:

      Dietary Recommendations for Chronic Kidney Disease Patients

      Chronic kidney disease patients are recommended to follow a specific diet to reduce the strain on their kidneys. This diet includes low levels of protein, phosphate, sodium, and potassium. The reason for this is that these substances are typically excreted by the kidneys, and reducing their intake can help ease the burden on the kidneys. By following this diet, patients can help slow the progression of their kidney disease and improve their overall health. It is important for patients to work with a healthcare professional or registered dietitian to ensure they are meeting their nutritional needs while following these dietary restrictions.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      16.7
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  • Question 6 - A 56-year-old woman presents to the emergency department with symptoms of malaise and...

    Correct

    • A 56-year-old woman presents to the emergency department with symptoms of malaise and diarrhoea. She reports feeling shivery and achy for the past 3 days and has had 4 watery stools in the past 24 hours. The patient has a history of breast cancer and is currently undergoing chemotherapy. Her last dose of doxorubicin and cyclophosphamide was administered 10 days ago. She has no known allergies and takes no other medications. On examination, her heart rate is 103/min, respiratory rate is 20/min with saturations of 100% in room air, blood pressure is 100/79 mmHg, and temperature is 39.1ºC.

      What is the initial management approach for this patient while awaiting the results of her blood culture?

      Your Answer: Piperacillin with tazobactam (tazocin)

      Explanation:

      The recommended empirical antibiotic for managing neutropenic sepsis is Piperacillin with tazobactam (Tazocin). This is because the patient is displaying symptoms such as malaise, diarrhoea, flu-like aching, mild tachycardia, and a temperature >38ºC, and has a history of chemotherapy within the past 7-14 days. As the patient has no allergies, Tazocin should be administered until blood cultures show a specific sensitivity. Amoxicillin is not effective in treating neutropenic sepsis as it is not broad-spectrum enough. Meropenem is only indicated in patients with previous or suspected ESBL, acute leukaemia, or allogeneic stem cell transplants, and is not recommended as first-line treatment according to NICE guidelines. Teicoplanin is recommended for patients with penicillin or beta-lactam allergies and evidence of neutropenic sepsis, but should be used in combination with another non-penicillin antibiotic as per local guidelines. Vancomycin is an alternative for penicillin-allergic patients, and should be administered with gentamicin, ciprofloxacin, or amikacin depending on local guidelines and the severity of the patient’s presentation.

      Neutropenic Sepsis: A Common Complication of Cancer Therapy

      Neutropenic sepsis is a frequent complication of cancer therapy, particularly chemotherapy. It typically occurs within 7-14 days after chemotherapy and is characterized by a neutrophil count of less than 0.5 * 109 in patients undergoing anticancer treatment who exhibit a temperature higher than 38ºC or other signs or symptoms consistent with clinically significant sepsis.

      To prevent neutropenic sepsis, patients who are likely to have a neutrophil count of less than 0.5 * 109 as a result of their treatment should be offered a fluoroquinolone. In the event of neutropenic sepsis, antibiotics must be initiated immediately, without waiting for the white blood cell count.

      According to NICE guidelines, empirical antibiotic therapy should begin with piperacillin with tazobactam (Tazocin) immediately. While some units may add vancomycin if the patient has central venous access, NICE does not support this approach. After initial treatment, patients are typically assessed by a specialist and risk-stratified to determine if they may be able to receive outpatient treatment.

      If patients remain febrile and unwell after 48 hours, an alternative antibiotic such as meropenem may be prescribed, with or without vancomycin. If patients do not respond after 4-6 days, the Christie guidelines suggest ordering investigations for fungal infections (e.g. HRCT) rather than blindly initiating antifungal therapy. In selected patients, G-CSF may be beneficial.

    • This question is part of the following fields:

      • Infectious Diseases
      33
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  • Question 7 - A 6-year-old boy is brought to his General Practitioner by his mother, who...

    Incorrect

    • A 6-year-old boy is brought to his General Practitioner by his mother, who reports that he has been feeling tired and has developed mouth sores. Additionally, he has bruises on his knees and palms. A bone marrow aspirate reveals a hypocellular image.

      What is the most probable diagnosis?

      Your Answer: Infectious mononucleosis

      Correct Answer: Aplastic anaemia

      Explanation:

      Differential Diagnosis for a Patient with Hypocellular Bone Marrow and Thrombocytopenia

      Aplastic anaemia is a condition characterized by bone marrow failure, resulting in peripheral pancytopenia and bone-marrow hypoplasia. This leads to a deficiency in the production of red blood cells, causing anaemia, and a reduced production of white blood cells, leading to immunodeficiency. Patients may experience symptoms such as shortness of breath, lethargy, pallor, mouth ulcers, and increased frequency of infections. The reduced production of platelets causes easy bruising.

      Idiopathic thrombocytopenic purpura (ITP) is a condition characterized by an isolated reduction in platelets with normal bone marrow, in the absence of another identifiable cause. Patients may present with abnormal bleeding and bruising, petechiae, and purpura.

      Haemophilia A is an X-linked-recessive condition causing a deficiency in clotting factor VIII, leading to easy bruising, prolonged bleeding after injury, or spontaneous bleeding in severe cases.

      Infectious mononucleosis is the result of Epstein–Barr virus infection, characterized by fever, pharyngitis, lymphadenopathy, and a macular or maculopapular rash.

      Autoimmune neutropenia is associated with opportunistic infections, most commonly otitis media. However, this condition would not account for the thrombocytopenia observed in this patient.

