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Question 1
Correct
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A 28-year-old female comes to the gastroenterology clinic for a follow-up on her Crohn's disease. She has been on budesonide for 3 months to induce remission and reports feeling well. She did not experience any acute episodes during treatment and her bowel habits are regular. The physician determines that she requires maintenance therapy. What is the most suitable medication to prescribe?
Your Answer: Azathioprine
Explanation:Bone marrow suppression, which can be fatal, is a potential risk associated with the use of azathioprine as a second-line treatment for Crohn’s disease. Budesonide, a corticosteroid medication primarily used for asthma prevention, may be considered as a second-line option for inducing remission in Crohn’s patients. Mesalazine, which acts locally on the colon’s mucous membrane and has various anti-inflammatory effects, is less effective than glucocorticoids but can be used as a second-line option to induce remission. Methotrexate, a folate derivative that inhibits enzymes responsible for nucleotide synthesis, is the second-line medication used to maintain remission in Crohn’s patients. However, in this case, there is no indication to use second-line management instead of first-line treatment.
Managing Crohn’s Disease: Guidelines and Treatment Options
Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract. To manage this condition, the National Institute for Health and Care Excellence (NICE) has published guidelines that provide recommendations for inducing and maintaining remission, as well as treating complications. One of the most important steps in managing Crohn’s disease is to advise patients to quit smoking, as this can worsen the condition. Additionally, some medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and the combined oral contraceptive pill, may increase the risk of relapse, although the evidence is not conclusive.
To induce remission, glucocorticoids are often used, either orally, topically, or intravenously. Budesonide is an alternative for some patients. Enteral feeding with an elemental diet may also be used, especially in young children or when there are concerns about the side effects of steroids. Second-line treatments for inducing remission include 5-ASA drugs like mesalazine, as well as azathioprine or mercaptopurine, which may be used in combination with other medications. Methotrexate is another option. Infliximab is useful for refractory disease and fistulating Crohn’s, and patients may continue on azathioprine or methotrexate.
To maintain remission, stopping smoking is a priority, and azathioprine or mercaptopurine is used first-line. TPMT activity should be assessed before starting these medications. Methotrexate is used second-line. Surgery may be necessary for around 80% of patients with Crohn’s disease, depending on the location and severity of the disease. Complications of Crohn’s disease include small bowel cancer, colorectal cancer, and osteoporosis. Perianal fistulae and abscesses require specific treatments, such as oral metronidazole, anti-TNF agents like infliximab, or a draining seton. By following these guidelines and treatment options, patients with Crohn’s disease can better manage their condition and improve their quality of life.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 2
Correct
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A 67-year-old man with a history of primary open-angle glaucoma presents with sudden painless loss of vision in his left eye. Upon examination of the left eye, there are multiple flame-shaped and blot haemorrhages with a swollen optic disc. What is the probable diagnosis?
Your Answer: Occlusion of central retinal vein
Explanation:Sudden painless vision loss and severe retinal hemorrhages observed on fundoscopy are indicative of central retinal vein occlusion.
Understanding Central Retinal Vein Occlusion
Central retinal vein occlusion (CRVO) is a possible cause of sudden, painless loss of vision. It is more common in older individuals and those with hypertension, cardiovascular disease, glaucoma, or polycythemia. The condition is characterized by a sudden reduction or loss of visual acuity, usually affecting only one eye. Fundoscopy reveals widespread hyperemia and severe retinal hemorrhages, which are often described as a stormy sunset.
Branch retinal vein occlusion (BRVO) is a similar condition that affects a smaller area of the fundus. It occurs when a vein in the distal retinal venous system is blocked, usually at arteriovenous crossings.
Most patients with CRVO are managed conservatively, but treatment may be necessary in some cases. For instance, intravitreal anti-vascular endothelial growth factor (VEGF) agents may be used to manage macular edema, while laser photocoagulation may be necessary to treat retinal neovascularization.
Overall, understanding the risk factors, features, and management options for CRVO is essential for prompt diagnosis and appropriate treatment. Proper management can help prevent further vision loss and improve the patient’s quality of life.
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This question is part of the following fields:
- Ophthalmology
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Question 3
Incorrect
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What is an accurate statement about alcoholic liver disease (ALD)?
Your Answer: Hepatic iron overload is indicative of concomitant heterozygote haemochromatosis
Correct Answer: In alcoholic hepatitis the AST : ALT ratio is at least 2 : 1
Explanation:Alcoholic Liver Disease: Facts and Myths
Alcoholic liver disease (ALD) is a common liver disease caused by overconsumption of alcohol. Here are some facts and myths about ALD:
Myth: In alcoholic hepatitis, the AST:ALT ratio is less than 2:1.
Fact: Unlike most other liver diseases, including viral hepatitis, alcoholic hepatitis exhibits at least a 2:1 AST:ALT ratio.Myth: Hepatic iron overload is not indicative of concomitant heterozygote haemochromatosis.
Fact: Evidence of iron overload, such as elevated levels of transferrin saturation and serum ferritin, is common in ALD and may indicate concomitant heterozygote haemochromatosis.Myth: Women are less susceptible to ALD than men.
Fact: Women are actually twice as susceptible to ALD than men, even when consumption is corrected for body weight, and may develop ALD with shorter durations and doses of chronic consumption.Myth: Alcoholic fatty infiltration is irreversible once established.
Fact: Although steatosis (fatty infiltration) will develop in any individual who consumes a large quantity of alcohol over a long period of time, this process is usually transient and reversible. Alcoholic hepatitis and alcoholic fatty infiltration are reversible with abstinence and adequate nutrition.Myth: Alcoholic cirrhosis does not progress to hepatocellular carcinoma.
