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  • Question 1 - A 35-year-old footballer presents with persistent pain in his left knee that began...

    Correct

    • A 35-year-old footballer presents with persistent pain in his left knee that began abruptly during a game. During the physical examination, you instruct the patient to lie down and flex his knee. As you internally rotate his foot, he experiences discomfort and you detect a clicking sensation. The patient inquires about the procedure, and you clarify that you are performing McMurray's test, a specialized examination for knee joint issues. What is the probable reason for his knee pain?

      Your Answer: Meniscal tear

      Explanation:

      A positive McMurray test is indicative of a meniscal tear, which is typically caused by twisting of the knee. During the test, the knee is flexed while the sole of the foot is held, and one hand is placed on the medial side of the knee to pull it towards a varus position. The other hand is used to internally rotate the leg while extending the knee. If the patient experiences pain or a clicking sensation, the test is considered positive. On the other hand, a positive draw test is a sign of an anterior cruciate ligament tear, which is also commonly caused by twisting of the knee.

      Knee problems are common among older adults, and it is important to be aware of the key features of each condition. Osteoarthritis of the knee is often seen in patients over 50 years of age who are overweight. This condition can cause severe pain, intermittent swelling, crepitus, and limited movement. Infrapatellar bursitis, also known as Clergyman’s knee, is associated with kneeling, while prepatellar bursitis, or Housemaid’s knee, is associated with more upright kneeling. Anterior cruciate ligament injuries may be caused by twisting of the knee, and patients may have heard a popping noise. Rapid onset of knee effusion and a positive draw test are also common features. Posterior cruciate ligament injuries may be caused by anterior force applied to the proximal tibia, such as during a car accident. Collateral ligament injuries can cause tenderness over the affected ligament and knee effusion. Meniscal lesions may be caused by twisting of the knee and can cause locking and giving-way, as well as tenderness along the joint line.

    • This question is part of the following fields:

      • Musculoskeletal
      17.3
      Seconds
  • Question 2 - A 32-year-old woman presents to the gynaecology clinic with her partner, reporting 2...

    Correct

    • A 32-year-old woman presents to the gynaecology clinic with her partner, reporting 2 years of unsuccessful attempts at conceiving. Neither she nor her partner have any children from previous relationships. The patient has a medical history of polycystic ovarian syndrome. On examination, her vital signs are within normal limits and her BMI is 24 kg/m². What is the recommended initial approach to enhance fertility?

      Your Answer: Clomifene

      Explanation:

      Clomifene is the recommended first-line treatment for infertility in patients with PCOS. This patient has been diagnosed with PCOS, which can cause infertility and other symptoms such as hirsutism. Clomifene works by inducing ovulation and has been shown to improve fertility outcomes in these patients.

      Goserelin is not a suitable treatment for infertility in PCOS patients. It is a gonadotrophin-releasing hormone agonist used for conditions such as prostate carcinoma, endometriosis, and dysfunctional uterine bleeding. In-vitro fertilisation is not typically the first option for improving fertility in PCOS patients and is usually considered later on.

      While metformin is an important drug in the management of PCOS, it is not the primary treatment for improving fertility. It is often prescribed in combination with clomifene to address metabolic issues associated with PCOS. However, clomifene is the key drug for improving overall fertility outcomes in these patients.

      Managing Polycystic Ovarian Syndrome

      Polycystic ovarian syndrome (PCOS) is a condition that affects a significant percentage of women of reproductive age. The exact cause of PCOS is not fully understood, but it is associated with high levels of luteinizing hormone and hyperinsulinemia. Management of PCOS is complex and varies depending on the individual’s symptoms. Weight reduction is often recommended, and a combined oral contraceptive pill may be used to regulate menstrual cycles and manage hirsutism and acne. If these symptoms do not respond to the pill, topical eflornithine or medications like spironolactone, flutamide, and finasteride may be used under specialist supervision.

      Infertility is another common issue associated with PCOS. Weight reduction is recommended, and the management of infertility should be supervised by a specialist. There is ongoing debate about the most effective treatment for infertility in patients with PCOS. Clomifene is often used, but there is a potential risk of multiple pregnancies with anti-oestrogen therapies like clomifene. Metformin is also used, either alone or in combination with clomifene, particularly in patients who are obese. Gonadotrophins may also be used to stimulate ovulation. The Royal College of Obstetricians and Gynaecologists (RCOG) published an opinion paper in 2008 and concluded that on current evidence, metformin is not a first-line treatment of choice in the management of PCOS.

    • This question is part of the following fields:

      • Reproductive Medicine
      42.5
      Seconds
  • Question 3 - A 27-year-old female patient presents to her doctor seeking guidance on pregnancy and...

    Correct

    • A 27-year-old female patient presents to her doctor seeking guidance on pregnancy and the postpartum period. She is currently 12 weeks pregnant and has not experienced any complications thus far. The patient has a history of HIV and is currently taking antiretroviral medication. She has expressed a desire to breastfeed her baby once it is born.

      What recommendations should be given to this patient?

      Your Answer: She should not breastfeed

      Explanation:

      In the UK, it is recommended that all women who are HIV-positive should not breastfeed their babies. This advice remains the same even if the mother’s viral load is undetectable. The decision should not be left to the HIV consultant as the national guidelines are clear on this matter. Although breastfeeding may reduce the risk of transmission if the maternal viral load is less than 50 copies/ml, there is still a risk involved. Therefore, the advice remains not to breastfeed. Continuing with antiretroviral therapy is expected regardless of the decision not to breastfeed as it significantly reduces the risk of vertical transmission during pregnancy. Babies born to HIV-positive mothers are given antiretroviral therapy, either zidovudine alone if the maternal viral load is less than 50 copies/ml or triple-therapy if it is higher. However, this does not change the advice to avoid breastfeeding.

      HIV and Pregnancy: Guidelines for Minimizing Vertical Transmission

      With the increasing prevalence of HIV infection among heterosexual individuals, there has been a rise in the number of HIV-positive women giving birth in the UK. In fact, in London alone, the incidence may be as high as 0.4% of pregnant women. The primary goal of treating HIV-positive women during pregnancy is to minimize harm to both the mother and fetus, and to reduce the chance of vertical transmission.

      To achieve this goal, various factors must be considered. Firstly, all pregnant women should be offered HIV screening, according to NICE guidelines. Additionally, antiretroviral therapy should be offered to all pregnant women, regardless of whether they were taking it previously. This therapy has been shown to significantly reduce vertical transmission rates, which can range from 25-30% to just 2%.

      The mode of delivery is also an important consideration. Vaginal delivery is recommended if the viral load is less than 50 copies/ml at 36 weeks. If the viral load is higher, a caesarean section is recommended, and a zidovudine infusion should be started four hours before the procedure. Neonatal antiretroviral therapy is also typically administered to the newborn, with zidovudine being the preferred medication if the maternal viral load is less than 50 copies/ml. If the viral load is higher, triple ART should be used, and therapy should be continued for 4-6 weeks.

      Finally, infant feeding is an important consideration. In the UK, all women should be advised not to breastfeed, as this can increase the risk of vertical transmission. By following these guidelines, healthcare providers can help to minimize the risk of vertical transmission and ensure the best possible outcomes for both mother and child.

    • This question is part of the following fields:

      • Reproductive Medicine
      13.8
      Seconds
  • Question 4 - A 25-year-old man presents to his General Practitioner with a 3-month history of...

    Correct

    • A 25-year-old man presents to his General Practitioner with a 3-month history of diarrhoea and intermittent abdominal pain. He has also noticed blood mixed with his stools over the past week. He is referred to secondary care where he has a colonoscopy and is diagnosed with Crohn’s disease.
      Which of the following medications would be used to induce remission in this patient with a first presentation of Crohn’s disease?
      Select the SINGLE most appropriate management from the list below.