    • This question is part of the following fields:

      • Paediatrics
      30.7
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  • Question 8 - A 32-year-old woman comes in for a check-up. She has been experiencing fatigue...

    Correct

    • A 32-year-old woman comes in for a check-up. She has been experiencing fatigue and has not had a regular period for the past 5 months. She previously had a consistent 28-day cycle. A pregnancy test is negative, her pelvic exam is normal, and routine blood work is ordered:

      - Complete blood count: Normal
      - Blood urea nitrogen and electrolytes: Normal
      - Thyroid function test: Normal
      - Follicle-stimulating hormone: 40 iu/l ( < 35 iu/l)
      - Luteinizing hormone: 30 mIU/l (< 20 mIU/l)
      - Oestradiol: 75 pmol/l ( > 100 pmol/l)

      What is the most likely diagnosis?

      Your Answer: Premature ovarian failure

      Explanation:

      Premature Ovarian Insufficiency: Causes and Management

      Premature ovarian insufficiency is a condition where menopausal symptoms and elevated gonadotrophin levels occur before the age of 40. It affects approximately 1 in 100 women and can be caused by various factors such as idiopathic reasons, family history, bilateral oophorectomy, radiotherapy, chemotherapy, infection, autoimmune disorders, and resistant ovary syndrome. The symptoms of premature ovarian insufficiency are similar to those of normal menopause, including hot flushes, night sweats, infertility, secondary amenorrhoea, raised FSH and LH levels, and low oestradiol.

      Management of premature ovarian insufficiency involves hormone replacement therapy (HRT) or a combined oral contraceptive pill until the age of the average menopause, which is 51 years. It is important to note that HRT does not provide contraception in case spontaneous ovarian activity resumes. Early diagnosis and management of premature ovarian insufficiency can help alleviate symptoms and improve quality of life for affected women.

    • This question is part of the following fields:

      • Reproductive Medicine
      63.9
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  • Question 9 - A 42-year-old woman visits her doctor with complaints of a persistent blocked nose...

    Correct

    • A 42-year-old woman visits her doctor with complaints of a persistent blocked nose and reduced sense of smell for the past few months. During examination, the doctor observes pale grey mucosal sacs in both nostrils. The patient has a history of allergies but is otherwise healthy. What is the most likely condition she is suffering from?

      Your Answer: Aspirin usage

      Explanation:

      Medical Conditions and Medication Usage: A Brief Overview

      Aspirin Usage and Nasal Polyps
      Nasal polyps, asthma, and rhinosinusitis are all symptoms of aspirin-exacerbated respiratory disease. This condition is caused by hypersensitivity to aspirin or other cyclooxygenase 1 inhibitors and typically develops in individuals aged 30-40 years. Treatment involves avoiding non-steroidal anti-inflammatory drugs, and in some cases, aspirin desensitization may be performed.

      COPD and Nasal Polyps
      While nasal polyps can be associated with asthma, there is no known association with chronic obstructive pulmonary disease (COPD). Smokers with nosebleeds or unilateral nasal polyps should be referred for urgent ENT assessment to rule out malignancy.

      Infective Endocarditis and Nasal Polyps
      Infective endocarditis occurs when bacteria enters the bloodstream, usually via poor dentition, an open wound, or mechanical device placed in the heart. There is no known association between nasal polyps and infective endocarditis.

      Paracetamol Usage and Nasal Polyps
      Nasal polyps are associated with aspirin sensitivity, not sensitivity to paracetamol. According to the British National Formulary, the only side effect of oral paracetamol is thrombocytopenia, which is considered very rare.

      Simvastatin Usage and Nasal Polyps
      Nasal polyps are not a recognized side effect of statins, which can cause muscle aches, headaches, diarrhea, and sleep disturbances.

      Understanding Medical Conditions and Medication Usage

    • This question is part of the following fields:

      • ENT
      26.8
      Seconds
  • Question 10 - A 60-year-old woman has blood tests done by her primary care physician during...

    Correct

    • A 60-year-old woman has blood tests done by her primary care physician during a routine check-up. The results show a decline in her renal function. Upon further examination, she reports experiencing ankle swelling and increased fatigue. The renal team suspects she may have amyloidosis. What diagnostic test could be used to confirm this diagnosis?

      Your Answer: Renal biopsy

      Explanation:

      Diagnostic Methods for Renal Amyloidosis

      Renal amyloidosis is a condition that can be challenging to diagnose. It is caused by the accumulation of proteinaceous material in tissues, which can be identified through a biopsy. Congo-red staining extracellular fibrillar material is a characteristic feature of amyloid protein in the kidney. While a urine dip may show proteinuria, a renal biopsy is necessary for a definitive diagnosis as proteinuria can be caused by other conditions. A bone marrow biopsy can confirm amyloidosis if there is suspicion of bone marrow infiltration. CT scans of the abdomen may reveal abnormalities in the kidneys or lymph nodes, but a renal biopsy is still required for a definitive diagnosis. As amyloidosis can affect other organs, a lung biopsy may not be the most targeted approach for diagnosing renal amyloidosis. Overall, a renal biopsy is the most reliable method for diagnosing renal amyloidosis.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      81.6
      Seconds
  • Question 11 - A 45-year-old woman presents to her General Practitioner with a 3-day history of...

    Correct

    • A 45-year-old woman presents to her General Practitioner with a 3-day history of increased urinary frequency, urgency, nocturia and mild, lower abdominal discomfort.
      On examination, she looks well. She is afebrile, while her abdomen is soft and nontender. A urine dipstick is performed. Her estimated glomerular filtration rate was normal: > 90 ml/minute per 1.73 m2 three months ago.
      Urinalysis reveals the following:
      Investigation Result
      Leukocytes +++
      Nitrates +
      Blood +
      What is the most appropriate initial treatment option?