Fact: Like other causes of liver cirrhosis, alcoholic cirrhosis can also progress to hepatocellular carcinoma.In conclusion, ALD is a serious liver disease that can have irreversible consequences if not addressed in a timely manner. It is important to understand the facts and myths surrounding this disease to ensure proper diagnosis and treatment.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 4
Incorrect
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A 40-year-old woman undergoing treatment for rheumatoid arthritis complains of nephrotic syndrome.
Which medication is the probable cause of this issue?Your Answer: Cyclophosphamide
Correct Answer: Penicillamine
Explanation:Overview of Medications Used in the Treatment of Rheumatoid Arthritis
Rheumatoid arthritis is a chronic autoimmune disease that affects the joints and can lead to disability. There are several medications used in the management of this condition, each with their own benefits and potential side effects.
Penicillamine is a drug commonly used in the treatment of rheumatoid arthritis, but it can also cause secondary membranous nephropathy, a condition characterized by proteinuria. Hydroxychloroquine is another medication that can be used for active rheumatoid arthritis, but its main complication is ocular toxicity. Sulfasalazine is primarily used for ulcerative colitis, but can also be used for rheumatoid arthritis under expert advice. Cyclophosphamide is rarely used for rheumatoid arthritis and is associated with the rare but serious complication of haemorrhagic cystitis. Methotrexate is a commonly used medication for severe Crohn’s disease and moderate to severe rheumatoid arthritis, but its main complication is bone marrow suppression.
It is important for patients to work closely with their healthcare providers to determine the most appropriate medication for their individual needs and to monitor for potential side effects.
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This question is part of the following fields:
- Renal Medicine/Urology
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Question 5
Correct
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A 25-year-old male comes to the neurology department with complaints of weakness. He initially experienced weakness in his legs a few days ago, which has now progressed to involve his arms. Additionally, he is experiencing shooting pains in his back and limbs. About four weeks ago, he had a brief episode of vomiting and diarrhea. Upon examination, reduced tendon reflexes and weakness are confirmed.
What test results would you anticipate for this patient?Your Answer: Abnormal nerve conduction studies
Explanation:Guillain-Barre syndrome can be diagnosed with the help of nerve conduction studies. The presence of ascending weakness after an infection is a common symptom of this syndrome. Most patients with Guillain-Barre syndrome show abnormal nerve conduction study results. If there are cord signal changes, it may indicate spinal cord compression or a spinal lesion. Inflammatory infiltrates on muscle biopsy are typically observed in patients with myositis. Myasthenia gravis is characterized by the presence of anti-acetylcholine receptor antibodies. In Guillain-Barre syndrome, the CSF protein level is usually elevated, not decreased.
Understanding Guillain-Barre Syndrome: Symptoms and Features
Guillain-Barre syndrome is a condition that affects the peripheral nervous system and is caused by an immune-mediated demyelination. It is often triggered by an infection, with Campylobacter jejuni being a common culprit. The initial symptoms of the illness include back and leg pain, which is experienced by around 65% of patients. The characteristic feature of Guillain-Barre syndrome is a progressive, symmetrical weakness of all the limbs, with the weakness typically starting in the legs and ascending upwards. Reflexes are reduced or absent, and sensory symptoms tend to be mild, with very few sensory signs.
Other features of Guillain-Barre syndrome may include a history of gastroenteritis, respiratory muscle weakness, cranial nerve involvement, diplopia, bilateral facial nerve palsy, oropharyngeal weakness, and autonomic involvement. Autonomic involvement may manifest as urinary retention or diarrhea. Less common findings may include papilloedema, which is thought to be secondary to reduced CSF resorption.
To diagnose Guillain-Barre syndrome, a lumbar puncture may be performed, which can reveal a rise in protein with a normal white blood cell count (albuminocytologic dissociation) in 66% of cases. Nerve conduction studies may also be conducted, which can show decreased motor nerve conduction velocity due to demyelination, prolonged distal motor latency, and increased F wave latency. Understanding the symptoms and features of Guillain-Barre syndrome is crucial for prompt diagnosis and treatment.
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This question is part of the following fields:
- Neurology
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Question 6
Correct
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A 29-year-old man who has recently arrived in the UK from Uganda visits the clinic with complaints of exhaustion and purple skin lesions all over his body. During the examination, you observe multiple raised purple lesions on his trunk and arms. Additionally, you notice some smaller purple lesions in his mouth. He has recently initiated acyclovir treatment for herpes zoster infection. What is the probable diagnosis?
Your Answer: Kaposi's sarcoma
Explanation:The presence of raised purple lesions is a typical indication of Kaposi’s sarcoma, which may suggest that the patient has an underlying HIV infection. Given the high prevalence of HIV in Uganda and the recent occurrence of herpes zoster, it is possible that the patient’s immune system is compromised. Dermatofibromas, which are typically small and firm, would not be found in the mouth, while psoriasis is characterized by red, scaly lesions that do not appear on mucosal surfaces. A drug reaction is an unlikely explanation for the patient’s symptoms. Although a haemangioma can present as a purple raised lesion, it is uncommon to find them in the mouth, and Kaposi’s sarcoma is a more likely diagnosis in this case.
Kaposi’s Sarcoma in HIV Patients
Kaposi’s sarcoma is a type of cancer that is commonly seen in patients with HIV. It is caused by the human herpes virus 8 (HHV-8) and is characterized by the appearance of purple papules or plaques on the skin or mucosa. These lesions may later ulcerate, causing discomfort and pain. In some cases, respiratory involvement may occur, leading to massive haemoptysis and pleural effusion.
