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Question 1
Correct
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A 15-year-old athlete suffers an injury during a soccer game after a fall. Due to the injury, she cannot flex the metacarpophalangeal joint or proximal interphalangeal joint of her middle finger. All other sensory and motor functions remain intact.
What anatomical structure is likely to have been affected?Your Answer: Flexor digitorum superficialis
Explanation:The muscle responsible for flexing the MCPs and PIPs is the flexor digitorum superficialis. The flexor digitorum profundus is responsible for flexing the distal interphalangeal joint, while the flexor carpi ulnaris flexes and adducts the wrist. The flexor digiti minimi brevis is responsible for flexing the little (5th) finger. It should be noted that there is no muscle called the flexor indicis distalis.
The forearm flexor muscles include the flexor carpi radialis, palmaris longus, flexor carpi ulnaris, flexor digitorum superficialis, and flexor digitorum profundus. These muscles originate from the common flexor origin and surrounding fascia, and are innervated by the median and ulnar nerves. Their actions include flexion and abduction of the carpus, wrist flexion, adduction of the carpus, and flexion of the metacarpophalangeal and interphalangeal joints.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 2
Incorrect
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Into which of the following structures does the superior part of the fibrous capsule of the shoulder joint insert?
Your Answer: The surgical neck of the humerus
Correct Answer: The anatomical neck of the humerus
Explanation:Due to its shallow nature, the shoulder joint has a high degree of mobility, but this is achieved at the cost of stability. The fibrous capsule is connected to the anatomical neck in a superior position and the surgical neck in an inferior position.
The shoulder joint is a shallow synovial ball and socket joint that is inherently unstable but capable of a wide range of movement. Stability is provided by the muscles of the rotator cuff. The glenoid labrum is a fibrocartilaginous rim attached to the free edge of the glenoid cavity. The fibrous capsule attaches to the scapula, humerus, and tendons of various muscles. Movements of the shoulder joint are controlled by different muscles. The joint is closely related to important anatomical structures such as the brachial plexus, axillary artery and vein, and various nerves and vessels.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 3
Correct
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A 50-year-old woman presents with painful tingling in her fingers and relief when hanging her arm over the side of the bed. She exhibits a positive Tinel's sign at the wrist. What is the most probable factor contributing to her diagnosis?
Your Answer: Rheumatoid arthritis
Explanation:The patient has been diagnosed with carpal tunnel syndrome, which is often caused by rheumatological disorders. During the clinical examination, it is important to look for signs of rheumatoid arthritis, such as rheumatoid nodules, vasculitic lesions, and arthritis in the metacarpophalangeal joints.
Carpal tunnel syndrome is a condition that occurs when the median nerve in the carpal tunnel is compressed. This can cause pain and pins and needles sensations in the thumb, index, and middle fingers. In some cases, the symptoms may even travel up the arm. Patients may shake their hand to alleviate the discomfort, especially at night. During an examination, weakness in thumb abduction and wasting of the thenar eminence may be observed. Tapping on the affected area may also cause paraesthesia, and flexing the wrist can trigger symptoms.
There are several potential causes of carpal tunnel syndrome, including idiopathic factors, pregnancy, oedema, lunate fractures, and rheumatoid arthritis. Electrophysiology tests may reveal prolongation of the action potential in both motor and sensory nerves. Treatment options may include a six-week trial of conservative measures such as wrist splints at night or corticosteroid injections. If symptoms persist or are severe, surgical decompression may be necessary, which involves dividing the flexor retinaculum.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 4
Incorrect
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You are attending a cardiology clinic one morning. A 54-year-old man presents for a medication review. He is currently taking a beta-blocker but is still frequently symptomatic. From his medication history, it is evident that he does not tolerate calcium channel blockers.
The consultant considers the option of starting him on a new drug called nicorandil. The patient is hesitant to try it out as he believes it is a calcium channel blocker. You have been asked to explain the mechanism of action of nicorandil to this patient.
What is the way in which the new drug exerts its effect?Your Answer: Causes vasodilation by inhibiting guanylyl cyclase which causes an increase in cGMP
Correct Answer: Causes vasodilation by activating guanylyl cyclase which causes an increase in cGMP
Explanation:Nicorandil induces vasodilation by activating guanylyl cyclase, leading to an increase in cyclic GMP. This results in the relaxation of vascular smooth muscles through the prevention of calcium ion influx and dephosphorylation of myosin light chains. Additionally, nicorandil activates ATP-sensitive potassium channels, causing hyperpolarization and preventing intracellular calcium overload, which plays a cardioprotective role.
Nicorandil is a medication that is commonly used to treat angina. It works by activating potassium channels, which leads to vasodilation. This process is achieved through the activation of guanylyl cyclase, which results in an increase in cGMP. However, there are some adverse effects associated with the use of nicorandil, including headaches, flushing, and the development of ulcers on the skin, mucous membranes, and eyes. Additionally, gastrointestinal ulcers, including anal ulceration, may also occur. It is important to note that nicorandil should not be used in patients with left ventricular failure.
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This question is part of the following fields:
- Cardiovascular System
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Question 5
Incorrect
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A 79-year-old woman with a history of heart failure visits the clinic complaining of swollen ankles and difficulty walking. She has previously experienced fluid retention due to her heart failure. During the examination, soft heart sounds are heard and pitting edema is observed in both lower limbs up to 15 cm above the ankles. The decision is made to increase her daily furosemide dose from 40mg to 80 mg. Which part of the nephron does furosemide target?
Your Answer: Distal convoluted tubule
Correct Answer: Ascending limb of the loop of Henle
Explanation:Furosemide is a loop diuretic that works by inhibiting the Na-K-Cl cotransporter in the thick ascending limb of the loop of Henle. It is commonly used to treat fluid retention in patients with heart failure. Other diuretic agents work on different parts of the nephron, such as carbonic anhydrase inhibitors in the proximal and distal tubules, thiazide diuretics in the distal convoluted tubule, and potassium-sparing diuretics like amiloride and spironolactone in the cortical collecting ducts. Understanding the mechanism of action of diuretics can help clinicians choose the most appropriate medication for their patients.
Loop Diuretics: Mechanism of Action and Clinical Applications
Loop diuretics, such as furosemide and bumetanide, are medications that inhibit the Na-K-Cl cotransporter (NKCC) in the thick ascending limb of the loop of Henle. By doing so, they reduce the absorption of NaCl, resulting in increased urine output. Loop diuretics act on NKCC2, which is more prevalent in the kidneys. These medications work on the apical membrane and must first be filtered into the tubules by the glomerulus before they can have an effect. Patients with poor renal function may require higher doses to ensure sufficient concentration in the tubules.
Loop diuretics are commonly used in the treatment of heart failure, both acutely (usually intravenously) and chronically (usually orally). They are also indicated for resistant hypertension, particularly in patients with renal impairment. However, loop diuretics can cause adverse effects such as hypotension, hyponatremia, hypokalemia, hypomagnesemia, hypochloremic alkalosis, ototoxicity, hypocalcemia, renal impairment, hyperglycemia (less common than with thiazides), and gout. Therefore, careful monitoring of electrolyte levels and renal function is necessary when using loop diuretics.
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This question is part of the following fields:
- Cardiovascular System
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Question 6
Incorrect
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A 72-year-old female presents to her local physician complaining of general fatigue and tiredness. She reports no fever, night sweats, or weight loss. She maintains an active lifestyle and attends fitness classes weekly. Her medical history includes hypertension, type II diabetes mellitus, constipation, and depression.
The physician orders blood tests, and the results are as follows:
- Hb: 113 g/l
- Platelets: 239 * 109/l
- WBC: 6 * 109/l
- Neuts: 2 * 109/l
- Lymphs: 2 * 109/l
- Eosin: 0.3 * 109/l
- Na+: 142 mmol/l
- K+: 3.2 mmol/l
- Bilirubin: 12 µmol/l
- ALP: 23 u/l
- ALT: 10 u/l
- γGT: 23 u/l
- Urea: 4 mmol/l
- Creatinine: 50 µmol/l
- Albumin: 30 g/l
Which medication is most likely causing her symptoms?Your Answer: Amiloride
Correct Answer: Senna
Explanation:Prolonged use of senna increases the risk of hypokalemia, which is evident in the patient’s blood results. The symptoms of mild hypokalemia are non-specific and include fatigue, muscle weakness, constipation, and rhabdomyolysis. Given the patient’s medical history of constipation, it is likely that she has been taking a laxative, which could be either osmotic or a stimulant. Both types of laxatives are known to cause hypokalemia, and in this case, senna is the likely culprit.
Heparin can cause hyperkalemia, especially when used in conjunction with spironolactone, ACE inhibitors, non-steroidal anti-inflammatory drugs, and trimethoprim. Heparin inhibits aldosterone synthesis, leading to increased potassium retention and sodium excretion. This effect is more pronounced in elderly individuals, diabetics, and those with renal failure. The risk of hyperkalemia increases with higher doses, prolonged use, and unfractionated heparin therapy.
Amiloride is a potassium-sparing diuretic that works by inhibiting sodium reabsorption in the kidneys. It promotes the loss of sodium and water from the body without depleting potassium. Amiloride causes hyperkalemia by inhibiting sodium reabsorption at various points in the kidneys, which reduces potassium and hydrogen secretion and subsequent excretion.
Losartan is an angiotensin II receptor blocker that is known to cause hyperkalemia and is therefore not the cause of the patient’s hypokalemia.
Understanding Laxatives
Laxatives are frequently prescribed medications in clinical practice, with constipation being a common issue among patients. While constipation may be a symptom of underlying pathology, many patients experience simple idiopathic constipation. The British National Formulary (BNF) categorizes laxatives into four groups: osmotic, stimulant, bulk-forming, and faecal softeners.
Osmotic laxatives, such as lactulose, macrogols, and rectal phosphates, work by drawing water into the bowel to soften stools and promote bowel movements. Stimulant laxatives, including senna, docusate, bisacodyl, and glycerol, stimulate the muscles in the bowel to contract and move stool along. Co-danthramer, a combination of a stimulant and a bulk-forming laxative, should only be prescribed to palliative patients due to its potential carcinogenic effects.
Bulk-forming laxatives, such as ispaghula husk and methylcellulose, work by increasing the bulk of stool and promoting regular bowel movements. Faecal softeners, such as arachis oil enemas, are not commonly prescribed but can be used to soften stool and ease bowel movements.
In summary, understanding the different types of laxatives and their mechanisms of action can help healthcare professionals prescribe the most appropriate treatment for patients experiencing constipation.
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This question is part of the following fields:
- Gastrointestinal System
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Question 7
Incorrect
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A young man in his early twenties collapses during a game of basketball and is declared dead upon arrival at the hospital. The autopsy shows irregularities in his heart. What is the probable cause of the irregularities?
Your Answer: Acute myocarditis
Correct Answer: Hypertrophic cardiomyopathy
Explanation:The condition that is most commonly associated with sudden death is hypertrophic cardiomyopathy, making the other options less likely.
Symptoms of acute myocarditis may include chest pain, fever, palpitations, tachycardia, and difficulty breathing.
Dilated cardiomyopathy may cause right ventricular failure, leading to symptoms such as difficulty breathing, pulmonary edema, and atrial fibrillation.
Restrictive cardiomyopathy and constrictive pericarditis have similar presentations, with right heart failure symptoms such as elevated JVP, hepatomegaly, edema, and ascites being predominant.
Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic disorder that affects muscle tissue and is inherited in an autosomal dominant manner. It is caused by mutations in genes that encode contractile proteins, with the most common defects involving the β-myosin heavy chain protein or myosin-binding protein C. HOCM is characterized by left ventricle hypertrophy, which leads to decreased compliance and cardiac output, resulting in predominantly diastolic dysfunction. Biopsy findings show myofibrillar hypertrophy with disorganized myocytes and fibrosis. HOCM is often asymptomatic, but exertional dyspnea, angina, syncope, and sudden death can occur. Jerky pulse, systolic murmurs, and double apex beat are also common features. HOCM is associated with Friedreich’s ataxia and Wolff-Parkinson White. ECG findings include left ventricular hypertrophy, non-specific ST segment and T-wave abnormalities, and deep Q waves. Atrial fibrillation may occasionally be seen.
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This question is part of the following fields:
- Cardiovascular System
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Question 8
Incorrect
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Which of the following structures is situated between the lateral and medial heads of the triceps muscle?
Your Answer: Axillary nerve
Correct Answer: Radial nerve
Explanation:The correct nerve that runs in its groove between the two heads is the radial nerve. The ulnar nerve is positioned anterior to the medial head, while the axillary nerve passes through the quadrangular space located above the lateral head of the triceps muscle. As a result, the lateral border of the quadrangular space is the humerus.
Anatomy of the Triceps Muscle
The triceps muscle is a large muscle located on the back of the upper arm. It is composed of three heads: the long head, lateral head, and medial head. The long head originates from the infraglenoid tubercle of the scapula, while the lateral head originates from the dorsal surface of the humerus, lateral and proximal to the groove of the radial nerve. The medial head originates from the posterior surface of the humerus on the inferomedial side of the radial groove and both of the intermuscular septae.
All three heads of the triceps muscle insert into the olecranon process of the ulna, with some fibers inserting into the deep fascia of the forearm and the posterior capsule of the elbow. The triceps muscle is innervated by the radial nerve and supplied with blood by the profunda brachii artery.
The primary action of the triceps muscle is elbow extension. The long head can also adduct the humerus and extend it from a flexed position. The radial nerve and profunda brachii vessels lie between the lateral and medial heads of the triceps muscle. Understanding the anatomy of the triceps muscle is important for proper diagnosis and treatment of injuries or conditions affecting this muscle.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 9
Incorrect
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A 49-year-old woman arrives at the day surgery unit for a bilateral salpingo-oophorectomy. The surgeon provides her with an explanation of the procedure.
What ligaments must the surgeon open to reach the fallopian tubes and ovaries?Your Answer: Round ligament
Correct Answer: Broad ligament
Explanation:Within the broad ligament of the uterus, one can locate the ovaries and the fallopian tubes.
Pelvic Ligaments and their Connections
Pelvic ligaments are structures that connect various organs within the female reproductive system to the pelvic wall. These ligaments play a crucial role in maintaining the position and stability of these organs. There are several types of pelvic ligaments, each with its own unique function and connection.
The broad ligament connects the uterus, fallopian tubes, and ovaries to the pelvic wall, specifically the ovaries. The round ligament connects the uterine fundus to the labia majora, but does not connect to any other structures. The cardinal ligament connects the cervix to the lateral pelvic wall and is responsible for supporting the uterine vessels. The suspensory ligament of the ovaries connects the ovaries to the lateral pelvic wall and supports the ovarian vessels. The ovarian ligament connects the ovaries to the uterus, but does not connect to any other structures. Finally, the uterosacral ligament connects the cervix and posterior vaginal dome to the sacrum, but does not connect to any other structures.
Overall, pelvic ligaments are essential for maintaining the proper position and function of the female reproductive organs. Understanding the connections between these ligaments and the structures they support is crucial for diagnosing and treating any issues that may arise.
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This question is part of the following fields:
- Reproductive System
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Question 10
Incorrect
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Which muscle is not a part of the rotator cuff?
Your Answer: Subscapularis
Correct Answer: Deltoid
Explanation:Understanding the Rotator Cuff Muscles
The rotator cuff muscles are a group of four muscles that are responsible for the movement and stability of the shoulder joint. These muscles are known as the SItS muscles, which stands for Supraspinatus, Infraspinatus, teres minor, and Subscapularis. Each of these muscles has a specific function in the movement of the shoulder joint.
The Supraspinatus muscle is responsible for abducting the arm before the deltoid muscle. It is the most commonly injured muscle in the rotator cuff. The Infraspinatus muscle rotates the arm laterally, while the teres minor muscle adducts and rotates the arm laterally. Lastly, the Subscapularis muscle adducts and rotates the arm medially.
Understanding the functions of each of these muscles is important in diagnosing and treating rotator cuff injuries. By identifying which muscle is injured, healthcare professionals can develop a treatment plan that targets the specific muscle and promotes healing. Overall, the rotator cuff muscles play a crucial role in the movement and stability of the shoulder joint.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 11
Correct
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A 67-year-old woman is scheduled for a total hip replacement on her right side. The surgeon plans to use the lateral approach to access the hip joint, which involves dividing the tensor fascia lata, as well as the gluteus medius and minimus muscles. However, this approach poses a risk to the nerve supply of these muscles. Can you identify the nerve that innervates the tensor fascia lata and gluteus medius muscles?
Your Answer: Superior gluteal nerve
Explanation:Nerves and Approaches to the Hip Joint
The superior gluteal nerve originates from L4-S1 and exits the pelvis through the greater sciatic foramen. It provides innervation to the gluteus medius, gluteus minimus, and tensor fascia lata muscles. However, the nerves in danger depend on the approach used to access the hip joint.
The posterior approach involves an incision through the deep fascia and gluteus maximus, followed by division of the external rotators. This approach puts the sciatic nerve at risk. On the other hand, the anterior approach involves the planes between tensor fascia lata and sartorius, and then rectus femoris and gluteus medius. This approach endangers the lateral femoral cutaneous nerve of the thigh.
In summary, the nerves at risk during hip joint access depend on the approach used. The posterior approach puts the sciatic nerve in danger, while the anterior approach endangers the lateral femoral cutaneous nerve of the thigh. It is important for medical professionals to be aware of these potential risks to minimize complications during hip joint procedures.
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This question is part of the following fields:
- Clinical Sciences
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Question 12
Incorrect
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Which of the following surgical procedures will have the most significant long-term effect on a patient's calcium metabolism?
Your Answer: Cholecystectomy
Correct Answer: Extensive small bowel resection
Explanation:Maintaining Calcium Balance in the Body
Calcium ions are essential for various physiological processes in the body, and the largest store of calcium is found in the skeleton. The levels of calcium in the body are regulated by three hormones: parathyroid hormone (PTH), vitamin D, and calcitonin.
PTH increases calcium levels and decreases phosphate levels by increasing bone resorption and activating osteoclasts. It also stimulates osteoblasts to produce a protein signaling molecule that activates osteoclasts, leading to bone resorption. PTH increases renal tubular reabsorption of calcium and the synthesis of 1,25(OH)2D (active form of vitamin D) in the kidney, which increases bowel absorption of calcium. Additionally, PTH decreases renal phosphate reabsorption.
Vitamin D, specifically the active form 1,25-dihydroxycholecalciferol, increases plasma calcium and plasma phosphate levels. It increases renal tubular reabsorption and gut absorption of calcium, as well as osteoclastic activity. Vitamin D also increases renal phosphate reabsorption in the proximal tubule.