      Your Answer: Nitrofurantoin 100 mg twice a day for seven days

      Explanation:

      The recommended first-line treatment for uncomplicated UTIs is nitrofurantoin, with trimethoprim as an alternative if resistance is low. Painless haematuria warrants investigation of the renal tract, and this should also be considered in men with confirmed UTIs. Amoxicillin is not typically recommended for UTIs due to its inactivation by penicillinase produced by E. coli, but it may be appropriate if the causative organism is sensitive to it. While waiting for MSU results, empirical antibiotic treatment should be started immediately if a UTI is suspected. Ciprofloxacin is indicated for acute prostatitis or pyelonephritis, not uncomplicated lower UTIs, and caution is needed when prescribing quinolones to the elderly due to the risk of tendon rupture. Trimethoprim is an appropriate first-line antibiotic for lower UTIs in men, with a 7-day course recommended, while a 3-day course is suitable for non-pregnant women under 65.

    • This question is part of the following fields:

      • Infectious Diseases
      58.8
      Seconds
  • Question 12 - A 42-year-old man with known gallstones awaiting elective laparoscopic cholecystectomy attends his general...

    Incorrect

    • A 42-year-old man with known gallstones awaiting elective laparoscopic cholecystectomy attends his general practice surgery, complaining of a fever. He also has flu-like symptoms and pain in his abdomen.
      On examination, his temperature is 38.5 °C. His pulse is 120 bpm. He has yellow sclera and an abdomen which is soft but tender in the right upper quadrant.
      What is the most likely diagnosis?
      Select the SINGLE most likely diagnosis from the list below. Select ONE option only.

      Your Answer: Biliary colic

      Correct Answer: Ascending cholangitis

      Explanation:

      Distinguishing Causes of Obstructive Jaundice: A Medical Overview

      Obstructive jaundice is a condition characterized by the yellowing of the skin and eyes due to the blockage of the bile ducts. Ascending cholangitis is a common cause of this condition, often associated with gallstone disease. Patients with this condition may experience fever, tachycardia, and abdominal pain. Influenza, on the other hand, rarely causes localized pain in the right upper quadrant and is unlikely to result in obstructive jaundice. Pancreatic cancer typically presents with painless jaundice, while acute hepatitis is often associated with a history of travel or high-risk behaviors. Biliary colic, which is caused by gallstones, can lead to colicky pain after eating. Understanding the different causes of obstructive jaundice is crucial in determining the appropriate treatment plan for patients.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      47.1
      Seconds
  • Question 13 - A 68-year-old man presents to his GP with symptoms of urinary frequency, mild...

    Correct

    • A 68-year-old man presents to his GP with symptoms of urinary frequency, mild incontinence, and nocturia. Upon rectal examination, an enlarged and nontender prostate is noted, leading to a diagnosis of benign prostatic hyperplasia. The patient is prescribed finasteride. What is the mechanism of action of finasteride?

      Your Answer: It is a 5-alpha reductase inhibitor

      Explanation:

      Finasteride inhibits 5-alpha reductase, an enzyme that converts testosterone to DHT, and is prescribed for benign prostatic hyperplasia. This reduces the size of the prostate. Trimethoprim binds to dihydrofolate reductase, which interferes with bacterial DNA synthesis. Tamsulosin is an alpha blocker that selectively blocks alpha 1 receptors in the bladder neck and prostate, causing smooth muscle relaxation. Oxybutynin competitively antagonizes muscarinic receptors on the bladder, providing a direct spasmolytic effect on the bladder smooth muscle. Sildenafil inhibits cGMP specific phosphodiesterase type 5, improving blood flow to the penis and treating erectile dysfunction.

      Understanding Finasteride: Its Uses and Side Effects

      Finasteride is a medication that works by inhibiting the activity of 5 alpha-reductase, an enzyme responsible for converting testosterone into dihydrotestosterone. This drug is commonly used to treat benign prostatic hyperplasia and male-pattern baldness.

      However, like any medication, finasteride has its own set of adverse effects. Some of the most common side effects include impotence, decreased libido, ejaculation disorders, gynaecomastia, and breast tenderness. It is important to note that finasteride can also cause decreased levels of serum prostate-specific antigen.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      18.9
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  • Question 14 - A 14-year-old girl is referred to haematology due to heavy and prolonged periods...

    Incorrect

    • A 14-year-old girl is referred to haematology due to heavy and prolonged periods that have not responded well to tranexamic acid and the combined oral contraceptive pill. Her blood tests reveal Hb of 10.3 g/dl, Plt of 239 * 109/l, WBC of 6.5 * 109/l, PT of 12.9 secs, and APTT of 37 secs. What is the probable diagnosis?

      Your Answer: Idiopathic thrombocytopenic purpura

      Correct Answer: Von Willebrand's disease

      Explanation:

      Understanding Von Willebrand’s Disease

      Von Willebrand’s disease is a common inherited bleeding disorder that is usually passed down in an autosomal dominant manner. It behaves like a platelet disorder, with symptoms such as nosebleeds and heavy menstrual bleeding being common, while joint and muscle bleeding are rare. The disease is caused by a deficiency or abnormality in von Willebrand factor, a large glycoprotein that promotes platelet adhesion to damaged endothelium and acts as a carrier molecule for factor VIII.