      Your Answer: Prednisolone

      Explanation:

      Treatment Options for Crohn’s Disease

      Crohn’s disease is a chronic inflammatory bowel disease that can cause a range of symptoms, including abdominal pain, diarrhea, and weight loss. There are several treatment options available for patients with Crohn’s disease, depending on the severity of their symptoms and the stage of their disease.

      Prednisolone is a commonly used corticosteroid for patients with a first presentation of Crohn’s disease or a single inflammatory exacerbation within a 12-month period. Azathioprine may be added to glucocorticoid treatment to induce remission if there are more than two exacerbations in a 12-month period or difficulty in tapering the glucocorticoid dose. Infliximab is recommended for adults with severe active Crohn’s disease who have not responded to or are intolerant to conventional therapy.

      Mesalazine, an aminosalicylate, may be used for a first presentation of Crohn’s disease if glucocorticoids are contraindicated or not tolerated. It may also be used in addition to oral steroid treatment. Methotrexate should not be used as a monotherapy to induce remission. Instead, corticosteroids are the first-line treatment for inducing remission in patients with a first presentation of Crohn’s disease. If an adjuvant treatment is required, azathioprine or mercaptopurine can be taken with the corticosteroid. If these medications cannot be tolerated, methotrexate may be added instead.

      In summary, the treatment options for Crohn’s disease vary depending on the severity of the disease and the patient’s response to previous treatments. It is important for patients to work closely with their healthcare provider to determine the best course of treatment for their individual needs.

    • This question is part of the following fields:

      • Pharmacology/Therapeutics
      17.6
      Seconds
  • Question 5 - A 5-year-old boy is brought to the Emergency Department by his parents with...

    Incorrect

    • A 5-year-old boy is brought to the Emergency Department by his parents with a 3-day history of diarrhoea; he has also vomited twice today. He is alert and responsive and his observations are within normal limits.
      On examination, he has moist mucous membranes, normal skin turgor, normal skin colour, normal peripheral pulses and a normal capillary refill time. His abdomen is soft and nontender and his peripheries are warm.
      What is the most appropriate initial management option for this patient?

      Your Answer: Encourage intake of fluids

      Correct Answer: Oral rehydration solution (ORS)

      Explanation:

      Management of Dehydration in Children with Gastroenteritis

      Gastroenteritis is a common illness in children that can lead to dehydration if not managed properly. Oral rehydration solution (ORS) is the first-line treatment for children at increased risk of dehydration, including those who have vomited more than twice in the last 24 hours or have other risk factors such as age less than one year, low birth weight, or signs of malnutrition. However, if a child is clinically dehydrated and not responding to ORS, intravenous (IV) fluids may be necessary.

      It is important to encourage fluid intake in children with gastroenteritis, but carbonated drinks and fruit juices should be avoided as they can worsen diarrhea. If a child is unable to drink, an NG tube may be considered, but ORS should be attempted first. A bolus of IV fluids is only indicated in cases of suspected or confirmed shock.

      Overall, prompt recognition and management of dehydration in children with gastroenteritis can prevent serious complications and improve outcomes.

    • This question is part of the following fields:

      • Paediatrics
      17.7
      Seconds
  • Question 6 - A 40-year-old woman with amyotrophic lateral sclerosis is in a meeting with her...

    Correct

    • A 40-year-old woman with amyotrophic lateral sclerosis is in a meeting with her clinical team to discuss her ongoing care. The team notes that she has been experiencing weight loss and increased fatigue. The patient reports struggling with chewing and swallowing food, even when it has been mashed or pureed. What is the most suitable long-term management plan for this patient?

      Your Answer: Insert a percutaneous gastrostomy tube

      Explanation:

      The most appropriate way to provide nutritional support for patients with motor neuron disease is through the insertion of a percutaneous gastrostomy (PEG) tube. If a patient is struggling to feed themselves, they may initially benefit from smaller, more liquid-like meals, but if this is not sufficient, a PEG tube is a definitive long-term management option. Continuing with their current diet regimen is not recommended as it may lead to poor nutrition and a risk of aspiration. Total parenteral nutrition is only used as a last resort when there is impaired nutrient absorption. Inserting a nasogastric tube is not a suitable option as it must be removed after a few weeks to avoid adverse effects. A percutaneous jejunostomy tube is also not recommended as it is less commonly used and harder to maintain than a PEG tube.

      Managing Motor Neuron Disease

      Motor neuron disease is a neurological condition that affects both upper and lower motor neurons. It typically presents after the age of 40 and can manifest in different patterns, such as amyotrophic lateral sclerosis, progressive muscular atrophy, and bulbar palsy. The cause of the disease is unknown.

      One medication used in the management of motor neuron disease is riluzole, which works by preventing the stimulation of glutamate receptors. It is mainly used in cases of amyotrophic lateral sclerosis and has been shown to prolong life by approximately three months.

      Respiratory care is also an important aspect of managing motor neuron disease. Non-invasive ventilation, usually in the form of BIPAP, is used at night and has been associated with a survival benefit of around seven months.

      Nutrition support is also crucial in managing motor neuron disease. The preferred method is percutaneous gastrostomy tube (PEG), which has been linked to prolonged survival.

      Unfortunately, the prognosis for motor neuron disease is poor, with 50% of patients dying within three years.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      15
      Seconds
  • Question 7 - A 26-year-old man is being examined for persistent back pain. What symptom would...

    Correct

    • A 26-year-old man is being examined for persistent back pain. What symptom would strongly indicate a diagnosis of ankylosing spondylitis?

      Your Answer: Reduced lateral flexion of the lumbar spine

      Explanation:

      Ankylosing spondylitis is characterized by an early reduction in lateral flexion of the lumbar spine. Patients with this condition often experience a decrease in lumbar lordosis and an increase in thoracic kyphosis.

      Ankylosing spondylitis is a type of spondyloarthropathy that is associated with HLA-B27. It is more commonly seen in young males, with a sex ratio of 3:1, and typically presents with lower back pain and stiffness that develops gradually. The stiffness is usually worse in the morning and improves with exercise, while pain at night may improve upon getting up. Clinical examination may reveal reduced lateral and forward flexion, as well as reduced chest expansion. Other features associated with ankylosing spondylitis include apical fibrosis, anterior uveitis, aortic regurgitation, Achilles tendonitis, AV node block, amyloidosis, cauda equina syndrome, and peripheral arthritis (more common in females).

    • This question is part of the following fields:

      • Musculoskeletal
      8.9
      Seconds
  • Question 8 - A 75-year-old woman comes to the clinic with a painful swelling on the...

    Correct

    • A 75-year-old woman comes to the clinic with a painful swelling on the left side of her neck below the jaw angle that has been bothering her for the past 5 days. She also reports a bad taste in her mouth. During the physical examination, the patient has a temperature of 37.8ºC and a tender submandibular mass measuring 4x5cm. Additionally, there is tender lymphadenopathy. What is the probable diagnosis?

      Your Answer: Sialadenitis

      Explanation:

      This woman is experiencing sialadenitis, which is inflammation of the salivary gland. It is likely caused by a stone blocking the duct. The submandibular gland is located below the jawline and its duct drains into the floor of the mouth. When there is a discharge from this duct, it can cause a bad taste in the mouth. There are three main salivary glands: the parotid glands, which are located in front of and below each ear, the submandibular glands, which are located below the jawline, and the sublingual glands, which are located beneath the tongue. Disorders of these glands can be caused by infection, inflammation, obstruction, or malignancy. Swelling of the submandibular gland can be caused by a stone or a tumor, which can be either benign or malignant.