Treatment for Kaposi’s sarcoma typically involves a combination of radiotherapy and resection. This can help to reduce the size of the lesions and prevent further spread of the cancer. However, it is important to note that Kaposi’s sarcoma can be a serious and potentially life-threatening condition, particularly in patients with HIV. As such, it is important for individuals with HIV to be regularly screened for this condition and to seek prompt medical attention if any symptoms are present.
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This question is part of the following fields:
- Infectious Diseases
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Question 7
Incorrect
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A 35-year-old female patient presents to the eye hospital emergency department with a 1-week history of blurred vision and right eye pain worse on movement. The patient also reports a missing area of the visual field in the right eye. On examination, there is decreased visual acuity and impaired colour vision in the right eye and a right relative afferent pupillary defect. Fundoscopy reveals mildly swollen right optic disc. Intraocular pressure is 18 mmHg in the right eye. Her past medical history includes type 1 diabetes mellitus and hypertension. What is the most likely diagnosis for this 35-year-old female patient with blurred vision and right eye pain?
Your Answer: Anterior ischaemic optic neuropathy
Correct Answer: Optic neuritis
Explanation:Optic neuritis is the likely cause of this patient’s symptoms, which may be idiopathic or secondary to multiple sclerosis. One of the common symptoms of optic neuritis is a reduction in colour vision, along with pain around the eye during movement. Visual field defects, particularly central scotoma, may also occur. If only one eye is affected, there may be a relative afferent pupillary defect. While the patient has some risk factors for stroke, stroke would not cause eye pain or affect colour vision. Anterior ischaemic optic neuropathy typically causes painless visual loss and is more common in individuals over 50 years of age. The patient’s intraocular pressure is within the normal range, ruling out acute angle closure glaucoma. Additionally, the patient does not have papilloedema, as only one optic disc is swollen.
Optic neuritis is a condition that can be caused by multiple sclerosis, diabetes, or syphilis. It is characterized by a decrease in visual acuity in one eye over a period of hours or days, as well as poor color discrimination and pain that worsens with eye movement. Other symptoms include a relative afferent pupillary defect and a central scotoma. The condition can be diagnosed through an MRI of the brain and orbits with gadolinium contrast. Treatment typically involves high-dose steroids, and recovery usually takes 4-6 weeks. If an MRI shows more than three white-matter lesions, the risk of developing multiple sclerosis within five years is approximately 50%.
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This question is part of the following fields:
- Ophthalmology
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Question 8
Correct
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A 7-year-old boy who has haemophilia A presents to the Emergency Department after falling off a skateboard and hitting his head. He is drowsy and confused with a Glasgow Coma Score of 9.
What would be the next most appropriate step in this patient’s management?
Your Answer: Immediate administration of factor VIII
Explanation:Immediate Treatment for Serious Bleeding in Patients with Haemophilia
Serious or life-threatening bleeding in patients with haemophilia requires immediate evaluation and therapy with replacement factor. The immediate goal is to raise the activity of the deficient factor to a level sufficient to achieve haemostasis. For patients with potentially serious or life-threatening bleeding, treatment should be initiated immediately, even before completing diagnostic assessment.
In the case of haemophilia A, factor VIII must be replaced. Waiting to find out factor VIII levels prior to administering it could lead to further bleeding. Therefore, immediate administration of factor VIII is the most appropriate option.
While obtaining imaging of the head may be useful, the main objective is to obtain rapid haemostasis. Thus, transferring the patient immediately for a CT scan of the head is not the first action to take.
In a patient with haemophilia, evacuation of a clot may lead to further potentially catastrophic bleeding. If surgery is required, the patient must have adequate levels of factor VIII present to achieve haemostasis. Therefore, transferring the patient to the theatre for evacuation of an intracranial haematoma should not be the first action taken.
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This question is part of the following fields:
- Haematology/Oncology
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Question 9
Correct
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A woman presents with an area of dermatitis on her right ankle. She suspects she may have a nickel allergy. What is the most appropriate test to confirm this suspicion?
Your Answer: Skin patch test
Explanation:Types of Allergy Tests
Allergy tests are used to determine if a person has an allergic reaction to a particular substance. There are several types of allergy tests available, each with its own advantages and limitations. The most commonly used test is the skin prick test, which is easy to perform and inexpensive. Drops of diluted allergen are placed on the skin, and a needle is used to pierce the skin. A wheal will typically develop if a patient has an allergy. This test is useful for food allergies and pollen.
Another type of allergy test is the radioallergosorbent test (RAST), which determines the amount of IgE that reacts specifically with suspected or known allergens. Results are given in grades from 0 (negative) to 6 (strongly positive). This test is useful for food allergies, inhaled allergens (e.g. pollen), and wasp/bee venom.
Skin patch testing is useful for contact dermatitis. Around 30-40 allergens are placed on the back, and irritants may also be tested for. The patches are removed 48 hours later, and the results are read by a dermatologist after a further 48 hours. Blood tests may be used when skin prick tests are not suitable, for example if there is extensive eczema or if the patient is taking antihistamines. Overall, allergy tests are an important tool in diagnosing and managing allergies.
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This question is part of the following fields:
- Immunology/Allergy
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Question 10
Correct
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A 65-year-old man who works as a pipe lagger is referred to you with a 6-month history of increasing shortness of breath and weight loss. He is a lifelong non-smoker and has always led a fit, healthy life. Clinical examination indicates a left pleural effusion, which is confirmed on the chest radiograph. Which of the following malignant causes is most likely? Select the SINGLE malignant cause from the list below. Select ONE option only.
Your Answer: Mesothelioma
Explanation:Understanding Mesothelioma and Other Possible Malignancies
Mesothelioma is a rare and aggressive form of cancer that is often linked to asbestos exposure. Those who worked as pipe laggers in the past were frequently exposed to asbestos, which can lead to mesothelioma. Symptoms of mesothelioma include cough, shortness of breath, chest pain, and weight loss. While the prognosis for mesothelioma remains poor, some cases can be surgically resected and chemotherapy can provide palliative care.