      There are three types of Von Willebrand’s disease. Type 1 is the most common and is characterized by a partial reduction in von Willebrand factor. Type 2 is further divided into four subtypes, each with a different abnormality in the von Willebrand factor. Type 3 is the most severe form and is caused by a total lack of von Willebrand factor, inherited in an autosomal recessive manner.

      Diagnosis of Von Willebrand’s disease involves tests such as a prolonged bleeding time, APTT, factor VIII levels, and platelet aggregation with ristocetin. Management options include tranexamic acid for mild bleeding, desmopressin to raise levels of von Willebrand factor, and factor VIII concentrate. While there is no clear correlation between symptomatic presentation and type of Von Willebrand’s disease, common themes among patients include excessive mucocutaneous bleeding, bruising in the absence of trauma, and menorrhagia in females.

    • This question is part of the following fields:

      • Haematology/Oncology
      42.8
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  • Question 15 - A highly active 12-year-old boy who plays football for his local team reports...

    Correct

    • A highly active 12-year-old boy who plays football for his local team reports knee pain for several months. Upon examination, tenderness is noted over the tibial tuberosity.
      What is the most probable diagnosis?

      Your Answer: Osgood-Schlatter disease

      Explanation:

      Common Causes of Knee Pain in Young Patients

      Knee pain is a common complaint among young patients, especially those who are active in sports. Here are some of the most common causes of knee pain in this population:

      1. Osgood-Schlatter disease: This condition is caused by overuse of quadriceps, putting strain on the patellar ligament attachment to the tibia, which is not yet fully developed. The key clinical examination finding is tenderness over the tibial tuberosity, and there may well be a bony lump over the area as well.

      2. Patellar subluxation: This describes the temporary but recurring lateral subluxation of the patella. Patients may describe the knee ‘giving way’ or feeling it move out of place, most commonly during activity such as running or jumping.

      3. Chondromalacia patellae: This is caused by abnormal softening of the cartilage on the underside of the patella. Patients will describe anterior knee pain, which is worse after sitting for a prolonged length of time, or for activities including walking down the stairs, jumping, running or climbing.

      4. Osteoarthritis: This is a disease of older age, owing to degeneration of the articular cartilage. It is often seen in the weight-bearing areas, including the knee and hip, as well as in the hands.

      5. Osteochondritis dissecans: This 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 a vague and achy joint pain that is made worse by activity, and may be accompanied by swelling.

      It is important to note that knee pain in children could also be due to hip pathology, such as SUFE (slipped upper femoral epiphysis). Proper diagnosis and management are crucial for the long-term health of the joint.

    • This question is part of the following fields:

      • Musculoskeletal
      16.5
      Seconds
  • Question 16 - A 75-year-old woman visits her general practitioner with a complaint of itchy white...

    Incorrect

    • A 75-year-old woman visits her general practitioner with a complaint of itchy white plaques on her vulva and inner thigh. She denies experiencing any vaginal discharge or bleeding. What is the probable diagnosis?

      Your Answer: Lichen planus

      Correct Answer: Lichen sclerosus

      Explanation:

      Lichen sclerosus is a condition characterized by itchy white spots that are commonly observed on the vulva of older women. While candida can also cause itching and white patches, it would not result in lesions appearing on the inner thigh as well.

      Understanding Lichen Sclerosus

      Lichen sclerosus, previously known as lichen sclerosus et atrophicus, is an inflammatory condition that commonly affects the genitalia, particularly in elderly females. This condition leads to the atrophy of the epidermis, resulting in the formation of white plaques. The most prominent feature of lichen sclerosus is the presence of white patches that may scar. Patients may also experience itching and pain during intercourse or urination.

      Diagnosis of lichen sclerosus is usually made based on clinical examination, but a biopsy may be performed if atypical features are present. Management of this condition involves the use of topical steroids and emollients. Patients with lichen sclerosus are at an increased risk of developing vulval cancer, and routine follow-up is necessary to monitor for any changes.

      The Royal College of Obstetricians and Gynaecologists advise against performing a skin biopsy if a diagnosis can be made on clinical examination. However, a biopsy may be necessary if the patient fails to respond to treatment or if there is a suspicion of neoplastic change. The British Association of Dermatologists also recommends a biopsy if there are atypical features or diagnostic uncertainty. Patients under routine follow-up will need a biopsy if there is a suspicion of neoplastic change, if the disease fails to respond to treatment, if there is extragenital lichen sclerosus, or if second-line therapy is to be used.

      Understanding lichen sclerosus is important for early diagnosis and management of this condition. Patients with this condition should seek medical attention if they experience any symptoms or changes in their condition.

    • This question is part of the following fields:

      • Dermatology
      39
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  • Question 17 - Which of the following is most commonly associated with the syndrome of inappropriate...

    Correct

    • Which of the following is most commonly associated with the syndrome of inappropriate ADH secretion?

      Your Answer: Small cell lung cancer

      Explanation:

      SIADH is a frequent endocrine complication associated with small cell lung cancer.

      SIADH is a condition where the body retains too much water, leading to low sodium levels in the blood. This can be caused by a variety of factors, including malignancies such as small cell lung cancer, neurological conditions like stroke or meningitis, infections such as tuberculosis or pneumonia, and certain drugs like sulfonylureas and SSRIs. Other causes may include positive end-expiratory pressure and porphyrias. Treatment for SIADH involves slowly correcting the sodium levels to avoid complications like central pontine myelinolysis. This can be done through fluid restriction, the use of demeclocycline to reduce responsiveness to ADH, or the use of ADH receptor antagonists. It is important to note that certain drugs, such as glimepiride and glipizide, have been reported to cause SIADH according to the BNF.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      13.6
      Seconds
  • Question 18 - A 45-year-old man with known permanent AF (atrial fibrillation) on warfarin has a...