Calcitonin, secreted by C cells of the thyroid, inhibits osteoclast activity and renal tubular absorption of calcium.
Although growth hormone and thyroxine play a small role in calcium metabolism, the primary regulation of calcium levels in the body is through PTH, vitamin D, and calcitonin. Maintaining proper calcium balance is crucial for overall health and well-being.
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This question is part of the following fields:
- Neurological System
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Question 13
Correct
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You examine a patient who suffered a severe stroke two years prior.
What clinical examination features would you anticipate observing?Your Answer: Increased deep tendon reflexes
Explanation:If there is an increased reflex response, it may indicate an upper motor neuron lesion. This type of lesion can be caused by a stroke and can result in spastic weakness and heightened reflex responses. The reason for hyperreflexia is due to the loss of inhibitory signals that normally regulate spinal reflex circuits. On the other hand, a lower motor neuron lesion will cause flaccid weakness, reduced deep tendon reflexes, fasciculations, and muscle atrophy.
Reflexes are automatic responses that our body makes in response to certain stimuli. These responses are controlled by the nervous system and do not require conscious thought. There are several common reflexes that are associated with specific roots in the spinal cord. For example, the ankle reflex is associated with the S1-S2 root, while the knee reflex is associated with the L3-L4 root. Similarly, the biceps reflex is associated with the C5-C6 root, and the triceps reflex is associated with the C7-C8 root. Understanding these reflexes can help healthcare professionals diagnose and treat certain conditions.
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This question is part of the following fields:
- Neurological System
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Question 14
Incorrect
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A 55-year-old woman with hypertension comes in for a routine check-up with her GP. She mentions feeling fatigued for the past few days and has been taking antihypertensive medication for almost a year, but cannot recall the name. Her ECG appears normal.
Hb 142 g/L Male: (135-180)
Female: (115 - 160)
Platelets 180 * 109/L (150 - 400)
WBC 7.5 * 109/L (4.0 - 11.0)
Na+ 133 mmol/L (135 - 145)
K+ 3.8 mmol/L (3.5 - 5.0)
Urea 5.5 mmol/L (2.0 - 7.0)
Creatinine 98 µmol/L (55 - 120)
What medication might she be taking?Your Answer: Atenolol
Correct Answer: Hydrochlorothiazide
Explanation:Thiazide diuretics have been known to cause hyponatremia, as seen in the clinical scenario and blood tests. The question aims to test knowledge of antihypertensive medications that may lead to hyponatremia.
The correct answer is Hydrochlorothiazide, as ACE inhibitors, angiotensin receptor blockers, and calcium channel blockers may also cause hyponatremia. Beta-blockers, such as Atenolol, typically do not cause hyponatremia. Similarly, central agonists like Clonidine and alpha-blockers like Doxazosin are not known to cause hyponatremia.
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 thiazide diuretics are useful in treating mild heart failure, loop diuretics are more effective in reducing overload. Bendroflumethiazide was previously used to manage hypertension, but recent NICE guidelines recommend other thiazide-like diuretics such as indapamide and chlorthalidone.
Common side effects of thiazide diuretics include dehydration, postural hypotension, and electrolyte imbalances such as hyponatremia, hypokalemia, and hypercalcemia. Other potential adverse effects include gout, impaired glucose tolerance, and impotence. Rare side effects may include thrombocytopenia, agranulocytosis, photosensitivity rash, and pancreatitis.
It is worth noting that while thiazide diuretics may cause hypercalcemia, they can also reduce the incidence of renal stones by decreasing urinary calcium excretion. According to current NICE guidelines, the management of hypertension involves the use of thiazide-like diuretics, along with other medications and lifestyle changes, to achieve optimal blood pressure control and reduce the risk of cardiovascular disease.
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This question is part of the following fields:
- Cardiovascular System
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Question 15
Correct
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What is the main factor that determines glomerular filtration rate (GFR)?
Your Answer: Glomerular hydrostatic pressure
Explanation:Glomerular Filtration Rate
Glomerular filtration rate (GFR) is the measure of how well the kidneys are functioning. It is determined by the sum of hydrostatic and osmotic forces across the glomerular membrane, which gives the overall net filtration pressure and the glomerular capillary filtration coefficient. The net filtration pressure is made up of four opposing forces, including the glomerular hydrostatic pressure promoting filtration, the hydrostatic pressure within the Bowman’s capsule opposing filtration, the osmotic pressure of the glomerular capillary plasma proteins opposing filtration, and the osmotic pressure of the proteins within the Bowman’s capsule promoting filtration.
Changes to these relative pressures can alter the GFR, which can occur in both normal physiology and pathological conditions. the factors that influence GFR is important in diagnosing and treating kidney diseases. By monitoring GFR, healthcare professionals can determine the extent of kidney damage and develop appropriate treatment plans. Overall, GFR is a crucial measure of kidney function that helps to maintain overall health and well-being.
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This question is part of the following fields:
- Clinical Sciences
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Question 16
Incorrect
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A 31-year-old woman is brought to the emergency department after collapsing at home, witnessed by her partner while walking in the garden. She has a medical history of vascular Ehlers-Danlos syndrome. On examination, she is unresponsive with a Glasgow Coma Score of 3. A non-contrast CT head shows no pathology, but an MRI brain reveals a basilar artery dissection. What is the probable outcome of this patient's presentation?
Your Answer: Medial medullary syndrome
Correct Answer: Locked-in syndrome
Explanation:The correct answer is locked-in syndrome, which is characterized by the paralysis of all voluntary muscles except for those controlling eye movements, while cognitive function remains preserved. Lesions in the basilar artery can cause quadriplegia and bulbar palsies as it supplies the pons, which transmits the corticospinal tracts.
While brainstem lesions can cause Horner’s syndrome, it is typically caused by involvement of the hypothalamus, which is supplied by the circle of Willis. Therefore, Horner’s syndrome is not typically caused by basilar artery lesions.
Medial medullary syndrome can be caused by lesions of the anterior spinal artery and is characterized by contralateral hemiplegia, altered sensorium, and deviation of the tongue toward the affected side.
Wallenberg syndrome can be caused by lesions of the posterior inferior cerebellar artery (PICA) and presents with dysphagia, ataxia, vertigo, and contralateral deficits in temperature and pain sensation.
Stroke can affect different parts of the brain depending on which artery is affected. If the anterior cerebral artery is affected, the person may experience weakness and loss of sensation on the opposite side of the body, with the lower extremities being more affected than the upper. If the middle cerebral artery is affected, the person may experience weakness and loss of sensation on the opposite side of the body, with the upper extremities being more affected than the lower. They may also experience vision loss and difficulty with language. If the posterior cerebral artery is affected, the person may experience vision loss and difficulty recognizing objects.
Lacunar strokes are a type of stroke that are strongly associated with hypertension. They typically present with isolated weakness or loss of sensation on one side of the body, or weakness with difficulty coordinating movements. They often occur in the basal ganglia, thalamus, or internal capsule.
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This question is part of the following fields:
- Neurological System
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Question 17
Correct
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A 55-year-old woman reports a gradual onset of numbness and tingling that extends from her heel to the first three toes over the past six months. She experiences increased symptoms when pressure is applied to the area behind the medial malleolus for thirty seconds.
Which foot movement is likely to worsen this patient's discomfort?Your Answer: Plantarflexion of the foot
Explanation:The structures that pass behind the medial malleolus can be remembered using the mnemonic Tom, Dick and Very Nervous Harry which stands for Tibialis posterior, flexor Digitorum longus, posterior tibial Artery, posterior tibial Vein, tibial Nerve and flexor Hallucis longus.
The patient in this case is experiencing tarsal tunnel syndrome which is characterized by numbness and tingling along the distribution of the posterior tibial nerve. Tinel’s test, which involves tapping on the area behind the medial malleolus, can help diagnose nerve compression.
The abductor hallucis muscle is responsible for abducting the big toe and its tendon does not pass through the tarsal tunnel. Dorsiflexion of the foot is primarily performed by the tibialis anterior muscle, while the tibialis posterior tendon runs through the tarsal tunnel. Extension of the big toe is performed by the extensor hallucis brevis and longus muscles, while extension of the toes is primarily performed by the extensor digitorum longus muscle. The big toe can be extended independently from the other toes due to the action of the extensor hallucis muscles.
Anatomy of the Ankle Joint
The ankle joint is a type of synovial joint that is made up of the tibia and fibula superiorly and the talus inferiorly. It is supported by several ligaments, including the deltoid ligament, lateral collateral ligament, and talofibular ligaments. The calcaneofibular ligament is separate from the fibrous capsule of the joint, while the two talofibular ligaments are fused with it. The syndesmosis is composed of the antero-inferior tibiofibular ligament, postero-inferior tibiofibular ligament, inferior transverse tibiofibular ligament, and interosseous ligament.
The ankle joint allows for plantar flexion and dorsiflexion movements, with a range of 55 and 35 degrees, respectively. Inversion and eversion movements occur at the level of the sub talar joint. The ankle joint is innervated by branches of the deep peroneal and tibial nerves.
Reference:
Golano P et al. Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc. 2010 May;18(5):557-69. -
This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 18
Incorrect
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A 47-year-old man is under the care of an ophthalmologist for open angle glaucoma. He visits his GP to express his worries about the medication prescribed after reading online information. What is the medication that the ophthalmologist has prescribed, which can function as a diuretic by acting on the proximal convoluted tubule of the kidney?
Your Answer: Mannitol (osmotic diuretic)
Correct Answer: Acetazolamide (carbonic anhydrase inhibitor)
Explanation:Diuretic drugs are classified into three major categories based on the location where they inhibit sodium reabsorption. Loop diuretics act on the thick ascending loop of Henle, thiazide diuretics on the distal tubule and connecting segment, and potassium sparing diuretics on the aldosterone-sensitive principal cells in the cortical collecting tubule. Sodium is reabsorbed in the kidney through Na+/K+ ATPase pumps located on the basolateral membrane, which return reabsorbed sodium to the circulation and maintain low intracellular sodium levels. This ensures a constant concentration gradient.
The physiological effects of commonly used diuretics vary based on their site of action. furosemide, a loop diuretic, inhibits the Na+/K+/2Cl- carrier in the ascending limb of the loop of Henle and can result in up to 25% of filtered sodium being excreted. Thiazide diuretics, which act on the distal tubule and connecting segment, inhibit the Na+Cl- carrier and typically result in between 3 and 5% of filtered sodium being excreted. Finally, spironolactone, a potassium sparing diuretic, inhibits the Na+/K+ ATPase pump in the cortical collecting tubule and typically results in between 1 and 2% of filtered sodium being excreted.
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This question is part of the following fields:
- Renal System
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Question 19
Incorrect
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A 50-year-old previously healthy man presents with chest pain that is radiating to his left arm and accompanied by nausea, vomiting, and sweating. Despite no ST-segment changes on the ECG, his troponin T level at six hours post-onset of pain is significantly elevated at 350 ng/L (<14). As a result, he is diagnosed with a non-ST elevation myocardial infarction and prescribed aspirin 300mg. What is the mechanism of action of this treatment?
Your Answer: Undergoes isolated cyclooxygenase (COX) 2 inhibition
Correct Answer: Decreases the formation of thromboxane A2
Explanation:How Aspirin Works and its Use in Cardiovascular Disease
Aspirin is a medication that works by blocking the action of cyclooxygenase-1 and 2, which are responsible for the synthesis of prostaglandin, prostacyclin, and thromboxane. By blocking the formation of thromboxane A2 in platelets, aspirin reduces their ability to aggregate, making it a widely used medication in cardiovascular disease. However, recent trials have cast doubt on the use of aspirin in primary prevention of cardiovascular disease, and guidelines have not yet changed to reflect this. Aspirin should not be used in children under 16 due to the risk of Reye’s syndrome, except in cases of Kawasaki disease where the benefits outweigh the risks. As for its use in ischaemic heart disease, aspirin is recommended as a first-line treatment. It can also potentiate the effects of oral hypoglycaemics, warfarin, and steroids. It is important to note that recent guidelines recommend clopidogrel as a first-line treatment for ischaemic stroke and peripheral arterial disease, while the use of aspirin in TIAs remains a topic of debate among different guidelines.
Overall, aspirin’s mechanism of action and its use in cardiovascular disease make it a valuable medication in certain cases. However, recent studies have raised questions about its effectiveness in primary prevention, and prescribers should be aware of the potential risks and benefits when considering its use.
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This question is part of the following fields:
- General Principles
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Question 20
Correct
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What factor triggers a direct rise in the production of aldosterone?
Your Answer: Increased levels of angiotensin II
Explanation:The Renin-Angiotensin-Aldosterone System
The renin-angiotensin-aldosterone system (RAAS) is a series of events that occur in response to a fall in renal perfusion. When the kidneys do not receive enough blood flow, renin is released from the juxtaglomerular apparatus and stimulates the activation of angiotensin I into angiotensin II, a potent vasoconstrictor. Angiotensin II then triggers the production of aldosterone in the adrenal cortex. Although aldosterone is a hormone of the adrenal cortex, it is secreted in response to angiotensin II.
Aldosterone acts via the mineralocorticoid receptor (MR) and has several actions. It prevents the loss of sodium in the kidney, leading to sodium retention. It promotes renal potassium excretion, causing potassium loss. Additionally, it promotes renal loss of hydrogen ions, leading to a tendency towards alkalosis. Aldosterone plays a crucial role in regulating blood pressure and electrolyte balance in the body.
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This question is part of the following fields:
- Clinical Sciences
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Question 21
Incorrect
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What grade of proof does a group of specialists provide, as per the Oxford Centre for Evidence-Based Medicine (CEBM)?
Your Answer: 4
Correct Answer: 5
Explanation:Levels and Grades of Evidence in Evidence-Based Medicine
In order to evaluate the quality of evidence in evidence-based medicine, levels or grades are often used to organize the evidence. Traditional hierarchies placed systematic reviews or randomized control trials at the top and case-series/report at the bottom. However, this approach is overly simplistic as certain research questions cannot be answered using RCTs. To address this, the Oxford Centre for Evidence-Based Medicine introduced their 2011 Levels of Evidence system which separates the type of study questions and gives a hierarchy for each. On the other hand, the GRADE system is a grading approach that classifies the quality of evidence as high, moderate, low, or very low. The process begins by formulating a study question and identifying specific outcomes. Outcomes are then graded as critical or important, and the evidence is gathered and criteria are used to grade the evidence. Evidence can be promoted or downgraded based on certain circumstances. The use of levels and grades of evidence helps to evaluate the quality of evidence and make informed decisions in evidence-based medicine.
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This question is part of the following fields:
- General Principles
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Question 22
Incorrect
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A 28-year-old woman visits her doctor with complaints of fatigue. Upon further inquiry, the doctor learns that she has been experiencing heavy menstrual bleeding for the past 8 months. To investigate further, the doctor orders a complete blood count and iron level test. What is the typical lifespan of a red blood cell?
Your Answer: 110 days
Correct Answer: 120 days
Explanation:The bone marrow in large bones is responsible for the production of human red blood cells through erythropoiesis. Stem cells undergo a 7-day development process to become red blood cells, which then circulate for around 120 days before being eliminated by the spleen. Eryptosis, or programmed red cell death, occurs at the same rate as production.
However, certain diseases can increase the rate of eryptosis, resulting in a shorter lifespan for red blood cells. These diseases include haemolytic uraemic syndrome, sepsis, malaria, sickle cell disease, thalassaemia, iron deficiency, and Wilson’s disease.
Iron deficiency anaemia is a prevalent condition worldwide, with preschool-age children being the most affected. The lack of iron in the body leads to a decrease in red blood cells and haemoglobin, resulting in anaemia. The primary causes of iron deficiency anaemia are excessive blood loss, inadequate dietary intake, poor intestinal absorption, and increased iron requirements. Menorrhagia is the most common cause of blood loss in pre-menopausal women, while gastrointestinal bleeding is the most common cause in men and postmenopausal women. Vegans and vegetarians are more likely to develop iron deficiency anaemia due to the lack of meat in their diet. Coeliac disease and other conditions affecting the small intestine can prevent sufficient iron absorption. Children and pregnant women have increased iron demands, and the latter may experience dilution due to an increase in plasma volume.
The symptoms of iron deficiency anaemia include fatigue, shortness of breath on exertion, palpitations, pallor, nail changes, hair loss, atrophic glossitis, post-cricoid webs, and angular stomatitis. To diagnose iron deficiency anaemia, a full blood count, serum ferritin, total iron-binding capacity, transferrin, and blood film tests are performed. Endoscopy may be necessary to rule out malignancy, especially in males and postmenopausal females with unexplained iron-deficiency anaemia.
The management of iron deficiency anaemia involves identifying and treating the underlying cause. Oral ferrous sulfate is commonly prescribed, and patients should continue taking iron supplements for three months after the iron deficiency has been corrected to replenish iron stores. Iron-rich foods such as dark-green leafy vegetables, meat, and iron-fortified bread can also help. It is crucial to exclude malignancy by taking an adequate history and appropriate investigations if warranted.
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This question is part of the following fields:
- Haematology And Oncology
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Question 23
Incorrect
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A 45-year-old female with known type 1 diabetes and Graves' disease presents to the GP with worsening fatigue. She describes a history of headaches, shortness of breath and palpitations. Blood tests are taken and the results are displayed below.
Haemoglobin 79 g/dl
MCV 103 fl
White cell count 4.2 mmol/l
Platelets 220 mmol/l
What is the most likely vitamin or mineral deficiency in this patient?Your Answer: Iron
Correct Answer: B12
Explanation:Anaemia is characterized by classic symptoms such as headaches, shortness of breath, and palpitations. The primary nutritional factors that can cause anaemia are deficiencies in B12, Folate, and Iron.
Pernicious anaemia is a condition that results in a deficiency of vitamin B12 due to an autoimmune disorder affecting the gastric mucosa. The term pernicious refers to the gradual and subtle harm caused by the condition, which often leads to delayed diagnosis. While pernicious anaemia is the most common cause of vitamin B12 deficiency, other causes include atrophic gastritis, gastrectomy, and malnutrition. The condition is characterized by the presence of antibodies to intrinsic factor and/or gastric parietal cells, which can lead to reduced vitamin B12 absorption and subsequent megaloblastic anaemia and neuropathy.