      Salivary Glands and Their Pathologies

      Salivary glands are responsible for producing saliva, which aids in digestion and protects the mouth from harmful bacteria. There are three pairs of salivary glands: parotid, submandibular, and sublingual. The parotid gland is the most common site for tumors, while the submandibular gland is most commonly affected by stones.

      Tumors in the salivary glands are rare, but when they do occur, 80% of them are found in the parotid gland. Of these, 80% are pleomorphic adenomas, which are benign. These tumors typically grow slowly and are painless, but surgical removal carries a risk of damage to the facial nerve (CN VII). Warthin’s tumor is another benign tumor that affects the salivary glands, but it is less common than pleomorphic adenomas.

      Stones in the salivary glands can cause recurrent pain and swelling, especially when eating. They are most commonly found in the submandibular gland and can lead to infection if left untreated. Other causes of salivary gland enlargement include viral or bacterial infections, as well as autoimmune disorders like Sjogren’s syndrome. Proper diagnosis and treatment are important for managing these conditions and preventing complications.

    • This question is part of the following fields:

      • ENT
      21.1
      Seconds
  • Question 9 - A 6-year-old boy has been treated for a first urinary tract infection. There...

    Correct

    • A 6-year-old boy has been treated for a first urinary tract infection. There was no evidence of pyelonephritis. Urine culture demonstrated growth of Escherichia coli. He was given a course of trimethoprim and recovered well.
      Which of the following is the most appropriate next step in his management?
      Select the SINGLE most appropriate next step from the list below. Select ONE option only.

      Your Answer: No imaging required

      Explanation:

      Imaging Guidelines for Urinary Tract Infections in Children

      Urinary tract infections (UTIs) are common in children and can be divided into upper and lower UTIs. Current guidelines recommend different imaging investigations based on the type of UTI and the child’s age. For infants and children aged ≥6 months with a first-time UTI that responds to treatment, routine ultrasonography is not recommended unless the child has an atypical UTI. Micturating cystourethrography (MCUG) is indicated if renal and bladder ultrasonography reveals hydronephrosis, scarring, or other findings that suggest high-grade vesicoureteral reflux (VUR) or obstructive uropathy. Ultrasonography of the urinary tract is the imaging study of choice in children with a UTI, and it is useful in excluding obstructive uropathy and identifying renal damage caused by pyelonephritis. Technectium-99m-labelled dimercaptosuccinic acid (99mTc-DMSA) is a scintigraphic agent that can be used to assess acute pyelonephritis, renal cortical scarring, and the identification of a malpositioned kidney. However, no imaging is required for a typical, non-recurrent UTI in a child aged ≥3 years. Atypical UTI features include being seriously ill, having poor urine flow, an abdominal or bladder mass, raised creatinine, septicaemia, failure to respond to treatment with suitable antibiotics within 48 hours, or infection with non-E. coli organisms.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      15.6
      Seconds
  • Question 10 - You are assisting in the care of a 65-year-old man who has been...

    Correct

    • You are assisting in the care of a 65-year-old man who has been hospitalized for chest pain. He has a medical history of hypertension, angina, and is a current smoker of 20 cigarettes per day. Upon admission, blood tests were conducted in the Emergency Department and revealed the following results:
      - Na+ 133 mmol/l
      - K+ 3.3 mmol/l
      - Urea 4.5 mmol/l
      - Creatinine 90 µmol/l
      What is the most likely cause of the electrolyte abnormalities observed in this patient?

      Your Answer: Bendroflumethiazide therapy

      Explanation:

      Hyponatraemia and hypokalaemia are caused by bendroflumethiazide, while spironolactone is linked to hyperkalaemia. Smoking would only be significant if the patient had lung cancer that resulted in syndrome of inappropriate ADH secretion, but there is no evidence of this in the given scenario.

      Thiazide diuretics are medications that work by blocking the thiazide-sensitive Na+-Cl− symporter, which inhibits sodium reabsorption at the beginning of the distal convoluted tubule (DCT). This results in the loss of potassium as more sodium reaches the collecting ducts. While loop diuretics are better for reducing overload, thiazide diuretics have a role in the treatment of mild heart failure. Bendroflumethiazide was commonly used for managing hypertension, but recent NICE guidelines recommend other thiazide-like diuretics such as indapamide and chlortalidone.

      Like any medication, thiazide diuretics have potential adverse effects. Common side effects include dehydration, postural hypotension, and electrolyte imbalances such as hyponatraemia, hypokalaemia, and hypercalcaemia. Gout, impaired glucose tolerance, and impotence are also possible. Rare adverse effects include thrombocytopaenia, agranulocytosis, photosensitivity rash, and pancreatitis.

      To manage hypertension, current NICE guidelines recommend using thiazide-like diuretics such as indapamide or chlortalidone as first-line treatment. If blood pressure is not adequately controlled, a calcium channel blocker or ACE inhibitor can be added. If blood pressure remains high, a thiazide-like diuretic can be combined with a calcium channel blocker or ACE inhibitor. In some cases, a beta-blocker or aldosterone antagonist may also be added. Regular monitoring and adjustment of medication is necessary to ensure optimal blood pressure control.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      22.6
      Seconds
  • Question 11 - A 54 year old woman presents to the General Practice clinic with complaints...

    Correct

    • A 54 year old woman presents to the General Practice clinic with complaints of increasing dyspepsia, dysphagia, and fatigue. She reports a prolonged history of dark brown stools, but denies any recent episodes of fresh blood. She has not experienced any unexplained weight loss and underwent surgery for a peptic ulcer a decade ago. Upon investigation, she is found to have H. pylori. What should be the subsequent course of action?

      Your Answer: 2 week referral to endoscopy

      Explanation:

      Management of Dyspepsia and Referral for Possible Cancer

      Dyspepsia is a common symptom that can be caused by various factors, including medication and lifestyle choices. However, it can also be a sign of underlying conditions such as stomach or oesophageal cancer. The 2015 NICE guidelines provide updated advice on when urgent referral for endoscopy is necessary. Patients with dysphagia or an upper abdominal mass consistent with stomach cancer should be referred urgently. Patients aged 55 years or older with weight loss and upper abdominal pain, reflux, or dyspepsia should also be referred urgently. Non-urgent referrals include patients with haematemesis or those with treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin levels, or raised platelet count with other symptoms.

      For patients with undiagnosed dyspepsia, a step-wise approach is recommended. First, medications should be reviewed for possible causes. Lifestyle advice should also be given. If symptoms persist, a trial of full-dose proton pump inhibitor for one month or a ‘test and treat’ approach for H. pylori can be tried. If symptoms persist after either approach, the alternative should be attempted. Testing for H. pylori infection can be done using a carbon-13 urea breath test, stool antigen test, or laboratory-based serology. If symptoms resolve following test and treat, there is no need to check for H. pylori eradication. However, if repeat testing is required, a carbon-13 urea breath test should be used.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      16.2
      Seconds
  • Question 12 - A 25-year-old female student attends the blood transfusion service wishing to donate blood....

    Incorrect

    • A 25-year-old female student attends the blood transfusion service wishing to donate blood. She is currently well, has never had a serious illness and weighs 60 kg. About three months ago she spent the summer doing voluntary work in Nigeria. She also had her ears pierced three years ago and had a tattoo put on her left arm one year ago. She is not acceptable as a donor.
      Which of the following is the reason for her rejection to donate blood in the UK?

      Your Answer: Tattoo

      Correct Answer: Recent travel to an endemic area

      Explanation:

      Blood Donation Eligibility Criteria: Factors to Consider

      When it comes to donating blood, there are several factors to consider to ensure the safety of both the donor and the recipient. Here are some examples:

      Recent travel to an endemic area: If a person has recently traveled to a country with a high risk of infectious diseases, they may have to wait a certain period before donating blood. For instance, if someone has returned from Nigeria, they must wait at least six months before donating blood in the UK.