    Incorrect

    • A 45-year-old man with known permanent AF (atrial fibrillation) on warfarin has a fast, irregularly irregular pulse. He has no other past medical history. The ECG confirms AF with a rate of 132 beats/min. He is haemodynamically stable and well. He denies any history of palpitations, shortness of breath or syncope.
      Which of the following is the most appropriate intervention?

      Your Answer: Digoxin

      Correct Answer: Bisoprolol

      Explanation:

      Treatment Options for Atrial Fibrillation: A Comprehensive Guide

      Atrial fibrillation (AF) is a common cardiac arrhythmia that requires prompt and appropriate management to prevent complications. Here are some treatment options for AF:

      Rate Control: This is recommended for patients who have had AF for more than 48 hours. Beta-blockers are the first-line treatment unless there is a contraindication such as asthma. Calcium channel blockers can also be used.

      Digoxin: This drug can be used as rate control if the patient cannot have beta-blockers or calcium channel blockers. However, it should only be used as a third-line treatment or as an adjunct because it has been shown to increase mortality. It is also only effective in sedentary patients.

      DC Cardioversion: This can be used to treat new-onset AF if the patient has had it for less than 48 hours. It can also be considered in patients who have had it for longer than that, once they have been on stable anticoagulation for at least 3 weeks.

      Flecainide: This is a class Ic antiarrhythmic drug that can be used as chemical cardioversion in new AF (<48 hours) or if a patient has been anticoagulated for >3 weeks.

      Rhythm Control: Nice guidelines advise that rhythm control can be used if AF onset was <48 hours ago, but should be avoided if longer ago because it can increase the risk of stroke from an atrial thrombus. In longer cases, rate control should be used, which is with beta-blockers or rate-limiting calcium channel blockers. Digoxin can be used third line or as an adjunct. In conclusion, the appropriate treatment for AF depends on the duration of the arrhythmia, the patient’s comorbidities, and other factors. It is important to consult with a healthcare professional to determine the best course of action.

    • This question is part of the following fields:

      • Cardiovascular
      66.1
      Seconds
  • Question 19 - A 60-year-old smoker presents with non-healing sores on his lower lip that have...

    Correct

    • A 60-year-old smoker presents with non-healing sores on his lower lip that have been gradually enlarging for several months. Upon examination, a lesion is found at the vermilion border of the lower lip. What is the most probable type of lesion?

      Your Answer: Squamous cell carcinoma (SCC)

      Explanation:

      Common Skin Lesions and Cancers: Characteristics and Clinical Presentations

      Squamous cell carcinoma (SCC), actinic keratosis, Bowen’s disease, cold sores, and leukoplakia are common skin lesions and cancers that have distinct characteristics and clinical presentations.

      SCC is a malignant tumour that commonly affects the backs of the hands and forearms, the upper part of the face, and the lower lip and pinna in men. The first clinical sign is induration, which may take on nodular, plaque-like, verrucous, or ulcerated characteristics. The limits of induration are not sharp and usually extend beyond the visible margins of the lesion. The surrounding tissue is often inflamed. SCCs rarely metastasize.

      Actinic keratosis is a sun-induced scaly or hyperkeratotic lesion that has the potential to become malignant. It is characterized by multifocal, scaly, hyperpigmented or scaly lesions, usually brown with a scaly base, occurring on the head, neck, forearms, and hands.

      Bowen’s disease is an intraepidermal (in situ) squamous cell carcinoma that arises in sun-exposed sites, especially the lower legs in women. It is characterized by well-defined pink and scaly patches or plaques that may become crusty, fissured, or ulcerated as lesions grow.

      Cold sores are recurrent infections of orofacial herpes simplex that present as grouped vesicles, especially of the lips and perioral skin. The eruption is often preceded by a tingling, itching, or burning sensation. Over a few days, the vesicles form a crust, and the eruption resolves within 7–10 days.

      Leukoplakia is a white patch or plaque of the oral mucosa that cannot be characterized clinically or pathologically as any other condition.

      A non-healing lesion is also of concern, especially in patients with a history of smoking and advanced age, as it may indicate a malignant cause. Early detection and treatment are crucial in preventing the progression of these skin lesions and cancers.

    • This question is part of the following fields:

      • Dermatology
      13.1
      Seconds
  • Question 20 - At what point in the childhood immunisation schedule is the Meningitis B vaccine...

    Incorrect

    • At what point in the childhood immunisation schedule is the Meningitis B vaccine administered?

      Your Answer: 3 and 12 months, and 12-13 years

      Correct Answer: 2, 4, and 12 months

      Explanation:

      The most prevalent cause of meningococcal disease in children in the UK is currently Meningitis B. In 2015, the Meningitis B vaccination was added to the NHS routine childhood immunisation schedule. It is administered at 2, 4, and 12 months of age, in conjunction with other immunisations in the schedule. If given at a different time, doses must be spaced at least 2 months apart. For children over one year old, only two doses are necessary.

      Meningitis B Vaccine Now Part of Routine NHS Immunisation

      Children in the UK have been vaccinated against meningococcus serotypes A and C for many years, leaving meningococcal B as the most common cause of bacterial meningitis in the country. However, a new vaccine called Bexsero has been developed to combat this strain. Initially, the Joint Committee on Vaccination and Immunisation (JCVI) rejected the use of Bexsero due to a cost-benefit analysis. However, the decision was eventually reversed, and the vaccine has been added to the routine NHS immunisation schedule.