Pernicious anaemia is more common in middle to old age females and is associated with other autoimmune disorders such as thyroid disease, type 1 diabetes mellitus, Addison’s, rheumatoid, and vitiligo. Symptoms of the condition include anaemia, lethargy, pallor, dyspnoea, peripheral neuropathy, subacute combined degeneration of the spinal cord, neuropsychiatric features, mild jaundice, and glossitis. Diagnosis is made through a full blood count, vitamin B12 and folate levels, and the presence of antibodies.
Management of pernicious anaemia involves vitamin B12 replacement, usually given intramuscularly. Patients with neurological features may require more frequent doses. Folic acid supplementation may also be necessary. Complications of the condition include an increased risk of gastric cancer.
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This question is part of the following fields:
- Gastrointestinal System
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Question 24
Incorrect
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A 30-year-old man presents to the emergency department with complaints of abdominal pain, nausea, and vomiting for a few hours. He has a history of type 1 diabetes mellitus, which is managed with insulin. He admits to running out of his insulin a few days ago. On examination, his temperature is 37.8ºC, pulse is 120/min, respirations are 25/min, and blood pressure is 100/70 mmHg. Dry mucous membranes are noted, and he has a fruity odour on his breath.
The following laboratory results are obtained:
Hb 142 g/L Male: (135-180)
Female: (115 - 160)
Platelets 250 * 109/L (150 - 400)
WBC 11.2 * 109/L (4.0 - 11.0)
Na+ 138 mmol/L (135 - 145)
K+ 5.2 mmol/L (3.5 - 5.0)
Urea 2.8 mmol/L (2.0 - 7.0)
Creatinine 110 µmol/L (55 - 120)
Glucose 28 mmol/L (4 - 7)
Which of the following laboratory findings is most likely to be seen in this patient?Your Answer: PH 7.2; pCO2 6.5 kPa; Anion Gap 11
Correct Answer: PH 7.1; pCO2 2.3 kPa; Anion Gap 21
Explanation:The patient is experiencing diabetic ketoacidosis, which results in a raised anion gap metabolic acidosis. To determine the correct answer, we must eliminate options with a normal or raised pH (7.4 and 7.5), as well as those with respiratory acidosis (as the patient has an increased respiratory rate and should have a low pCO2). The anion gap is also a crucial factor, with a normal range of 3 to 16. Therefore, the correct option is the one with an anion gap of 21.
Understanding Metabolic Acidosis
Metabolic acidosis is a condition that can be classified based on the anion gap, which is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium. The normal range for anion gap is 10-18 mmol/L. If a question provides the chloride level, it may be an indication to calculate the anion gap.
Hyperchloraemic metabolic acidosis is a type of metabolic acidosis with a normal anion gap. It can be caused by gastrointestinal bicarbonate loss, prolonged diarrhea, ureterosigmoidostomy, fistula, renal tubular acidosis, drugs like acetazolamide, ammonium chloride injection, and Addison’s disease. On the other hand, raised anion gap metabolic acidosis is caused by lactate, ketones, urate, acid poisoning, and other factors.
Lactic acidosis is a type of metabolic acidosis that is caused by high lactate levels. It can be further classified into two types: lactic acidosis type A, which is caused by sepsis, shock, hypoxia, and burns, and lactic acidosis type B, which is caused by metformin. Understanding the different types and causes of metabolic acidosis is important in diagnosing and treating the condition.
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This question is part of the following fields:
- Renal System
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Question 25
Incorrect
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A 68-year-old male comes to the emergency department with a sudden onset of numbness in his right arm and leg. During the examination, you observe that he has left-sided facial numbness. There are no alterations in his speech or hearing, and he has no weakness in any of his limbs.
What is the probable diagnosis?Your Answer: Bell's palsy
Correct Answer: Lateral medullary syndrome
Explanation:Understanding Lateral Medullary Syndrome
Lateral medullary syndrome, also referred to as Wallenberg’s syndrome, is a condition that arises when the posterior inferior cerebellar artery becomes blocked. This condition is characterized by a range of symptoms that affect both the cerebellum and brainstem. Cerebellar features of the syndrome include ataxia and nystagmus, while brainstem features include dysphagia, facial numbness, and cranial nerve palsy such as Horner’s. Additionally, patients may experience contralateral limb sensory loss. Understanding the symptoms of lateral medullary syndrome is crucial for prompt diagnosis and treatment.
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This question is part of the following fields:
- Neurological System
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Question 26
Incorrect
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A 35-year-old female presents to a clinic with worsening joint pains, low-grade fever and tiredness for the past 6 months. She also has chest pain that increases when breathing in. On examination, there are painless ulcers in her oral cavity. There is a reddish butterfly-patterned rash on her cheeks. She mentions that the rash worsens when she goes out into the sun. Her blood tests show:
Hb 98 g/L Male: (135-180)
Female: (115 - 160)
Platelets 95 * 109/L (150 - 400)
WBC 3.2 * 109/L (4.0 - 11.0)
ESR 90 mm/hr (0 - 20)
Urinalysis reveals proteinuria and red cell casts. Investigations for autoantibodies are sent for the patient.
What is the most sensitive test for the condition that this 35-year-old female patient is likely to have?Your Answer: Anti-dsDNA antibodies
Correct Answer: Antinuclear antibodies (ANA)
Explanation:Systemic lupus erythematosus (SLE) can be investigated through various tests, including antibody tests. ANA testing is highly sensitive and useful for ruling out SLE, but it has low specificity. About 99% of SLE patients are ANA positive. Rheumatoid factor testing is positive in 20% of SLE patients. Anti-dsDNA testing is highly specific (>99%) but less sensitive (70%). Anti-Smith testing is also highly specific (>99%) but has a lower sensitivity (30%). Other antibody tests that can be used include anti-U1 RNP, SS-A (anti-Ro), and SS-B (anti-La).
Monitoring of SLE can be done through various markers, including inflammatory markers such as ESR. During active disease, CRP levels may be normal, and a raised CRP may indicate an underlying infection. Complement levels (C3, C4) are low during active disease due to the formation of complexes that lead to the consumption of complement. Anti-dsDNA titres can also be used for disease monitoring, but it is important to note that they are not present in all SLE patients. Overall, these investigations can help diagnose and monitor SLE, allowing for appropriate management and treatment.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 27
Incorrect
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A 68-year-old woman visits her doctor reporting a burning and stabbing pain that has been present for a few days across her left breast, extending to her back. She also mentions a new rash in the same area. The patient states that she has been feeling generally unwell since the onset of the pain and rash. During the physical examination, a vesicular rash with an erythematous base is observed on her left breast and around the left side of her back in a straight line, without crossing the midline. Which nerve root is likely to be affected in this case?
Your Answer: T1
Correct Answer: T5
Explanation:The most probable nerve root to be affected in shingles, which causes a rash to follow straight lines along dermatomes without crossing the midline, is T4-T6. This is because the breast is innervated by intercostal nerve branches from these nerve roots.
The breast is situated on a layer of pectoral fascia and is surrounded by the pectoralis major, serratus anterior, and external oblique muscles. The nerve supply to the breast comes from branches of intercostal nerves from T4-T6, while the arterial supply comes from the internal mammary (thoracic) artery, external mammary artery (laterally), anterior intercostal arteries, and thoraco-acromial artery. The breast’s venous drainage is through a superficial venous plexus to subclavian, axillary, and intercostal veins. Lymphatic drainage occurs through the axillary nodes, internal mammary chain, and other lymphatic sites such as deep cervical and supraclavicular fossa (later in disease).
The preparation for lactation involves the hormones oestrogen, progesterone, and human placental lactogen. Oestrogen promotes duct development in high concentrations, while high levels of progesterone stimulate the formation of lobules. Human placental lactogen prepares the mammary glands for lactation. The two hormones involved in stimulating lactation are prolactin and oxytocin. Prolactin causes milk secretion, while oxytocin causes contraction of the myoepithelial cells surrounding the mammary alveoli to result in milk ejection from the breast. Suckling of the baby stimulates the mechanoreceptors in the nipple, resulting in the release of both prolactin and oxytocin from the pituitary gland (anterior and posterior parts respectively).
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This question is part of the following fields:
- Reproductive System
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Question 28
Incorrect
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A 75-year-old male is admitted to the ICU with a fever, headache, vomiting, and a Glasgow Coma Scale score of 13. The medical team suspects herpes simplex encephalitis and orders an MRI while starting the appropriate treatment. What is the likely mechanism of action of the drug administered?
Your Answer: Binds to 30S subunit causing misreading of mRNA
Correct Answer: Competitively inhibits viral DNA polymerases
Explanation:acyclovir is a highly specific antiviral agent that targets viral DNA polymerase with greater affinity than cellular DNA polymerase. It works by incorporating into the DNA and causing chain termination due to the missing 2′ and 3′ carbons. To become active, acyclovir must first be converted to acyclovir monophosphate by the virus-specific enzyme thymidine kinase (TK), and then to its active triphosphate form by human enzymes. acyclovir is effective against most herpesvirus species.
Penicillins prevent peptidoglycan cross-linking by binding to penicillin-binding-proteins, leading to cell lysis and making them bactericidal. They can be given with β-lactamase inhibitors to prevent antibiotic breakdown, such as co-amoxiclav (amoxicillin with clavulanic acid).
Quinolones are topoisomerase inhibitors that inhibit DNA synthesis and are bactericidal. However, they can cause tendon rupture as a side effect.
Aminoglycosides bind to the 30S subunit, causing mRNA misreading. Gentamicin is an example used to treat various bacterial infections, but it can cause ototoxicity and nephrotoxicity.
Macrolides like clindamycin bind to the 50S subunit, inhibiting translocation. Clindamycin is primarily used to treat anaerobic infections caused by susceptible anaerobic bacteria, including dental, respiratory, skin, and soft tissue infections, as well as peritonitis.
Antiviral agents are drugs used to treat viral infections. They work by targeting specific mechanisms of the virus, such as inhibiting viral DNA polymerase or neuraminidase. Some common antiviral agents include acyclovir, ganciclovir, ribavirin, amantadine, oseltamivir, foscarnet, interferon-α, and cidofovir. Each drug has its own mechanism of action and indications for use, but they all aim to reduce the severity and duration of viral infections.
In addition to these antiviral agents, there are also specific drugs used to treat HIV, a retrovirus. Nucleoside analogue reverse transcriptase inhibitors (NRTI), protease inhibitors (PI), and non-nucleoside reverse transcriptase inhibitors (NNRTI) are all used to target different aspects of the HIV life cycle. NRTIs work by inhibiting the reverse transcriptase enzyme, which is needed for the virus to replicate. PIs inhibit a protease enzyme that is necessary for the virus to mature and become infectious. NNRTIs bind to and inhibit the reverse transcriptase enzyme, preventing the virus from replicating. These drugs are often used in combination to achieve the best possible outcomes for HIV patients.
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This question is part of the following fields:
- General Principles
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Question 29
Incorrect
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At which stage does the aorta divide into the left and right common iliac arteries?
Your Answer: L2
Correct Answer: L4
Explanation:The point of bifurcation of the aorta is typically at the level of L4, which is a consistent location and is frequently assessed in examinations.
Anatomical Planes and Levels in the Human Body
The human body can be divided into different planes and levels to aid in anatomical study and medical procedures. One such plane is the transpyloric plane, which runs horizontally through the body of L1 and intersects with various organs such as the pylorus of the stomach, left kidney hilum, and duodenojejunal flexure. Another way to identify planes is by using common level landmarks, such as the inferior mesenteric artery at L3 or the formation of the IVC at L5.
In addition to planes and levels, there are also diaphragm apertures located at specific levels in the body. These include the vena cava at T8, the esophagus at T10, and the aortic hiatus at T12. By understanding these planes, levels, and apertures, medical professionals can better navigate the human body during procedures and accurately diagnose and treat various conditions.
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This question is part of the following fields:
- Neurological System
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Question 30
Correct
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A patient in his 60s with dilated cardiomyopathy visits his primary care physician complaining of heart failure symptoms. What is the reason behind his heart condition causing heart failure?
Your Answer: Ventricular dilatation increases afterload due to Laplace's law
Explanation:Laplace’s law states that the pressure in a lumen is equal to the wall tension divided by the lumen radius. Heart failure occurs when the heart is unable to meet the body’s demands for cardiac output. While an increased end diastolic volume can initially increase cardiac output, if myocytes become too stretched, cardiac output will decrease. Insufficient blood supply to the myocardium can also cause heart failure, but this is not related to dilated cardiomyopathy. The Bainbridge reflex and baroreceptor reflex are the main controllers of heart rate, with the former responding to increased stretch in the atrium. Ventricular dilatation does not directly cause an increase in aortic pressure. Laplace’s law shows that as the ventricle dilates, tension must increase to maintain pressure, but at a certain point, myocytes will no longer be able to exert enough force, leading to heart failure. Additionally, as the ventricle dilates, afterload increases, which is the force the heart must contract against.
The heart has four chambers and generates pressures of 0-25 mmHg on the right side and 0-120 mmHg on the left. The cardiac output is the product of heart rate and stroke volume, typically 5-6L per minute. The cardiac impulse is generated in the sino atrial node and conveyed to the ventricles via the atrioventricular node. Parasympathetic and sympathetic fibers project to the heart via the vagus and release acetylcholine and noradrenaline, respectively. The cardiac cycle includes mid diastole, late diastole, early systole, late systole, and early diastole. Preload is the end diastolic volume and afterload is the aortic pressure. Laplace’s law explains the rise in ventricular pressure during the ejection phase and why a dilated diseased heart will have impaired systolic function. Starling’s law states that an increase in end-diastolic volume will produce a larger stroke volume up to a point beyond which stroke volume will fall. Baroreceptor reflexes and atrial stretch receptors are involved in regulating cardiac output.
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This question is part of the following fields:
- Cardiovascular System
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Question 31
Correct
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A 29-year-old woman, who is 30 weeks' pregnant, visits your clinic to discuss breast feeding. She expresses her interest in trying to breast feed her baby but would like to know more about best practices in neonatal feeding.
What are the recommendations of the World Health Organization regarding breast feeding?Your Answer: 6 months' exclusive breast feeding with gradual introduction of solid foods after this point
Explanation:WHO Recommendations for Infant Feeding
The World Health Organization (WHO) recommends early initiation of breast feeding, ideally from birth. Infants who are exclusively breast fed until six months have reduced risks of gastrointestinal infections compared to those who start weaning onto solid foods at three to four months. Breast feeding should continue on demand to 24 months or beyond, while solid food should be introduced gradually from six months. There should be a gradual increase in the consistency and variety of food offered. Infants who do not have ongoing breast feeding after six months will require fluid to be provided in an alternative form.
In countries where there are particular risks of nutrient deficiencies, supplements can be provided. However, in most developed nations, nutrient supplements are not required. It is important to adhere to hygienic practices in the preparation of food. WHO recommends breast feeding in all situations, even for mothers who are HIV positive and infants who are HIV negative, provided that the mothers have satisfactory anti-retroviral therapy. In resource-poor situations, WHO considers that the positive benefits of breast feeding in a population causing improved infant mortality outweigh the risk of a minority of infants contracting HIV through breast milk.
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This question is part of the following fields:
- Paediatrics
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Question 32
Correct
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A 30-year-old patient presents with complaints of recurrent bloody diarrhoea and symptoms of iritis. On examination, there is a painful nodular erythematous eruption on the shin and anal tags are observed. What diagnostic test would you recommend to confirm the diagnosis?
Your Answer: Colonoscopy
Explanation:Inflammatory Bowel Disease with Crohn’s Disease Suggestion
The patient’s symptoms and physical examination suggest inflammatory bowel disease, with anal skin tags indicating a possible diagnosis of Crohn’s disease. Other symptoms consistent with this diagnosis include iritis and a skin rash that may be erythema nodosum. To confirm the diagnosis, a colonoscopy with biopsies would be the initial investigation. While serum ACE levels can aid in diagnosis, they are often elevated in conditions other than sarcoidosis.
Overall, the patient’s symptoms and physical examination point towards inflammatory bowel disease, with Crohn’s disease as a possible subtype. Further testing is necessary to confirm the diagnosis and rule out other conditions.
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This question is part of the following fields:
- Rheumatology
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Question 33
Incorrect
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A 63-year-old woman, with a history of rate-controlled atrial fibrillation and HIV, visits the emergency department due to vaginal bleeding. She is taking warfarin and denies any accidental overdose. Recently, her general physician prescribed a new medication.
During her examination, her INR is discovered to be 7.
What is the most probable medication that the patient was prescribed?Your Answer: Rifampicin
Correct Answer: Ritonavir
Explanation:Ritonavir, a protease inhibitor, strongly inhibits the CYP3A4 system and may interfere with warfarin metabolism. Conversely, the other options listed are CYP inducers and may increase warfarin metabolism, leading to a suboptimal therapeutic effect. To remember the most common CYP inducers, use the mnemonic SARS: St. John’s Wort, Anti-epileptics (phenytoin, phenobarbital, carbamazepine), Rifampicin, and Smoking.
The P450 system is responsible for metabolizing many drugs in the body, and drug interactions can occur when certain drugs inhibit or induce the activity of these enzymes. The most common and important enzyme system involved in drug interactions is CYP3A4. Macrolides, antiretrovirals, and calcium channel blockers are substrates for this enzyme, while macrolides, protease inhibitors (including ritonavir), and imidazoles are inhibitors. Carbamazepine, phenytoin, phenobarbitone, rifampicin, and St John’s Wort are inducers of CYP3A4. Other enzyme systems affected by common drugs include CYP2D6, CYP2C9, CYP1A2, and CYP2E1. Tricyclic antidepressants and antipsychotics are substrates for CYP2D6, while SSRIs and ritonavir are inhibitors. Warfarin and sulfonylureas are substrates for CYP2C9, while imidazoles, amiodarone, and sodium valproate are inhibitors. Theophylline is a substrate for CYP1A2, while ciprofloxacin and omeprazole are inhibitors. Chronic alcohol and isoniazid are inducers of CYP2E1. It is important to be aware of these interactions to avoid adverse effects and ensure optimal drug therapy.
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This question is part of the following fields:
- General Principles
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Question 34
Incorrect
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A 32-year-old man has a sarcoma removed from his right buttock, resulting in sacrifice of the sciatic nerve. What is one outcome that will not occur as a result of this procedure?
Your Answer: Loss of sensation to the posterior aspect of the thigh
Correct Answer: Loss of extension at the knee joint
Explanation:The obturator and femoral nerves are responsible for causing extension of the knee joint.