      Underweight: A person must weigh at least 50 kg to donate blood. If they weigh less than that, they may not have enough blood volume to spare.

      Body piercing: If someone has had a body piercing within the last 12 months, they should inform the staff before donating blood. They may have to wait for at least four months before donating.

      Tattoo: Similarly, if someone has had a tattoo within the last 12 months, they should inform the staff before donating blood. They may have to wait for at least four months before donating.

      Age: To donate blood, a person must be between 17 and 66 years old (or 70 if they have donated blood before). If they are over 70, they can still donate if they have donated blood in the last two years.

      By considering these factors, blood donation centers can ensure that the blood they collect is safe and suitable for transfusion.

    • This question is part of the following fields:

      • Haematology/Oncology
      17.3
      Seconds
  • Question 13 - A 28-year-old male patient complains of a painful rash on his forehead that...

    Correct

    • A 28-year-old male patient complains of a painful rash on his forehead that has been present for one day. The patient has no significant medical history. Upon examination, a vesicular rash is observed on the right side in the distribution of the ophthalmic nerve. There is no discharge or pus, and no ocular involvement is present. What is the recommended treatment for this condition?

      Your Answer: Oral acyclovir for 7-10 days

      Explanation:

      In the case of herpes zoster ophthalmicus, topical antiviral treatment is not recommended. The first line of treatment is oral acyclovir, which should be initiated promptly and continued for 7-10 days. If there are any indications of ocular involvement, the patient should be referred to an ophthalmologist immediately. While steroids can be administered concurrently, they do not decrease the likelihood of post-herpetic neuralgia. Topical mupirocin is not an appropriate treatment option.

      Herpes Zoster Ophthalmicus: Symptoms, Treatment, and Complications

      Herpes zoster ophthalmicus (HZO) is a condition that occurs when the varicella-zoster virus reactivates in the area supplied by the ophthalmic division of the trigeminal nerve. It is responsible for approximately 10% of shingles cases. The main symptom of HZO is a vesicular rash around the eye, which may or may not involve the eye itself. Hutchinson’s sign, a rash on the tip or side of the nose, is a strong indicator of nasociliary involvement and increases the risk of ocular involvement.

      Treatment for HZO involves oral antiviral medication for 7-10 days, ideally started within 72 hours of symptom onset. Intravenous antivirals may be necessary for severe infections or immunocompromised patients. Topical antiviral treatment is not recommended for HZO, but topical corticosteroids may be used to treat any secondary inflammation of the eye. Ocular involvement requires urgent ophthalmology review to prevent complications such as conjunctivitis, keratitis, episcleritis, anterior uveitis, ptosis, and post-herpetic neuralgia.

      In summary, HZO is a condition caused by the reactivation of the varicella-zoster virus in the ophthalmic division of the trigeminal nerve. It presents with a vesicular rash around the eye and may involve the eye itself. Treatment involves oral antiviral medication and urgent ophthalmology review is necessary for ocular involvement. Complications of HZO include various eye conditions, ptosis, and post-herpetic neuralgia.

    • This question is part of the following fields:

      • Ophthalmology
      19.4
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  • Question 14 - As a foundation doctor in general surgery, you are assisting your consultant in...

    Correct

    • As a foundation doctor in general surgery, you are assisting your consultant in a surgical exploration of a suspected testicular torsion in a patient with a bell clapper deformity. The patient, who is in his early twenties, has been experiencing symptoms for six hours. Upon examination, the surgery confirms the presence of testicular torsion.

      What is the appropriate course of action for the surgeon to take in this situation?

      Your Answer: Fixation of both testicles

      Explanation:

      To prevent future torsion of the other testicle, it is recommended that both testes be fixed during testicular torsion surgery. While manual rotation may be successful in some cases, it is not appropriate once surgery has begun. If a bell clapper deformity is present, both testes should be fixed if they are still viable. Given the short duration of symptoms (only six hours), it is unlikely that surgical removal (orchiectomy) will be necessary.

      Testicular Torsion: Causes, Symptoms, and Treatment

      Testicular torsion is a medical condition that occurs when the spermatic cord twists, leading to testicular ischaemia and necrosis. This condition is most common in males aged between 10 and 30, with a peak incidence between 13 and 15 years. The symptoms of testicular torsion are sudden and severe pain, which may be referred to the lower abdomen. Nausea and vomiting may also be present. On examination, the affected testis is usually swollen, tender, and retracted upwards, with reddened skin. The cremasteric reflex is lost, and elevation of the testis does not ease the pain (Prehn’s sign).

      The treatment for testicular torsion is urgent surgical exploration. If a torted testis is identified, both testes should be fixed, as the condition of bell clapper testis is often bilateral.

    • This question is part of the following fields:

      • Renal Medicine/Urology
      14.6
      Seconds
  • Question 15 - A 35-year-old woman presents with a 3-day history of a painful and swollen...

    Correct

    • A 35-year-old woman presents with a 3-day history of a painful and swollen right ankle. She is pyrexial with a temperature of 38.2 °C. Examination of her cardiovascular and respiratory systems is normal, and an abdominal examination is also normal. She mentions that she developed a painful left ear and saw another doctor 4 days ago, who told her that she had an infected ear and prescribed antibiotics. Her right ankle is swollen, red, tender and slightly flexed. A diagnosis of septic arthritis is made.
      Which of the following is the most likely causative organism?
      Select the SINGLE most likely causative organism.

      Your Answer: Staphylococcus aureus (S. aureus)

      Explanation:

      Common Bacterial Infections and their Causes

      Septic arthritis is a joint infection caused by pyogenic organisms, with S. aureus being the most common culprit. Other organisms responsible include streptococci, Neisseria species, and Gram-negative bacilli. The infection typically spreads to the joint via the bloodstream or from adjacent osteomyelitis or trauma. Symptoms include pain, redness, warmth, and swelling in the affected joint. Diagnosis is established by aspirating and culturing the joint fluid. Immediate treatment with appropriate antibiotics is crucial to prevent cartilage destruction, and needle aspiration or surgical drainage may be necessary.

      N. meningitidis is a Gram-negative bacterium that causes meningococcaemia and meningococcal meningitis, particularly in children and young adults. It is spread via respiratory secretions and can be carried asymptomatically by 5-10% of adults, with higher rates in close communities. The disease carries significant morbidity and mortality.

      S. viridans is commonly found in the mouth and can cause endocarditis if introduced into the bloodstream. It is the most common cause of subacute bacterial endocarditis.

      S. epidermidis is a Gram-positive staphylococcus that normally resides on human skin and mucosa. It commonly causes infections on catheters and implants, and is a frequent cause of nosocomial infections, particularly in TPN and bone marrow transplant patients.

      E. coli is commonly found in the large intestine and is a major cause of urinary tract infections, cholecystitis and cholangitis, and neonatal meningitis.

    • This question is part of the following fields:

      • Musculoskeletal
      39.8
      Seconds
  • Question 16 - A 55-year-old woman with a history of diabetes complains of left-sided ear pain...

    Correct

    • A 55-year-old woman with a history of diabetes complains of left-sided ear pain and discharge. During examination, her temperature is recorded at 37.9ºC and there is red discharge in the ear canal. The tympanic membrane is partially visible and appears normal. Despite visiting the out of hours clinic twice and using different ear drops for two weeks, her symptoms persist. What course of treatment should be recommended?