      The vaccine is administered in three doses at 2 months, 4 months, and 12-13 months. Additionally, Bexsero will be available on the NHS for individuals at high risk of meningococcal disease, such as those with asplenia, splenic dysfunction, or complement disorder. This new vaccine is a significant step in protecting children and vulnerable individuals from meningitis B.

    • This question is part of the following fields:

      • Paediatrics
      5.7
      Seconds
  • Question 21 - A 56-year-old man has been experiencing fatigue and bone pain, prompting his regular...

    Incorrect

    • A 56-year-old man has been experiencing fatigue and bone pain, prompting his regular GP to conduct investigations. Blood tests revealed an elevated paraprotein level, leading to further investigations to rule out multiple myeloma as the primary differential. What other potential cause could result in a raised paraprotein level?

      Your Answer: Polycythaemia

      Correct Answer: MGUS (Monoclonal gammopathy of undetermined significance)

      Explanation:

      MGUS is a possible differential diagnosis for elevated paraproteins in the blood.

      Thrombocytopenia is a characteristic feature of haemolytic uraemic syndrome.

      The presence of paraproteins in the blood is an abnormal finding and not a normal variant.

      While a viral infection may cause neutropenia, it would not typically result in the presence of paraproteins in the blood.

      Paraproteinaemia is a medical condition characterized by the presence of abnormal proteins in the blood. There are various causes of paraproteinaemia, including myeloma, monoclonal gammopathy of uncertain significance (MGUS), benign monoclonal gammopathy, Waldenstrom’s macroglobulinaemia, amyloidosis, CLL, lymphoma, heavy chain disease, and POEMS. Benign monoclonal gammopathy can also cause paraproteinaemia, as well as non-lymphoid malignancy (such as colon or breast cancer), infections (such as CMV or hepatitis), and autoimmune disorders (such as RA or SLE).

      Paraproteinaemia is a medical condition that is characterized by the presence of abnormal proteins in the blood. This condition can be caused by various factors, including myeloma, MGUS, benign monoclonal gammopathy, Waldenstrom’s macroglobulinaemia, amyloidosis, CLL, lymphoma, heavy chain disease, and POEMS. Additionally, benign monoclonal gammopathy, non-lymphoid malignancy (such as colon or breast cancer), infections (such as CMV or hepatitis), and autoimmune disorders (such as RA or SLE) can also cause paraproteinaemia. It is important to identify the underlying cause of paraproteinaemia in order to determine the appropriate treatment plan.

    • This question is part of the following fields:

      • Haematology/Oncology
      17
      Seconds
  • Question 22 - A 30-year-old female patient visits the GP clinic with a tiny lump in...

    Correct

    • A 30-year-old female patient visits the GP clinic with a tiny lump in her right breast. Upon examination, a smooth fluctuant lump is found in the right upper quadrant of the breast. The patient is referred to the breast clinic for an ultrasound scan, which reveals a 2cm cyst in the right upper quadrant of the breast. What is the most suitable course of action for management?

      Your Answer: Aspiration of the cyst

      Explanation:

      Aspirating breast cysts is necessary due to the potential risk of breast cancer, particularly in younger women. Merely monitoring the cysts with ultrasound or mammogram without aspiration is not a suitable approach. There is no need for wide local excision at this point. Providing false reassurance to the patient is not advisable.

      Benign breast lesions have different features and treatments. Fibroadenomas are firm, mobile lumps that develop from a whole lobule and usually do not increase the risk of malignancy. Breast cysts are smooth, discrete lumps that may be aspirated, but blood-stained or persistently refilling cysts should be biopsied or excised. Sclerosing adenosis, radial scars, and complex sclerosing lesions cause mammographic changes that may mimic carcinoma, but do not increase the risk of malignancy. Epithelial hyperplasia may present as general lumpiness or a discrete lump, and atypical features and family history of breast cancer increase the risk of malignancy. Fat necrosis may mimic carcinoma and requires imaging and core biopsy. Duct papillomas usually present with nipple discharge and may require microdochectomy.

    • This question is part of the following fields:

      • Haematology/Oncology
      24
      Seconds
  • Question 23 - A 42-year-old woman presents to the Emergency Department with dizziness and headache. On...

    Incorrect

    • 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: Phaeochromocytoma

      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.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      30.8
      Seconds
  • Question 24 - A 42-year-old woman presents with bilateral hearing loss and tinnitus for several months....

    Incorrect

    • A 42-year-old woman presents with bilateral hearing loss and tinnitus for several months. Her mother and brother had similar issues. Ear examination reveals no abnormalities. An audiometry test indicates bilateral conductive hearing loss.
      What is the most probable diagnosis?

      Your Answer: Meniere’s disease

      Correct Answer: Otosclerosis

      Explanation:

      Common Causes of Hearing Loss and Their Characteristics

      Hearing loss can be caused by various factors, including genetic factors, abnormal bone formation, and tumors. Here are some common causes of hearing loss and their characteristics:

      1. Otosclerosis: This condition affects young adults and causes conductive deafness. It is caused by abnormal bone formation around the base of the stapes, which eventually fuses with the bone of the cochlea, reducing normal sound transmission.

      2. Glue ear: This is a type of conductive hearing loss that is more common in children. There is no evidence of ear examination, but it can cause hearing difficulties.

      3. Meniere’s disease: This is a sensorineural type of hearing loss that is usually accompanied by vertigo and a sensation of fullness or pressure in the ear.

      4. Presbycusis: This is a sensorineural hearing loss that is associated with aging. Audiometry should show a bilateral high-frequency hearing loss.