However, other malignancies can also present with similar symptoms, such as non-small-cell cancer, small-cell lung cancer, squamous-cell lung cancer, and bronchial carcinoid tumors. It is important to exclude these possibilities and properly diagnose the specific type of cancer in order to provide the most effective treatment.
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This question is part of the following fields:
- Haematology/Oncology
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Question 11
Correct
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A 3-year-old boy is taken to his pediatrician by his father due to constant scratching of his bottom at night. The father reports observing some unusual white particles when cleaning his son's bottom after a bowel movement. What would be the best course of action for management?
Your Answer: Prescribe a single dose of mebendazole for the whole household and issue hygiene advice.
Explanation:Threadworm Infestation in Children
Threadworm infestation, caused by Enterobius vermicularis or pinworms, is a common occurrence among children in the UK. The infestation happens when eggs present in the environment are ingested. In most cases, threadworm infestation is asymptomatic, but some possible symptoms include perianal itching, especially at night, and vulval symptoms in girls. Diagnosis can be made by applying Sellotape to the perianal area and sending it to the laboratory for microscopy to see the eggs. However, most patients are treated empirically, and this approach is supported in the CKS guidelines.
The CKS recommends a combination of anthelmintic with hygiene measures for all members of the household. Mebendazole is the first-line treatment for children over six months old, and a single dose is given unless the infestation persists. It is essential to treat all members of the household to prevent re-infection. Proper hygiene measures, such as washing hands regularly, keeping fingernails short, and washing clothes and bedding at high temperatures, can also help prevent the spread of threadworm infestation.
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This question is part of the following fields:
- Paediatrics
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Question 12
Incorrect
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A 21-year-old soccer player comes to you with complaints of shoulder and lower back pain. He reports that his back has been getting stiffer over the past few months and has worsened. During the examination, you find out that he is also experiencing enthesitis of the Achilles tendon. You suspect a particular diagnosis and want to confirm it. What antigen's presence would confirm the diagnosis?
Your Answer: HLA-B24
Correct Answer: HLA-B27
Explanation: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).
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This question is part of the following fields:
- Musculoskeletal
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Question 13
Correct
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A 30-year-old male is brought to the emergency department after being found unconscious on the street with a syringe and used pack of oxycodone and alprazolam nearby. Upon examination, he is lethargic with pinpoint pupils, reduced bowel sounds, and fresh needle marks on his right arm. His vital signs are: blood pressure 110/70 mmHg, heart rate 55/min, oxygen saturation of 95% on room air, temperature 36ºC, and respiratory rate of 5 breaths per minute. His blood glucose level is 8 mmol/L. What is the most appropriate management for this patient?
Your Answer: Naloxone
Explanation:The individual displays classic symptoms of acute opioid overdose, including slow breathing, constricted pupils, and changes in consciousness.
The management of overdoses and poisonings involves specific treatments for each toxin. For paracetamol overdose, activated charcoal is recommended if ingested within an hour, followed by N-acetylcysteine or liver transplantation if necessary. Salicylate overdose can be managed with urinary alkalinization using IV bicarbonate or haemodialysis. Opioid/opiate overdose can be treated with naloxone, while benzodiazepine overdose can be treated with flumazenil in severe cases. Tricyclic antidepressant overdose may require IV bicarbonate to reduce the risk of seizures and arrhythmias, but class 1a and class Ic antiarrhythmics should be avoided. Lithium toxicity may respond to volume resuscitation with normal saline or haemodialysis in severe cases. Warfarin overdose can be treated with vitamin K or prothrombin complex, while heparin overdose can be treated with protamine sulphate. Beta-blocker overdose may require atropine or glucagon. Ethylene glycol poisoning can be managed with fomepizole or ethanol, while methanol poisoning can be treated with the same. Organophosphate insecticide poisoning can be treated with atropine, and digoxin overdose can be treated with digoxin-specific antibody fragments. Iron overdose can be managed with desferrioxamine, and lead poisoning can be treated with dimercaprol or calcium edetate. Carbon monoxide poisoning can be managed with 100% oxygen or hyperbaric oxygen, while cyanide poisoning can be treated with hydroxocobalamin or a combination of amyl nitrite, sodium nitrite, and sodium thiosulfate.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 14
Correct
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A 42-year-old female presents to the GP with a two-week history of feeling generally unwell. She reports experiencing hot flashes and sweating, as well as difficulty sleeping at night. Her husband has also noticed that she seems more agitated and on edge than usual. The patient has no significant medical history but reports having had flu-like symptoms six weeks ago that have since resolved. On examination, there is a tender goitre present. Thyroid function tests reveal a TSH level of 0.5 mU/L (normal range 0.5-5.5) and a free T4 level of 21 pmol/L (normal range 9.0-18). What is the first-line management for the most likely diagnosis?
Your Answer: Conservative management with ibuprofen
Explanation:Subacute (De Quervain’s) thyroiditis is the likely cause of this patient’s hyperthyroidism, as evidenced by symptoms such as heat intolerance, insomnia, and agitation, as well as a normal TSH and high T4 level. The presence of a tender goitre and recent viral illness further support this diagnosis. Conservative management, including observation and NSAIDs for pain relief, is the most appropriate course of action as subacute thyroiditis is typically self-limiting. Antithyroid drugs such as carbimazole and propylthiouracil are not indicated for this condition, as they are used to treat chronic hyperthyroidism such as Grave’s disease. Radioactive iodine therapy is also not appropriate for subacute thyroiditis.
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.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 15
Correct
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A 55-year-old man with a history of coronary artery disease is interested in using sildenafil to treat his erectile dysfunction. Is there any medication that could potentially prohibit its use?