      Your Answer: Referral to secondary care

      Explanation:

      It is probable that the patient is suffering from malignant otitis externa, a condition that affects individuals with weakened immune systems like those with diabetes. This condition is characterized by osteomyelitis of the temporal bone. Despite receiving several rounds of antibiotic drops, the patient’s symptoms have not improved. It is recommended that the patient be referred to an ENT specialist for a CT scan of the temporal bones and treated with an extended course of intravenous antibiotics.

      Understanding Otitis Externa: Causes, Features, and Management

      Otitis externa is a common condition that often prompts patients to seek medical attention. It is characterized by ear pain, itch, and discharge, and is caused by various factors such as infection, seborrhoeic dermatitis, and contact dermatitis. Swimming is also a common trigger of otitis externa. Upon examination, the ear canal appears red, swollen, or eczematous.

      The recommended initial management of otitis externa involves the use of topical antibiotics or a combination of topical antibiotics with a steroid. However, if the tympanic membrane is perforated, aminoglycosides are traditionally not used. In cases where there is canal debris, removal may be necessary, while an ear wick may be inserted if the canal is extensively swollen. Second-line options include oral antibiotics, taking a swab inside the ear canal, and empirical use of an antifungal agent.

      It is important to note that if a patient fails to respond to topical antibiotics, referral to an ENT specialist may be necessary. Malignant otitis externa is a more serious condition that is more common in elderly diabetics. It involves the extension of infection into the bony ear canal and the soft tissues deep to the bony canal, and may require intravenous antibiotics.

      Overall, understanding the causes, features, and management of otitis externa is crucial in providing appropriate care and preventing complications.

    • This question is part of the following fields:

      • ENT
      23.6
      Seconds
  • Question 17 - You are taking the history of an Emergency Department patient who was assaulted....

    Correct

    • You are taking the history of an Emergency Department patient who was assaulted. The victim is a 20-year-old female who has a deep laceration on her thigh caused by a rusty machete. The wound has exposed tendon, muscle, and subcutaneous fat. According to her medical records, she received all her childhood immunizations on schedule, including 5 doses of tetanus vaccine, with the last one administered when she was 16 years old.

      What is the appropriate management for tetanus risk in this patient?

      Your Answer: No tetanus vaccine booster and no immunoglobulins required

      Explanation:

      If a patient has received 5 doses of the tetanus vaccine, with the most recent dose administered less than 10 years ago, they do not need a booster vaccine or immunoglobulins, regardless of the severity of the wound. This is the correct course of action. The patient’s childhood vaccinations would have included 5 doses of the tetanus vaccine, with the last dose given at age 14 or later. Therefore, the patient is already adequately protected and does not require a booster or immunoglobulin, regardless of the severity of the wound.

      The option of administering a tetanus vaccine booster with antibiotics is not the correct course of action. While antibiotics may be considered for protection against other bacteria, the patient already has sufficient protection against tetanus and does not require vaccination.

      Similarly, administering a tetanus vaccine booster with tetanus immunoglobulin is not necessary. As previously mentioned, the patient already has adequate protection from previous vaccinations. Immunoglobulin would only be necessary if the patient had an incomplete or unknown vaccine history or if it had been more than 10 years since the last vaccine.

      Lastly, administering a tetanus vaccine booster alone is not necessary. The patient already has protection from previous vaccinations and does not require a booster.

      Tetanus Vaccination and Management of Wounds

      The tetanus vaccine is a purified toxin that is given as part of a combined vaccine. In the UK, it is given as part of the routine immunisation schedule at 2, 3, and 4 months, 3-5 years, and 13-18 years, providing a total of 5 doses for long-term protection against tetanus.

      When managing wounds, the first step is to classify them as clean, tetanus-prone, or high-risk tetanus-prone. Clean wounds are less than 6 hours old and have negligible tissue damage, while tetanus-prone wounds include puncture-type injuries acquired in a contaminated environment or wounds containing foreign bodies. High-risk tetanus-prone wounds include wounds or burns with systemic sepsis, certain animal bites and scratches, heavy contamination with material likely to contain tetanus spores, wounds or burns with extensive devitalised tissue, and wounds or burns that require surgical intervention.

      If the patient has had a full course of tetanus vaccines with the last dose less than 10 years ago, no vaccine or tetanus immunoglobulin is required regardless of the wound severity. If the patient has had a full course of tetanus vaccines with the last dose more than 10 years ago, a reinforcing dose of vaccine is required for tetanus-prone wounds, and a reinforcing dose of vaccine plus tetanus immunoglobulin is required for high-risk wounds. If the vaccination history is incomplete or unknown, a reinforcing dose of vaccine is required regardless of the wound severity, and a reinforcing dose of vaccine plus tetanus immunoglobulin is required for tetanus-prone and high-risk wounds.

      Overall, proper vaccination and wound management are crucial in preventing tetanus infection.

    • This question is part of the following fields:

      • Infectious Diseases
      36.2
      Seconds
  • Question 18 - A 35-year-old man with psoriatic arthritis presents with a severely painful red eye....

    Correct

    • A 35-year-old man with psoriatic arthritis presents with a severely painful red eye. The pain has been affecting his sleep for a few days. On examination, his visual acuity is normal but there is inflammation of the scleral, episcleral and conjunctival vessels. Both pupils are equal and react normally to light. There is no blanching of the episcleral vessels when 2.5% phenylephrine is applied to the eye.
      Which of the following is this patient most likely to be suffering from?

      Your Answer: Scleritis

      Explanation:

      Differentiating Ocular Inflammatory Conditions: Symptoms and Treatment

      Scleritis: A severe inflammation of the sclera, often associated with underlying inflammatory conditions such as rheumatoid arthritis. Symptoms include severe eye pain, watering, photophobia, and affected visual acuity. Treatment requires systemic medication such as non-steroidal anti-inflammatory drugs, corticosteroids, or immunosuppressants.

      Sjögren Syndrome: An association of dry eye and/or dry mouth with rheumatoid arthritis or other connective-tissue disorders. Pain is not a feature, but conjunctival hyperemia may be present.

      Anterior Uveitis: Inflammation of the iris with or without ciliary body involvement, often seen in patients with inflammatory bowel disease or ankylosing spondylitis. Symptoms include an acutely painful red eye with photophobia and a small, irregular, poorly reactive pupil.

      Conjunctivitis: Inflammation of the conjunctival vessels, causing sore red eyes with a sticky discharge. Pain is not a feature, and scleral and episcleral vessels are not affected. Often caused by bacterial or viral infections or irritants/allergens, it is usually self-limiting but may require topical antibiotics.

      Episcleritis: A mild inflammation of the episclera, often seen as an extra-articular manifestation of rheumatoid arthritis. Symptoms include mild eye irritation, redness, and sometimes photophobia. Application of 2.5% phenylephrine causes episcleral vessels to blanch, distinguishing it from scleritis. Visual acuity is unaffected, and it is usually self-limiting.

    • This question is part of the following fields:

      • Musculoskeletal
      12.9
      Seconds
  • Question 19 - A 59-year-old man comes to his General Practitioner complaining of severe dizziness, double...

    Correct

    • A 59-year-old man comes to his General Practitioner complaining of severe dizziness, double vision and tinnitus whenever he lifts weights. He is a non-smoker and is in good health otherwise. During the examination, there is a difference of 35 mmHg between the systolic blood pressure (BP) in his left and right arms. His cardiovascular examination is otherwise unremarkable. His neurological examination is also normal.
      What is the most probable diagnosis?

      Your Answer: Subclavian steal syndrome

      Explanation:

      Differentiating Subclavian Steal Syndrome from Other Conditions

      Subclavian steal syndrome is a condition that occurs when the subclavian artery is narrowed or blocked, leading to reversed blood flow in the vertebral artery. This can cause arm claudication and transient neurological symptoms when the affected arm is exercised. A key diagnostic feature is a systolic blood pressure difference of at least 15 mmHg between the affected and non-affected arms. However, other conditions can also cause discrepancies in blood pressure or similar symptoms, making it important to differentiate subclavian steal syndrome from other possibilities.