Understanding the Sciatic Nerve
The sciatic nerve is the largest nerve in the body, formed from the sacral plexus and arising from spinal nerves L4 to S3. It passes through the greater sciatic foramen and emerges beneath the piriformis muscle, running under the cover of the gluteus maximus muscle. The nerve provides cutaneous sensation to the skin of the foot and leg, as well as innervating the posterior thigh muscles and lower leg and foot muscles. Approximately halfway down the posterior thigh, the nerve splits into the tibial and common peroneal nerves. The tibial nerve supplies the flexor muscles, while the common peroneal nerve supplies the extensor and abductor muscles.
The sciatic nerve also has articular branches for the hip joint and muscular branches in the upper leg, including the semitendinosus, semimembranosus, biceps femoris, and part of the adductor magnus. Cutaneous sensation is provided to the posterior aspect of the thigh via cutaneous nerves, as well as the gluteal region and entire lower leg (except the medial aspect). The nerve terminates at the upper part of the popliteal fossa by dividing into the tibial and peroneal nerves. The nerve to the short head of the biceps femoris comes from the common peroneal part of the sciatic, while the other muscular branches arise from the tibial portion. The tibial nerve goes on to innervate all muscles of the foot except the extensor digitorum brevis, which is innervated by the common peroneal nerve.
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This question is part of the following fields:
- Neurological System
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Question 35
Incorrect
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A 70-year-old male visits his GP complaining of increased difficulty in breathing. He has a history of left ventricular heart failure, and his symptoms suggest a worsening of his condition. The doctor prescribes spironolactone as a diuretic. What is the mechanism of action of this medication?
Your Answer: Inhibitor of the sodium reabsorption in the distal convoluted tubule
Correct Answer: Aldosterone antagonist
Explanation:The mechanism of action of spironolactone involves blocking the aldosterone receptor in the distal tubules and collecting duct of the kidneys. In contrast, furosemide acts as a loop diuretic by inhibiting the sodium/potassium/2 chloride inhibitor in the loop of Henle, while acetazolamide functions as a carbonic anhydrase inhibitor.
Spironolactone is a medication that works as an aldosterone antagonist in the cortical collecting duct. It is used to treat various conditions such as ascites, hypertension, heart failure, nephrotic syndrome, and Conn’s syndrome. In patients with cirrhosis, spironolactone is often prescribed in relatively large doses of 100 or 200 mg to counteract secondary hyperaldosteronism. It is also used as a NICE ‘step 4’ treatment for hypertension. In addition, spironolactone has been shown to reduce all-cause mortality in patients with NYHA III + IV heart failure who are already taking an ACE inhibitor, according to the RALES study.
However, spironolactone can cause adverse effects such as hyperkalaemia and gynaecomastia, although the latter is less common with eplerenone. It is important to monitor potassium levels in patients taking spironolactone to prevent hyperkalaemia, which can lead to serious complications such as cardiac arrhythmias. Overall, spironolactone is a useful medication for treating various conditions, but its potential adverse effects should be carefully considered and monitored.
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This question is part of the following fields:
- Renal System
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Question 36
Correct
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A 25-year-old individual is undergoing testing for asthma. Prior to administering bronchodilators, their FEV1/FVC ratio is measured at 0.85, with the FVC at 90% of normal. What does this indicate?
Your Answer: Normal exam
Explanation:The FEV1/FVC ratio is a measure used in lung function tests to assess the health of the lungs. In normal individuals, this ratio ranges from 0.75 to 0.85. If the ratio falls below 0.70, it suggests an obstructive problem that reduces the volume of air that can be expelled in one second (FEV1). However, in restrictive lung disease, the FVC is also reduced, which can result in a normal or high FEV1/FVC ratio.
It is important to understand the FEV1/FVC ratio as it can help diagnose and monitor lung diseases such as chronic obstructive pulmonary disease (COPD) and asthma. A low ratio indicates that the airways are obstructed, while a normal or high ratio suggests a restrictive lung disease. Lung function tests are often used to assess the severity of these conditions and to monitor the effectiveness of treatment. By the FEV1/FVC ratio, healthcare professionals can provide appropriate care and management for patients with lung diseases.
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This question is part of the following fields:
- Clinical Sciences
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Question 37
Incorrect
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A 50-year-old woman presents to the Emergency Department with a several-hour history of excruciating pain in the left knee. Her medical history is significant for hypertension and a previous episode of gout. She takes amlodipine.
On examination, she is in severe pain and the left knee is swollen, red, warm and tender. Arthroscopic evaluation of the synovial fluid aspirate showed monosodium crystals that are negatively birefringent under polarized light. A diagnosis of recurrent gout is made and ultimately the patient is commenced on prophylaxis using allopurinol.
What is the mechanism of action of allopurinol?Your Answer: Oxidises urate
Correct Answer: Inhibits xanthine oxidase
Explanation:Allopurinol is a medication that inhibits xanthine oxidase, which is used for gout prophylaxis. By blocking the conversion of hypoxanthine to xanthine and xanthine to uric acid, it reduces the levels of uric acid in the blood. The other options, such as inhibition of dihydrofolate reductase, ribonucleotide reductase, and thymidylate synthase, are not related to gout prophylaxis. Rasburicase, which oxidizes urate to allantoin, is also used for gout prophylaxis, but it works differently than allopurinol.
Allopurinol can interact with other medications such as azathioprine, cyclophosphamide, and theophylline. It can lead to high levels of 6-mercaptopurine when used with azathioprine, reduced renal clearance when used with cyclophosphamide, and an increase in plasma concentration of theophylline. Patients at a high risk of severe cutaneous adverse reaction should be screened for the HLA-B *5801 allele.
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This question is part of the following fields:
- General Principles
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Question 38
Incorrect
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A 20-year-old male comes to the clinic complaining of fatigue and a sore throat. During the examination, the doctor observes cervical lymphadenopathy and splenomegaly. Mono is suspected as the diagnosis. Which type of cancer is most commonly linked to Epstein-Barr Virus?
Your Answer: Hepatocellular carcinoma
Correct Answer: Burkitt's lymphoma
Explanation:Epstein-Barr Virus is linked to Burkitt’s lymphoma.
Hepatitis C is linked to hepatocellular carcinoma.
Alcohol excess and smoking are linked to oesophageal cancer.
Individuals with Down’s syndrome have a higher incidence of acute lymphoblastic leukaemia.
Conditions Linked to Epstein-Barr Virus
Epstein-Barr virus (EBV) is associated with various conditions, including malignancies and non-malignant conditions. Malignancies linked to EBV infection include Burkitt’s lymphoma, Hodgkin’s lymphoma, nasopharyngeal carcinoma, and HIV-associated central nervous system lymphomas. Burkitt’s lymphoma is currently believed to be associated with both African and sporadic cases.
Apart from malignancies, EBV infection is also linked to non-malignant conditions such as hairy leukoplakia. This condition is characterized by white patches on the tongue and inside of the cheeks, and it is often seen in people with weakened immune systems.
In summary, EBV infection is associated with various conditions, including malignancies and non-malignant conditions. Understanding the link between EBV and these conditions can help in the development of effective prevention and treatment strategies.
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This question is part of the following fields:
- General Principles
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Question 39
Incorrect
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A 25-year-old man presents to the Emergency department with acute onset of shortness of breath during a basketball game. He reports no history of trauma and is typically healthy. Upon examination, he appears tall and lean, and respiratory assessment reveals reduced breath sounds and hyper-resonant percussion notes on the right side. The trachea remains centrally located. A chest x-ray confirms a diagnosis of a collapsed lung due to a right-sided pneumothorax. What is the reason for the lung's failure to re-expand?
Your Answer: Decrease in intrapleural pressure
Correct Answer: Increase in intrapleural pressure
Explanation:The process of lung expansion relies on the negative pressure in the intrapleural space between the visceral and parietal pleura, which is present throughout respiration. This negative pressure pulls the lung towards the chest wall, allowing it to expand. However, if air enters the intrapleural space, the negative pressure is lost and the lung cannot fully reinflate. It is important to note that the intrapleural space is a potential space between the pleural surfaces, and there is typically no actual space present under normal circumstances.
Management of Pneumothorax: BTS Guidelines
Pneumothorax is a condition where air accumulates in the pleural space, causing the lung to collapse. The British Thoracic Society (BTS) has published guidelines for the management of spontaneous pneumothorax, which can be primary or secondary. Primary pneumothorax occurs without any underlying lung disease, while secondary pneumothorax is associated with lung disease.
The BTS recommends that patients with a rim of air less than 2 cm and no shortness of breath may be discharged, while those with a larger rim of air or shortness of breath should undergo aspiration or chest drain insertion. For secondary pneumothorax, patients over 50 years old with a rim of air greater than 2 cm or shortness of breath should undergo chest drain insertion. Aspiration may be attempted for those with a rim of air between 1-2 cm, but chest drain insertion is recommended if aspiration fails.
Patients with iatrogenic pneumothorax, which is caused by medical procedures, have a lower likelihood of recurrence than those with spontaneous pneumothorax. Observation is usually sufficient, but chest drain insertion may be required in some cases. Ventilated patients and those with chronic obstructive pulmonary disease (COPD) may require chest drain insertion.
Patients with pneumothorax should be advised to avoid smoking to reduce the risk of further episodes. They should also be aware of restrictions on air travel and scuba diving. The CAA recommends a waiting period of two weeks after successful drainage before air travel, while the BTS advises against scuba diving unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.
In summary, the BTS guidelines provide a comprehensive approach to the management of pneumothorax, taking into account the type of pneumothorax and the patient’s individual circumstances. Early intervention and appropriate follow-up can help prevent complications and improve outcomes.
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This question is part of the following fields:
- Respiratory System
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Question 40
Incorrect
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A 45-year-old patient comes in with symptoms of weight loss, nausea, vomiting, abdominal pain, and hyperpigmentation of the skin. The doctor orders a urea & electrolyte test and a short Synacthen test which comes back abnormal and diagnoses the patient with Addison's disease.
What electrolyte abnormality is most likely to be observed in this patient?Your Answer: Hypokalaemia & hypernatraemia
Correct Answer: Hyperkalaemia & hyponatraemia
Explanation:In Addison’s disease, there is a deficiency in the production of both aldosterone and cortisol.
Aldosterone plays a crucial role in the reabsorption of sodium and the excretion of potassium.
Therefore, the absence of aldosterone leads to an imbalance in the levels of sodium and potassium in the body, resulting in hyperkalemia (high potassium levels) and hyponatremia (low sodium levels).
Addison’s disease is the most common cause of primary hypoadrenalism in the UK, with autoimmune destruction of the adrenal glands being the main culprit, accounting for 80% of cases. This results in reduced production of cortisol and aldosterone. Symptoms of Addison’s disease include lethargy, weakness, anorexia, nausea and vomiting, weight loss, and salt-craving. Hyperpigmentation, especially in palmar creases, vitiligo, loss of pubic hair in women, hypotension, hypoglycemia, and hyponatremia and hyperkalemia may also be observed. In severe cases, a crisis may occur, leading to collapse, shock, and pyrexia.
Other primary causes of hypoadrenalism include tuberculosis, metastases (such as bronchial carcinoma), meningococcal septicaemia (Waterhouse-Friderichsen syndrome), HIV, and antiphospholipid syndrome. Secondary causes include pituitary disorders, such as tumours, irradiation, and infiltration. Exogenous glucocorticoid therapy can also lead to hypoadrenalism.
It is important to note that primary Addison’s disease is associated with hyperpigmentation, while secondary adrenal insufficiency is not.
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This question is part of the following fields:
- Endocrine System
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Question 41
Incorrect
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As a busy surgical trainee on the colorectal unit, you have been tasked with reviewing the histopathology results for colonic polyps. Which type of polyp described below poses the highest risk of malignant transformation? Please note that this question is specifically for a trainee who is slightly older and more experienced.
Your Answer: Hyperplastic polyp
Correct Answer: Villous adenoma
Explanation:The risk of malignant transformation is highest in villous adenomas, while hyperplastic polyps pose little risk. Hamartomatous polyp syndromes may increase the risk of malignancy in patients, but the polyps themselves have low malignant potential.
Understanding Colonic Polyps and Follow-Up Procedures
Colonic polyps can occur in isolation or as part of polyposis syndromes, with greater than 100 polyps typically present in FAP. The risk of malignancy is related to size, with a 10% risk in a 1 cm adenoma. While isolated adenomas seldom cause symptoms, distally sited villous lesions may produce mucous and electrolyte disturbances if very large.
Follow-up procedures for colonic polyps depend on the number and size of the polyps. Low-risk cases with 1 or 2 adenomas less than 1 cm require no follow-up or re-colonoscopy for 5 years. Moderate-risk cases with 3 or 4 small adenomas or 1 adenoma greater than 1 cm require a re-scope at 3 years. High-risk cases with more than 5 small adenomas or more than 3 with 1 of them greater than 1 cm require a re-scope at 1 year.
Segmental resection or complete colectomy may be necessary in cases of incomplete excision of malignant polyps, malignant sessile polyps, malignant pedunculated polyps with submucosal invasion, polyps with poorly differentiated carcinoma, or familial polyposis coli. Screening from teenager up to 40 years by 2 yearly sigmoidoscopy/colonoscopy is recommended. Rectal polypoidal lesions may be treated with trans anal endoscopic microsurgery.
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This question is part of the following fields:
- Gastrointestinal System
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Question 42
Incorrect
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A 43-year-old woman presents to the clinic with a 4-month history of fatigue and constipation. Upon examination, no significant findings were observed except for the following blood results:
- Hb: 125 g/L (Female: 115-160)
- Platelets: 162 * 109/L (150-400)
- WBC: 6.8 * 109/L (4.0-11.0)
- Na+: 142 mmol/L (135-145)
- K+: 3.8 mmol/L (3.5-5.0)
- Urea: 6.2 mmol/L (2.0-7.0)
- Creatinine: 105 µmol/L (55-120)
- CRP: 2 mg/L (<5)
- TSH: 105.5 mU/L (0.5-5.5)
- Free thyroxine (T4): 6.8 pmol/L (9.0-18)
The appropriate medication was prescribed to treat the underlying condition. What is the receptor targeted by this drug?Your Answer: Cyclic AMP
Correct Answer: Nuclear
Explanation:Levothyroxine functions by binding to nuclear receptors, while drugs such as lidocaine primarily act on ion channels, specifically voltage-gated sodium channels. G-protein coupled receptors are more intricate, with drugs binding to the receptor causing a series of events within the G-protein subunits, ultimately leading to the production of secondary messengers like cyclic AMP or protein phosphorylation cascades. Adrenoreceptors are an example of G-protein coupled receptors.
Pharmacodynamics refers to the effects of drugs on the body, as opposed to pharmacokinetics which is concerned with how the body processes drugs. Drugs typically interact with a target, which can be a protein located either inside or outside of cells. There are four main types of cellular targets: ion channels, G-protein coupled receptors, tyrosine kinase receptors, and nuclear receptors. The type of target determines the mechanism of action of the drug. For example, drugs that work on ion channels cause the channel to open or close, while drugs that activate tyrosine kinase receptors lead to cell growth and differentiation.
It is also important to consider whether a drug has a positive or negative impact on the receptor. Agonists activate the receptor, while antagonists block the receptor preventing activation. Antagonists can be competitive or non-competitive, depending on whether they bind at the same site as the agonist or at a different site. The binding affinity of a drug refers to how readily it binds to a specific receptor, while efficacy measures how well an agonist produces a response once it has bound to the receptor. Potency is related to the concentration at which a drug is effective, while the therapeutic index is the ratio of the dose of a drug resulting in an undesired effect compared to that at which it produces the desired effect.
The relationship between the dose of a drug and the response it produces is rarely linear. Many drugs saturate the available receptors, meaning that further increased doses will not cause any more response. Some drugs do not have a significant impact below a certain dose and are considered sub-therapeutic. Dose-response graphs can be used to illustrate the relationship between dose and response, allowing for easy comparison of different drugs. However, it is important to remember that dose-response varies between individuals.
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This question is part of the following fields:
- General Principles
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Question 43
Incorrect
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An emergency medicine doctor has been called to verify the death of an 86-year-old male patient. After washing his hands, he carefully observes the patient for signs of pallor, rigour mortis, and lividity. He proceeds to palpate the carotid arteries and applies painful stimulus to the sternum around the sternal angle. The doctor completes his examination by auscultating the chest for 1 minute and notes the vertebral landmark that corresponds to the sternal angle as the site of painful stimulus application.
Can you correctly identify the location of the sternal angle based on the doctor's examination findings?Your Answer: Lower border of the T2 vertebrae
Correct Answer: Lower border of the T4 vertebrae
Explanation:The correct location of the sternal angle, also known as the angle of Louis, is at the lower border of the T4 vertebrae. While some sources may state that it lies between the 4th and 5th intercostal space, this still does not make the third answer correct as the sternal angle would then be located between the lower border of the 4th vertebrae and the upper border of the 5th vertebrae, which are the boundaries of the intercostal space between the two vertebral planes.
The sternal angle is a significant anatomical landmark located at the level of the upper sternum and manubrium. It is characterized by several structures, including the upper part of the manubrium, left brachiocephalic vein, brachiocephalic artery, left common carotid, left subclavian artery, lower part of the manubrium, and costal cartilages of the 2nd ribs. Additionally, the sternal angle marks the transition point between the superior and inferior mediastinum, and is also associated with the arch of the aorta, tracheal bifurcation, union of the azygos vein and superior vena cava, and the crossing of the thoracic duct to the midline. Overall, the sternal angle is a crucial anatomical structure that serves as a reference point for various medical procedures and diagnoses.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 44
Incorrect
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Which section of the digestive system is primarily involved in the enterohepatic circulation?
Your Answer: Pancreas
Correct Answer: Terminal ileum
Explanation:The Enterohepatic Circulation and Bile Recycling
The enterohepatic circulation is a process that allows for the recycling of certain waste materials that are excreted in the bile. This process occurs at the terminal ileum, where bile salts and some bilirubin derivatives are reabsorbed and returned to the liver through the portal circulation. The regulation of this process involves transporter proteins in both the liver canaliculi and the ileum.
Bacterial flora in the colon also play a role in the enterohepatic circulation of bilirubin derivatives. Some bacteria contain an enzyme called beta-glucuronidase, which converts conjugated bilirubin to unconjugated bilirubin. This unconjugated form is more lipid-soluble and can be more easily reabsorbed.
Overall, the enterohepatic circulation is an important mechanism for bile recycling and waste management in the body.
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This question is part of the following fields:
- Clinical Sciences
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Question 45
Correct
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A patient in their 50s complains of tenderness in the anatomical snuffbox following a fall. The tendons of the abductor pollicis longus are located along the radial (lateral) border of the anatomical snuffbox.