Your Answer: Nicorandil
Explanation:Nitrates and nicorandil are contraindicated with PDE 5 inhibitors such as sildenafil due to the nitrate component in nicorandil and its additional function as a potassium channel activator.
Understanding Phosphodiesterase Type V Inhibitors
Phosphodiesterase type V (PDE5) inhibitors are medications used to treat erectile dysfunction and pulmonary hypertension. These drugs work by increasing the levels of cGMP, which leads to the relaxation of smooth muscles in the blood vessels supplying the corpus cavernosum. The most well-known PDE5 inhibitor is sildenafil, also known as Viagra, which was the first drug of its kind. It is a short-acting medication that is usually taken one hour before sexual activity.
Other PDE5 inhibitors include tadalafil (Cialis) and vardenafil (Levitra). Tadalafil is longer-acting than sildenafil and can be taken on a regular basis, while vardenafil has a similar duration of action to sildenafil. However, these drugs are not suitable for everyone. Patients taking nitrates or related drugs, those with hypotension, and those who have had a recent stroke or myocardial infarction should not take PDE5 inhibitors.
Like all medications, PDE5 inhibitors can cause side effects. These may include visual disturbances, blue discolouration, non-arteritic anterior ischaemic neuropathy, nasal congestion, flushing, gastrointestinal side-effects, headache, and priapism. It is important to speak to a healthcare professional before taking any medication to ensure that it is safe and appropriate for you.
Overall, PDE5 inhibitors are an effective treatment for erectile dysfunction and pulmonary hypertension. However, they should only be used under the guidance of a healthcare professional and with careful consideration of the potential risks and benefits.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 16
Incorrect
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A 72-year-old retired teacher visits the doctor with a painless gradual loss of vision. She reports difficulty reading as the words on the page are becoming harder to see. Additionally, she notices that straight lines in her artwork are appearing distorted, which is confirmed by Amsler grid testing. What is the probable diagnosis?
Your Answer: Wet age-related macular degeneration
Correct Answer: Dry age-related macular degeneration
Explanation:The most likely diagnosis for this patient’s gradual central loss of vision and difficulty reading is dry age-related macular degeneration. This subtype accounts for the majority of cases of macular degeneration and typically presents with a gradual loss of vision. Glaucoma and retinal detachment are unlikely diagnoses as they present with different symptoms such as peripheral vision loss and sudden vision loss with flashes and floaters, respectively.
Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by the degeneration of the central retina (macula) and the formation of drusen. It is more prevalent in females and is strongly associated with advancing age, smoking, family history, and conditions that increase the risk of ischaemic cardiovascular disease. ARMD can be classified into two forms: dry and wet. Dry ARMD is more common and is characterized by drusen, while wet ARMD is characterized by choroidal neovascularisation and carries a worse prognosis. Clinical features of ARMD include subacute onset of visual loss, difficulties in dark adaptation, and visual disturbances such as photopsia and glare.
To diagnose ARMD, slit-lamp microscopy and color fundus photography are used to identify any pigmentary, exudative, or haemorrhagic changes affecting the retina. Fluorescein angiography and indocyanine green angiography may also be used to visualize changes in the choroidal circulation. Treatment for dry ARMD involves a combination of zinc with anti-oxidant vitamins A, C, and E, which has been shown to reduce disease progression by around one third. For wet ARMD, anti-VEGF agents such as ranibizumab, bevacizumab, and pegaptanib are used to limit disease progression and stabilize or reverse visual loss. Laser photocoagulation may also be used to slow progression, but anti-VEGF therapies are usually preferred due to the risk of acute visual loss after treatment.
In summary, ARMD is a common cause of blindness in the UK that is strongly associated with advancing age, smoking, and family history. It can be classified into dry and wet forms, with wet ARMD carrying a worse prognosis. Diagnosis involves the use of various imaging techniques, and treatment options include a combination of zinc and anti-oxidant vitamins for dry ARMD and anti-VEGF agents or laser photocoagulation for wet ARMD.
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This question is part of the following fields:
- Ophthalmology
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Question 17
Correct
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A 35-year-old woman presents to her General Practitioner (GP) after experiencing daily headaches for the past week. She is usually healthy but drinks three cups of coffee a day. She describes sudden onset of severe, unilateral periorbital pain and tearing of the eye. The attacks last around 30 minutes and have all occurred in the late afternoon.
What is the most suitable treatment to be administered to this patient during an acute episode of headache?
Select the MOST appropriate treatment from the options below.Your Answer: Intranasal sumatriptan
Explanation:Treatment options for Cluster Headaches
Cluster headaches are a type of headache that is more common in men and presents with intense pain localized around one eye, accompanied by lacrimation and nasal congestion. The pain can last for a few minutes up to three hours and occurs every day for a number of weeks, followed by a symptom-free period. Here are some treatment options for cluster headaches:
Intranasal Sumatriptan: People over the age of 18 with acute bouts of confirmed cluster headache may be given a subcutaneous or nasal triptan for acute attacks.
Verapamil: Verapamil may be prescribed as a preventative treatment for cluster headaches but is not used during an acute attack. It is usually only prescribed following a discussion with a neurologist or a GP with a special interest in headaches.
Carbamazepine: Carbamazepine is used in the treatment of trigeminal neuralgia, which presents with sudden attacks of severe, shooting unilateral facial pain that feels like an ‘electric shock’. However, for cluster headaches, it is not the first-line treatment.
Codeine: Patients with cluster headaches should not be offered paracetamol, non-steroidal anti-inflammatory drugs or opioids as acute treatment, as they are too slow to take effect.