      Aortic dissection is a medical emergency that can cause a sudden onset of chest pain and rapidly deteriorating symptoms. Benign paroxysmal positional vertigo (BPPV) is characterized by vertigo triggered by head movements, but does not involve blood pressure differences or diplopia. Buerger’s disease is a rare condition that can cause blood pressure discrepancies, but also involves skin changes and tissue ischemia. Carotid sinus hypersensitivity (CSH) can cause syncope when pressure is applied to the neck, but does not explain the other symptoms reported by the patient.

      In summary, a thorough evaluation is necessary to distinguish subclavian steal syndrome from other conditions that may present with similar symptoms.

    • This question is part of the following fields:

      • Cardiovascular
      20.3
      Seconds
  • Question 20 - A 59-year-old man comes to the hospital complaining of central chest pain that...

    Correct

    • A 59-year-old man comes to the hospital complaining of central chest pain that spreads to his left arm, accompanied by sweating and nausea. In the Emergency Department, an ECG reveals ST elevation in leads V1, V2, V3, and V4, and he is given 300mg of aspirin before undergoing primary percutaneous coronary intervention. After a successful procedure, he is admitted to the Coronary Care Unit and eventually discharged with secondary prevention medication and lifestyle modification advice, as well as a referral to a cardiac rehabilitation program.
      During a check-up with his GP three weeks later, the patient reports feeling well but still experiences fatigue and shortness of breath during rehab activities. He has not had any further chest pain episodes. However, an ECG shows Q waves and convex ST elevation in leads V1, V2, V3, and V4.
      What is the most likely diagnosis?

      Your Answer: Left ventricular aneurysm

      Explanation:

      Complications of Myocardial Infarction

      Myocardial infarction (MI) can lead to various complications, which can occur immediately, early, or late after the event. Cardiac arrest is the most common cause of death following MI, usually due to ventricular fibrillation. Patients are treated with defibrillation as per the ALS protocol. Cardiogenic shock may occur if a significant portion of the ventricular myocardium is damaged, leading to a decrease in ejection fraction. This condition is challenging to treat and may require inotropic support and/or an intra-aortic balloon pump. Chronic heart failure may develop if the patient survives the acute phase, and loop diuretics such as furosemide can help decrease fluid overload. Tachyarrhythmias, such as ventricular fibrillation and ventricular tachycardia, are common complications of MI. Bradyarrhythmias, such as atrioventricular block, are more common following inferior MI.

      Pericarditis is a common complication of MI in the first 48 hours, characterized by typical pericarditis pain, a pericardial rub, and a pericardial effusion. Dressler’s syndrome, which occurs 2-6 weeks after MI, is an autoimmune reaction against antigenic proteins formed during myocardial recovery. It is treated with NSAIDs. Left ventricular aneurysm may form due to weakened myocardium, leading to persistent ST elevation and left ventricular failure. Patients are anticoagulated due to the increased risk of thrombus formation and stroke. Left ventricular free wall rupture and ventricular septal defect are rare but serious complications that require urgent surgical correction. Acute mitral regurgitation may occur due to ischaemia or rupture of the papillary muscle, leading to acute hypotension and pulmonary oedema. Vasodilator therapy and emergency surgical repair may be necessary.

    • This question is part of the following fields:

      • Cardiovascular
      22
      Seconds
  • Question 21 - A 6-month-old infant presents to the Emergency Department with respiratory distress. The child...

    Correct

    • A 6-month-old infant presents to the Emergency Department with respiratory distress. The child has epicanthic folds and a single palmar crease. Genetic testing confirms an autosomal trisomy. What is the most frequent cardiac anomaly observed in infants with this disorder?

      Your Answer: Atrioventricular septal defect

      Explanation:

      Cardiac Abnormalities in Down Syndrome Patients

      Down syndrome is a genetic disorder that often presents with physical characteristics such as epicanthic folds, single creases, and an autosomal trisomy. It is common for children with Down syndrome to have congenital heart disease, with 42% of the population affected. Of those, 23% have multiple cardiac abnormalities. The most prevalent cardiac abnormality, found in 37% of cases, is a complete atrioventricular septal defect. Ventricular septal defects are the second most common, affecting 30% of patients. Mitral valve disorders occur in up to 40% of Down syndrome patients, but mitral stenosis is less common. Atrial septal defects affect 15% of patients, while patent ductus arteriosus affects only 2%. Understanding the prevalence of these cardiac abnormalities in Down syndrome patients is crucial for proper diagnosis and treatment.

    • This question is part of the following fields:

      • Genetics
      10.6
      Seconds
  • Question 22 - You are advising a 26-year-old woman who has recently discovered she is expecting...

    Incorrect

    • You are advising a 26-year-old woman who has recently discovered she is expecting a baby. She is a smoker and consumes 20 cigarettes per day. What is the primary risk factor linked to smoking while pregnant?

      Your Answer: Pre-eclampsia

      Correct Answer: Increased risk of pre-term labour

      Explanation:

      Risks of Smoking, Alcohol, and Illegal Drugs During Pregnancy

      During pregnancy, drug use can have serious consequences for both the mother and the developing fetus. Smoking during pregnancy increases the risk of miscarriage, pre-term labor, stillbirth, and sudden unexpected death in infancy. Alcohol consumption can lead to fetal alcohol syndrome, which can cause learning difficulties, characteristic facial features, and growth restrictions. Binge drinking is a major risk factor for fetal alcohol syndrome. Cannabis use poses similar risks to smoking due to the tobacco content. Cocaine use can lead to hypertension in pregnancy, including pre-eclampsia, and placental abruption. Fetal risks include prematurity and neonatal abstinence syndrome. Heroin use can result in neonatal abstinence syndrome. It is important for pregnant women to avoid drug use to ensure the health and well-being of both themselves and their unborn child.

    • This question is part of the following fields:

      • Reproductive Medicine
      10.4
      Seconds
  • Question 23 - The mother of a 3-month-old boy presents to the clinic with concerns about...

    Correct

    • The mother of a 3-month-old boy presents to the clinic with concerns about a soft lump in his right groin area. The baby has been breastfeeding well and having regular bowel movements. There is no significant medical history. Upon examination, a 1 cm swelling is noted in the right inguinal region, which is reducible and disappears when the baby is laid flat. Scrotal examination reveals no abnormalities. What is the best course of action in this situation?

      Your Answer: Refer to paediatric surgery

      Explanation:

      Abdominal wall hernias occur when an organ or the fascia of an organ protrudes through the wall of the cavity that normally contains it. Risk factors for developing these hernias include obesity, ascites, increasing age, and surgical wounds. Symptoms of abdominal wall hernias include a palpable lump, cough impulse, pain, obstruction (more common in femoral hernias), and strangulation (which can compromise the bowel blood supply and lead to infarction). There are several types of abdominal wall hernias, including inguinal hernias (which account for 75% of cases and are more common in men), femoral hernias (more common in women and have a high risk of obstruction and strangulation), umbilical hernias (symmetrical bulge under the umbilicus), paraumbilical hernias (asymmetrical bulge), epigastric hernias (lump in the midline between umbilicus and xiphisternum), incisional hernias (which may occur after abdominal surgery), Spigelian hernias (rare and seen in older patients), obturator hernias (more common in females and can cause bowel obstruction), and Richter hernias (a rare type of hernia that can present with strangulation without symptoms of obstruction). In children, congenital inguinal hernias and infantile umbilical hernias are the most common types, with surgical repair recommended for the former and most resolving on their own for the latter.