What is the nerve that innervates this muscle?Your Answer: Radial nerve
Explanation:The correct answer is that the posterior interosseous branch of the radial nerve supplies abductor pollicis longus, along with all the other extensor muscles of the forearm, including supinator. The main trunk of the radial nerve supplies triceps, anconeus, extensor carpi radialis, and brachioradialis. The anterior interosseous nerve supplies flexor digitorum profundus (radial half), flexor pollicis longus, and pronator quadratus. The median nerve supplies the LOAF muscles (lumbricals 1 and 2, opponens pollicis, abductor pollicis brevis, and flexor pollicis brevis). The lateral cutaneous nerve of the forearm has no motor innervation, and the ulnar nerve supplies most of the intrinsic muscles of the hand and two muscles of the anterior forearm: the flexor carpi ulnaris and the medial flexor digitorum profundus.
The Radial Nerve: Anatomy, Innervation, and Patterns of Damage
The radial nerve is a continuation of the posterior cord of the brachial plexus, with root values ranging from C5 to T1. It travels through the axilla, posterior to the axillary artery, and enters the arm between the brachial artery and the long head of triceps. From there, it spirals around the posterior surface of the humerus in the groove for the radial nerve before piercing the intermuscular septum and descending in front of the lateral epicondyle. At the lateral epicondyle, it divides into a superficial and deep terminal branch, with the deep branch crossing the supinator to become the posterior interosseous nerve.
The radial nerve innervates several muscles, including triceps, anconeus, brachioradialis, and extensor carpi radialis. The posterior interosseous branch innervates supinator, extensor carpi ulnaris, extensor digitorum, and other muscles. Denervation of these muscles can lead to weakness or paralysis, with effects ranging from minor effects on shoulder stability to loss of elbow extension and weakening of supination of prone hand and elbow flexion in mid prone position.
Damage to the radial nerve can result in wrist drop and sensory loss to a small area between the dorsal aspect of the 1st and 2nd metacarpals. Axillary damage can also cause paralysis of triceps. Understanding the anatomy, innervation, and patterns of damage of the radial nerve is important for diagnosing and treating conditions that affect this nerve.
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This question is part of the following fields:
- Neurological System
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Question 46
Incorrect
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During a neck dissection, a nerve is observed to pass behind the medial aspect of the second rib. Which nerve from the list below is the most probable?
Your Answer: Long thoracic nerve
Correct Answer: Phrenic nerve
Explanation:The crucial aspect to note is that the phrenic nerve travels behind the inner side of the first rib. Towards the top, it is situated on the exterior of scalenus anterior.
The Phrenic Nerve: Origin, Path, and Supplies
The phrenic nerve is a crucial nerve that originates from the cervical spinal nerves C3, C4, and C5. It supplies the diaphragm and provides sensation to the central diaphragm and pericardium. The nerve passes with the internal jugular vein across scalenus anterior and deep to the prevertebral fascia of the deep cervical fascia.
The right phrenic nerve runs anterior to the first part of the subclavian artery in the superior mediastinum and laterally to the superior vena cava. In the middle mediastinum, it is located to the right of the pericardium and passes over the right atrium to exit the diaphragm at T8. On the other hand, the left phrenic nerve passes lateral to the left subclavian artery, aortic arch, and left ventricle. It passes anterior to the root of the lung and pierces the diaphragm alone.
Understanding the origin, path, and supplies of the phrenic nerve is essential in diagnosing and treating conditions that affect the diaphragm and pericardium.
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This question is part of the following fields:
- Respiratory System
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Question 47
Incorrect
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A 26-year-old male patient visits his general practitioner complaining of fatigue. Upon conducting blood tests, it is revealed that the patient has a megaloblastic, macrocytic anaemia.
What is the most probable cause of the patient's anaemia?Your Answer: Iron deficiency
Correct Answer: Crohn's disease
Explanation:Vitamin B12 deficiency can be caused by Crohn’s disease, which is indicated by macrocytic, megaloblastic anaemia. Malabsorption in cystic fibrosis can lead to various types of vitamin deficiency, particularly fat-soluble vitamins A, D, E, and K due to reduced fat absorption caused by pancreatic insufficiency. Microcytic anaemia is a result of iron deficiency, while hypothyroidism can cause normoblastic, macrocytic anaemia.
Vitamin B12 is a type of water-soluble vitamin that belongs to the B complex group. Unlike other vitamins, it can only be found in animal-based foods. The human body typically stores enough vitamin B12 to last for up to 5 years. This vitamin plays a crucial role in various bodily functions, including acting as a co-factor for the conversion of homocysteine into methionine through the enzyme homocysteine methyltransferase, as well as for the isomerization of methylmalonyl CoA to Succinyl Co A via the enzyme methylmalonyl mutase. Additionally, it is used to regenerate folic acid in the body.
However, there are several causes of vitamin B12 deficiency, including pernicious anaemia, Diphyllobothrium latum infection, and Crohn’s disease. When the body lacks vitamin B12, it can lead to macrocytic, megaloblastic anaemia and peripheral neuropathy. To prevent these consequences, it is important to ensure that the body has enough vitamin B12 through a balanced diet or supplements.
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This question is part of the following fields:
- General Principles
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Question 48
Incorrect
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A 50-year-old man comes to surgical outpatients complaining of recurrent abdominal pain and vomiting. During examination, a peripheral motor neuropathy is observed. What is the probable diagnosis?
Your Answer: Huntington's disease
Correct Answer: Acute intermittent porphyria
Explanation:Unless proven otherwise, the presence of neurological symptoms along with abdominal pain may indicate either acute intermittent porphyria or lead poisoning.
Understanding Acute Intermittent Porphyria
Acute intermittent porphyria (AIP) is a rare genetic disorder that affects the biosynthesis of haem due to a defect in the porphobilinogen deaminase enzyme. This results in the accumulation of delta aminolaevulinic acid and porphobilinogen, leading to a range of symptoms. AIP typically presents in individuals aged 20-40 years, with females being more commonly affected.
The condition is characterized by a combination of abdominal, neurological, and psychiatric symptoms. Abdominal symptoms include pain and vomiting, while neurological symptoms may manifest as motor neuropathy. Psychiatric symptoms may include depression. Hypertension and tachycardia are also common.
Diagnosis of AIP involves a range of tests, including urine analysis, assay of red cells for porphobilinogen deaminase, and measurement of serum levels of delta aminolaevulinic acid and porphobilinogen. A classic sign of AIP is the deep red color of urine on standing.
Management of AIP involves avoiding triggers and treating acute attacks with IV haematin/haem arginate. In cases where these treatments are not immediately available, IV glucose may be used. With proper management, individuals with AIP can lead healthy and fulfilling lives.
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This question is part of the following fields:
- Haematology And Oncology
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Question 49
Incorrect
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A 78-year-old woman has presented with dyspnea. During cardiovascular examination, a faint murmur is detected in the mitral area. If the diagnosis is mitral stenosis, what is the most probable factor that would increase the loudness and clarity of the murmur during auscultation?
Your Answer: Listen over the 4th intercostal space
Correct Answer: Ask the patient to breathe out
Explanation:To accentuate the sound of a left-sided murmur consistent with mitral stenosis during a cardiovascular examination, the patient should be asked to exhale. Conversely, a right-sided murmur is louder during inspiration. Listening in the left lateral position while the patient is lying down can also emphasize a mitral stenosis. To identify a mitral regurgitation murmur, listening in the axilla is helpful as it radiates. Diastolic murmurs can be heard better with a position change, while systolic murmurs tend to radiate and can be distinguished by listening in different anatomical landmarks. For example, an aortic stenosis may radiate to the carotids, while an aortic regurgitation may be heard better with the patient leaning forward.
Understanding Mitral Stenosis
Mitral stenosis is a condition where the mitral valve, which controls blood flow from the left atrium to the left ventricle, becomes obstructed. This leads to an increase in pressure within the left atrium, pulmonary vasculature, and right side of the heart. The most common cause of mitral stenosis is rheumatic fever, but it can also be caused by other rare conditions such as mucopolysaccharidoses, carcinoid, and endocardial fibroelastosis.
Symptoms of mitral stenosis include dyspnea, hemoptysis, a mid-late diastolic murmur, a loud S1, and a low volume pulse. Severe cases may also present with an increased length of murmur and a closer opening snap to S2. Chest x-rays may show left atrial enlargement, while echocardiography can confirm a cross-sectional area of less than 1 sq cm for a tight mitral stenosis.
Management of mitral stenosis depends on the severity of the condition. Asymptomatic patients are monitored with regular echocardiograms, while symptomatic patients may undergo percutaneous mitral balloon valvotomy or mitral valve surgery. Patients with associated atrial fibrillation require anticoagulation, with warfarin currently recommended for moderate/severe cases. However, there is an emerging consensus that direct-acting anticoagulants may be suitable for mild cases with atrial fibrillation.
Overall, understanding mitral stenosis is important for proper diagnosis and management of this condition.
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This question is part of the following fields:
- Cardiovascular System
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Question 50
Correct
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A couple in their late 30s come to the clinic seeking information about the risk of their three children inheriting Huntington's disease. The husband has recently been diagnosed with the disease, while the wife is not affected. What is the likelihood, expressed as a percentage, that their children will inherit the disease?
Your Answer: 50%
Explanation:Huntington’s Disease
Huntington’s disease is a genetic disorder that typically appears later in life and is characterized by symptoms such as chorea, cognitive decline, and personality changes. It is an autosomal dominant disease, meaning that there is a 50% chance of passing it on to offspring. If the gene is inherited from an unaffected parent, the child will not be affected. This is different from autosomal recessive inheritance, where both parents must pass on the gene for it to affect their children.
The disease is caused by an increase in the length of a repeating trinucleotide sequence (CAG) in the Huntington protein. This sequence can change in length through generations, and longer sequences are associated with earlier onset of symptoms (genetic anticipation). Since Huntington’s disease usually presents itself after people have already started their families, there are many issues associated with genetic testing.
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This question is part of the following fields:
- Basic Sciences
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Question 51
Incorrect
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Which drug is most likely to trigger an episode of acute intermittent porphyria?
Your Answer: Atenolol
Correct Answer: Oral contraceptive pill
Explanation:Drugs to Avoid and Use in Acute Intermittent Porphyria
Acute intermittent porphyria (AIP) is a genetic disorder that affects the production of haem. It is characterized by abdominal and neuropsychiatric symptoms and is more common in females. AIP is caused by a defect in the porphobilinogen deaminase enzyme. Certain drugs can trigger an attack in individuals with AIP, including barbiturates, halothane, benzodiazepines, alcohol, oral contraceptive pills, and sulphonamides. Therefore, it is important to avoid these drugs in individuals with AIP. However, there are some drugs that are considered safe to use, such as paracetamol, aspirin, codeine, morphine, chlorpromazine, beta-blockers, penicillin, and metformin.
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This question is part of the following fields:
- General Principles
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Question 52
Incorrect
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A 58-year-old male complains of intense pain in the center of his abdomen that extends to his back and is accompanied by nausea and vomiting. Upon examination, his abdomen is tender and guarded, and his pulse is 106 bpm while his blood pressure is 120/82 mmHg. What diagnostic test would be beneficial in this case?
Your Answer: Liver function tests
Correct Answer: Amylase
Explanation:Diagnostic Tests and Severity Assessment for Acute Pancreatitis
Acute pancreatitis is a medical condition that requires prompt diagnosis and treatment. One of the most useful diagnostic tests for this condition is the measurement of amylase levels in the blood. In patients with acute pancreatitis, amylase levels are typically elevated, often reaching three times the upper limit of normal. Other blood parameters, such as troponin T, are not specific to pancreatitis and may be used to diagnose other medical conditions.
To assess the severity of acute pancreatitis, healthcare providers may use the Modified Glasgow Criteria, which is a mnemonic tool that helps to evaluate various clinical parameters. These parameters include PaO2, age, neutrophil count, calcium levels, renal function, enzymes such as LDH and AST, albumin levels, and blood sugar levels. Depending on the severity of these parameters, patients may be classified as having mild, moderate, or severe acute pancreatitis.
In summary, the diagnosis of acute pancreatitis relies on the measurement of amylase levels in the blood, while the severity of the condition can be assessed using the Modified Glasgow Criteria. Early diagnosis and prompt treatment are crucial for improving outcomes in patients with acute pancreatitis.
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This question is part of the following fields:
- Cardiovascular System
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Question 53
Incorrect
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A mother brings her 3-month-old son for his routine check-up. She mentions that his left hand has been in a fixed 'claw-like' position since birth. Upon examination, the left forearm is found to be supinated and the left wrist and fingers are flexed. Additionally, a slight droop is observed in the right eyelid and the right pupil is constricted.
What is the probable diagnosis?Your Answer: Radial nerve palsy
Correct Answer: Klumpke palsy
Explanation:Klumpke palsy is a condition that can occur due to shoulder dystocia during birth or sudden upward jerking of the hand. It results from damage to the lower trunk of the brachial plexus (C8, T1) and can cause a flattened forearm, flexed wrist, and fingers. Klumpke injury may also be associated with Horner’s syndrome, which can cause ptosis and miosis on the opposite side of the face.
Erb-Duchenne palsy is another condition that can occur due to shoulder dystocia during birth, but it results from damage to the upper trunk of the brachial plexus (C5, C6). The affected arm hangs by the side, is internally rotated, and has an extended elbow.
Radial nerve palsy can be caused by a humeral midshaft fracture and can result in wrist drop.
Median nerve palsy can have different features depending on the site of the lesion. If the lesion is in the wrist, it can cause paralysis of the thenar muscles, leading to an inability to abduct and oppose the thumb. If the lesion is in the elbow, it can cause a loss of pronation of the forearm and weak wrist flexion.
Horner’s syndrome is a condition characterized by several features, including a small pupil (miosis), drooping of the upper eyelid (ptosis), a sunken eye (enophthalmos), and loss of sweating on one side of the face (anhidrosis). The cause of Horner’s syndrome can be determined by examining additional symptoms. For example, congenital Horner’s syndrome may be identified by a difference in iris color (heterochromia), while anhidrosis may be present in central or preganglionic lesions. Pharmacologic tests, such as the use of apraclonidine drops, can also be helpful in confirming the diagnosis and identifying the location of the lesion. Central lesions may be caused by conditions such as stroke or multiple sclerosis, while postganglionic lesions may be due to factors like carotid artery dissection or cluster headaches. It is important to note that the appearance of enophthalmos in Horner’s syndrome is actually due to a narrow palpebral aperture rather than true enophthalmos.
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This question is part of the following fields:
- Neurological System
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Question 54
Incorrect
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A 25-year-old patient is undergoing routine pulmonary function testing to assess her chronic condition. The results are compared to a standardised predicted value and presented in the table below:
FEV1 75% of predicted
FVC 70% of predicted
FEV1/FVC 105%
What is the probable condition that this patient is suffering from, which can account for the above findings?Your Answer: Asthma
Correct Answer: Neuromuscular disorder
Explanation:The patient’s pulmonary function tests indicate a restrictive pattern, as both FEV1 and FVC are reduced. This suggests a possible neuromuscular disorder, as all other options would result in an obstructive pattern on the tests. Asthma, bronchiectasis, and COPD are unlikely diagnoses for a 20-year-old and would not match the test results. Pneumonia may affect the patient’s ability to perform the tests, but it is typically an acute condition that requires immediate treatment with antibiotics.
Understanding Pulmonary Function Tests
Pulmonary function tests are a useful tool in determining whether a respiratory disease is obstructive or restrictive. These tests measure various aspects of lung function, such as forced expiratory volume in one second (FEV1) and forced vital capacity (FVC). By analyzing the results of these tests, doctors can diagnose and monitor conditions such as asthma, COPD, pulmonary fibrosis, and neuromuscular disorders.
In obstructive lung diseases, such as asthma and COPD, the FEV1 is significantly reduced, while the FVC may be reduced or normal. The FEV1% (FEV1/FVC) is also reduced. On the other hand, in restrictive lung diseases, such as pulmonary fibrosis and asbestosis, the FEV1 is reduced, but the FVC is significantly reduced. The FEV1% (FEV1/FVC) may be normal or increased.
It is important to note that there are many conditions that can affect lung function, and pulmonary function tests are just one tool in diagnosing and managing respiratory diseases. However, understanding the results of these tests can provide valuable information for both patients and healthcare providers.
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This question is part of the following fields:
- Respiratory System
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Question 55
Correct
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Samantha, a 75-year-old female, arrives at the emergency department after falling down a flight of stairs. She reports experiencing discomfort in her right upper arm.
Upon examination, the physician orders an X-ray which reveals a mid shaft humeral fracture on the right.
What is the most probable symptom associated with this type of fracture?Your Answer: Wrist drop
Explanation:A mid shaft humeral fracture can result in wrist drop, which is a clinical sign indicating damage to the radial nerve. The radial nerve controls the muscles responsible for extending the wrist, and when it is damaged, the wrist remains in a flexed position. Other clinical signs associated with nerve or vascular damage include the hand of benediction (median nerve), ulnar claw (ulnar nerve), and Volkmann’s contracture (brachial artery).
The Radial Nerve: Anatomy, Innervation, and Patterns of Damage
The radial nerve is a continuation of the posterior cord of the brachial plexus, with root values ranging from C5 to T1. It travels through the axilla, posterior to the axillary artery, and enters the arm between the brachial artery and the long head of triceps. From there, it spirals around the posterior surface of the humerus in the groove for the radial nerve before piercing the intermuscular septum and descending in front of the lateral epicondyle. At the lateral epicondyle, it divides into a superficial and deep terminal branch, with the deep branch crossing the supinator to become the posterior interosseous nerve.
The radial nerve innervates several muscles, including triceps, anconeus, brachioradialis, and extensor carpi radialis. The posterior interosseous branch innervates supinator, extensor carpi ulnaris, extensor digitorum, and other muscles. Denervation of these muscles can lead to weakness or paralysis, with effects ranging from minor effects on shoulder stability to loss of elbow extension and weakening of supination of prone hand and elbow flexion in mid prone position.
Damage to the radial nerve can result in wrist drop and sensory loss to a small area between the dorsal aspect of the 1st and 2nd metacarpals. Axillary damage can also cause paralysis of triceps. Understanding the anatomy, innervation, and patterns of damage of the radial nerve is important for diagnosing and treating conditions that affect this nerve.
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This question is part of the following fields:
- Neurological System
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Question 56
Incorrect
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A 67-year-old man is brought to the emergency department with unilateral weakness and loss of sensation. He is later diagnosed with an ischaemic stroke. After initial treatment, he is started on dipyridamole as part of his ongoing therapy.