Short-burst oxygen therapy (home oxygen): Short-burst oxygen therapy (12–15 l/min via a non-rebreathe mask) can be prescribed to reduce the length of an attack, unless it is contraindicated. However, home oxygen is contraindicated for smokers due to the risk of fire.
In conclusion, cluster headaches can be debilitating, but there are various treatment options available to manage the symptoms. It is important to consult with a healthcare professional to determine the best course of treatment for each individual.
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This question is part of the following fields:
- Neurology
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Question 18
Incorrect
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A 26-year-old female presents for follow-up. She was diagnosed with asthma four years ago and is currently utilizing a salbutamol inhaler 100mcg as needed in combination with beclometasone dipropionate inhaler 200 mcg twice daily. However, her asthma remains poorly controlled. Upon examination, her chest is clear and she demonstrates proper inhaler technique. In accordance with NICE recommendations, what is the most suitable course of action for further management?
Your Answer: Increase beclometasone dipropionate to 400mcg bd
Correct Answer: Add a leukotriene receptor antagonist
Explanation:According to NICE 2017 guidelines, if a patient with asthma is not effectively managed with a SABA + ICS, the first step should be to add a LTRA rather than a LABA.
The management of asthma in adults has been updated by NICE in 2017, following the 2016 BTS guidelines. One of the significant changes is in ‘step 3’, where patients on a SABA + ICS whose asthma is not well controlled should be offered a leukotriene receptor antagonist instead of a LABA. NICE does not follow the stepwise approach of the previous BTS guidelines, but to make the guidelines easier to follow, we have added our own steps. The steps range from newly-diagnosed asthma to SABA +/- LTRA + one of the following options, including increasing ICS to high-dose, a trial of an additional drug, or seeking advice from a healthcare professional with expertise in asthma. Maintenance and reliever therapy (MART) is a form of combined ICS and LABA treatment that is only available for ICS and LABA combinations in which the LABA has a fast-acting component. It should be noted that NICE does not recommend changing treatment in patients who have well-controlled asthma simply to adhere to the latest guidance. The definitions of what constitutes a low, moderate, or high-dose ICS have also changed, with <= 400 micrograms budesonide or equivalent being a low dose, 400 micrograms - 800 micrograms budesonide or equivalent being a moderate dose, and > 800 micrograms budesonide or equivalent being a high dose for adults.
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This question is part of the following fields:
- Respiratory Medicine
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Question 19
Correct
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A 45-year-old woman presents to the Emergency Department with symptoms of nausea, upper abdominal discomfort and distension. She has been taking aspirin regularly for the past 8 weeks due to a chronic back pain. She has been tested for Helicobacter pylori and was negative so the aspirin has been discontinued. A gastroscopy is performed which reveals the presence of gastritis and a benign duodenal ulcer that is not actively bleeding.
What is the most appropriate next step in managing this patient?Your Answer: Start intravenous proton-pump inhibitors (PPIs)
Explanation:Treatment Options for Gastric Ulcers
Gastric ulcers can be caused by long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) and can lead to severe symptoms requiring hospitalization. Treatment options for gastric ulcers include intravenous proton pump inhibitors (PPIs) followed by long-term oral PPIs. A repeat gastroscopy is usually carried out to ensure that the ulcer has healed. In cases where the ulcer has perforated or is malignant, a partial gastrectomy may be indicated. Retesting for H. pylori may be necessary if the patient had previously tested positive. Adrenalin injection is only indicated for bleeding gastric ulcers. Placing the patient nil by mouth is not necessary for healing the ulcer.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 20
Correct
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A 50-year-old woman with known ovarian cancer presented to the emergency department complaining of severe right leg pain since yesterday. She had a hysterectomy 1 month ago.
Which of the following is the most likely cause of her symptoms?
Your Answer: DVT (deep-vein thrombosis)
Explanation:After undergoing surgery, a woman presents with leg pain. Several potential causes are considered, including deep-vein thrombosis (DVT), acute limb ischaemia, air embolus, lumbar disc herniation, and paradoxical embolus. Based on the patient’s risk factors and symptoms, DVT is deemed the most likely diagnosis. Other causes are ruled out due to lack of relevant history or low probability. Understanding the possible causes of leg pain after urological surgery can help healthcare providers make an accurate diagnosis and provide timely treatment.
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This question is part of the following fields:
- Haematology/Oncology
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Question 21
Correct
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A 21-year-old woman presents with a rash on her trunk that developed a few weeks after a sore throat. On examination, small, drop-shaped, salmon-pink plaques are observed. What is the most probable cause of this rash?
Your Answer: Guttate psoriasis
Explanation:Understanding Different Skin Conditions: Guttate Psoriasis, Dermatitis, Hand, Foot and Mouth Disease, Pityriasis Rosea, and Pustular Psoriasis
Skin conditions can be uncomfortable and sometimes even painful. Here are some common skin conditions and their characteristics:
Guttate psoriasis is a type of psoriasis that causes small, drop-shaped plaques on the chest, arms, legs, and scalp. It is usually caused by a streptococcal infection and can last for up to three months. Topical agents, such as steroids or calcipotriol, can be used to treat it.
Dermatitis, also known as eczema, results in rough patches of skin that are dry and itchy, particularly with exposure to irritants. In children and adults with long-standing disease, eczema is often localised to the flexure of the limbs.
Hand, foot and mouth disease (HFMD) is an acute viral illness characterised by vesicular eruptions in the mouth and papulovesicular lesions of the distal limbs. It should not be confused with foot and mouth disease of animals, which is caused by a different virus.
Pityriasis rosea is a skin rash that is characterised by distinctive, scaly, erythematous lesions. It is thought to be a reaction to exposure to infection.
Pustular psoriasis is a rarer type of psoriasis that causes pus-filled blisters (pustules) to appear on your skin. Different types of pustular psoriasis affect different parts of the body.