      5. Vestibular schwannomas: This is a benign primary intracranial tumor that affects the vestibulocochlear nerve. It commonly presents with unilateral hearing loss and can affect the facial nerve causing facial palsy as well.

      Understanding the characteristics of these common causes of hearing loss can help in early detection and management of the condition.

    • This question is part of the following fields:

      • ENT
      14.2
      Seconds
  • Question 25 - A 25-year-old woman who is 14 weeks pregnant complains of worsening acne that...

    Incorrect

    • 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: Topical retinoid

      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.

    • This question is part of the following fields:

      • Dermatology
      14.8
      Seconds
  • Question 26 - A 32-year-old woman presents to the endocrine clinic with thyroid function test results...

    Incorrect

    • A 32-year-old woman presents to the endocrine clinic with thyroid function test results indicating palpitations, excessive sweating, unintentional weight loss, and a notable thyroid goitre that is tender upon palpation. The test results show a TSH level of 9.4 mU/L (normal range: 0.5-5.5) and a free T4 level of 6.4 pmol/L (normal range: 9.0-18). What is the probable diagnosis?

      Your Answer: Hashimoto's disease

      Correct Answer: Subacute (De Quervain's) thyroiditis

      Explanation:

      Subacute Thyroiditis: A Self-Limiting Condition with Four Phases

      Subacute thyroiditis, also known as De Quervain’s thyroiditis or subacute granulomatous thyroiditis, is a condition that is believed to occur after a viral infection. It is characterized by hyperthyroidism, a painful goitre, and raised ESR during the first phase, which lasts for 3-6 weeks. The second phase, which lasts for 1-3 weeks, is characterized by euthyroidism. The third phase, which can last for weeks to months, is characterized by hypothyroidism. Finally, in the fourth phase, the thyroid structure and function return to normal.

      To diagnose subacute thyroiditis, thyroid scintigraphy is used to show a globally reduced uptake of iodine-131. However, most patients do not require treatment as the condition is self-limiting. Thyroid pain may respond to aspirin or other NSAIDs, but in more severe cases, steroids may be used, particularly if hypothyroidism develops.

      It is important to note that subacute thyroiditis is just one of the many causes of thyroid dysfunction. A Venn diagram can be used to show how different causes of thyroid dysfunction may manifest. It is interesting to note that many causes of hypothyroidism may have an initial thyrotoxic phase. Proper diagnosis and management of thyroid dysfunction are crucial to ensure optimal patient outcomes.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      14.6
      Seconds
  • Question 27 - A 65-year-old man visits his GP with a complaint of pain in his...

    Correct

    • A 65-year-old man visits his GP with a complaint of pain in his left eye. Upon examination, the sclera appears red and the cornea is hazy with a dilated pupil. What is the probable diagnosis?

      Your Answer: Acute angle closure glaucoma

      Explanation:

      Should red eye be attributed to glaucoma or uveitis?
      Glaucoma is characterized by intense pain, haloes, and a partially dilated pupil, while uveitis is indicated by a small, fixed oval pupil and ciliary flush.

      Understanding the Causes of Red Eye

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

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

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

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

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

      Subconjunctival haemorrhage may be caused by trauma or coughing bouts.

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

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

    • This question is part of the following fields:

      • Ophthalmology
      13.3
      Seconds
  • Question 28 - A 25-year-old man presents to the emergency department after experiencing syncope. He reports...

    Correct

    • A 25-year-old man presents to the emergency department after experiencing syncope. He reports an increase in palpitations since starting a new medication. On examination, his ECG reveals a prolonged QT interval of 500 msec. What is the probable medication he is taking?

      Your Answer: Citalopram

      Explanation:

      Prolonged QT interval syndrome can be caused by tricyclic antidepressants and selective serotonin reuptake inhibitors, with citalopram being particularly associated with this effect. As a result, the MHRA issued a warning on its use and reduced the maximum recommended daily dose from 80 mg to 40mg due to the dose-dependent nature of QT prolongation. Although not mandatory, some GPs may request an initial ECG before prescribing citalopram.

      Understanding Long QT Syndrome

      Long QT syndrome (LQTS) is a genetic condition that causes delayed repolarization of the ventricles, which can lead to ventricular tachycardia and sudden death. The most common types of LQTS are caused by defects in the alpha subunit of the slow delayed rectifier potassium channel. A normal corrected QT interval is less than 430 ms in males and 450 ms in females.

      There are various causes of a prolonged QT interval, including congenital factors, drugs, and other medical conditions. Some drugs that can prolong the QT interval include amiodarone, tricyclic antidepressants, and selective serotonin reuptake inhibitors. Electrolyte imbalances, acute myocardial infarction, and subarachnoid hemorrhage can also cause a prolonged QT interval.

      LQTS may be picked up on routine ECG or following family screening. The symptoms and events associated with LQTS can vary depending on the type of LQTS. Long QT1 is usually associated with exertional syncope, while Long QT2 is often associated with syncope following emotional stress or exercise. Long QT3 events often occur at night or at rest.

      Management of LQTS involves avoiding drugs that prolong the QT interval and other precipitants if appropriate. Beta-blockers may be used, and in high-risk cases, implantable cardioverter defibrillators may be necessary. It is important to recognize and manage LQTS to prevent sudden cardiac death.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      8.7
      Seconds
  • Question 29 - An 88-year-old woman visits her doctor with her daughter. She was diagnosed with...

    Correct

    • An 88-year-old woman visits her doctor with her daughter. She was diagnosed with Alzheimer's dementia two years ago and has recently moved in with her daughter for care. Lately, she has become increasingly isolated and has reported seeing animals in the house that are not actually there. She denies any other symptoms. All vital signs are normal and physical examination is unremarkable.