What is the mechanism of action of dipyridamole?Your Answer: Angiotensin-converting enzyme (ACE) inhibitor
Correct Answer: Non-specific phosphodiesterase inhibitor
Explanation:Understanding the Mechanism of Action of Dipyridamole
Dipyridamole is a medication that is commonly used in combination with aspirin to prevent the formation of blood clots after a stroke or transient ischemic attack. The drug works by inhibiting phosphodiesterase, which leads to an increase in the levels of cyclic adenosine monophosphate (cAMP) in platelets. This, in turn, reduces the levels of intracellular calcium, which is necessary for platelet activation and aggregation.
Apart from its antiplatelet effects, dipyridamole also reduces the cellular uptake of adenosine, a molecule that plays a crucial role in regulating blood flow and oxygen delivery to tissues. By inhibiting the uptake of adenosine, dipyridamole can increase its levels in the bloodstream, leading to vasodilation and improved blood flow.
Another mechanism of action of dipyridamole is the inhibition of thromboxane synthase, an enzyme that is involved in the production of thromboxane A2, a potent platelet activator. By blocking this enzyme, dipyridamole can further reduce platelet activation and aggregation, thereby preventing the formation of blood clots.
In summary, dipyridamole exerts its antiplatelet effects through multiple mechanisms, including the inhibition of phosphodiesterase, the reduction of intracellular calcium levels, the inhibition of thromboxane synthase, and the modulation of adenosine uptake. These actions make it a valuable medication for preventing thrombotic events in patients with a history of stroke or transient ischemic attack.
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This question is part of the following fields:
- Cardiovascular System
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Question 57
Correct
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A 48-year-old man is under your care after being diagnosed with pneumonia. On the day before his expected discharge, he experiences severe diarrhea without blood and needs intravenous fluids. A request for stool culture is made.
What would the microbiology report likely indicate as the responsible microbe?Your Answer: Gram-positive bacillus
Explanation:Clostridium difficile is a type of gram-positive bacillus that can cause pseudomembranous colitis, particularly after the use of broad-spectrum antibiotics.
Clostridium difficile is a type of bacteria that is commonly found in hospitals. It produces a toxin that can damage the intestines and cause a condition called pseudomembranous colitis. This bacteria usually develops when the normal gut flora is disrupted by broad-spectrum antibiotics, with second and third generation cephalosporins being the leading cause. Other risk factors include the use of proton pump inhibitors. Symptoms of C. difficile infection include diarrhea, abdominal pain, and a raised white blood cell count. The severity of the infection can be determined using the Public Health England severity scale.
To diagnose C. difficile infection, a stool sample is tested for the presence of the C. difficile toxin. Treatment involves reviewing current antibiotic therapy and stopping antibiotics if possible. For a first episode of infection, oral vancomycin is the first-line therapy for 10 days, followed by oral fidaxomicin as second-line therapy and oral vancomycin with or without IV metronidazole as third-line therapy. Recurrent infections may require different treatment options, such as oral fidaxomicin within 12 weeks of symptom resolution or oral vancomycin or fidaxomicin after 12 weeks of symptom resolution. In life-threatening cases, oral vancomycin and IV metronidazole may be used, and surgery may be considered with specialist advice. Other therapies, such as bezlotoxumab and fecal microbiota transplant, may also be considered for preventing recurrences in certain cases.
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This question is part of the following fields:
- Gastrointestinal System
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Question 58
Correct
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An 80-year-old woman presents to the emergency department with a 2-day history of severe abdominal pain, accompanied by nausea and vomiting. Upon examination, she has a distended abdomen that is tender to the touch, and bowel sounds are infrequent. Her medical history includes a hysterectomy and cholecystectomy. A CT scan is ordered, which reveals a bowel obstruction at the L1 level. What is the most likely affected area?
Your Answer: Duodenum
Explanation:The 2nd segment of the duodenum is situated at the transpyloric plane, which corresponds to the level of L1 and is a significant anatomical reference point.
The Transpyloric Plane and its Anatomical Landmarks
The transpyloric plane is an imaginary horizontal line that passes through the body of the first lumbar vertebrae (L1) and the pylorus of the stomach. It is an important anatomical landmark used in clinical practice to locate various organs and structures in the abdomen.
Some of the structures that lie on the transpyloric plane include the left and right kidney hilum (with the left one being at the same level as L1), the fundus of the gallbladder, the neck of the pancreas, the duodenojejunal flexure, the superior mesenteric artery, and the portal vein. The left and right colic flexure, the root of the transverse mesocolon, and the second part of the duodenum also lie on this plane.
In addition, the upper part of the conus medullaris (the tapered end of the spinal cord) and the spleen are also located on the transpyloric plane. Knowing the location of these structures is important for various medical procedures, such as abdominal surgeries and diagnostic imaging.
Overall, the transpyloric plane serves as a useful reference point for clinicians to locate important anatomical structures in the abdomen.
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This question is part of the following fields:
- Respiratory System
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Question 59
Correct
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A 75-year-old man with a history of type 2 diabetes mellitus comes to the Emergency Department complaining of diplopia and ophthalmoplegia. Upon physical examination, it is found that his pupils are equal and reactive to light with an intact accommodation reflex. However, his right eye is abducted and looking downwards, while the rest of the examination is normal.
Which cranial nerve is impacted in this case?Your Answer: Cranial nerve III
Explanation:A patient with a ‘down and out’ eye is likely experiencing a lesion to cranial nerve III, also known as the oculomotor nerve. This nerve controls all extraocular muscles except for the lateral rectus and superior oblique muscles, and a lesion can result in unopposed action of these muscles, causing the ‘down and out’ gaze. Possible causes of cranial nerve III palsy include a posterior communicating artery aneurysm or diabetic ophthalmoplegia. In this case, the patient’s history of type 2 diabetes mellitus and absence of pupillary dilation suggest that diabetes is the more likely cause. Lesions to other cranial nerves, such as II, IV, V, or VI, would present with different symptoms.
Cranial nerves are a set of 12 nerves that emerge from the brain and control various functions of the head and neck. Each nerve has a specific function, such as smell, sight, eye movement, facial sensation, and tongue movement. Some nerves are sensory, some are motor, and some are both. A useful mnemonic to remember the order of the nerves is Some Say Marry Money But My Brother Says Big Brains Matter Most, with S representing sensory, M representing motor, and B representing both.
In addition to their specific functions, cranial nerves also play a role in various reflexes. These reflexes involve an afferent limb, which carries sensory information to the brain, and an efferent limb, which carries motor information from the brain to the muscles. Examples of cranial nerve reflexes include the corneal reflex, jaw jerk, gag reflex, carotid sinus reflex, pupillary light reflex, and lacrimation reflex. Understanding the functions and reflexes of the cranial nerves is important in diagnosing and treating neurological disorders.
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This question is part of the following fields:
- Neurological System
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Question 60
Incorrect
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As a medical student observing a metabolic medicine clinic, a 40-year-old woman comes in seeking answers about her obesity. With a BMI of 46 kg/m² and a family history of obesity, she is referred for further investigation. After genetic sequencing, it is discovered that she has a mutation in a hormone-regulating gene that is secreted by adipose tissue.
Which hormone is likely impacted by this genetic mutation?Your Answer: Ghrelin
Correct Answer: Leptin
Explanation:Leptin is produced by adipose tissue and is responsible for regulating feelings of fullness and satiety. Mutations in the leptin gene can lead to severe obesity in infants due to increased appetite and reduced feelings of satiety. Ghrelin, on the other hand, is a hormone released by the stomach that stimulates hunger. Melatonin, produced by the pineal gland, regulates the sleep-wake cycle and circadian rhythms but is not known to play a significant role in obesity. Obestatin, released by stomach epithelial cells, has a controversial role in obesity.
The Physiology of Obesity: Leptin and Ghrelin
Leptin is a hormone produced by adipose tissue that plays a crucial role in regulating body weight. It acts on the hypothalamus, specifically on the satiety centers, to decrease appetite and induce feelings of fullness. In cases of obesity, where there is an excess of adipose tissue, leptin levels are high. Leptin also stimulates the release of melanocyte-stimulating hormone (MSH) and corticotrophin-releasing hormone (CRH), which further contribute to the regulation of appetite. On the other hand, low levels of leptin stimulate the release of neuropeptide Y (NPY), which increases appetite.
Ghrelin, on the other hand, is a hormone that stimulates hunger. It is mainly produced by the P/D1 cells lining the fundus of the stomach and epsilon cells of the pancreas. Ghrelin levels increase before meals, signaling the body to prepare for food intake, and decrease after meals, indicating that the body has received enough nutrients.
In summary, the balance between leptin and ghrelin plays a crucial role in regulating appetite and body weight. In cases of obesity, there is an imbalance in this system, with high levels of leptin and potentially disrupted ghrelin signaling, leading to increased appetite and weight gain.
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This question is part of the following fields:
- Endocrine System
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Question 61
Incorrect
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In which location do most intracerebral hemorrhages take place?
Your Answer: Brainstem
Correct Answer: Basal ganglia
Explanation:Types and Locations of Intracranial Bleeds
Intracranial bleeds refer to any type of bleeding that occurs within the cranium. There are four main types of intracranial bleeds: extradural, subdural, subarachnoid, and intracerebral. Extradural bleeds occur outside the periosteal dura mater, while subdural bleeds occur between the meningeal dura mater and arachnoid mater. Subarachnoid bleeds occur between the arachnoid mater and pia mater, where cerebrospinal fluid circulates. Intracerebral bleeds, on the other hand, occur within the cerebral tissue itself.
Of all the types of intracranial bleeds, intracerebral bleeds are the most common. They typically occur deep within the cerebral hemispheres, affecting the basal ganglia, such as the caudate nucleus and putamen. These types of bleeds are usually caused by hypertension, rather than trauma or atherosclerosis. While it is possible for bleeds to occur in any area of the brain, those that occur in the brainstem are particularly debilitating.
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This question is part of the following fields:
- Clinical Sciences
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Question 62
Incorrect
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What is the definition of liver cirrhosis?
Your Answer: Severe fibrosis of portal tracts
Correct Answer: Nodules, fibrosis, and architectural disruption
Explanation:Cirrhosis: End-Stage Fibrosis of the Liver
Cirrhosis is a condition that describes the changes that occur in the liver when it reaches end-stage fibrosis. This happens due to chronic inflammation that leads to the death of liver cells or hepatocyte apoptosis. Initially, the dead cells are replaced by new ones through hepatocyte regeneration. However, in cases of chronic inflammation, activated stellate cells deposit fibrous tissue in the liver, leading to the formation of large bands that stretch between portal tracts. These tracts are also expanded with fibrosis, and areas of hepatocyte regeneration occur, forming nodules. Unfortunately, at this stage, the normal relationship between hepatocytes, portal triads, and central vein is lost, leading to poor drainage of portal blood through the liver. This results in increased back-pressure and portal hypertension. It is important to note that these features alone do not necessarily indicate cirrhosis.
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This question is part of the following fields:
- Histology
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Question 63
Incorrect
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As a doctor on the cardiology ward, I am currently treating a 50-year-old patient who was admitted due to syncope and dyspnoea. The patient has just returned from an echocardiography which revealed a pedunculated mass. What is the most probable primary tumor that this patient is suffering from?
Your Answer: Lipoma
Correct Answer: Myxoma
Explanation:Atrial myxoma is the most frequently occurring primary cardiac tumor.
Primary cardiac tumors are uncommon, and among them, myxomas are the most prevalent. Most of these tumors are benign and are found in the atria. Imaging typically reveals a pedunculated mass.
The remaining options are also primary cardiac tumors.
Atrial Myxoma: Overview and Features
Atrial myxoma is a primary cardiac tumor that is commonly found in the left atrium, with 75% of cases occurring in this area. It is more prevalent in females and is often attached to the fossa ovalis. Symptoms of atrial myxoma include dyspnea, fatigue, weight loss, pyrexia of unknown origin, and clubbing. Emboli and atrial fibrillation may also occur. A mid-diastolic murmur, known as a tumor plop, may be present. Diagnosis is typically made through echocardiography, which shows a pedunculated heterogeneous mass attached to the fossa ovalis region of the interatrial septum.
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This question is part of the following fields:
- Cardiovascular System
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Question 64
Incorrect
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A study can only make confident claims about cause and effect if it has what?
Your Answer: Good external validity
Correct Answer: Good internal validity
Explanation:Claims about cause and effect require good internal validity.
Validity refers to how accurately something measures what it claims to measure. There are two main types of validity: internal and external. Internal validity refers to the confidence we have in the cause and effect relationship in a study. This means we are confident that the independent variable caused the observed change in the dependent variable, rather than other factors. There are several threats to internal validity, such as poor control of extraneous variables and loss of participants over time. External validity refers to the degree to which the conclusions of a study can be applied to other people, places, and times. Threats to external validity include the representativeness of the sample and the artificiality of the research setting. There are also other types of validity, such as face validity and content validity, which refer to the general impression and full content of a test, respectively. Criterion validity compares tests, while construct validity measures the extent to which a test measures the construct it aims to.
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This question is part of the following fields:
- General Principles
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Question 65
Incorrect
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A 62-year-old man visited his primary care physician after his family noticed a significant weight loss over the past few months. The man confirms the weight loss and denies intentionally trying to lose weight or any changes in his appetite. He also reports experiencing night sweats and a fever, which he attributes to a cold. The patient has a history of well-controlled hypertension and no surgical history. He has not traveled recently and does not smoke or drink alcohol. During the physical examination, an enlarged lymph node in the armpit and splenomegaly were noted. The most likely diagnosis was confirmed through fluorescent in-situ hybridization (FISH), which revealed a translocation of the heavy-chain immunoglobulin and cyclin D1. What is the most likely translocation found in this patient?
Your Answer: t(14;18)
Correct Answer: t(11;14)
Explanation:Understanding Mantle Cell Lymphoma
Mantle cell lymphoma is a type of B-cell lymphoma that is characterized by the over-expression of the cyclin D1 (BCL-1) gene due to a translocation (11;14). This cancer is identified by the presence of CD5+, CD19+, CD22+, and CD23- markers. Unfortunately, mantle cell lymphoma has a poor prognosis and is often associated with widespread lymphadenopathy.
In summary, mantle cell lymphoma is a type of cancer that affects B-cells and is caused by a specific genetic translocation. It is identified by certain markers and is known for its poor prognosis and widespread lymphadenopathy. Understanding the basics of this disease can help with early detection and treatment.
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This question is part of the following fields:
- Haematology And Oncology
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Question 66
Correct
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Which of the following complications is the least commonly associated with ventricular septal defects in pediatric patients?
Your Answer: Atrial fibrillation
Explanation:Understanding Ventricular Septal Defect
Ventricular septal defect (VSD) is a common congenital heart disease that affects many individuals. It is caused by a hole in the wall that separates the two lower chambers of the heart. In some cases, VSDs may close on their own, but in other cases, they require specialized management.
There are various causes of VSDs, including chromosomal disorders such as Down’s syndrome, Edward’s syndrome, Patau syndrome, and cri-du-chat syndrome. Congenital infections and post-myocardial infarction can also lead to VSDs. The condition can be detected during routine scans in utero or may present post-natally with symptoms such as failure to thrive, heart failure, hepatomegaly, tachypnea, tachycardia, pallor, and a pansystolic murmur.
Management of VSDs depends on the size and symptoms of the defect. Small VSDs that are asymptomatic may require monitoring, while moderate to large VSDs may result in heart failure and require nutritional support, medication for heart failure, and surgical closure of the defect.
Complications of VSDs include aortic regurgitation, infective endocarditis, Eisenmenger’s complex, right heart failure, and pulmonary hypertension. Eisenmenger’s complex is a severe complication that results in cyanosis and clubbing and is an indication for a heart-lung transplant. Women with pulmonary hypertension are advised against pregnancy as it carries a high risk of mortality.
In conclusion, VSD is a common congenital heart disease that requires specialized management. Early detection and appropriate treatment can prevent severe complications and improve outcomes for affected individuals.
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This question is part of the following fields:
- Cardiovascular System
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Question 67
Incorrect
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A 67-year-old man is scheduled for surgery to treat transitional cell carcinoma of the left kidney. During the procedure, the surgeon needs to locate and dissect the left renal artery. Can you identify the vertebral level where the origin of this artery can be found?
Your Answer: T12
Correct Answer: L1
Explanation:The L1 level is where the left renal artery is located.
Located just below the superior mesenteric artery at L1, the left renal artery arises from the abdominal aorta. It is positioned slightly lower than the right renal artery.
At the T10 vertebral level, the vagal trunk accompanies the oesophagus as it passes through the diaphragm.
The T12 vertebral level marks the point where the aorta passes through the diaphragm, along with the thoracic duct and azygous veins. Additionally, this is where the coeliac trunk branches out.
The aorta is a major blood vessel that carries oxygenated blood from the heart to the rest of the body. At different levels along the aorta, there are branches that supply blood to specific organs and regions. These branches include the coeliac trunk at the level of T12, which supplies blood to the stomach, liver, and spleen. The left renal artery, at the level of L1, supplies blood to the left kidney. The testicular or ovarian arteries, at the level of L2, supply blood to the reproductive organs. The inferior mesenteric artery, at the level of L3, supplies blood to the lower part of the large intestine. Finally, at the level of L4, the abdominal aorta bifurcates, or splits into two branches, which supply blood to the legs and pelvis.
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This question is part of the following fields:
- Cardiovascular System
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Question 68
Incorrect
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A 49-year-old woman is having surgery to remove an adrenal adenoma on her left side. During the procedure, the superior adrenal artery is damaged and begins to bleed. What is the origin of this vessel?
Your Answer: Splenic
Correct Answer: Inferior phrenic artery
Explanation:The inferior phrenic artery gives rise to the superior adrenal artery.
Adrenal Gland Anatomy
The adrenal glands are located superomedially to the upper pole of each kidney. The right adrenal gland is posteriorly related to the diaphragm, inferiorly related to the kidney, medially related to the vena cava, and anteriorly related to the hepato-renal pouch and bare area of the liver. On the other hand, the left adrenal gland is postero-medially related to the crus of the diaphragm, inferiorly related to the pancreas and splenic vessels, and anteriorly related to the lesser sac and stomach.
The arterial supply of the adrenal glands is through the superior adrenal arteries from the inferior phrenic artery, middle adrenal arteries from the aorta, and inferior adrenal arteries from the renal arteries. The right adrenal gland drains via one central vein directly into the inferior vena cava, while the left adrenal gland drains via one central vein into the left renal vein.