    • This question is part of the following fields:

      • Paediatrics
      21
      Seconds
  • Question 24 - A 6-year-old boy presents to his General Practitioner with his mother three weeks...

    Correct

    • A 6-year-old boy presents to his General Practitioner with his mother three weeks following his recent admission to the Paediatric Ward where he was treated for Kawasaki disease. He responded well to his treatment in the hospital.
      His mother asks if her son still needs to be taking the treatment prescribed by the Paediatric Team.
      Which of the following treatments is the patient likely to still be taking?

      Your Answer: Oral aspirin daily

      Explanation:

      Treatment Options for Kawasaki Disease: Understanding the Use of Aspirin

      Kawasaki disease is a condition that affects children and causes inflammation in the blood vessels throughout the body. When diagnosed, treatment typically involves intravenous immunoglobulin and aspirin. In this article, we will discuss the use of aspirin in the treatment of Kawasaki disease and why it is important.

      Oral aspirin is given to patients with Kawasaki disease due to its anti-inflammatory and antiplatelet properties. It helps to reduce the chances of blood clots if there are developing problems in the heart, such as coronary artery aneurysms that can occur in Kawasaki disease. The dosage of aspirin is usually higher (30 mg/kg per day) for up to two weeks and then continued at lower doses (3-5 mg/kg per day) until a review of echocardiogram, which is usually 6-8 weeks after the onset of illness.

      If the review echocardiogram at 6-8 weeks shows no evidence of any coronary artery aneurysms, then aspirin is usually stopped. However, until that time, patients with Kawasaki disease will continue to take oral aspirin daily.

      It is important to note that other non-steroidal anti-inflammatory medications such as ibuprofen should be avoided while taking aspirin. Additionally, oral steroids are a second-line treatment that are considered when there is failure to respond to initial intravenous immunoglobulin therapy.

      In conclusion, aspirin is an important part of the treatment for Kawasaki disease due to its anti-inflammatory and antiplatelet properties. Patients with Kawasaki disease will continue to take oral aspirin daily until a review echocardiogram shows no evidence of any coronary artery aneurysms. It is important to follow the treatment plan prescribed by a specialist to ensure the best possible outcome for the patient.

    • This question is part of the following fields:

      • Musculoskeletal
      13.3
      Seconds
  • Question 25 - You are a senior doctor in the paediatrics department. A fifteen year-old whose...

    Correct

    • You are a senior doctor in the paediatrics department. A fifteen year-old whose parents are devout Jehovah's witnesses requires a blood transfusion. Both parents state that they do not wish their child to have a potentially life saving transfusion. The fifteen year-old herself understands the risks and benefits of a transfusion and wishes to have the transfusion regardless.

      Which of the following is correct?

      Your Answer: The blood can be transfused without the parents consent

      Explanation:

      Once a child reaches the age of 16, they are considered competent to provide consent for treatment. In this case, the 16-year-old child can provide consent for the blood transfusion, but cannot refuse it. Therefore, the blood can be given as the child has provided consent. If the child were to refuse the treatment, the blood could still be given in their best interests without the consent of the child or their parents, using the Children Act 1989 and a High Court Order. However, in this particular case, such an order is not necessary. While some Jehovah witnesses may accept certain blood products, such as fresh frozen plasma or albumin, they may decline a complete blood transfusion. However, this is not appropriate in this situation. It may be advisable to contact the hospital liaison representative, but as the child is of age and understands the situation, they are able to provide consent for the treatment.

      Understanding Consent in Children

      The issue of consent in children can be complex and confusing. However, there are some general guidelines to follow. If a patient is under 16 years old, they may be able to consent to treatment if they are deemed competent. This is determined by the Fraser guidelines, which were previously known as Gillick competence. However, even if a child is competent, they cannot refuse treatment that is deemed to be in their best interest.

      For patients between the ages of 16 and 18, it is generally assumed that they are competent to give consent to treatment. Patients who are 18 years or older can consent to or refuse treatment.

      When it comes to providing contraceptives to patients under 16 years old, the Fraser Guidelines outline specific requirements that must be met. These include ensuring that the young person understands the advice given by the healthcare professional, cannot be persuaded to inform their parents, is likely to engage in sexual activity with or without treatment, and will suffer physical or mental health consequences without treatment. Ultimately, the young person’s best interests must be taken into account when deciding whether to provide contraceptive advice or treatment, with or without parental consent.

      In summary, understanding consent in children requires careful consideration of age, competence, and best interests. The Fraser Guidelines provide a useful framework for healthcare professionals to follow when providing treatment and advice to young patients.

    • This question is part of the following fields:

      • Paediatrics
      17.7
      Seconds
  • Question 26 - A 35-year-old woman presents to her General Practitioner with headaches. Her blood pressure...

    Correct

    • A 35-year-old woman presents to her General Practitioner with headaches. Her blood pressure is 170/96 mmHg. Routine investigations reveal the following results:
      Investigation Result Normal value
      Sodium 148 mmol/l 137–144 mmol/l
      Potassium 2.8 mmol/l 3.5–4.9 mmol/l
      Chloride 103 mmol/l 95–107 mmol/l
      The renin level is undetectable and aldosterone levels are raised. The urea and creatinine are normal.
      Which of the following is the most likely cause of her hypertension?

      Your Answer: Conn syndrome

      Explanation:

      Differentiating between causes of hypertension: A brief overview

      One possible cause of hypertension is Conn syndrome, which is characterized by primary hyperaldosteronism due to a benign adrenal adenoma that secretes aldosterone. This leads to hypokalaemia, hypertension, and elevated sodium levels. Renin levels are reduced due to negative feedback from high aldosterone levels. Treatment options include surgical excision of the adenoma or potassium-sparing diuretics.

      Acromegaly, on the other hand, is caused by excessive secretion of growth hormone, usually due to a pituitary tumor. While hypertension may be present, other clinical features such as visual field defects, abnormal increase in size of hands and feet, frontal bossing, and hyperhidrosis are expected. Abnormal electrolytes, renin, and aldosterone levels are not typically seen in acromegaly.

      Cushing syndrome is characterized by hypercortisolism and may present with central obesity, skin and muscle atrophy, osteoporosis, and gonadal dysfunction. While hypertension may also be present, low renin levels and elevated aldosterone are not expected.

      Phaeochromocytoma is a catecholamine-producing tumor that presents with episodic headaches, sweating, and tachycardia. While hypertension is also present, a low renin and elevated aldosterone are not expected.

      Finally, renal artery stenosis is caused by renal hypoperfusion, leading to a compensatory increase in renin secretion, secondary hyperaldosteronism, and hypertension. This may result in hypokalaemia and hypernatraemia, but both renin and aldosterone levels would be raised.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      20
      Seconds
  • Question 27 - A 28-year-old woman comes in for a check-up. She reports having 'IBS' and...

    Correct

    • A 28-year-old woman comes in for a check-up. She reports having 'IBS' and experiencing occasional episodes of abdominal pain, bloating, and loose stools for the past two years. However, her symptoms have worsened significantly over the past two weeks. She is now having 3-4 watery, grey, 'frothy' stools per day, along with increased abdominal bloating, cramps, and flatulence. She also feels that she has lost weight based on the fit of her clothes. The following blood tests are ordered:
      Hb 10.9 g/dl
      Platelets 199 * 109/l
      WBC 7.2 * 109/l
      Ferritin 15 ng/ml
      Vitamin B12 225 ng/l
      Folate 2.1 nmol/l
      What is the most likely diagnosis?

      Your Answer: Coeliac disease

      Explanation:

      The key indicators in this case are the presence of anaemia and low levels of ferritin and folate, which are all typical of coeliac disease. The description of the diarrhoea also matches the usual symptoms, although some patients may have stools that are visibly fatty.