      What is the probable cause of her current symptoms?

      Your Answer: Delirium

      Explanation:

      Cognitively impaired patients can experience delirium when placed in new surroundings. Even minor changes in environment can trigger delirium in individuals with dementia, leading to visual hallucinations. While community-acquired pneumonia and urinary tract infections are common causes of delirium in the elderly, they seem unlikely in this case as there are no other clues in the history or examination. Depression is a common differential for dementia in the elderly, but the acute onset of symptoms in this woman suggests delirium. It is important to note that symptoms of depression in the elderly can be non-specific. While psychosis could explain the visual hallucinations, the absence of other symptoms and the acute onset of the condition suggest delirium.

      Acute confusional state, also known as delirium or acute organic brain syndrome, is a condition that affects up to 30% of elderly patients admitted to hospital. It is more common in patients over the age of 65, those with a background of dementia, significant injury, frailty or multimorbidity, and those taking multiple medications. The condition is often triggered by a combination of factors, such as infection, metabolic imbalances, change of environment, and underlying medical conditions.

      The symptoms of acute confusional state can vary widely, but may include memory disturbances, agitation or withdrawal, disorientation, mood changes, visual hallucinations, disturbed sleep, and poor attention. Treatment involves identifying and addressing the underlying cause, modifying the patient’s environment, and using sedatives such as haloperidol or olanzapine. However, managing the condition can be challenging in patients with Parkinson’s disease, as antipsychotics can worsen Parkinsonian symptoms. In such cases, careful reduction of Parkinson medication may be helpful, and atypical antipsychotics such as quetiapine and clozapine may be preferred for urgent treatment.

      Overall, acute confusional state is a complex condition that requires careful management and individualized treatment. By addressing the underlying causes and providing appropriate sedation, healthcare professionals can help patients recover from this condition and improve their overall quality of life.

    • This question is part of the following fields:

      • Neurology
      10.3
      Seconds
  • Question 30 - A 70-year-old man is admitted to the hospital with a 5-day history of...

    Correct

    • A 70-year-old man is admitted to the hospital with a 5-day history of severe diarrhoea accompanied by abdominal pain, fever, and fatigue. He has never experienced these symptoms before. In the past 3 months, the patient has undergone treatment for upper urinary tract infections with both co-amoxiclav and ciprofloxacin. He has no known allergies and does not take any regular medications. Blood tests reveal an elevated white cell count, and a stool sample confirms the presence of Clostridium difficile toxin. According to national guidelines, what is the most appropriate treatment for this patient?

      Your Answer: A course of oral vancomycin

      Explanation:

      The recommended first-line antibiotic for patients with confirmed Clostridium difficile infection is oral vancomycin. This infection typically occurs in patients who have recently taken broad-spectrum antibiotics, such as co-amoxiclav and ciprofloxacin, which disrupt the gut flora. Discontinuing the implicated antibiotic and starting appropriate eradicative therapy is necessary. Oral fidaxomicin is an alternative but is less available. Metronidazole is no longer a first-line antibiotic due to lower cure rates than vancomycin, but it may be used if vancomycin is not available. IV vancomycin is ineffective as insufficient quantities are excreted into the gut lumen. Clindamycin is not a cure for Clostridium difficile but is associated with an increased risk of developing it. Conservative management is not recommended as the infection may worsen and lead to complications such as toxic megacolon.

      Clostridioides difficile is a type of bacteria that is commonly found in hospitals. It is a Gram positive rod that produces an exotoxin which can cause damage to the intestines, leading to a condition called pseudomembranous colitis. This bacteria usually develops when the normal gut flora is suppressed by broad-spectrum antibiotics, with second and third generation cephalosporins being the leading cause of C. difficile. Other risk factors include proton pump inhibitors. Symptoms of C. difficile include diarrhea, abdominal pain, and a raised white blood cell count. The severity of the infection can be determined using the Public Health England severity scale, which ranges from mild to life-threatening.

      To diagnose C. difficile, a stool sample is tested for the presence of C. difficile toxin (CDT). Treatment for a first episode of C. difficile infection typically involves oral vancomycin for 10 days, with fidaxomicin or a combination of oral vancomycin and IV metronidazole being used as second and third-line therapies. Recurrent infections occur in around 20% of patients, increasing to 50% after their second episode. In such cases, oral fidaxomicin is recommended within 12 weeks of symptom resolution, while oral vancomycin or fidaxomicin can be used after 12 weeks. For life-threatening C. difficile infections, oral vancomycin and IV metronidazole are used, and surgery may be considered with specialist advice. Other therapies, such as bezlotoxumab and fecal microbiota transplant, may also be considered for preventing recurrences in certain cases.

    • This question is part of the following fields:

      • Infectious Diseases
      24.7
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SESSION STATS - PERFORMANCE PER SPECIALTY

ENT (1/3) 33%
Musculoskeletal (1/2) 50%
Paediatrics (1/3) 33%
Neurology (1/2) 50%
Renal Medicine/Urology (1/2) 50%
Infectious Diseases (3/3) 100%
Reproductive Medicine (1/1) 100%
Gastroenterology/Nutrition (0/1) 0%
Pharmacology/Therapeutics (2/2) 100%
Haematology/Oncology (1/3) 33%
Dermatology (1/3) 33%
Endocrinology/Metabolic Disease (1/3) 33%
Cardiovascular (0/1) 0%
Ophthalmology (1/1) 100%
Passmed