In summary, the adrenal glands are small but important endocrine glands located above the kidneys. They have a unique blood supply and drainage system, and their location and relationships with other organs in the body are crucial for their proper functioning.
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This question is part of the following fields:
- Renal System
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Question 69
Correct
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A 42-year-old male patient comes to the clinic complaining of shoulder weakness. During the examination, it is observed that he cannot initiate shoulder abduction. Which of the following nerves is most likely to be dysfunctional?
Your Answer: Suprascapular nerve
Explanation:The Suprascapular Nerve and its Function
The suprascapular nerve is a nerve that originates from the upper trunk of the brachial plexus. It is located superior to the trunks of the brachial plexus and runs parallel to them. The nerve passes through the scapular notch, which is located deep to the trapezius muscle. Its main function is to innervate both the supraspinatus and infraspinatus muscles, which are responsible for initiating abduction of the shoulder.
If the suprascapular nerve is damaged, patients may experience difficulty in initiating abduction of the shoulder. However, they may still be able to abduct the shoulder by leaning over the affected side, as the deltoid muscle can then continue to abduct the shoulder. Overall, the suprascapular nerve plays an important role in the movement and function of the shoulder joint.
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This question is part of the following fields:
- Respiratory System
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Question 70
Incorrect
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Which one of the following statements relating to the root of the spine is false?
Your Answer: The roots and trunks of the Brachial plexus lie between scalenus anterior and scalenus medius muscles
Correct Answer: The subclavian artery arches over the first rib anterior to scalenus anterior
Explanation:The suprapleural membrane, also known as Sibson’s fascia, is located above the pleural cavity. The scalenus anterior muscle is positioned in front of the subclavian vein, while the subclavian artery is situated behind it.
Thoracic Outlet: Where the Subclavian Artery and Vein and Brachial Plexus Exit the Thorax
The thoracic outlet is the area where the subclavian artery and vein and the brachial plexus exit the thorax and enter the arm. This passage occurs over the first rib and under the clavicle. The subclavian vein is the most anterior structure and is located immediately in front of scalenus anterior and its attachment to the first rib. Scalenus anterior has two parts, and the subclavian artery leaves the thorax by passing over the first rib and between these two portions of the muscle. At the level of the first rib, the lower cervical nerve roots combine to form the three trunks of the brachial plexus. The lowest trunk is formed by the union of C8 and T1, and this trunk lies directly posterior to the artery and is in contact with the superior surface of the first rib.
Thoracic outlet obstruction can cause neurovascular compromise.
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This question is part of the following fields:
- Respiratory System
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Question 71
Correct
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A patient in his 50s with heart failure is prescribed a diuretic by his GP and subsequently develops gynaecomastia. Which specific agent is most likely responsible for this adverse effect?
Your Answer: Spironolactone
Explanation:Drugs that may cause side effects and the role of Spironolactone
There are several drugs that may cause side effects, including cimetidine, oestrogens, digoxin, and ketoconazole. These drugs can affect the body in different ways, leading to various symptoms. For instance, cimetidine may cause confusion, while oestrogens may cause breast tenderness. Digoxin may cause nausea and vomiting, and ketoconazole may cause liver problems.
One drug that can help maintain plasma potassium levels is Spironolactone. It acts as an aldosterone antagonist, which means it blocks the effects of aldosterone, a hormone that regulates sodium and potassium levels in the body. By blocking aldosterone, Spironolactone helps to maintain a balance of potassium in the blood. This is important because too much or too little potassium can cause serious health problems, such as irregular heartbeats or muscle weakness. Therefore, Spironolactone is often prescribed to people with conditions such as heart failure, liver disease, or high blood pressure.
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This question is part of the following fields:
- Pharmacology
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Question 72
Incorrect
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A 55-year-old woman had undergone bilateral breast augmentation surgery several years ago. Recently, she has been experiencing discomfort and tension in her breasts, leading to the removal of the implants. During the procedure, the surgeon discovered a dense membrane surrounding the implants with a coarse granular appearance. The tissue was sent for histology, which revealed fibrosis with the presence of calcification. What is the underlying process responsible for these changes? Is it hyperplasia, dysplasia, metastatic calcification, dystrophic calcification, or necrosis? It is important to note that breast implants can often develop a pseudocapsule, which may undergo dystrophic calcification over time.
Your Answer: Hyperplasia
Correct Answer: Dystrophic calcification
Explanation:Breast implants can develop a pseudocapsule around them, which may eventually undergo dystrophic calcification.
Types of Pathological Calcification
Pathological calcification refers to the abnormal deposition of calcium in tissues. There are two types of pathological calcification: dystrophic and metastatic. Dystrophic calcification occurs when calcium deposits accumulate in tissues that have undergone degeneration, damage, or disease, even when serum calcium levels are normal. On the other hand, metastatic calcification occurs when calcium deposits accumulate in otherwise normal tissues due to increased serum calcium levels.
In dystrophic calcification, the calcium deposits are a result of tissue damage or disease, which triggers an inflammatory response. This response leads to the release of cytokines and other molecules that attract calcium to the affected area. In metastatic calcification, the increased serum calcium levels can be caused by various factors such as hyperparathyroidism, renal failure, or vitamin D toxicity. The excess calcium then accumulates in tissues that are not normally prone to calcification, such as the kidneys, lungs, and blood vessels.
Understanding the different types of pathological calcification is important in diagnosing and treating various diseases. Dystrophic calcification can occur in a variety of conditions, including atherosclerosis, arthritis, and cancer. Metastatic calcification, on the other hand, is commonly seen in patients with chronic kidney disease or hyperparathyroidism. By identifying the type of calcification present, healthcare professionals can better manage and treat the underlying condition.
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This question is part of the following fields:
- General Principles
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Question 73
Incorrect
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A study is conducted for a new anti-aging cream that aims to improve skin elasticity. 200 volunteers are recruited and split into two groups - cream or placebo - without being told which group they are put into. 120 are put in the cream group and 80 in the control (placebo) group. They are asked to apply their cream, not knowing if it is the anti-aging cream or a placebo, and to record whether or not they achieve an acceptable level of improvement in skin elasticity.
Out of the 120 in the cream group, 90 report successfully achieving adequate improvement in skin elasticity. Out of the 80 in the control group, 20 report achieving adequate improvement in skin elasticity.
What are the odds of achieving adequate improvement in skin elasticity with the new anti-aging cream?Your Answer: 0.75
Correct Answer: 3
Explanation:Understanding Odds and Odds Ratio
When analyzing data, it is important to understand the difference between odds and probability. Odds are a ratio of the number of people who experience a particular outcome to those who do not. On the other hand, probability is the fraction of times an event is expected to occur in many trials. While probability is always between 0 and 1, odds can be any positive number.
In case-control studies, odds ratios are the usual reported measure. This ratio compares the odds of a particular outcome with experimental treatment to that of a control group. It is important to note that odds ratios approximate to relative risk if the outcome of interest is rare.
For example, in a trial comparing the use of paracetamol for dysmenorrhoea compared to placebo, the odds of achieving significant pain relief with paracetamol were 2, while the odds of achieving significant pain relief with placebo were 0.5. Therefore, the odds ratio was 4.
Understanding odds and odds ratio is crucial in interpreting data and making informed decisions. By knowing the difference between odds and probability and how to calculate odds ratios, researchers can accurately analyze and report their findings.
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This question is part of the following fields:
- General Principles
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Question 74
Incorrect
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A 49-year-old woman visits the clinic complaining of occasional palpitations over the last 7 days. The palpitations occur without any physical exertion and are not accompanied by chest pain. Upon examination, her heart appears to be functioning normally. An ECG is conducted, revealing indications of hyperkalaemia. What is an ECG indicator of hyperkalaemia?
Your Answer: ST segment depression
Correct Answer: Small or absent P waves
Explanation:The presence of small or inverted T waves on an ECG can indicate hyperkalaemia, along with other signs such as absent or reduced P waves, broad and bizarre QRS complexes, and tall-tented T waves. In severe cases, hyperkalaemia can lead to asystole.
Hyperkalaemia is a condition where there is an excess of potassium in the blood. The levels of potassium in the plasma are regulated by various factors such as aldosterone, insulin levels, and acid-base balance. When there is metabolic acidosis, hyperkalaemia can occur as hydrogen and potassium ions compete with each other for exchange with sodium ions across cell membranes and in the distal tubule. The ECG changes that can be seen in hyperkalaemia include tall-tented T waves, small P waves, widened QRS leading to a sinusoidal pattern, and asystole.
There are several causes of hyperkalaemia, including acute kidney injury, drugs such as potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers, spironolactone, ciclosporin, and heparin, metabolic acidosis, Addison’s disease, rhabdomyolysis, and massive blood transfusion. Foods that are high in potassium include salt substitutes, bananas, oranges, kiwi fruit, avocado, spinach, and tomatoes.
It is important to note that beta-blockers can interfere with potassium transport into cells and potentially cause hyperkalaemia in renal failure patients. In contrast, beta-agonists such as Salbutamol are sometimes used as emergency treatment. Additionally, both unfractionated and low-molecular weight heparin can cause hyperkalaemia by inhibiting aldosterone secretion.
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This question is part of the following fields:
- Renal System
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Question 75
Incorrect
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A 32-year-old female patient comes to your clinic complaining of double vision that has been present for 2 days. After taking a thorough medical history, she reports no other visual changes. During the examination, you observe that she is unable to abduct her left eye. Which cranial nerve is most likely affected?
Your Answer: Cranial nerve 3
Correct Answer: Cranial nerve 6
Explanation:The muscle responsible for abduction of the eye is the lateral rectus, which is controlled by the 6th cranial nerve (abducens).
The optic nerve (cranial nerve 2) provides innervation to the retina.
The oculomotor nerve (cranial nerve 3) controls the inferior oblique, medial superior and inferior rectus muscles.
The trochlear nerve (cranial nerve 4) controls the superior oblique muscle.
The trigeminal nerve (cranial nerve 5) provides sensory input to the face and controls the muscles used for chewing.Cranial nerves are a set of 12 nerves that emerge from the brain and control various functions of the head and neck. Each nerve has a specific function, such as smell, sight, eye movement, facial sensation, and tongue movement. Some nerves are sensory, some are motor, and some are both. A useful mnemonic to remember the order of the nerves is Some Say Marry Money But My Brother Says Big Brains Matter Most, with S representing sensory, M representing motor, and B representing both.
In addition to their specific functions, cranial nerves also play a role in various reflexes. These reflexes involve an afferent limb, which carries sensory information to the brain, and an efferent limb, which carries motor information from the brain to the muscles. Examples of cranial nerve reflexes include the corneal reflex, jaw jerk, gag reflex, carotid sinus reflex, pupillary light reflex, and lacrimation reflex. Understanding the functions and reflexes of the cranial nerves is important in diagnosing and treating neurological disorders.
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This question is part of the following fields:
- Neurological System
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Question 76
Incorrect
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Which of the following drugs is not associated with thrombocytopenia?
Your Answer: Quinine
Correct Answer: Warfarin
Explanation:Understanding Drug-Induced Thrombocytopenia
Drug-induced thrombocytopenia is a condition where a person’s platelet count drops due to the use of certain medications. This condition is believed to be immune-mediated, meaning that the body’s immune system mistakenly attacks and destroys platelets. Some of the drugs that have been associated with drug-induced thrombocytopenia include quinine, abciximab, NSAIDs, diuretics like furosemide, antibiotics such as penicillins, sulphonamides, and rifampicin, and anticonvulsants like carbamazepine and valproate. Heparin, a commonly used blood thinner, is also known to cause drug-induced thrombocytopenia. It is important to be aware of the potential side effects of medications and to consult with a healthcare provider if any concerning symptoms arise. Proper management and monitoring of drug-induced thrombocytopenia can help prevent serious complications.
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This question is part of the following fields:
- General Principles
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Question 77
Incorrect
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A 2-year-old child is diagnosed with Erb's palsy due to a brachial plexus injury. The child is unable to move their arm properly and it is fixated medially. What risk factor increases the likelihood of this condition?
Your Answer: Family history of preeclampsia
Correct Answer: Macrosomia
Explanation:Macrosomia is a significant risk factor for neonatal brachial plexus injuries resulting from shoulder dystocia. Maternal diabetes mellitus, not diabetes insipidus, is the leading cause of macrosomia, which is often associated with a high BMI. While polyhydramnios may result from foetal insulin resistance due to maternal diabetes mellitus, it is not a specific risk factor for brachial plexus injuries as there are many other causes of polyhydramnios. A family history of preeclampsia is not relevant to this condition.
Shoulder dystocia is a complication that can occur during vaginal delivery when the body of the fetus cannot be delivered after the head has already been delivered. This is usually due to the anterior shoulder of the fetus becoming stuck on the mother’s pubic bone. Shoulder dystocia can cause harm to both the mother and the baby.
There are several risk factors that increase the likelihood of shoulder dystocia, including fetal macrosomia (large baby), high maternal body mass index, diabetes mellitus, and prolonged labor.
If shoulder dystocia is identified, it is important to call for senior medical assistance immediately. The McRoberts’ maneuver is often used to help deliver the baby. This involves flexing and abducting the mother’s hips to increase the angle of the pelvis and facilitate delivery. An episiotomy may be performed to provide better access for internal maneuvers, but it will not relieve the bony obstruction. Symphysiotomy and the Zavanelli maneuver are not recommended as they can cause significant harm to the mother. Oxytocin administration is not effective in treating shoulder dystocia.
Complications of shoulder dystocia can include postpartum hemorrhage and perineal tears for the mother, and brachial plexus injury or neonatal death for the baby. It is important to manage shoulder dystocia promptly and effectively to minimize these risks.
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This question is part of the following fields:
- Reproductive System
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Question 78
Correct
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Which of the following structures suspends the spinal cord in the dural sheath?
Your Answer: Denticulate ligaments
Explanation:The length of the spinal cord is around 45cm in males and 43cm in females. The denticulate ligament is an extension of the pia mater, which has sporadic lateral projections that connect the spinal cord to the dura mater.
The spinal cord is a central structure located within the vertebral column that provides it with structural support. It extends rostrally to the medulla oblongata of the brain and tapers caudally at the L1-2 level, where it is anchored to the first coccygeal vertebrae by the filum terminale. The cord is characterised by cervico-lumbar enlargements that correspond to the brachial and lumbar plexuses. It is incompletely divided into two symmetrical halves by a dorsal median sulcus and ventral median fissure, with grey matter surrounding a central canal that is continuous with the ventricular system of the CNS. Afferent fibres entering through the dorsal roots usually terminate near their point of entry but may travel for varying distances in Lissauer’s tract. The key point to remember is that the anatomy of the cord will dictate the clinical presentation in cases of injury, which can be caused by trauma, neoplasia, inflammatory diseases, vascular issues, or infection.
One important condition to remember is Brown-Sequard syndrome, which is caused by hemisection of the cord and produces ipsilateral loss of proprioception and upper motor neuron signs, as well as contralateral loss of pain and temperature sensation. Lesions below L1 tend to present with lower motor neuron signs. It is important to keep a clinical perspective in mind when revising CNS anatomy and to understand the ways in which the spinal cord can become injured, as this will help in diagnosing and treating patients with spinal cord injuries.
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This question is part of the following fields:
- Neurological System
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Question 79
Incorrect
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A 28-year-old male comes to urology for evaluation of pyelonephritis. He complains of fatigue, fever, swollen lymph nodes, and a rash with raised bumps. Despite a negative Monospot test, due to his history of engaging in high-risk sexual activities, you are requested to rule out a possible HIV seroconversion illness. What test would be the most suitable for this investigation?
Your Answer: CCR5 polymerase chain reaction
Correct Answer: p24 antigen test
Explanation:HIV seroconversion is a process where the body develops antibodies against the virus. This process is symptomatic in 60-80% of patients and usually presents as a glandular fever type illness. The severity of symptoms is associated with a poorer long-term prognosis. The symptoms typically occur 3-12 weeks after infection and include a sore throat, lymphadenopathy, malaise, myalgia, arthralgia, diarrhea, maculopapular rash, mouth ulcers, and rarely meningoencephalitis.
Diagnosing HIV involves testing for HIV antibodies, which may not be present in early infection. However, most people develop antibodies to HIV at 4-6 weeks, and 99% do so by 3 months. The diagnosis usually involves both a screening ELISA test and a confirmatory Western Blot Assay. Additionally, a p24 antigen test can be used to detect a viral core protein that appears early in the blood as the viral RNA levels rise. Combination tests that test for both HIV p24 antigen and HIV antibody are now standard for the diagnosis and screening of HIV. If the combined test is positive, it should be repeated to confirm the diagnosis. Some centers may also test the viral load (HIV RNA levels) if HIV is suspected at the same time. Testing for HIV in asymptomatic patients should be done at 4 weeks after possible exposure, and after an initial negative result, a repeat test should be offered at 12 weeks.
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This question is part of the following fields:
- General Principles
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Question 80
Incorrect
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Which one of the following statements relating to the pharmacology of warfarin is false?
Your Answer: The half life of warfarin is 40 hours
Correct Answer: Warfarin has a large volume of distribution
Explanation:To impair fibrin formation, warfarin impacts the carboxylation of glutamic acid residues in clotting factors 2, 7, 9, and 10. Factor 2 has the lengthiest half-life of around 60 hours, so it may take up to three days for warfarin to take full effect. Warfarin is protein-bound, resulting in a small distribution volume.
Understanding Warfarin: Mechanism of Action, Indications, Monitoring, Factors, and Side-Effects
Warfarin is an oral anticoagulant that has been widely used for many years to manage venous thromboembolism and reduce stroke risk in patients with atrial fibrillation. However, it has been largely replaced by direct oral anticoagulants (DOACs) due to their ease of use and lack of need for monitoring. Warfarin works by inhibiting epoxide reductase, which prevents the reduction of vitamin K to its active hydroquinone form. This, in turn, affects the carboxylation of clotting factor II, VII, IX, and X, as well as protein C.
Warfarin is indicated for patients with mechanical heart valves, with the target INR depending on the valve type and location. Mitral valves generally require a higher INR than aortic valves. It is also used as a second-line treatment after DOACs for venous thromboembolism and atrial fibrillation, with target INRs of 2.5 and 3.5 for recurrent cases. Patients taking warfarin are monitored using the INR, which may take several days to achieve a stable level. Loading regimes and computer software are often used to adjust the dose.