      While irritable bowel syndrome is a common condition, it is unlikely to be the cause in this case due to the abnormal blood test results. Low levels of ferritin and folate would not typically be associated with IBS or gastroenteritis. Even if the patient had menorrhagia, this would not explain the low folate levels, although it could account for the anaemia and low ferritin.

      Coeliac disease is much more common than Crohn’s disease, with a prevalence that is around 100 times higher. In an exam scenario, there would typically be more clues pointing towards a diagnosis of Crohn’s disease, such as the presence of mouth ulcers.

      Understanding Coeliac Disease

      Coeliac disease is an autoimmune disorder that affects approximately 1% of the UK population. It is caused by sensitivity to gluten, a protein found in wheat, barley, and rye. Repeated exposure to gluten leads to villous atrophy, which causes malabsorption. Coeliac disease is associated with various conditions, including dermatitis herpetiformis and autoimmune disorders such as type 1 diabetes mellitus and autoimmune hepatitis. It is strongly linked to HLA-DQ2 and HLA-DQ8.

      To diagnose coeliac disease, NICE recommends screening patients who exhibit signs and symptoms such as chronic or intermittent diarrhea, unexplained gastrointestinal symptoms, sudden weight loss, and autoimmune thyroid disease. Other conditions associated with coeliac disease include irritable bowel syndrome, dermatitis herpetiformis, and type 1 diabetes. First-degree relatives of patients with coeliac disease should also be screened.

      Complications of coeliac disease include anemia, hyposplenism, osteoporosis, lactose intolerance, and enteropathy-associated T-cell lymphoma of the small intestine. In rare cases, coeliac disease may lead to esophageal cancer or other malignancies.

      Overall, understanding coeliac disease is crucial for early diagnosis and management of the condition. Screening for coeliac disease in patients with relevant symptoms and conditions can help prevent complications and improve quality of life.

    • This question is part of the following fields:

      • Gastroenterology/Nutrition
      29.5
      Seconds
  • Question 28 - A 42-year-old man comes to his General Practitioner complaining of a persistent tremor....

    Correct

    • A 42-year-old man comes to his General Practitioner complaining of a persistent tremor. During examination, it is observed that there is a symmetrical bilateral tremor of his arms which worsens when they are outstretched. His father also had a similar problem. What is the most appropriate initial treatment?

      Your Answer: Propranolol

      Explanation:

      Treatment Options for Essential Tremor: Understanding the Differences from Parkinson’s Disease

      Essential tremor is a neurological disorder that causes involuntary shaking, typically in the hands, head, and voice. It is important to differentiate between essential tremor and Parkinson’s disease (PD) as the treatment options differ. Propranolol is considered the first-line treatment for essential tremor, while levodopa is used for PD.

      To distinguish between the two conditions, it is important to note that essential tremor worsens with movement and is often symmetrical, while PD tremors occur mostly at rest and are asymmetrical. Additionally, essential tremor often has a family history component.

      Other medications, such as diazepam, fluoxetine, and gabapentin, are not typically used for essential tremor. Diazepam is used for acute muscle spasms and anxiety, fluoxetine is used for depression and other mental health conditions, and gabapentin is used for seizure disorders and neuropathic pain.

      In summary, understanding the differences between essential tremor and PD is crucial in determining the appropriate treatment options. Propranolol is the preferred medication for essential tremor, while levodopa is used for PD.

    • This question is part of the following fields:

      • Neurology
      9.3
      Seconds
  • Question 29 - A 6-year-old boy comes to the pediatrician's office as his parents are concerned...

    Correct

    • A 6-year-old boy comes to the pediatrician's office as his parents are concerned about his early development. He is now a lot taller than most of his friends and he has started to develop hair around his genitalia and armpits. On examination, his penis is also large for his age however his testes remain prepubertal. Which of the following is the most likely cause of this boy's precocious puberty?

      Your Answer: Adrenal hyperplasia

      Explanation:

      When dealing with precocious puberty, it is important to examine the size of the testicles to determine the underlying cause. In cases where the testicles are small, such as in this situation, it suggests an adrenal origin of the symptoms. On the other hand, if there is bilateral testicular enlargement, it may indicate central precocious puberty caused by an astrocytoma or other brain tumor. Testotoxicosis, which is associated with a history of childhood sexual aggression, would result in advanced development in all areas. A sex cord-gonadal stromal tumor would cause unilateral enlargement of the affected testicle. Finally, an idiopathic cause of precocious puberty would lead to advanced development in all pubertal areas, resulting in enlarged testicles.

      Understanding Precocious Puberty

      Precocious puberty is a condition where secondary sexual characteristics develop earlier than expected, before the age of 8 in females and 9 in males. It is more common in females and can be classified into two types: gonadotrophin dependent and gonadotrophin independent. The former is caused by premature activation of the hypothalamic-pituitary-gonadal axis, resulting in raised levels of FSH and LH. The latter is caused by excess sex hormones, with low levels of FSH and LH. In males, precocious puberty is uncommon and usually has an organic cause, such as gonadotrophin release from an intracranial lesion, gonadal tumour, or adrenal cause. In females, it is usually idiopathic or familial and follows the normal sequence of puberty. Organic causes are rare and associated with rapid onset, neurological symptoms and signs, and dissonance, such as in McCune Albright syndrome. Understanding precocious puberty is important for early detection and management of the condition.

    • This question is part of the following fields:

      • Paediatrics
      17.8
      Seconds
  • Question 30 - A 28 year-old carpenter complains of itchy and painful skin on his hands...

    Correct

    • A 28 year-old carpenter complains of itchy and painful skin on his hands and wrists. He suspects that it might be due to something he is exposed to at work. What test would be most appropriate to investigate this hypothesis?

      Your Answer: Patch testing

      Explanation:

      When there is a suspicion of allergic contact dermatitis, patch testing is the preferred method of investigation. This condition can be caused by either irritants or allergens. The patient’s back is exposed to different allergens, including standard batteries and any substances that the patient suspects. The skin is then evaluated for any reaction after 48 hours and 7 days.

      Understanding Contact Dermatitis

      Contact dermatitis is a skin condition that can be caused by two main types of reactions. The first type is irritant contact dermatitis, which is a non-allergic reaction that occurs due to exposure to weak acids or alkalis, such as detergents. This type of dermatitis is commonly seen on the hands and is characterized by erythema, but crusting and vesicles are rare. The second type is allergic contact dermatitis, which is a type IV hypersensitivity reaction. This type of dermatitis is uncommon and is often seen on the head following hair dyes. It presents as an acute weeping eczema that predominantly affects the margins of the hairline rather than the hairy scalp itself. Topical treatment with a potent steroid is indicated for this type of dermatitis.

      Cement is a frequent cause of contact dermatitis. The alkaline nature of cement may cause an irritant contact dermatitis, while the dichromates in cement can also cause an allergic contact dermatitis. It is important to understand the different types of contact dermatitis and their causes to properly diagnose and treat the condition. Proper treatment can help alleviate symptoms and prevent further complications.

    • This question is part of the following fields:

      • Dermatology
      15.1
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Musculoskeletal (5/5) 100%
Reproductive Medicine (2/3) 67%
Pharmacology/Therapeutics (1/1) 100%
Paediatrics (3/4) 75%
Gastroenterology/Nutrition (3/3) 100%
ENT (2/2) 100%
Renal Medicine/Urology (3/3) 100%
Haematology/Oncology (0/1) 0%
Ophthalmology (1/1) 100%
Infectious Diseases (1/1) 100%
Cardiovascular (2/2) 100%
Genetics (1/1) 100%
Endocrinology/Metabolic Disease (1/1) 100%
Neurology (1/1) 100%
Dermatology (1/1) 100%
Passmed