It is important to consult a healthcare professional for proper diagnosis and treatment of any skin condition.
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This question is part of the following fields:
- Dermatology
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Question 22
Correct
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A 32-year-old female sex worker presents to the emergency department complaining of a high fever and severe headache. During the physical examination, you observe neck stiffness and mild photophobia, prompting you to perform a lumbar puncture. The results of the lumbar puncture reveal the presence of a yeast and a capsule in the CSF stained with India ink.
What is the most probable diagnosis?Your Answer: Cryptococcal meningitis
Explanation:Cryptococcus neoformans is a yeast that has a protective capsule and requires oxygen to survive. It can thrive in both plants and animals, and when it infects humans, it causes cryptococcosis. While the infection typically affects the lungs, it can also lead to fungal meningitis and encephalitis in individuals with weakened immune systems. HIV-positive patients are particularly susceptible to this infection, and given the patient’s history as a sex worker, it’s possible that they have an undiagnosed HIV infection that has progressed to AIDS. Additionally, cryptococcus neoformans can be detected through india ink staining during a lumbar puncture.
The investigation and management of suspected bacterial meningitis are intertwined due to the potential negative impact of delayed antibiotic treatment. Patients should be urgently transferred to the hospital, and an ABC approach should be taken initially. A lumbar puncture should be delayed in certain circumstances, and IV antibiotics should be given as a priority if there is any doubt. The bloods and CSF should be tested for various parameters, and prophylaxis should be offered to households and close contacts of patients affected with meningococcal meningitis.
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This question is part of the following fields:
- Infectious Diseases
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Question 23
Correct
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As a GPST1 in a GP practice, I have a patient named Sarah who is 24 years old and has come to me seeking information on cystic fibrosis. She has been informed in the past that she is a carrier. Can you provide me with the correct information to share with her?
Your Answer: Cystic fibrosis is due to a defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR)
Explanation:Delta F508 on the long arm of chromosome 7 accounts for the majority of CF cases, with approximately 1 in 2500 births being affected by the disease. The carrier rate is estimated to be around 1 in 25.
Understanding Cystic Fibrosis and the Organisms that Affect Patients
Cystic fibrosis is a genetic disorder that causes thickened secretions in the lungs and pancreas. This condition is caused by a defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which regulates chloride channels. In the UK, 80% of CF cases are due to delta F508 on chromosome 7, and the carrier rate is approximately 1 in 25.
CF patients are susceptible to colonization by certain organisms, including Staphylococcus aureus, Pseudomonas aeruginosa, Burkholderia cepacia, and Aspergillus. These organisms can cause infections and exacerbate symptoms in CF patients. It is important for healthcare providers to monitor and manage these infections to improve patient outcomes. By understanding the genetic basis of CF and the organisms that affect patients, healthcare providers can provide better care for those with this condition.
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This question is part of the following fields:
- Paediatrics
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Question 24
Correct
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A 28-year-old woman who is 20 weeks pregnant visits the GP clinic to inquire about the whooping cough vaccine. She mentions that her friend, who also sees the same GP, received the vaccine at 32 weeks of pregnancy. She wants to know if she can get the vaccine at this stage of her pregnancy.
Your Answer: She can have the vaccine now
Explanation:Pregnant women at 16-32 weeks are given the option to receive the pertussis vaccine.
Whooping Cough: Causes, Symptoms, Diagnosis, and Management
Whooping cough, also known as pertussis, is a contagious disease caused by the bacterium Bordetella pertussis. It is commonly found in children, with around 1,000 cases reported annually in the UK. The disease is characterized by a persistent cough that can last up to 100 days, hence the name cough of 100 days.
Infants are particularly vulnerable to whooping cough, which is why routine immunization is recommended at 2, 3, 4 months, and 3-5 years. However, neither infection nor immunization provides lifelong protection, and adolescents and adults may still develop the disease.
Whooping cough has three phases: the catarrhal phase, the paroxysmal phase, and the convalescent phase. The catarrhal phase lasts around 1-2 weeks and presents symptoms similar to a viral upper respiratory tract infection. The paroxysmal phase is characterized by a severe cough that worsens at night and after feeding, and may be accompanied by vomiting and central cyanosis. The convalescent phase is when the cough subsides over weeks to months.
To diagnose whooping cough, a person must have an acute cough that has lasted for 14 days or more without another apparent cause, and have one or more of the following features: paroxysmal cough, inspiratory whoop, post-tussive vomiting, or undiagnosed apnoeic attacks in young infants. A nasal swab culture for Bordetella pertussis is used to confirm the diagnosis, although PCR and serology are increasingly used.
Infants under 6 months with suspected pertussis should be admitted, and in the UK, pertussis is a notifiable disease. An oral macrolide, such as clarithromycin, azithromycin, or erythromycin, is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread. Household contacts should be offered antibiotic prophylaxis, although antibiotic therapy has not been shown to alter the course of the illness. School exclusion is recommended for 48 hours after commencing antibiotics or 21 days from onset of symptoms if no antibiotics are given.
Complications of whooping cough include subconjunctival haemorrhage, pneumonia, bronchiectasis, and
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This question is part of the following fields:
- Paediatrics
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Question 25
Correct
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A 9-month-old girl is presented to the clinic. About 5 days ago, she became feverish after being fussy the day before. The fever subsided after approximately 3 days, but she developed a rash afterwards, which prompted her mother to bring her to the clinic. She is consuming about 80% of her usual feeds, has wet nappies, and has had three instances of loose stools. On examination, she is alert, has a temperature of 37.2ºC, and has clear lungs and unremarkable ears/throat. There are several blanching, rose pink macules on her trunk. What is the most probable diagnosis?