Factors that may potentiate warfarin include liver disease, P450 enzyme inhibitors, cranberry juice, drugs that displace warfarin from plasma albumin, and NSAIDs that inhibit platelet function. Warfarin may cause side-effects such as haemorrhage, teratogenic effects, skin necrosis, temporary procoagulant state, thrombosis, and purple toes.
In summary, understanding the mechanism of action, indications, monitoring, factors, and side-effects of warfarin is crucial for its safe and effective use in patients. While it has been largely replaced by DOACs, warfarin remains an important treatment option for certain patients.
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This question is part of the following fields:
- Cardiovascular System
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Question 81
Correct
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A truck mechanic is discovered by his supervisor sitting on the ground of the garage workshop, complaining of a severe headache, vertigo, and difficulty breathing. As they wait for the ambulance, he starts to breathe rapidly. After being given oxygen in the ambulance, his breathing returns to normal. The paramedics suspect carbon monoxide poisoning. Where in the brain are the central chemoreceptors located that detected the alterations in interstitial fluid and the patient's heightened respiratory rate?
Your Answer: Medulla oblongata
Explanation:The central chemoreceptors located in the medulla oblongata can detect alterations in the levels of carbon dioxide and hydrogen ions in the cerebrospinal fluid. They can then adjust the respiratory rate accordingly, superseding any voluntary signals from the cerebral cortex. Compared to the peripheral chemoreceptors found in the aortic and carotid bodies, the central chemoreceptors have a higher degree of sensitivity.
Carbon monoxide poisoning occurs when carbon monoxide binds to haemoglobin and myoglobin, leading to tissue hypoxia. Symptoms include headache, nausea, vomiting, vertigo, confusion, and in severe cases, pink skin and mucosae, hyperpyrexia, arrhythmias, extrapyramidal features, coma, and death. Diagnosis is made through measuring carboxyhaemoglobin levels in arterial or venous blood gas. Treatment involves administering 100% high-flow oxygen via a non-rebreather mask for at least six hours, with hyperbaric oxygen therapy considered for more severe cases.
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This question is part of the following fields:
- General Principles
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Question 82
Correct
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A 28-year-old woman visits her GP after experiencing a sudden deterioration of vision in her left eye 10 days ago. She reports that her vision became blurry and has only partially improved since. Additionally, the patient describes intermittent sensations of pain and burning around her left eye. She has no significant medical history.
During the examination, the direct pupillary light reflex is weaker in her left eye. Her left eye has a visual acuity of 6/12, while her right eye has a visual acuity of 6/6. The patient experiences pain when her left eye is abducted.
What is the most frequent cause of this presentation?Your Answer: Multiple sclerosis
Explanation:Optic neuritis, which is characterized by unilateral vision loss and pain, is most commonly caused by multiple sclerosis. This is an inflammatory disease that affects the central nervous system and is more prevalent in individuals of white ethnicity living in northern latitudes. Behcet’s disease, a rare vasculitis, can also cause optic neuritis but is less strongly associated with the condition. Conjunctivitis, on the other hand, does not cause vision loss and is characterized by redness and irritation of the outer surface of the eye. Myasthenia gravis, an autoimmune condition that causes muscle weakness, does not cause optic neuritis but can affect ocular muscles and lead to symptoms such as drooping eyelids and double vision.
Understanding Optic Neuritis: Causes, Features, Investigation, Management, and Prognosis
Optic neuritis is a condition that causes a decrease in visual acuity in one eye over a period of hours or days. It is often associated with multiple sclerosis, diabetes, or syphilis. Other features of optic neuritis include poor discrimination of colors, pain that worsens with eye movement, relative afferent pupillary defect, and central scotoma.
To diagnose optic neuritis, an MRI of the brain and orbits with gadolinium contrast is usually performed. High-dose steroids are the primary treatment for optic neuritis, and recovery typically takes 4-6 weeks.
The prognosis for optic neuritis is dependent on the number of white-matter lesions found on an MRI. If there are more than three lesions, the five-year risk of developing multiple sclerosis is approximately 50%. Understanding the causes, features, investigation, management, and prognosis of optic neuritis is crucial for early diagnosis and effective treatment.
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This question is part of the following fields:
- Neurological System
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Question 83
Incorrect
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You are observing a tarsal tunnel release surgery on a patient you had interviewed earlier that afternoon. Upon incision of the flexor retinaculum, you notice several structures that are visible.
Can you list the structural contents in order from anterior to posterior?Your Answer: Tibial nerve, flexor digitorum longus tendon, posterior tibial artery and vein, tibialis anterior tendon, flexor hallucis longus tendon
Correct Answer: Tibialis posterior tendon, flexor digitorum longus tendon, posterior tibial artery and vein, tibial nerve, flexor hallucis longus tendon
Explanation:The correct order of contents in the tarsal tunnel, from anterior to posterior, is as follows: tibialis posterior tendon, flexor digitorum longus tendon, posterior tibial artery and vein, tibial nerve, and flexor hallucis longus tendon. Therefore, the correct answer is 3. Answers 1 and 2 are incorrect as they include the tibialis anterior tendon, which is not located in the tarsal tunnel.
The foot has two arches: the longitudinal arch and the transverse arch. The longitudinal arch is higher on the medial side and is supported by the posterior pillar of the calcaneum and the anterior pillar composed of the navicular bone, three cuneiforms, and the medial three metatarsal bones. The transverse arch is located on the anterior part of the tarsus and the posterior part of the metatarsus. The foot has several intertarsal joints, including the sub talar joint, talocalcaneonavicular joint, calcaneocuboid joint, transverse tarsal joint, cuneonavicular joint, intercuneiform joints, and cuneocuboid joint. The foot also has various ligaments, including those of the ankle joint and foot. The foot is innervated by the lateral plantar nerve and medial plantar nerve, and it receives blood supply from the plantar arteries and dorsalis pedis artery. The foot has several muscles, including the abductor hallucis, flexor digitorum brevis, abductor digit minimi, flexor hallucis brevis, adductor hallucis, and extensor digitorum brevis.
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This question is part of the following fields:
- Musculoskeletal System And Skin
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Question 84
Incorrect
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Which of the following medications typically does not undergo significant first-pass metabolism?
Your Answer: Propranolol
Correct Answer: Diazepam
Explanation:Understanding Drug Metabolism: Phase I and Phase II Reactions
Drug metabolism involves two types of biochemical reactions, namely phase I and phase II reactions. Phase I reactions include oxidation, reduction, and hydrolysis, which are mainly performed by P450 enzymes. However, some drugs are metabolized by specific enzymes such as alcohol dehydrogenase and xanthine oxidase. The products of phase I reactions are typically more active and potentially toxic. On the other hand, phase II reactions involve conjugation, where glucuronyl, acetyl, methyl, sulphate, and other groups are typically involved. The products of phase II reactions are typically inactive and excreted in urine or bile. The majority of phase I and phase II reactions take place in the liver.
First-Pass Metabolism and Drugs Affected by Zero-Order Kinetics and Acetylator Status
First-pass metabolism is a phenomenon where the concentration of a drug is greatly reduced before it reaches the systemic circulation due to hepatic metabolism. This effect is seen in many drugs, including aspirin, isosorbide dinitrate, glyceryl trinitrate, lignocaine, propranolol, verapamil, isoprenaline, testosterone, and hydrocortisone.
Zero-order kinetics describe metabolism that is independent of the concentration of the reactant. This is due to metabolic pathways becoming saturated, resulting in a constant amount of drug being eliminated per unit time. Drugs exhibiting zero-order kinetics include phenytoin, salicylates (e.g. high-dose aspirin), heparin, and ethanol.
Acetylator status is also an important consideration in drug metabolism. Approximately 50% of the UK population are deficient in hepatic N-acetyltransferase. Drugs affected by acetylator status include isoniazid, procainamide, hydralazine, dapsone, and sulfasalazine. Understanding these concepts is important in predicting drug efficacy and toxicity, as well as in optimizing drug dosing.
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This question is part of the following fields:
- General Principles
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Question 85
Incorrect
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Which of the following illnesses is not regarded as a risk factor for stomach cancer?
Your Answer: Atrophic gastritis
Correct Answer: Long term therapy with H2 blockers
Explanation:Currently, the use of H2 blockers does not appear to increase the risk of gastric cancer, unlike certain acid lowering procedures that do.
Gastric cancer is a relatively uncommon type of cancer, accounting for only 2% of all cancer diagnoses in developed countries. It is more prevalent in older individuals, with half of patients being over the age of 75, and is more common in males than females. Several risk factors have been identified, including Helicobacter pylori infection, atrophic gastritis, certain dietary habits, smoking, and blood group. Symptoms of gastric cancer can include abdominal pain, weight loss, nausea, vomiting, and dysphagia. In some cases, lymphatic spread may result in the appearance of nodules in the left supraclavicular lymph node or periumbilical area. Diagnosis is typically made through oesophago-gastro-duodenoscopy with biopsy, and staging is done using CT. Treatment options depend on the extent and location of the cancer and may include endoscopic mucosal resection, partial or total gastrectomy, and chemotherapy.
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This question is part of the following fields:
- Gastrointestinal System
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Question 86
Incorrect
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A middle-aged man visits the doctor and presents with multiple skin nodules and cafe au lait spots on his body. The doctor suspects neurofibromatosis and advises genetic counselling. The patient is informed that if he has children, they may inherit the condition with variable manifestations that could be more or less severe than his own. What genetic concept is the doctor trying to convey?
Your Answer: Anticipation
Correct Answer: Variable expressivity
Explanation:Expressivity refers to the degree to which a particular genotype is manifested in an individual’s phenotype in genetics.
Understanding Penetrance and Expressivity in Genetic Disorders
Penetrance and expressivity are two important concepts in genetics that help explain why individuals with the same gene mutation may exhibit different degrees of observable characteristics. Penetrance refers to the proportion of individuals in a population who carry a disease-causing allele and express the related disease phenotype. In contrast, expressivity describes the extent to which a genotype shows its phenotypic expression in an individual.
There are several factors that can influence penetrance and expressivity, including modifier genes, environmental factors, and allelic variation. For example, some genetic disorders, such as retinoblastoma and Huntington’s disease, exhibit incomplete penetrance, meaning that not all individuals with the disease-causing allele will develop the condition. On the other hand, achondroplasia shows complete penetrance, meaning that all individuals with the disease-causing allele will develop the condition.
Expressivity, on the other hand, describes the severity of the phenotype. Some genetic disorders, such as neurofibromatosis, exhibit a high level of expressivity, meaning that the phenotype is more severe in affected individuals. Understanding penetrance and expressivity is important in genetic counseling and can help predict the likelihood and severity of a genetic disorder in individuals and their families.
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This question is part of the following fields:
- General Principles
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Question 87
Correct
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A 65-year-old man arrives at the emergency department with a sudden onset of aphasia lasting for 15 minutes. His partner mentions a similar incident occurred a month ago, but he did not seek medical attention as it resolved on its own.
Upon point of care testing, his capillary blood glucose level is 6.5 mmol/L (3.9 - 7.1). An urgent CT scan of his brain is conducted, which reveals no signs of acute infarct. However, upon returning from the scan, he regains full speech and denies experiencing any other neurological symptoms.
What aspect of the episode suggests a diagnosis of transient ischaemic attack?Your Answer: There was no evidence of acute infarction on CT imaging, and the episode was brief
Explanation:The definition of a TIA has been updated to focus on tissue-based factors rather than time-based ones. It is now defined as a brief episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction. The new guidelines emphasize the importance of focal neurology and negative brain imaging in diagnosing a TIA, which typically lasts less than an hour. This is a departure from the previous definition, which focused on symptoms resolving within 24 hours and led to delays in diagnosis and treatment. Patients may have a history of stereotyped episodes preceding a TIA. Focal neurology is a hallmark of TIA, which can affect motor, sensory, aphasic, or visual areas of the brain. In cases where isolated aphasia lasts only 30 minutes and brain imaging shows no infarction, the patient has had a TIA rather than a stroke.
A transient ischaemic attack (TIA) is a brief period of neurological deficit caused by a vascular issue, lasting less than an hour. The original definition of a TIA was based on time, but it is now recognized that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new ’tissue-based’ definition is now used. The clinical features of a TIA are similar to those of a stroke, but the symptoms resolve within an hour. Possible features include unilateral weakness or sensory loss, aphasia or dysarthria, ataxia, vertigo, or loss of balance, visual problems, sudden transient loss of vision in one eye (amaurosis fugax), diplopia, and homonymous hemianopia.
NICE recommends immediate antithrombotic therapy, giving aspirin 300 mg immediately unless the patient has a bleeding disorder or is taking an anticoagulant. If aspirin is contraindicated, management should be discussed urgently with the specialist team. Specialist review is necessary if the patient has had more than one TIA or has a suspected cardioembolic source or severe carotid stenosis. Urgent assessment within 24 hours by a specialist stroke physician is required if the patient has had a suspected TIA in the last 7 days. Referral for specialist assessment should be made as soon as possible within 7 days if the patient has had a suspected TIA more than a week previously. The person should be advised not to drive until they have been seen by a specialist.
Neuroimaging should be done on the same day as specialist assessment if possible. MRI is preferred to determine the territory of ischaemia or to detect haemorrhage or alternative pathologies. Carotid imaging is necessary as atherosclerosis in the carotid artery may be a source of emboli in some patients. All patients should have an urgent carotid doppler unless they are not a candidate for carotid endarterectomy.
Antithrombotic therapy is recommended, with clopidogrel being the first-line treatment. Aspirin + dipyridamole should be given to patients who cannot tolerate clopidogrel. Carotid artery endarterectomy should only be considered if the patient has suffered a stroke or TIA in the carotid territory and is not severely disabled. It should only be recommended if carotid stenosis is greater
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This question is part of the following fields:
- Neurological System
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Question 88
Correct
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A 65-year-old African American woman has been diagnosed with iodine deficiency.
What are the primary clinical manifestations of iodine deficiency?Your Answer: Impaired memory and concentration
Explanation:The Importance of Iodine in the Diet
Iodine is a crucial mineral that is necessary for the proper functioning of the body. Unfortunately, it is also one of the most common nutrient deficiencies worldwide. This deficiency can lead to a variety of iodine-related disorders, which are considered one of the most common preventable causes of mental incapacity.
One of the primary functions of iodine is the production of thyroid hormones, which are essential for all body cells. These hormones are particularly important for the development of the fetal brain, and a lack of thyroid hormones at this stage can lead to devastating and irreversible effects. Iodine deficiency commonly causes goitre, and the clinical effects are comparable to profound hypothyroidism.
The effects of iodine deficiency can be severe and long-lasting. In utero, it can lead to impaired cognitive function, deafness, and motor defects, a condition known as cretinism. In children and adolescents, it can cause cognitive impairment and poor growth. In adults, it can lead to confusion, poor concentration, and goitre.
Iodine is abundant in the sea, but inland areas are more at risk of iodine deficiency. If the soil is iodine deficient, all plants that grow on it, and livestock that feed upon them, will also be iodine deficient. It is essential to ensure that the diet contains sufficient iodine to prevent these devastating effects.
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This question is part of the following fields:
- Clinical Sciences
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Question 89
Correct
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What is the leading reason for hypoglycemia in adults?
Your Answer: Treated diabetes mellitus
Explanation:Hypoglycaemia in Adults
Hypoglycaemia is a condition where the blood glucose level falls below the typical fasting level, which is around <4 mmol/L for an adult. This condition can cause various symptoms, including tremors, sweating, nausea, lightheadedness, hunger, and disorientation. Severe hypoglycaemia can even lead to confusion, aggressive behaviour, and reduced consciousness. Drug-treated diabetes mellitus is the most common cause of hypoglycaemia in adults, especially due to insulin or hypoglycaemia drugs like sulphonylureas. Type 1 diabetes patients are at a higher risk of hypoglycaemia due to hypoglycaemia unawareness and blunted glucagon response. However, mild hypoglycaemia is common during fasting, pregnancy, and minor illness. Apart from diabetes, other causes of hypoglycaemia in adults include non-diabetic drugs, alcohol, hepatic failure, critical illness, hormone deficiency, malignancy, insulinoma, non-insulinoma pancreatogenous hypoglycaemia syndrome (NIPHS), and bariatric surgery. It is essential to understand the causes and symptoms of hypoglycaemia to manage the condition effectively. Early diagnosis and treatment can prevent severe complications and improve the quality of life for individuals with hypoglycaemia.
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This question is part of the following fields:
- Clinical Sciences
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Question 90
Incorrect
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As an out-of-hours GP, you encounter a 44-year-old man with a head injury who needs to be admitted for observation. He discloses that he has hepatitis B and lives alone in a remote area, making it impossible for him to have someone monitor him for the next 24 hours. Although he reluctantly agrees to a brief hospital stay, he insists that you keep his hepatitis B status confidential from the medical team who will be caring for him. The most recent hepatitis serology results indicate that he has inactive disease, and his most recent liver function tests were not significantly abnormal. What is your course of action?
Your Answer: In order to ensure he agrees to admission, advise him that you will not disclose information relating to his hepatitis B infection. However, in order to ensure the healthcare workers looking after him are not placed at risk, contact a friend you know is on duty on the ward where he will be admitted to advise her about the patient's infection but ask she does not share this with the team unless there is reason to do so (that is, the patient needs an operation or blood test).
Correct Answer: Advise him that you ought to inform the medical team involved in his care for their safety and that they will keep this medical information confidential. His rights and comfort will be maintained but should his clinical condition warrant blood tests or a blood transfusion, it would be better that the clinical team are aware from the outset. All patients are treated equally with universal precautions.
Explanation:Balancing Confidentiality and Patient Safety in Healthcare
When faced with a patient who refuses to disclose their hepatitis B status, healthcare professionals must weigh the potential harms and benefits of admission. The potential harms include the patient self-discharging, healthcare workers being exposed to contaminated equipment, and a breach of confidentiality. On the other hand, admission ensures that the patient does not come to harm as a result of their injury.
In this scenario, the likelihood of a healthcare worker contracting hepatitis B is low, but it is still important to persuade the patient to share their status with the clinical team responsible for their care. A conversation that emphasizes the importance of sharing this information for the patient’s care and the safety of healthcare personnel is likely to resolve the situation. It is crucial to prioritize clinical need and assure the patient that they will be looked after sincerely and honestly, with no judgement.
It is important to note that other options, such as breaching confidentiality or coercing the patient into disclosing their status, are not appropriate. Healthcare professionals must balance the need for patient confidentiality with the need to ensure patient safety. By having open and honest conversations with patients, healthcare professionals can navigate this delicate balance and provide the best possible care.
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This question is part of the following fields:
- Ethics And Law
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