Your Answer: Roseola infantum
Explanation:Roseola infantum is a condition characterized by the occurrence of a fever, which is later followed by the appearance of a rash.
Understanding Roseola Infantum
Roseola infantum, also known as exanthem subitum or sixth disease, is a common illness that affects infants and is caused by the human herpes virus 6 (HHV6). This disease has an incubation period of 5-15 days and is typically seen in children aged 6 months to 2 years. The most common symptoms of roseola infantum include a high fever that lasts for a few days, followed by a maculopapular rash. Other symptoms may include Nagayama spots, which are papular enanthems on the uvula and soft palate, as well as cough and diarrhea.
In some cases, febrile convulsions may occur in around 10-15% of children with roseola infantum. While this can be concerning for parents, it is important to note that this is a common occurrence and typically resolves on its own. Additionally, HHV6 infection can lead to other possible consequences such as aseptic meningitis and hepatitis.
It is important to note that school exclusion is not necessary for children with roseola infantum. While this illness can be uncomfortable for infants, it is typically not serious and resolves on its own within a few days.
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This question is part of the following fields:
- Paediatrics
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Question 26
Correct
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In a 40-year-old woman, what is the probability of having a child with Down syndrome? Please choose one option from the list provided.
Your Answer: 1 in 100
Explanation:The chance of Down syndrome increases with maternal age:
Age (years) Chance
20 1:1500
30 1:800
35 1:270
40 1:100
>45 >1:50Therefore, the correct answer is 1 in 100.
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This question is part of the following fields:
- Paediatrics
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Question 27
Correct
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A 67-year-old male with a history of multiple myeloma presents with confusion. Blood tests are taken and the following results are obtained:
Adjusted calcium 3.1 mmol/l
What would be the best initial approach to manage this situation?Your Answer: Admit for IV normal saline
Explanation:The primary treatment for hypercalcaemia is IV fluid therapy.
Managing Hypercalcaemia
Hypercalcaemia is a condition where there is an excess of calcium in the blood. The initial management of hypercalcaemia involves rehydration with normal saline, typically 3-4 litres per day. This helps to flush out the excess calcium from the body. Once rehydration is achieved, bisphosphonates may be used to further lower the calcium levels. These drugs take 2-3 days to work, with maximal effect being seen at 7 days.
Calcitonin is another option for managing hypercalcaemia. It works quicker than bisphosphonates but is less commonly used due to its short duration of action. Steroids may be used in sarcoidosis, a condition that can cause hypercalcaemia.
Loop diuretics such as furosemide may also be used in hypercalcaemia, particularly in patients who cannot tolerate aggressive fluid rehydration. However, they should be used with caution as they may worsen electrolyte derangement and volume depletion.
In summary, the management of hypercalcaemia involves rehydration with normal saline followed by the use of bisphosphonates or other medications depending on the underlying cause of the condition. It is important to monitor electrolyte levels and adjust treatment accordingly to prevent complications.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 28
Incorrect
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A 45-year-old man visits his primary care physician complaining of various neurological symptoms that have persisted for the past few weeks. The doctor suspects that he may be experiencing idiopathic intracranial hypertension (IIH).
What is the primary symptom associated with IIH?Your Answer:
Correct Answer: Headache
Explanation:Understanding the Clinical Features of Idiopathic Intracranial Hypertension (IIH)
Idiopathic intracranial hypertension (IIH) is a condition that presents with non-specific complaints, making it difficult to diagnose. However, there are several clinical features that can help identify the condition. The most common symptom is a severe daily headache, often described as pulsatile, that may be associated with nausea and vomiting. Other symptoms include pulse-synchronous tinnitus, transient visual obscurations, visual loss, neck and back pain, diplopia, and photophobia. IIH can occur in any age group but is most commonly seen in women of childbearing age. Horizontal diplopia occurs in about 33% of patients with IIH, while hearing loss is a rare presentation. Tinnitus is described by two-thirds of patients, with pulse-synchronous tinnitus being a relatively specific symptom for elevated intracranial pressure. By understanding these clinical features, healthcare professionals can better diagnose and manage IIH.
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This question is part of the following fields:
- Neurology
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Question 29
Incorrect
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A 25-year-old male with a history of ankylosing spondylitis presents to the emergency department with a painful red eye, photophobia, lacrimation, and reduced visual acuity. On examination, an irregularly shaped pupil is noted. What is the most suitable approach to manage this patient's current condition?
Your Answer:
Correct Answer: Steroid and cycloplegic (mydriatic) eye drops
Explanation:Anterior uveitis, also known as iritis, is a type of inflammation that affects the iris and ciliary body in the front part of the uvea. It is a common cause of red eye and is associated with HLA-B27, which may also be linked to other conditions. Symptoms of anterior uveitis include sudden onset of eye discomfort and pain, small or irregular pupils, intense sensitivity to light, blurred vision, redness, tearing, and the presence of pus and inflammatory cells in the front part of the eye. This condition may be associated with ankylosing spondylitis, reactive arthritis, ulcerative colitis, Crohn’s disease, Behcet’s disease, and sarcoidosis. Urgent review by an ophthalmologist is necessary, and treatment may involve the use of cycloplegics and steroid eye drops.
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This question is part of the following fields:
- Ophthalmology
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Question 30
Incorrect
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A 35-year-old woman visits her doctor with complaints of dyspareunia, irregular menstrual cycles for the past 8 months, and missing 3 periods recently. She also reports experiencing sudden hot flashes for the last 4 months. The patient has a history of breast cancer and underwent chemotherapy and radiation. On examination, no abnormalities are found, and her pregnancy test is negative. What is the probable diagnosis?
Your Answer:
Correct 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.
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This question is part of the following fields:
- Reproductive Medicine
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